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Maria Ferre-Vallverdu,1– 3 Carmen Ligero,1– 3 Rafael Vidal-Perez,4 Antoni Martinez-Rubio,5 Xavier Vinolas,6 Josep M Alegret1– 3 1Department of Cardiology, Hospital Universitari de Sant Joan; 2Institut d’Investigació Sanitària Pere Virgili (IISPV); 3Department of Medicine and Surgery of the University Rovira i Virgili; Reus, Spain; 4Department of Cardiology, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain; 5Department of Cardiology, Hospital Parc Taulí, Sabadell, Spain; 6Department of Cardiology, Hospital de la Sta, Creu i St Pau, Barcelona, SpainCorrespondence: Josep M AlegretDepartment of Cardiology, Hospital Universitari de Sant Joan. Institut d’Investigació Sanitària Pere Virgili (IISPV). Department of Medicine and Surgery of the University Rovira i Virgili; Reus, Spain. C/Dr Josep Laporte, 4, Reus, 43204, Spain Email josepmaria.alegret@urv.catBackground: The European Heart Rhythm Association (EHRA) score is a proven and validated tool for assessing the symptoms of atrial fibrillation (AF). Little is known about the variables related to this score and how it changes after cardioversion.Methods: We analyzed 744 patients undergoing elective cardioversion in whom AF-related symptoms were assessed at baseline and after 6 months of follow-up using the EHRA score. We assessed the association between the EHRA score and other clinical and echocardiographic variables at baseline and after 6 months of follow-up.Results: At 6 months of follow-up, we observed a reduction in the EHRA score in 50% and worsening in 2.8% of patients who remained in sinus rhythm (SR) compared with 34.6% and 11.3%, respectively, of patients with AF episodes (p< 0.0001). Patients who maintained SR at 6 months were less symptomatic than those with AF (EHRA score 1.13 ± 0.35 vs 1.42 ± 0.59; p< 0.0001). The independent predictors for reduction in the EHRA score after cardioversion were NYHA ≥II at baseline and maintenance of SR (p< 0.0001).Conclusion: The greatest improvement in AF-related symptoms was in patients who remained in SR at 6 months after cardioversion and in patients with worse NYHA functional class at baseline.Keywords: atrial fibrillation, EHRA score, cardioversion, NYHA functional class, sinus rhythm, symptoms improvement

To analyze the temporal trends of atrial fibrillation (AF)-related ischemic stroke (IS) and their relationship with the prescription patterns of antithrombotic treatment from 2013 to 2019 in the Health Assistance Area of a regional hospital.First, a retrospective ecological study of aggregate data to analyze the annual incidence of IS between 2013 and 2019 was performed. Second, we selected those patients diagnosed with AF between 2013 and 2019 and performed a retrospective longitudinal study to assess the role of antithrombotic therapy in the development of AF-related IS.During this period, whereas the annual incidence of IS remained stable (from 1.3 in 2013 to 1.2 cases per 1000 inhabitants in 2019; adjustedThe prescription of oral anticoagulants, particularly direct oral anticoagulants, has increased from 2013 to 2019 in our Health Assistance Area. This increase might partially explain the reduction in AF-related IS.

The emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a very contagious virus, has led to the coronavirus disease 2019 (COVID-19) pandemic. The clinical manifestations of this virus in humans vary widely, from asymptomatic to severe, with diverse symptomatology and even death. The substantial transmission from asymptomatic people has facilitated the widespread transmission of SARS-CoV-2, hampering public health initiatives to identify and isolate infected people during the pre-symptomatic contagious period. COVID-19 is associated with cardiac complications that can progress from mild to life-threatening. The aim of this article is to analyse the present knowledge of COVID-19 and cardiac involvement, the development of arrhythmia risk and its treatment.

The human normal heart rhythm occurs when a person has a regular heart beat originated by depolarization of the sinus node, which is normally transmitted through the atria to the AV node, and thereafter normally using the His-Purkinje system to the myocytes of the ventricles. This normal heart beat occurs in a rate which is appropriated to the clinical circumstances of the individual (e.g. faster during exercise than at rest) and is called sinus rhythm. The term arrhythmia comprises a group of heterogeneous conditions with abnormal electrical activity of the heart in origin, rate or both (absence of sinus rhythm). Arrhythmias may be clinically silent (at least during a period) or cause symptoms and signs (palpitations, syncope or even sudden cardiac death). The terms bradycardia and tachycardia refer to a deficit and to an excess of heart rate (compared to normal), respectively.

