Search

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. [ABSTRACT FROM AUTHOR]

Purpose: Short-term outcomes have been well characterized in acute coronary syndromes; however, longer-term follow-up for the entire spectrum of these patients, including ST-segment-elevation myocardial infarction, non-ST-segment-elevation myocardial infarction, and unstable angina, is more limited. Therefore, we describe the longer-term outcomes, procedures, and medication use in Global Registry of Acute Coronary Events (GRACE) hospital survivors undergoing 6-month and 2-year follow-up, and the performance of the discharge GRACE risk score in predicting 2-year mortality., Methods: Between 1999 and 2007, 70,395 patients with a suspected acute coronary syndrome were enrolled. In 2004, 2-year prospective follow-up was undertaken in those with a discharge acute coronary syndrome diagnosis in 57 sites., Results: From 2004 to 2007, 19,122 (87.2%) patients underwent follow-up; by 2 years postdischarge, 14.3% underwent angiography, 8.7% percutaneous coronary intervention, 2.0% coronary bypass surgery, and 24.2% were re-hospitalized. In patients with 2-year follow-up, acetylsalicylic acid (88.7%), beta-blocker (80.4%), renin-angiotensin system inhibitor (69.8%), and statin (80.2%) therapy was used. Heart failure occurred in 6.3%, (re)infarction in 4.4%, and death in 7.1%. Discharge-to-6-month GRACE risk score was highly predictive of all-cause mortality at 2 years (c-statistic 0.80)., Conclusion: In this large multinational cohort of acute coronary syndrome patients, there were important later adverse consequences, including frequent morbidity and mortality. These findings were seen in the context of additional coronary procedures and despite continued use of evidence-based therapies in a high proportion of patients. The discriminative accuracy of the GRACE risk score in hospital survivors for predicting longer-term mortality was maintained., (Copyright © 2015 Elsevier Inc. All rights reserved.)

The risk of stroke in patients hospitalized with an acute coronary syndrome (ACS) ranges from <1% to ≥ 2.5%. The aim of this study was to develop a simple predictive tool for bedside risk estimation of in-hospital ischemic stroke in patients with ACS to help guide clinicians in the acute management of these high-risk patients. Data were obtained from 63,118 patients enrolled from April 1999 to December 2007 in the Global Registry of Acute Coronary Events (GRACE), a multinational registry involving 126 hospitals in 14 countries. A regression model was developed to predict the occurrence of in-hospital ischemic stroke in patients hospitalized with an ACS. The main study outcome was the development of ischemic stroke during the index hospitalization for an ACS. Eight risk factors for stroke were identified: older age, atrial fibrillation on index electrocardiogram, positive initial cardiac biomarkers, presenting systolic blood pressure ≥ 160 mm Hg, ST-segment change on index electrocardiogram, no history of smoking, higher Killip class, and lower body weight (c-statistic 0.7). The addition of coronary artery bypass graft surgery and percutaneous coronary intervention into the model increased the prediction of stroke risk. In conclusion, the GRACE stroke risk score is a simple tool for predicting in-hospital ischemic stroke risk in patients admitted for the entire spectrum of ACS, which is widely applicable to patients in various hospital settings and will assist in the management of high-risk patients with ACS., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Aims: Brief episode(s) of ischaemia may increase cardiac tolerance to a subsequent major ischaemic insult ('preconditioning'). Nitrates can pharmacologically mimic ischaemic preconditioning in animals. In this study, we investigated whether antecedent nitrate therapy affords protection toward acute ischaemic events using data from the Global Registry of Acute Coronary Events., Methods and Results: The dataset comprised 52,693 patients from 123 centres in 14 countries: 42,138 (80%) were nitrate-naïve and 10,555 (20%) were on chronic nitrates at admission. In nitrate-naïve patients, admission diagnosis was ST-segment elevation myocardial infarction (STEMI) in 41%, whereas 59% presented with non-ST-segment elevation acute coronary syndrome (NSTE-ACS). In contrast, only 18% nitrate users showed STEMI, whereas 82% presented with NSTE-ACS. Thus, among nitrate users clinical presentation was tilted toward NSTE-ACS by more than four-fold, STEMI occurring in less than one of five patients (P < 0.0001). After adjustment (age, sex, medical history, prior therapy, revascularization, previous angina), chronic nitrate use remained independent predictor of NSTE-ACS (OR 1.36; 95% CI 1.26-1.46; P < 0.0001). Furthermore, regardless of presentation, within both STEMI and NSTEMI populations, antecedent nitrate use was associated with significantly lower levels of CK-MB and troponin (P < 0.0001 for all)., Conclusion: In this large multinational registry, chronic nitrate use was associated with a shift away from STEMI in favour of NSTE-ACS and with less release of markers of cardiac necrosis. These findings suggest that in nitrate users acute coronary events may develop to a smaller extent. Randomized, placebo-controlled trials are warranted to establish whether nitrate therapy may pharmacologically precondition the heart toward ischaemic episodes.

