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A recent study in NEJM (DOSE-VF) showed that administering two consecutive defibrillation shocks with two separate defibrillators improves outcomes for patients with out-of-hospital cardiac arrest (OHCA). This approach was used when a shockable rhythm persisted after three standard shocks, raising the question of new strategies to improve survival for patients with persistent ventricular fibrillation (VF). In the Netherlands, there are around 8,000 OHCA cases annually, with 49% attributed to shockable rhythms. Prompt defibrillation is crucial, but some patients do not respond effectively to it. They may experience rapid VF recurrence or refractory VF, both associated with reduced survival rates. The current European resuscitation protocol emphasizes high-quality chest compressions, early defibrillation, and addressing reversible causes. The DOSE-VF study demonstrated the effectiveness of double sequential external defibrillation (DSED) in improving survival, spontaneous circulation, and neurological outcomes. Techniques such as changing pad positions, increasing initial shock energy, and pad compression can enhance energy transfer. However, implementing double sequential shocks in practice is challenging, requiring two separate defibrillators. The limited effect of this intervention may not warrant changes to extensively trained resuscitation protocols.

The implementation of the new guidelines for cardiopulmonary resuscitation in the Netherlands has been questioned with reference to the expected low cost-effectiveness. The implementation is based on the best available evidence, derived from studies that addressed the specific activities of lay rescuers as well as professionals, but not on studies that integrate all changes in the process, from initial actions of lay rescuers to the last elements of in-hospital management. Therefore, the efficacy of new guidelines cannot be evaluated prior to wide-scale implementation. It is not possible to calculate cost-effectiveness before guidelines are introduced, as controlled studies at population level are not feasible. For this reason, the decision to introduce the new guidelines cannot be based on ideal evidence, with survival as a measure of outcome. Effectiveness can be studied only after full introduction of the procedure, as was demonstrated when the previous guidelines were introduced in 2002. Cost-effectiveness is not a relevant issue, as the cost of implementation of guideline changes to lay rescuers has no impact on the budget for healthcare. In addition, the revision concerns items such as the recognition of circulatory arrest, the balance of thoracic compression versus ventilation and the use of the automatic external defibrillator, which are expected to be very effective. Hence, the implementation of the new guidelines for cardio-pulmonary resuscitation in the Netherlands is justified.

Patients with an untreated myocardial infarction may present with serious late complications. 3 patients are described. A 63-year-old woman became progressively more short of breath 4 days after an acute episode of chest pain accompanied by nausea and sweating. It proved to be a cardiogenic shock following a rupture of a papillary muscle. A man aged 65 collapsed 5 days after an episode of back pain and nausea. This was a cardiac tamponade due to rupture of the left ventricle. A woman aged 74 had transient aphasia and during investigations for this was seen to have anomalies on ECG. She had cerebral emboli and a cardiac aneurysm with associated thrombus. All 3 patients recovered following mitral-valve replacement, repair of the rupture and medicinal treatment for the clot, respectively. Around one-third of patients who have a myocardial infarction do not have chest pain but experience shortness of breath, autonomic nervous symptoms (sweating, nausea, vomiting), extreme and inexplicable tiredness and fainting. These atypical symptoms should suggest myocardial infarction. In order to avoid high morbidity and death from complications such as arrhythmias, heart failure, rupture and aneurysm formation it is important that a patient who has had a myocardial infarction should be treated as soon as possible, preferably by reperfusion therapy.

In 2002, the Netherlands Resuscitation Council published a translation of guidelines on Basic Life Support, use of the Automated External Defibrillator, and Advanced Life Support for adults and children, as laid down in 2000 by the International Liaison Committee on Resuscitation. The Dutch situation has altered in that there has been a change from the Netherlands-specific 'CAB' scheme to the internationally accepted 'ABC' scheme. This means that upon encountering a patient, the airways should be checked first (A), then artificial ventilation should be administered twice (B), after which the circulation should be checked in the third place (C) and chest compression should be initiated if necessary. In the Dutch guideline 'assessment of signs of circulation' for the identification of circulatory arrest by lay people was not accepted, but the pulse check at the carotid artery has been maintained. Medical professionals should also assess possible circulatory arrest in this way. Regardless of the number of people attending the patient, the ratio of chest compressions to artificial ventilation in adults is now 15:2 rather than the previously-advocated ratio of 5:1. This ratio is more effective in building up the blood pressure during the chest compressions. In terms of medication, the most important modification is the addition of amiodarone for persistent ventricular fibrillation.