Traditionally, antiarrhythmic strategies have focused almost exclusively on atrial electrophysiological alterations. Unfortunately, these interventions yield very limited success over the long-term and have a high side-effect profile. A number of ‘non-antiarrhythmic’ drugs (i.e., whose main effect is not exerted at ion channel level) have gained increasing attention due to their potential to prevent, delay, or even reverse atrial fibrillation (AF)-related atrial structural remodeling, while lacking the undesirable effects of ion channel blockers. By modifying the substrate upstream of AF, these new strategies are expected to prevent new-onset AF, to delay AF transition to more persistent forms, and/or to prevent recurrent AF. However, to date, with very few the exceptions, there is insufficient evidence to support the wide use of non-conventional antiarrhythmic drugs for AF prophylaxis in clinical practice. It still remains to be established whether this approach is truly effective, by itself or at least in addition to conventional rhythm control strategies. Clarification of the most adequate target population, of the most suitable drug, dose, and timing to intervene is also required.

Aim: To analyze the impact of implementing a program integrating cardiology and primary care in clinical practice. Methods: In the integrated care model, every cardiologist was assigned to each primary care center. Results & conclusion: The implementation of the new care model was associated with a significant reduction of 31.2% in requests of first visits. In addition, the delay to the cardiologist consultation significantly decreased by 54.5% for the first visits, and by 57.1% for the follow-up visits. The proportion of patients that achieved recommended low density lipoprotein-cholesterol goals significantly increased from 20.8 to 29.6%. The proportion of patients submitted to anticoagulant therapy significantly increased from 69.3 to 74.2%, as well as the proportion of patients taking direct oral anticoagulants (from 7.9 to 28.4%).

It is essential to prevent thromboembolic events in atrial fibrillation. The risks of thromboembolic and haemorrhagic events must be carefully assessed and weighed against one another, both in routine situations and in relation to invasive procedures. Vitamin K antagonists, until recently the first-line treatment for prophylaxis against thromboembolic events in patients with atrial fibrillation, have various drawbacks. Direct-acting oral anticoagulants overcome these limitations and are efficacious and safe. The recent developments of tests to monitor anticoagulant levels, and of target-specific reversal agents for these newer drugs, has facilitated their use in several situations, including emergencies. For these reasons, the European Society of Cardiology and other scientific societies now recommend direct-acting oral anticoagulants as first-line treatment for preventing thromboembolic events in atrial fibrillation.

Anemia and iron deficiency are often associated with heart failure, influencing the symptoms and prognosis. Correction of anemia and iron deficiency improves functional capacity and decreases hospitalizations. Many studies have analyzed echocardiographic parameters in iron deficiency and anemia and their evolution after iron treatment; however, the heterogeneity of the results makes it difficult to draw conclusions. The aim of this paper is to review the echocardiographic parameters during anemia and iron deficiency, and their evolution after treatment. Available data suggest that they lead to ventricular and atrial remodeling, a decrease in ventricular contractility, and an alteration of ventricular relaxation, although in heart failure with preserved ejection fraction these changes are not significant. Anemia and iron deficiency also increase systolic pulmonary artery pressure. There is consistent evidence that correction of these comorbidities leads to a reduction in preload and left ventricular cavity dimensions, an improvement in diastolic and load-independent ventricular systolic function parameters, and a decrease in systolic pulmonary artery pressure. However, the evidence is less consistent about the changes produced in ventricular hypertrophy, load-dependent systolic function parameters, and E-wave. Generally, anemia and iron deficiency affect the echocardiographic findings, and correcting these conditions often results in improvement in the affected echocardiographic parameters.

Atrial fibrillation (AF) is one of the most common arrhythmias and a recognized source of embolic ischemic stroke which has critical prognostic implications.

New oral anticoagulants (NOAC) have demonstrated their efficacy as an alternative to vitamin K antagonists (VKA) in the prophylaxis of cardioembolic events in patients with atrial fibrillation (AF). However, evidence on the benefits of NOAC in health-related quality of life (HRQoL) is lacking. We evaluated changes in HRQoL related to oral anticoagulation therapy employing a specific questionnaire in a cohort of 416 patients with AF undergoing electrical cardioversion. In terms of HRQoL, we observed a progressive adaptation to treatment with VKA; satisfaction with NOAC remained constant. Older age, higher left ventricular ejection fraction and NOAC were associated with better HRQoL.