Background: The Global Registry of Acute Coronary Events (GRACE)-a prospective, multinational study of patients hospitalized with acute coronary syndromes (ACSs)-was designed to improve the quality of care for patients with an ACS. Expanded GRACE aims to test the feasibility of a simplified data collection tool and provision of quarterly feedback to index individual hospital management practices to an international reference cohort., Methods: We describe the objectives; study design; study and data management; and the characteristics, management, and hospital outcomes of patients > or =18 years old enrolled with a presumptive diagnosis of ACS., Results: From 2001 to 2007, 31,982 patients were enrolled at 184 hospitals in 25 countries; 30% were diagnosed with ST-segment elevation myocardial infarction, 31% with non-ST-segment myocardial infarction, 26% with unstable angina, and 12% with another cardiac/noncardiac final diagnosis. The median age was 65 (interquartile range 55-75) years; 24% were >75 years old, and 33% were women. In general, increases were observed over time across the spectrum of ACS (1) in the use in the first 24 hours and at discharge of aspirin, clopidogrel, beta-blockers, and angiotensin-converting enzyme inhibitors/receptor blockers; (2) in the use at discharge of statins; (3) in the early use of glycoprotein IIb/IIIa inhibitors and low-molecular-weight heparin; and (4) in the use of cardiac catheterization and percutaneous coronary intervention. An increase in the use of primary percutaneous coronary intervention and a similar decrease in the use of fibrinolysis in ST-segment elevation myocardial infarction were also seen., Conclusions: Over the course of 7 years, general increases in the use of evidence-based therapies for ACS patients were observed in the expanded GRACE.

Background: There are limited recent data evaluating the use of the pulmonary artery catheter (PAC) in patients hospitalized with an acute coronary syndrome (ACS). Using data from the multinational Global Registry of Acute Coronary Events, we examined trends in PAC use among patients hospitalized for an ACS and the association between PAC and hospital outcomes., Methods: Trends in PAC utilization between 2000 and 2007 were examined through the review of data contained in hospital medical records. We identified factors associated with PAC utilization and compared differences in the length of hospitalization and in-hospital death rates between patients undergoing PAC during the index hospitalization (PAC+, n = 2,879) and those managed without PAC (PAC-, n = 56,091)., Results: The utilization of PAC during hospitalization for an ACS declined over time such that 3.0% of patients underwent PAC in 2007 compared with 5.4% in 2000. Admission Killip classification was the strongest factor associated with PAC insertion. The duration of hospitalization was significantly longer among PAC+ (median = 10.0 days) as compared with PAC- patients (median = 5.0 days). In-hospital death rates were significantly higher among PAC+ patients after adjustment for differences in baseline characteristics (odds ratio 4.00, 95% CI 3.41-4.70)., Conclusions: The frequency of PAC utilization in "real-world" patients hospitalized with ACS has declined during recent years. Our finding of increased in-hospital mortality among patients undergoing PAC is consistent with prior studies and may further challenge the efficacy of PAC in the setting of ACS.

