Salade malade: malignant ventricular arrhythmias due to an accidental intoxication with Aconitum napellus

Intoxication with Aconitum napellus is rare in our regions. Aconite alkaloids can cause ventricular arrhythmia by a prolonged activation of sodium channels. Because the margin of safety is low between the analgesic and toxic dose, intoxication is not rare when Aconite is used in herbal medicine. We present a case in which a 39-year-old male was accidentally intoxicated with Aconite. Even though no antidote or adequate therapy is available he was successfully resuscitated. (Neth Heart J 2008;16:96-9.).

Myocardial adaptation in different endurance sports: an echocardiographic study

OBJECTIVE

Of this study was to investigate three groups of highly trained competitive endurance athletes consisting of marathon runners, triathletes and cyclists for differences in left ventricular adaptation.

METHODS

25 marathon athletes, 21 triathlon athletes and 38 cyclists underwent a standard echocardiographic and Doppler study.

RESULTS

The left ventricular internal diameter in diastole divided by body surface area was significantly larger in cyclists than in marathon runners (31.6+/-3.0 vs. 30.0+/-2.0 mm/ m2, p < 0.05) but did not differ of that of triathletes. Left ventricular mass was significantly different between marathon runners and triathletes (253.6+/-63.7 vs. 322.0+/-62.1 g, p < 0.005) and between marathon runners and cyclists (253.6+/-63.7 vs. 314.2+/-79.2 g, p < 0.005). Systolic wall stress was significantly different between the marathon runners and the triathletes (88.4+/-11.7 vs. 78.9+/-11.0 g/cm2 p < 0.05). Only a minority of the endurance athletes showed concentric remodeling (7%), whereas a majority showed eccentric remodeling (65%) of the left ventricle. The prevalence of eccentric remodeling was more apparent in cyclists. There were some specific differences in left ventricular diastolic function between the three different endurance sports, but no left ventricular diastolic dysfunction could be detected.

CONCLUSION

There is a sport-specific left ventricular adaptation in endurance athletes. The triathlon heart and the heart of a cyclist differ significantly from a marathon heart.

Recommendations and cardiological evaluation of athletes with arrhythmias: Part 2

Confronted with a competitive or recreational athlete, the physician has to discriminate between benign, paraphysiological and pathological arrhythmias. Benign arrhythmias do not represent a risk for SCD, nor do they induce haemodynamic consequences during athletic activities. These arrhythmias are not markers for heart disease. Paraphysiological arrhythmias are related to athletic performance. Long periods of endurance training induce changes in rhythm, conduction and repolarisation. These changes are fully reversible and disappear when the sport is terminated. Pathological arrhythmias have haemodynamic consequences and express disease, such as sick sinus syndrome, cardiomyopathy or inverse consequences of physical training. Arrhythmias can be classified as bradyarrhythmias and tachyarrhythmias. Conduction disorders can be seen in fast as well as in slow arrhythmias.

Recommendations and cardiological evaluation of athletes with arrhythmias: Part 1

Besides the consensus meeting in Amersfoort in 1988 and the Bethesda conference in 1994 recommendations are not available in the Netherlands for screening and evaluation of athletes with cardiac arrhythmias. Guidelines for competitive athletes with cardiac arrhythmias in the United States and Italy were published in 2000. In 1998 Estes et al. published the most important opinions on sudden cardiac death, screening and evaluation of athletes and arrhythmias. This study addresses the physiological and morphological consequences of athletic training, cardiac pathology and risk stratification for sudden cardiac death. Recommendations for competitive athletes with cardiovascular abnormalities, arrhythmias and proposals for specific protocols are given.

Left atrial and ventricular dimensions in highly trained cyclists

OBJECTIVES

This study sought to investigate the development of left ventricular remodeling during active cycling.

METHODS

A group of 17-year-old (+/- 0.2 years) highly trained competitive cyclists (group I, n = 66) and a group of 29-year old (+/- 2.6 years) professional cyclists (group II, n = 35) underwent two-dimensional (2D) echocardiography. Data from groups I and II were compared with values of normal untrained subjects based on the literature.

RESULTS

Left atrial dimensions were significantly increased in group II as compared to group I (44 +/- 5 vs. 36 +/- 4 mm, p < 0.005). Left ventricular end diastolic diameter was significantly increased in group II as compared to group I (61 +/- 5 vs. 54 +/- 6 mm, p < 0.005). Left ventricular mass was also significantly increased in group II as compared to group I (321 +/- 77 vs. 246 +/- 59 g, p < 0.005). Wall stress showed a significant inverse relation: 104 +/- 42 mmHg in group I vs. 83 +/- 14 mmHg in group II (p < 0.005). The early filling phase of the left ventricular inflow was significantly larger in both athlete groups in relation to the normal value. The E-wave in the athletes compared to the E-wave in normal subjects was 0.87 +/- 0.17 vs. 0.71 +/- 0.14 m/s in group I, p < 0.005, 0.82 +/- 0.17 vs. 0.71 +/- 0.14 m/s in group II, p < 0.05. Late filling phase and the ratio of the diastolic filling pattern did not show significant differences between the two groups.

