Evaluation of a protocol to select patients of all ages for cardioversion from atrial fibrillation

OBJECTIVE

to audit the success of a decision protocol to select patients for cardioversion from atrial fibrillation or flutter by recording the success of cardioversion and the maintenance of sinus rhythm over a 2-year period.

DESIGN

retrospective case notes review.

SETTING

a teaching hospital coronary care unit and cardiology department.

PATIENTS

227 consecutive patients were considered for cardioversion from atrial fibrillation or flutter from 1989 to 1992; 128 fulfilled the selection criteria.

MAIN OUTCOME MEASURES

successful cardioversion and maintenance of sinus rhythm after cardioversion.

RESULTS

116 (91%) patients selected by application of the guidelines were successfully cardioverted. The probabilities of maintaining sinus rhythm at 6, 12 and 24 months were 0.92, 0.88 and 0.73 respectively.

CONCLUSION

careful selection of patients in atrial fibrillation identifies a group in whom cardioversion is likely to be safe and successful regardless of age.

Xamoterol improves the control of chronic atrial fibrillation in elderly patients

Twenty digitalized elderly patients with chronic atrial fibrillation were randomized into a double-blind cross-over study. None was in overt heart failure and all were taking < 80 mg frusemide daily. They received xamoterol 200 mg b.d. for 2 months with their usual dose of digoxin for 1 month and placebo digoxin for the other month. Twenty-four-hour heart rate analysis was done at baseline and at the end of each treatment period. Compared with baseline digoxin, xamoterol alone significantly increased nocturnal minimum heart rate [85 +/- 17 vs. 62 +/- 9 (mean +/- SD), p < 0.0001] without affecting daytime maximum heart rate (132 +/- 18 vs. 122 +/- 20, p = NS). Compared with baseline digoxin, xamoterol plus digoxin significantly increased nocturnal minimum heart rate (68 +/- 8, p < 0.05) and reduced daytime heart rate (114 +/- 17, p < 0.05). The mean number of pauses > 1.5 s was significantly reduced by xamoterol alone. Walking distance in 6 minutes was 406.1 +/- 27.1 m (mean +/- SE) at baseline and improved significantly on both treatments (450.3 +/- 19.8 on xamoterol; p < 0.02 and 453.7 +/- 19.2 on xamoterol plus digoxin; p < 0.01). No significant change was found in subjective measurements of palpitations, breathlessness and well-being using visual analogue scales. Xamoterol combined with digoxin improves effort tolerance and heart-rate control by reducing diurnal tachycardia and nocturnal bradycardia and pauses.

Reporting on reports--cardiological intervention in elderly patients

We asked consultant cardiologists and geriatricians in the Trent Region to assess the change in attitude towards cardiological investigations in the elderly over the last five years. We then reviewed data from three cardiothoracic centres to see if this change was reflected in the number of invasive cardiological procedures performed. The consultants' opinion that more elderly patients are being referred for and receiving more investigations and treatment was reflected in a disproportionate increase in cardiac catheterisations and revascularisation procedures in the elderly between 1990 and 1993. There is little to suggest that these changes came about as the result of the College report on cardiological intervention in elderly patients.

Unsatisfactory management of patients with myocardial infarction admitted to general medical wards

Patients admitted with acute myocardial infarction to general medical wards fared less well than those admitted over the same period to the coronary care unit. The median age of the 119 patients admitted to the general wards was 75 years, compared to 64 years for those on the coronary care unit. Although 13 of the 119 fulfilled the local guidelines for thrombolysis, none received it, only 64% were given aspirin and 49% nitrates. The death rate for these patients was 29% compared to 12% of those given thrombolysis on the coronary care unit and 26% of those who were ineligible for thrombolysis but had been admitted to the coronary care unit. Of the survivors on the general wards, 80% were given aspirin as secondary prevention, and 37% were given a beta-adrenergic blocker. None was referred to the hospital cardiac rehabilitation programme.

Contrasting effects of intravenous and oral etidronate on vitamin D metabolism in man

1. We have studied the early effects of intravenously and orally administered etidronate on vitamin D metabolism and indirect indices of calcium and skeletal metabolism in 17 patients with Paget's disease of bone. 2. Administration of etidronate by mouth (700-1400 mg daily for 1 month) or its intravenous infusion (300 mg daily for 5 days) decreased bone resorption as judged by urinary excretion of hydroxyproline and significantly increased renal tubular reabsorption of phosphate. No significant change in serum activity of alkaline phosphatase was noted with either regimen. 3. When etidronate was given by mouth there was a progressive decrease in fasting urinary calcium excretion and a rise in serum 1,25-dihydroxyvitamin D3 [1,25-(OH)2D3]. In contrast, intravenous etidronate decreased serum values of 1,25-(OH)2D3 and was associated with a progressive increase in fasting calcium excretion, suggesting a decrease in the net influx of calcium from the extracellular compartment to bone. Significant inverse correlations were noted between the change induced in 1,25-(OH)2D3 values at 2 weeks and the changes in serum calcium, phosphate and fasting urinary excretion of calcium. 4. These observations suggest that the different effects of intravenous and oral etidronate on 1,25-(OH)2D3 values are a consequence of different doses of etidronate used and the different effects of these regimens on the accretion of calcium into bone.

Abnormal vitamin D metabolism in Paget's disease of bone

We have studied several biochemical indices of bone turnover and vitamin D metabolism in 32 untreated patients with Paget's disease and in 32 age-matched control subjects. patients with Paget's disease, as expected, were characterized by high bone turnover, as judged by alkaline phosphatase and urinary excretion of hydorxyproline. Serum values of 24,25-dihydroxyvitamin D3 (24,25(OH)2D3) and the ratio of 24,25(OH)2D3 to 25-OHD were significantly lower in patients than in control subjects. Serum concentrations of 1,25(OH)2D3 were normal in Paget's disease. The distribution of values for 24,25(OH)2D3 was log normal. On the basis of the normal range computed from control subjects, patients were divided into those with low or normal values for 24,25(OH)2D3. Disease activity, as judged by biochemical indices was significantly higher in the patients with the lower values of 24,25(OH)2D3. We conclude that Paget's disease is characterized by low circulating concentrations of 24,25(OH)2D3, particularly in patients with more extensive or severe disease.