Addition of felodipine to metoprolol vs replacement of metoprolol by felodipine in patients with angina pectoris despite adequate beta-blockadeResults of the Felodipine ER and Metoprolol CR in Angina (FEMINA) StudyDunselman,, P.;Liem, A., H.;Verdel,, G.;Kragten,, H.;Bosma,, A.;Bernink,, P.
doi: 10.1093/oxfordjournals.eurheartj.a015170pmid: 9402450
Abstract Aims The study aimed to compare the addition of felodipine to metoprolol, and of the replacement of metoprolol by felodipine, with continuation of metoprolol, in patients with angina pectoris despite optimal beta-blockade. Methods and results The study was double-blind, parallel, randomized and controlled, and comprised 363 patients from 27 outpatient cardiology clinics in the Netherlands. The patients had angina and positive bicycle exercise tests despite optimal beta-blockade (resting heart rate <65 beats . min−1). Randomization was to three treatment groups: continuation of metoprolol (control), addition of felodipine to metoprolol, and replacement of metoprolol by felodipine. Exercise tests were repeated after 2 and 5 weeks. The main outcome measure was: exercise result after 5 weeks, compared with baseline, between-group comparison of changes vs control. There were no significant differences in exercise duration and onset of chest pain vs control. The addition of felodipine increased time until 1 mm ST depression (43 s, 95% confidence interval 20–65 s), and decreased both ST depression at highest comparable work load (0·46 mm, 95% confidence interval 0·19–0·72), and maximal ST depression (0·49 mm, 95% confidence interval 0·23–0·74). Exercise results after replacement of metoprolol by felodipine were not different from control, apart from a significant increase in rate pressure product. Significantly more patients experienced adverse events in the felodipine monotherapy group. Conclusion Combination of metoprolol and felodipine is to be preferred to felodipine monotherapy in patients who have signs and symptoms of myocardial ischaemia despite optimal beta-blockade. beta-blockers, calcium antagonists, dihydropyridines, metoprolol, felodipine, angina pectoris This content is only available as a PDF. © 1997 The European Society of Cardiology
Balloon mitral valvotomy: comparison between antegrade Inoue and retrograde non-transseptal techniquesBahl, V., K.;Chandra,, S.;Jhamb, D., K.;Goswami, K., C.;Juneja,, R.;Thatai,, D.;Talwar, K., K.;Wasir, H., S.
doi: 10.1093/oxfordjournals.eurheartj.a015171pmid: 9402451
Abstract Aims The results of percutaneous mitral valvotomy performed by the antegrade transseptal method using the Inoue balloon (n=1000; group 1) and by the retrograde non-transseptal technique using a polyethylene balloon (n=100; group 2) were compared in a retrospective, non-randomized study. Methods and results Both the groups were similar with respect to baseline characteristics. The success rate was 95% in group 1 and 93% in group 2. There was a significant increase in mitral valve area estimated by Gorlin's equation (Group 1: from 0·8 ± 0·5 to 2·1 ± 0·8 cm2; Group 2: from 0·8 ± 0·3 to 1·9 ± 0·8 cm2, both P<0·001) and by Doppler echocardiography using the pressure half-time method (Group 1: from 0·9 ± 0·4 to 2·2 ± 0·6 cm2; Group 2: from 0·9 ± 0·3 to 2·0 ± 0·7 cm2, both P<0·001). However, the calculated immediate post-valvotomy mitral valve area was larger with the Inoue technique (2·1 ± 0·8 vs 1·9 ± 0·8 cm2; P<0·02). Results were considered optimal when the mitral valve area increased to ≥ 1·5 cm2, the percentage increase was ≤50, and mitral regurgitation was ≤2/4. Out of the total successful procedures, optimal results were obtained in 95% patients in Group 1 and 94% in Group 2. Incidence of significant mitral regurgitation (≥grade 3/4) was similar in two groups (Group 1: 4% vs Group 2: 5%, P=ns). A significant left to right atrial shunt (Qp/Qs ≥ 1·5:1) in 2·5% and tamponade in 2% of cases occurred exclusively with the Inoue technique, while conduction disturbances, such as transient (<24 h) left bundle branch block (28%) and complete heart block (2%) were noted with the retrograde technique (Group 2). Local complications were significantly higher in Group 2 (3% vs 0·5%, P<0·01). The procedure time with the Inoue technique was shorter than with the retrograde (Group 1: 15 ± 8, range 10 to 35 min; Group 2: 22 ± 14, range 15 to 45 min, P=0·05). Echocardiographic follow-up at 1 year showed no significant difference in mitral valve area between the two groups (Group 1 (n=300): 1·8 ± 0·8 vs Group 2 (n=60): 1·9 ± 0·9 cm2; P=0·3). Conclusion Balloon mitral valvotomy using the Inoue balloon and the retrograde non-transseptal technique results in significant immediate haemodynamic and symptomatic improvement. The Inoue technique achieved a larger immediate post-valvotomy mitral valve area, but the difference was not apparent at 1 year follow-up. Incidence of significant mitral regurgitation was similar with both the techniques; however, local complications occurred more frequently with the retrograde technique. Both techniques may complement each other in technically difficult cases. Balloon mitral valvotomy, retrograde non-transseptal balloon mitral valvotomy, Inoue balloon This content is only available as a PDF. © 1997 The European Society of Cardiology
Survival and incidence of myocardial infarction in men with ambulatory ECG-detected frequent and complex ventricular arrhythmias10 year follow-up of the ‘Men born 1914’ study in Malmö, SwedenHedblad,, B.;Janzon,, L.;Johansson, B., W.;Juul-Möller,, S.