Background: Limited data suggest that ST elevation (ST elevation) in aVR is associated with higher mortality and more extensive coronary artery disease in the setting of non-ST elevation acute coronary syndromes (ACS)., Methods: In the prospective Global Registry of Acute Coronary Events (GRACE) electrocardiographic substudy, the admission electrocardiograms were analyzed by a blinded core laboratory. We performed multivariable analysis to determine (1) the independent prognostic significance of ST elevation in aVR and (2) its association with significant (> or = 50% stenosis) left main or 3-vessel disease (LM/3-vd)., Results: Among 5064 patients with non-ST elevation ACS, 4696 had no ST elevation in aVR, 292 (5.8%) had minor (0.5-1 mm) ST elevation in aVR, and 76 (1.5%) had major (>1 mm) ST elevation in aVR; their in-hospital mortality rates were 4.2%, 6.2%, and 7.9%, respectively (P for trend =.03). At 6 months follow-up, the cumulative mortality rates were 7.6%, 12.7%, and 18.3%, respectively (log-rank P for trend <.001). However, minor and major ST elevation in aVR were not independent predictors of in-hospital or 6-month death after adjusting for other validated prognosticators in the GRACE risk model. Of the 2416 patients without prior coronary bypass surgery who underwent cardiac catheterization, the prevalence of LM/3-vd was 26.1%, 36.2%, and 55.9% for the groups with no, minor, and major ST elevation in aVR, respectively (P for trend <.001). After adjusting for other clinical characteristics, major ST elevation in aVR remained an independent predictor of LM/3-vd (adjusted odds ratio, 2.68; 95% confidence interval, 1.29-5.58; P = .008)., Conclusion: ST elevation in aVR is less prevalent than reported in previous smaller studies. Although it is associated with higher unadjusted in-hospital and 6-month mortality, it does not provide incremental prognostic value beyond comprehensive risk stratification using the validated GRACE risk model. However, ST elevation greater than 1 mm in aVR may be useful in the early identification of LM/3-vd in ACS patients with ST depression.

Objectives: The purpose of this study is to evaluate hospital mortality and major bleeding rates among patients receiving low molecular weight heparin (LMWH), unfractionated heparin (UFH), or both, and to investigate whether concomitant glycoprotein (GP) IIb/IIIa antagonists and coronary intervention affect patterns of use and outcomes with different heparins., Background: With widespread use of glycoprotein (GP) IIb/IIIa inhibitors and invasive treatments, patients with high-risk acute coronary syndrome (ACS) may have a greater bleeding risk and may not gain additional benefit from LMWHs. The purpose of this study is to evaluate hospital mortality and major bleeding rates among patients receiving LMWH, UFH, or both, and to investigate whether concomitant GP IIb/IIIa antagonists and coronary intervention affect patterns of use and outcomes with different heparins., Methods: Data were analyzed from 28,445 patients with ACS; 21,287 had non-ST-segment elevation myocardial infarction or unstable angina and received LMWH or UFH., Results: Fifty-one percent of patients received LMWH, 32% UFH, and 17% both. The lowest inhospital mortality and bleeding rates occurred with LMWH (2.7% and 1.8% vs UFH, 4.1% and 2.7%; all P < .0001). After multivariable analysis, LMWH was associated with lower inhospital mortality rates in patients not treated with GP IIb/IIIa antagonists, irrespective of whether they had a percutaneous coronary intervention (PCI) (odds ratio 0.77, 95% confidence interval 0.63-0.94 without PCI vs odds ratio 0.45, 95% confidence interval 0.21-0.98 with PCI). Excess bleeding occurred with PCI in LMWH-treated patients. Patients older than 75 years who received GP IIb/IIIa antagonists and any antithrombotic but not PCI had an increased risk of major bleeding (LMWH 14%, UFH 8.3%)., Conclusions: In patients with non-ST-elevation ACS without GP IIb/IIIa antagonists, LMWH was associated with a lower mortality rate and more bleeding episodes in PCI-treated patients than UFH; no differences occurred with GP IIb/IIIa antagonists. Elderly patients managed medically with GP IIb/IIIa antagonists and either heparin had a very high major bleeding risk.

