Antiarrhythmic drugs or implantable cardioverter defibrillators in heart failure: the "poor heart"

Can nurses in cardiology areas prepare patients for implantable cardioverter defibrillator implant and life at home?

This study explored nurses' confidence and competence in preparing patients for having an implantable cardioverter defibrillator implanted and for life at home after discharge. Whilst research has identified various physical and psychosocial effects to patients and their partners associated with device implant and subsequent lifestyle adjustments, no research has explored nurses' knowledge of the device or these effects. A survey was designed using a purposive sample of 152 nurses from cardiology areas in four large teaching hospitals and a 28-point postal questionnaire to explore knowledge of the device and its impact. Most subjects were not confident in their abilities to prepare patients for implant or life at home after implant. Knowledge of the device and its effects appeared poorly understood by all nurses, irrespective of additional qualifications, length of time since qualifying or area of work. Many participants were aware of the poor knowledge level of nurses and identified it as a weakness in current care practices. Lack of understanding may impair preparation of patients for implantation of or for living with an implantable cardioverter defibrillator, and feasible strategies to change this situation will require careful consideration and further investment.

Transatrial dual chamber biventricular pacemaker-defibrillator placement in a patient with SVC obstruction

A patient with severe congestive heart failure and obstruction of the superior vena cava required biventricular pacing and ICD therapy. Via right minithoracotomy, a transatrial approach for lead placement was successfully utilized to provide cardiac resynchronization and ICD placement. This technique for pacing lead placement is reviewed and its application for biventricular pacemaker-defibrillator placement is reported.

E 047/1: a new class III antiarrhythmic agent

The efficacy, pharmacokinetics, safety, and tolerability of E 047/1, an amiodarone derivative, were evaluated in patients with acute supraventricular or ventricular arrhythmia. In an open, nonrandomized prospective multicenter trial, 20 patients were treated with three different i.v. dosage regimens of E 047/1. Arrhythmia termination indicated efficacy. Pharmacokinetics were determined by measurements of drug plasma levels. Safety was judged by changes of blood pressure, heart rate, ECG parameters, and appearance of adverse events. For local tolerability, effects at the site of infusion were assessed. In patients with atrial fibrillation and/or atrial flutter, drug plasma levels and prolongation of QT interval were correlated with efficacy. In 10 (50%) patients, therapeutic intervention with E 047/1 was successful. Drug plasma levels rapidly decreased within 1 h after administration. Blood pressure values and ECG parameters stayed constant during the observation period. Proarrhythmic effects were not observed. As adverse events, vertigo, vomiting, and nausea in three (15%) and hypotension in one (5%) patient, respectively, occurred in the high-dose bolus regimen only. At the site of infusion, no adverse effects were found. No dependency between drug plasma levels and arrhythmia termination was found. E 047/1 has proven to be efficient and safe in the treatment of arrhythmia. E 047/1 is characterized by rapid plasma elimination, absence of proarrhythmic or cardiodepressive effects, mild adverse events, and excellent local tolerability. For further investigation, we recommend a combined bolus- and weight-adapted infusion regimen.

[Prevention of sudden death in patients awaiting heart transplantation]

Sudden death, unexpectedly alters outcome in many patients awaiting heart transplantation. The prevention of sudden death in these patients has been the focus of intensive research to achieve a larger number of patients who finally receive transplants. Recent advances in the medical treatment of heart failure, have reduced mortality and in particular, that caused by sudden death. Nonetheless sudden death remains a frequent cause of mortality in patients awaiting cardiac transplantation. The recognition of patients at very high risk for sudden death is relatively easy, but most patients who suffer sudden death while awaiting cardiac transplantation, are not among those initially included in the overall high risk category. The betablockers, when patients are able to use them, can reduce sudden and total mortality. Class I antiarrhythmic drugs should not be used in patients with cardiac failure. Amiodarone does not increase mortality and may have a beneficial effect in some patients, but its efficacy is lower than that of the implantable defibrillator and its widespread use is not justified. The implantable defibrilator is the reference treatment to reduce sudden death in selected patients, awaiting transplantation.