CONCLUSIONS

Left atrial and left ventricular remodeling starts early in the athlete's career. Athletes of 17 years of age already show significant left atrial and left ventricular dilatation compared to data of untrained subjects described in literature. The process of dilatation continues during the athlete's career. Also left ventricular mass is increased at a young age which continues for several years. More than 60% of the athletes in both groups demonstrated an intermediate form of left ventricular hypertrophy. Diastolic function of the left ventricle remains normal during a long period of athletic career performance.

Arrhythmogenic right ventricular dysplasia and sudden cardiac death in endurance athletes

Arrhythmogenic right ventricular dysplasia (ARVD) is a cardiomyopathy with several time-dependent clinical presentations. The clinical characteristics depend on the penetration grade of the disease. There are two different histological patterns consisting of a lipomatous and a fibrolipomatous form. The presence of arrhythmias in the ARVD syndrome constitutes an important risk factor for sudden cardiac death in athletes. In this article, we describe two professional endurance athletes who died suddenly. One of these athletes had asymptomatic ARVD, the other had symptomatic polymorphic ventricular tachycardias. Both athletes showed fatty penetration of the disease in both the right and left ventricle; one of them also showed fatty involvement at the atrial level and in the other there were signs of myocarditis consistent with ARVD. In the last few years magnetic resonance imaging has become an important diagnostic tool in patients with ARVD.

The maximal lactate steady state in elite endurance athletes

The upper limit of blood lactate resulting in a lactate steady state during prolonged exercise is called the maximal lactate steady state (MLSS). The purpose of this study was to investigate the lactate response to steady-state exercise during a field test in elite endurance athletes. Plasma lactate levels were assessed in 13 elite triathletes and 13 elite cyclists (mean +/- SD; age 23.7 +/- 5.1 yr; HT 180.2 +/- 6.3 cm; WT 70.3 +/- 5.9 kg; VO2 max 68 +/- 3.7 ml/min/kg) during a 40 km-long time trial on a bicycle (4 km course x 10 laps). The steady state was demonstrated by monitoring the heart rate and timing every course run. The lactate levels were expected to correspond to MLSS. The mean level of lactate during the time trial was 7.4 +/- 2.5 mmol/l. Five athletes maintained plasma lactate levels which exceeded 10 mmol/l or more for almost 1 h. The large value of individual variability was conspicuous (range 3.2-12.2 mmol/l). These values exceeded all previous reported levels for MLSS from other investigators. Our observations are important in sport medical practice since the different lactate responses to exercise are used as parameters in training management.

Bilateral mammary artery surgery or percutaneous transluminal coronary angioplasty for multivessel coronary artery disease? An analysis of effects and costs

Seventy-two patients with stable or unstable angina treated since 1983 by multivessel-PTCA(MVP) were retrospectively compared with 44 similar patients that were suitable for MVP, but who had undergone bilateral mammary artery (BIMA) surgery (and additional vein grafts in 60.5% of the patients) since 1986. Both groups were comparable (P = not significant [NS]) for gender, age, most risk factors, objective ischaemia and left ventricular function; however, in the BIMA group there were more previous infarctions (P = 0.02), hypertension (P = 0.03), three-vessel disease (P = 0.0001), and less severe angina (P = 0.007). In the BIMA group, a mean of 3.1 (range 2-5) vessels were treated and in the MVP group 2.0 (range 2-3) vessels (P = 0.0001). Both groups were almost completely revascularized (NS). In 39.5% of the BIMA group, no veins were used and in 20.9% the BIMAs were used as sequential grafts. In-hospital mortality was comparable: 2.3% for BIMA and 1.4% for MVP, so were periprocedural infarctions (13.6% vs 8.3%), rethoracotomies (9.1% vs 0%), emergency procedures (0% vs 5.7%), low cardiac output (2.3% vs 5.6%) and other complications (18.2% vs 9.2%). The mean stay (days) on the ICU/CCU for BIMA was 2.3 and for MVP 1.6 (P = 0.005) and the mean hospital stay for BIMA 12.3 and for MVP 6.6 (P = 0.0001). The maximum and mean follow-up (months) of 43 BIMA and 71 MVP hospital survivors was 35 vs 72 and 9.5 vs 22.3 (P = 0.0001) with a late mortality of 0% and 4.2% (NS). MVP patients, including 12 with re-procedures, had more recurrent angina (17.7% vs 4.7%, P less than 0.05) and more often used anti-anginal medications (62.0% vs 18.6%, P less than 0.0001). Late complications (excluding re-procedures) were comparable for MVP and BIMA (20% vs 9.3%, 4.4% vs 0%, 9.2% vs 14%). MVP patients had more re-hospitalizations (34 vs 5, P less than 0.0001), re-catheterizations (33% vs 2.3%, P less than 0.0001) and cardiac re-procedures (16 vs 0, P = 0.0006) than BIMA patients. Recurrent-angina-free survival at 1 year was 96% after BIMA and 64% after MVP (P less than 0.01). Event-free survival at 1 year was 86% after BIMA and 58% after MVP (P less than 0.05).(ABSTRACT TRUNCATED AT 400 WORDS)