Purpose: We describe the use of antithrombotic therapy in the management of patients with acute coronary syndromes., Methods: Patients from the Global Registry of Acute Coronary Events, a multinational coronary disease registry, were characterized according to the early and continued use of low-molecular-weight heparin, unfractionated heparin, any crossover of heparin therapy (change in early vs late heparin treatment), and no heparin treatment. Hospital outcomes were analyzed according to the heparin treatment and the timing of percutaneous coronary interventions., Results: Data from 23,172 patients with non-ST-segment elevation myocardial infarction or unstable angina were analyzed. A total of 8791 patients were treated with low-molecular-weight heparin within the first 24 hours and continued thereafter; 4076 patients received unfractionated heparin; 2953 patients received neither heparin therapy; and 7352 patients received crossover heparin treatment. Concomitant treatment, including early or late percutaneous coronary intervention, varied according to the type of heparin therapy. Patients treated with a crossover therapy were more likely to undergo percutaneous coronary intervention. The rates of major bleeding and death were lower with low-molecular-weight heparin (1.4% and 1.8%, respectively) compared with unfractionated heparin (1.9% and 2.5%, respectively), crossover heparin (2.0% and 2.3%, respectively), or neither heparin (1.5% and 2.4%, respectively)., Conclusions: There is significant variability in heparin use in patients with acute coronary syndromes. Heparin type and use seem to be related to the timing and use of percutaneous coronary interventions. The early use of low-molecular-weight heparin in the setting of an acute coronary syndrome is associated with better short-term outcomes.

Background: The impact and prognostic value of the redefinition of myocardial infarction (MI) with more sensitive markers have not been evaluated prospectively in a large, less selected population with acute coronary syndrome (ACS)., Methods: We evaluated the attack and case-fatality rates of MI based on initial and/or peak creatine kinase (CK), creatine kinase-MB (CK-MB), and cardiac troponin (the upper limit of normal [ULN] was defined according to the local hospital's standard) in a prospective observational registry of 26,267 patients with ACS admitted to 106 hospitals in 14 countries., Results: The addition of cardiac troponin-positive status to CK status as a criterion for the diagnosis of MI resulted in as many as 1 in 4 additional patients meeting the redefined criteria. Compared with patients without elevated levels of CK and cardiac troponin, the crude odds for dying during hospitalization were significantly higher for patients with elevated troponin but not CK levels of greater than or equal to the ULN (odds ratio [OR] 2.2, 95% CI 1.6-2.9), those without CK levels >2 times the ULN (OR 2.8, 95% CI 2.2-3.5), and those with nonelevated levels of CK-MB (OR 2.1, 95% CI 1.4-3.2). The addition of cardiac troponin-positive status significantly increased the multivariable-adjusted odds for hospital death in patients with CK < or =2 times the ULN (OR 1.6, 95% CI 1.2-2.1) but not for patients without elevated levels of CK or CK-MB., Conclusions: The prognostic value of cardiac troponin, beyond that supplied by CK status or important baseline characteristics, assists in the identification of patients with ACS who are at increased risk for death.

Stenting and GP IIb/IIIa inhibition are promising adjunctive therapies in PCI. The Global Registry of Acute Coronary Events (GRACE) is a registry of unselected patients with acute coronary syndromes, allowing for the study of treatments in a real-world environment. Data from GRACE patients with AMI who underwent PCI were analyzed. After adjusting for demographics, baseline characteristics, and previous medications, treatment with GP IIb/IIIa inhibitors and a stent and treatment with a stent alone were significant predictors of survival at 6 months. Stents were used in 90.9% of patients. GP IIb/IIIa inhibitors were used in 59.7%; in most cases they were started after the beginning of the procedure. The in-hospital death rate (7.6%) was highest in patients undergoing urgent PCI. Mortality at 6 months following PCI was 14.4% among patients who received neither GP IIb/IIIa inhibitors nor a stent, compared to patients who received both GP IIb/IIIa inhibitors and a stent (7.3%), GP IIb/IIIa inhibitors alone (12.8%), or a stent alone (6.7%)., (Copyright 2003 Wiley-Liss, Inc.)

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.

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.

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.

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.

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.