doi: 10.1093/oxfordjournals.eurheartj.a015174pmid: 9402454
Abstract Aim To assess to what extent do frequent or complex ventricular arrhythmias, detected during 24 h ambulatory electrocardiographic recording (ECG), influence prognosis with regard to survival and incidence of ischaemic heart disease. Methods and results The study subjects were the 456 randomly selected men born in 1914, the population-based cohort study of 1982–83, in Malmö, Sweden. The main outcome measures were total mortality and incidence of cardiac event (myocardial infarction and death from ischaemic heart disease). Frequent or complex ventricular arrhythmias (Lown classes 2–5) were detected in 49% of the men with (n=77), and in 35% of those without, a history of myocardial infarction or angina pectoris at baseline, P=0·019. Independent of clinically evident coronary artery disease at baseline, and after adjustment for traditional atherosclerotic risk factors and use of digitalis or betablocker therapy, frequent or complex ventricular arrhythmias were associated with an increased mortality from ischaemic heart disease (relative risk (RR), 2·1; 95% confidence interval (CI), 1·2–3·9) and an increased cardiac event rate (RR, 1·6; 95% CI, 1·0–2·5)). Men free from both ischaemic-type ST depression and frequent or complex ventricular arrhythmias (used as the control group) had the lowest ischaemic heart disease death rate, 5·9 per 1000 person-years. The combination of ST depression and frequent or complex ventricular arrhythmias was associated with an ischaemic heart disease death rate of 20·9 per 1000 person-years. The cardiac event rate in these two groups was 15·6 and 76·1 per 1000 person-years, respectively (adjusted RR, 2·3; CI, 1·1–4·6). Conclusion In elderly men without a history of myocardial infarction and angina pectoris, frequent or complex ventricular arrhythmias during ambulatory ECG recording is associated with an increased incidence of myocardial infarction and mortality. Men who, during ambulatory ECG recording, also demonstrate ST-segment depression have an even less favourable prognosis. Ambulatory electrocardiographic recording, ventricular arrhythmia, prognosis This content is only available as a PDF. © 1997 The European Society of Cardiology
A comparison of treatment of atrial fibrillation with low-energy intracardiac cardioversion and conventional external cardioversionAlt,, E.;Ammer,, R.;Schmitt,, C.;Evans,, F.;Lehmann,, G.;Pasquantonio,, J.;Schömig,, A.
doi: 10.1093/oxfordjournals.eurheartj.a015175pmid: 9402455
Abstract Aim Low-energy (1 to 15 J), catheter-based intracardiac cardioversion was compared with transthoracic external cardioversion (360 J) in a prospective, cross-over clinical trial. Methods and results In 187 consecutive patients with chronic atrial fibrillation, over a period of a mean of 10·0±7·3 (SD) months, 217 cardioversion attempts were made. Intracardiac shocks were randomly applied between two 6-F catheters located in either the right atrium and coronary sinus or between the right atrium and left pulmonary artery. When a cardioversion attempt with one method failed, the other method was implemented. After cardioversion, all patients were treated orally with sotalol with a mean daily dose of 174±54 mg. Internal cardioversion was more effective than external cardioversion (65/70=93% vs 92/177 =79%, P<0·01). The mean energy for successful cardioversion was 5·8±3·2 J for the internal and 313±71 J for the external cardioversion group. At a mean follow-up of 12·5±6·4 months, 48% (38%) of the patients treated with internal (external) cardioversion were in sinus rhythm (P<0·05). In 22 of 25 patients in whom external cardioversion failed, sinus rhythm was restored with internal cardioversion at a mean energy of 6·5±3·0 J. Overweight patients had twice the risk of unsuccessful external cardioversion. Conclusion Internal cardioversion is effective in restoring sinus rhythm. It might be indicated in patients in whom external cardioversion had failed or in whom external cardioversion is assumed to be difficult or even contraindicated. Atrial fibrillation, defibrillation, internal cardioversion, sinus rhythm This content is only available as a PDF. © 1997 The European Society of Cardiology
Cardiopulmonary physiology after surgical closure of asymptomatic secundum atrial septal defects in childhoodExercise performance is unaffected by age at repairRosenthal,, M.;Redington,, A.;Bush,, A.