Application of the automatic external defibrillator can improve the chance of success during resuscitation of out-of-hospital cardiac arrest, because lay persons can defibrillate awaiting the arrival of the ambulance. Defibrillation is mentioned in the Dutch Individual Health Care Professionals Act as a precluded action. Defibrillation with an automatic external defibrillator should be excluded from the list of precluded actions, because application is almost 100% safe and because the subject is not within the scope of the law which is restricted to professional activities and non-emergency actions. Defibrillation with an automatic external defibrillator is acceptable.

New immunochemical assay methods for the cardiac markers creatine kinase (CK) MB mass, myoglobin, troponin T (TnT), troponin I (TnI), fatty acid binding protein (FABP) necessitate re-evaluation of their usefulness in the early diagnosis of myocardial damage. Cardiac markers play an important part in the exclusion of myocardial damage in patients with chest pain and an inconclusive ECG at admission. A serial CK-MB mass determination is particularly suitable for this exclusion of myocardial damage. The sensitivity of TnT shortly after an infarction is comparable with that of CK-MB mass; a single determination on admission is insufficient. The marker myoglobin is of limited value owing to the brief duration of myoglobin rise and insufficient heart specificity. An increased TnT or TnI value in patients with unstable angina pectoris is a prognostically negative sign. It is still not clear how this prognosis can be improved. A negative troponin finding appears not to exclude early complications. The department of Emergency Cardiac Care of the Academic Medical Centre, Amsterdam, the Netherlands, currently prefers the serial measurement of the CK-MB mass, in the future possibly to be supplemented by a troponin determination.

Objective: Determination of the trend in the occurrence of hospital admissions because of heart failure in the Netherlands., Design: Descriptive investigation., Setting: Dutch general and university hospitals., Method: Data on hospital admissions because of heart failure from 1980 to 1992, obtained from the National Medical Register, were analysed. Three ICD-9 CM diagnoses were combined (congestive heart failure 428.x, diseases of the heart due to hypertension 402.x and myocardial degeneration 429.I)., Results: From 1980 through 1992 the annual number of hospital admissions for heart failure increased by 69%, for both men and women, from 14,441 to 24,368. Age-adjusted admission rates increased by 43% for men, and by 30% for women. The admission rates were strongly age-related, with higher rates in the older age groups. Among men 89% of the patients in 1992 were older than 60 years, and 63% older than 70 years. Among women these figures were 94% and 79%, respectively. During the study period the age-specific admission rates rose in all relevant age groups. The rise was higher in the older age groups. In 1992 the average duration of stay in hospital was 14 days for men and 17 for women., Conclusion: Probable causes of the rise in the number of hospital admissions for heart failure were the increasing median age of the population, higher survival rates after acute myocardial infarction and longer survival of persons with heart disease. Demographic changes and medical progress will probably lead to a further rise in morbidity and mortality and of costs of heart failure.

We studied the localization of pain in the acute phase of myocardial infarction in comparison with localization in non-cardiac chest pain. Myocardial infarction patients could not be differentiated from patients with non-cardiac chest pain in localization of pain on mid-chest, left side of the chest and left arm. However, myocardial infarction patients reported pain on the right side of the chest and in the right arm twice as often as non-cardiac chest pain patients. Results are similar when patients indicated the localization of the pain symptoms on attending the Emergency Coronary Care Unit, or when asked five days later. Pain symptoms on the right side of the chest and the right arm differentiate better between myocardial infarction and non-cardiac chest pain than the 'classical' symptom pattern.

The clinical course of the first six weeks after discharge after consultation was studied in 527 patient contacts in 460 patients who were evaluated for acute cardiac symptoms in a six-month period at the acute cardiac care facility 'Eerste Harthulp' in the Academic Medical Centre. Analysis revealed that the initial diagnosis of acute ischaemia (261 cases) was correct in 118 (45%) and the initial diagnosis of arrhythmia (114 cases) in 92 (81%). In 220 patients there was no cardiac history; in those instances the initial diagnosis of acute ischaemia was confirmed in only 40% but the initial diagnosis of arrhythmia in 78%. Three patients died within six weeks after evaluation and 28 patients were admitted within that period. Patients without cardiac history and without a clear cardiac diagnosis consulted their general practitioner moderately frequently in the first six weeks and used specialist care only rarely.