The hospital courses of 882 consecutive patients with acute myocardial infarction admitted to the coronary care unit (CCU) during a 3-year period were evaluated. Their courses after discharge from the CCU were assessed with reference to the following serious complications which had occurred during their stay in the CCU; ventricular tachycardia or fibrillation, second-or third-degree heart block, pulmonary oedema, cardiogenic shock persistent sinus tachycardia, persistent hypotension, atrial flutter or fibrillation, or extension, or extension of infarction. Of the 494 patients (56%) with one or more of these complications, 38 (8%) died of cardiac causes in hospital after transfer from the CCU. Of 388 patients (44%) in the uncomplicated group, only 2(0,5%) died of cardiac causes after transfer from the CCU. The same patients were classified according to the Coronary Prognostic Index (CPI) of Norris. None of the 54% of patients with a CPI of less than 6 units died in hospital after transfer from the CCU. It is proposed that patients with a CPI of less than 6 units and with none of the listed serious complications during their CCU stay could safely be discharged from hospital earlier than is customary.

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.

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.

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.

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.

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.

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.

Two patients who underwent left ventricular bypass transplants are described. Both patients sustained postoperative rhythm disturbances of their own hearts during sinus rhythm of the donor hearts. Illustrative examples of atrial flutter, ventricular flutter, ventricular fibrillation, blocked atrial extrasystoles, and double ventricular parasystole in the recipient hearts are presented. The patients tolerated all these arrhythmias well during uninterrupted sinus rhythm in the donor heart. The problems in interpretation of arrhythmias in the presence of two hearts are discussed.

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.

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.

The efficacy of quinidine versus lidoflazine therapy was compared in the maintenance of sinus rhythm after electrical cardioversion for atrial flutter or fibrillation in a group of 35 patients. Both quinidine and lidoflazine were relatively ineffective in maintaining sinus rhythm after cardioversion. Lidoflazine was also used to prevent supraventricular and ventricular tachycardias in a miscellaneous group of patients; one of these with paroxysmal supraventricular tachycardia developed runs of venttricular tachycardia soon after starting lidoflazine. The trial was stopped after 4 patients died while receiving lidoflazine, on the suspicion that their deaths may have been related to drug-induced arrhythmias. The arrhythmogenic potential of lidoflazine when used in patients with supraventricular arrhythmias constrasts with reports of its apparent safety in large numbers of patients with angina pectoris.

The relation between peak plasma-free-fatty-acid (F.F.A) concentration and size of infarct--as estimated by the plasma-creatine-kinase technique--was investigated in twenty patients with acute myocardial infarction. In eight patients with large infarcts (more than 65 g equivalents) mean infarct size was 136+/-21 g equivalents and mean peak F.F.A. value in the first 12 h was 1-99+/-0-14 mmol/l (mean +/-S.E.M.). In twelve patients with small infarcts, mean infarct size was 36+/-5 g equivalents and mean peak F.F.A. was 1-22+/-0-13 mmol/l (P less than 0-001). Experimental evidence suggests that high circulating F.F.A. concentrations could further extend ischaemic damage. The association between high plasma-F.F.A. and infarct size may give rise to a vicious circle which increases the severity of the ischaemic process in patients with high plasma-F.F.A.

The natural history of angina and the influence of aortocoronary saphenous vein bypass grafting on the relief of symptoms and survival are reviewed. Indications and contraindications for coronary surgery and the complications and results of operation are discussed. Coronary artery surgery is occasionally indicated in situations other than angina, such as in selected cases of unstable angina, arrhythmias and acute myocardial infarction.

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.

Forty-two consecutive patients with acute myocardial infarction were studied over the first 3 days of their illness to determine the effect of oral or intravenous calorie intake on the circulating free fatty acid values. Repeated sampling in 9 patients showed that free fatty acid levels above 1000 mumol/l were seldom found beyond the first 10 hours after admission. Oral calories, chiefly in the form of carbohydrate, reduced free fatty acid by an average of 145 mumol/l for each intake of 90 or more calories (378kF) on the first day. Oral calories (especially carbohydrate) should be considered as possible antilipolytic therapy if it be held desirable to reduce circulating free fatty acid concentrations in patients with acute mycoardial infarction.