doi: 10.1093/oxfordjournals.eurheartj.a015177pmid: 9402457
Abstract Aims Most secundum atrial septal defects, once diagnosed, are corrected at a young age. The evidence to justify early vs delayed or even non-closure is equivocal and little is known regarding long-term effects of later closure. This is particularly pertinent to those patients awaiting transcatheter closure of their defect for whom a device is only just becoming available. We examined the exercise cardiorespiratory physiology of children surgically treated for an isolated secundum defect. Methods and results One hundred and six healthy control children and 22 children more than 6 months after surgical repair for an isolated secundum atrial septal defect were studied. All were asymptomatic. Measurements of effective pulmonary blood flow, stroke volume, arteriovenous oxygen difference, minute ventilation, heart rate, oxygen consumption and carbon dioxide production were made using a quadrupole mass spectrometer during rest and graded exercise. Data from the normal children allowed calculation of z scores for the atrial septal defect group matched for age, sex, pubertal stage and surface area. Maximal exercise performance was equal between control and atrial septal defect groups, however, the atrial septal defect group had a significantly greater effective pulmonary blood flow and stroke volume but a lower heart rate than controls at a given exercise stage. Stroke volume abnormalities were most closely related to duration of follow-up (29% of the variance explained, P< 0·01) rather than age at surgery. Conclusion We were unable to show a medium term benefit from early surgery for an asymptomatic secundum atrial septal defect during exercise. The clinical relevance of the haemodynamic differences that do exist remains unclear. Atrial septal defect, cardiopulmonary physiology, children This content is only available as a PDF. © 1997 The European Society of Cardiology
Compliance and adverse event withdrawaltheir impact on the West of Scotland Coronary Prevention Studydoi: 10.1093/oxfordjournals.eurheartj.a015165pmid: 9402445
Abstract Aims To assess the additional benefit gained from high compliance in the West of Scotland Coronary Prevention Study and to examine cases where withdrawal from trial medication was due to an adverse event. Methods The incidence of definite coronary heart disease or non-fatal myocardial infarction, cardiovascular mortality, definite or suspect coronary heart disease death or non-fatal myocardial infarction, the need for coronary revascularization procedures, all-cause mortality and incident cancers were measured in the entire cohort and compared with the high compliance group. The adverse events associated with withdrawal were coded by body system. Results In subjects with compliance ≥75%, treatment with pravastatin resulted in a 38% risk reduction for definite coronary heart disease death or non-fatal myocardial infarction and for cardiovascular mortality, a 46% reduction in risk or coronary revascularization and a 32% risk reduction (P=0·015) for all-cause mortality. Conclusion The analysis of the effect of pravastatin in the subgroup of high compliers to randomized medication demonstrated a substantial increase in the estimated risk reductions in comparison with that achieved in the intention-to-treat analysis. This result has significant implications for the motivation of high compliance among patients and for the assessment of the cost-effectiveness of treatment. Primary prevention, compliance, withdrawals, on-treatment analysis, coronary heart disease, all cause mortality, pravastatin This content is only available as a PDF. © 1997 The European Society of Cardiology
Predictive factors of maximal aerobic capacity after cardiac transplantationDouard,, H.;Parrens,, E.;Billes, M., A.;Labbe,, L.;Baudet,, E.;Broustet, J., P.
doi: 10.1093/oxfordjournals.eurheartj.a015178pmid: 9402458
Abstract Exercise capacity in cardiac transplanted patients has been reported to remain decreased in some studies; however, functional results after transplantation may vary, ranging from modest to spectacular improvement. The aim of the study was to quantify exercise capacity in a large series of transplanted patients and to search for factor predictive of a good functional result Eighty-five patients (mean 52·1±11·8 years) underwent exercise testing with respiratory gas exchange measurements 1 to 100 months after transplantation. Mean performance was 112·4±33 W with a peak Vo2 of 21·1±6 ml. min−1. kg−1. Heart rate was 103±14 at rest, reaching 142±22 beats. min−1 at the end of exercising. In univariate analysis, maximal or submaximal aerobic capacity parameters were strongly correlated with chronotropic reserve (r=0·63; P<0·001) without correlation with cold ischaemic time, number of rejection episodes or right bundle branch block. In multiple regression analysis, chronotropic reserve, time from transplantation, age of donor and age of patient were proved to be the variables best correlated with peak Vo2. Our study confirms the persistance of a large decrease in aerobic functional capacity despite cardiac transplantation; limited exercise capacity does not improve over time, and is limited not only by the patient's age but by that of the donor, and especially by chronotropic reserve. Cardiac transplantation, exercise testing, heart-rate, gas exchange analysis This content is only available as a PDF. © 1997 The European Society of Cardiology