Background Some healthcare facilities lack professionals qualified to interpret electrocardiograms. We aimed to assess the usefulness of transtelephonic electrocardiography in combination with patients' clinical histories in the diagnosis and management of patients with acute chest pain in out-of-hospital healthcare facilities with personnel without expertise in cardiology or electrocardiography. Methods Data from 506 consecutive patients (53.9 ± 16.2 years old) referred from 55 healthcare facilities without professionals specialized in cardiology or electrocardiography form the basis of analysis. Patients were classified into 2 groups according to the results of transtelephonic electrocardiography: (A) patients without electrocardiographic abnormalities (n = 445) and (B) patients who presented abnormalities suggesting a cardiac origin (n = 61) of the chest pain. The presence of risk factors was evaluated by multivariate analysis. Results The following risk factors were independent predictors of electrocardiographic abnormalities: male gender (P = .006), diabetes mellitus (P = .0001), and dyslipidemia (P = .001). The multivariate analysis yielded a high degree of specificity (99.6%). Follow-up visits confirmed the noncardiac origin of pain in 432 patients (97%) in group A and the cardiac origin of pain in 59 patients (97%) in group B. Conclusions Transtelephonic electrocardiography combined with awareness of the risk factors of patients presenting with chest pain is useful for the diagnostic management of these patients in health care facilities without the means to interpret electrocardiograms.

Background: Current recommendations on the rhythm control strategy for treatment of atrial fibrillation (AF) are more restrictive than a decade ago. Gender may play a role in decisions on the management of AF, including application of electrical cardioversion. Methods: We analyzed clinical characteristics by gender in patients participating in the observational survey about stable patients underlying cardioversion in Spain (CARDIOVERSE) study (n=915), a survey of the practice of electrical cardioversion in 67 Spanish hospitals. We compared these data with those from a previous survey of electrical cardioversion in Spain (REVERSE study) performed 8 years previously. Results: Patients undergoing electrical cardioversion were mainly men (76%). This finding was observed in all age groups, independently of symptoms. Men were younger (6210 years vs. 69 +/- 9 years; p

Although dermatophytoses can appear at any age, some types are particularly prevalent in children. There are no prior data on the prevalence of tinea capitis and tinea pedis in Barcelona, Spain. To identify the prevalence of tinea in school children in the area with the highest immigrant population in this city, a cross-sectional study was performed. A second objective was to identify the etiologic agent to study the possibility of the introduction of foreign dermatophyte species and to evaluate the possibility of encountering healthy hosts.From October 2002 until June 2003, we evaluated 1305 schoolchildren, ages 3-15 years, belonging to 21 schools located in the inner city of Barcelona to determine the prevalence of tinea capitis and pedis in school children. Cultures of scalp and feet were done in each child.36(2.8%) children had tinea pedis and 3 (0.23%) had tinea capitis. One child had tinea capitis and tinea pedis, caused by different species (t. capitis caused by Trichophyton mentagrophytes and tinea pedis caused by Trichophyton rubrum). Of the 39 positive cases for dermatophytes, the etiologic agent in 18 (46.1%) was T. mentagrophytes, 17 (43.5%) T. rubrum, 2 (5.5%) Epidermophyton floccosum and 2 (5.5%) Trichophyton tonsurans. Of these 39 cases of tinea, 15 (38.5%) were Spanish natives and 22 (56.4%) were immigrants.The prevalence of tinea capitis was lower that we had expected, and it was noted that there was a greater prevalence of tinea pedis among schoolchildren 13-15 years of age (64.10%), the great majority of them male. The number of cases of tinea was significantly greater in immigrants.

In the majority of patients with non-valvular atrial fibrillation (AF) anticoagulation is required to reduce the risk of stroke. Although vitamin K antagonists effectively reduce the risk of stroke, they have many disadvantages that limit their use. Rivaroxaban is a new once-daily oral anticoagulant that overcomes some of these limitations (i.e., no monitoring of anticoagulant effect required and fixed doses can be prescribed). In recent AF studies, rivaroxaban was reported to be at least as effective as warfarin for the prevention of stroke or systemic embolism but with a lesser risk of fatal bleeding and intracranial hemorrhage. More recent data have confirmed the beneficial effects of rivaroxaban, as originally described, and irrespective of the history of previous stroke, heart failure, myocardial infarction, diabetes, moderate renal dysfunction or age. In the present review the authors discuss current evidence regarding the efficacy and safety of rivaroxaban in patients with non-valvular AF.

Pain is an issue that medicine considers of great importance. The treatment of pain and discomfort is essential during hospitalisation procedures, specially for newborn infants because, first, they are not able to communicate that they are in pain; and second large periods of pain or discomfort can lead to major issues. In order to assess the pain/discomfort suffered by patients, healthcare professionals use pain assessment scales: using physiologic parameters (e.g., heart beat, blood oxygen level, etc.) and observed behavioural parameters (e.g., cry, spasmodic movements, etc.) a value for pain is obtained. Current methods for pain assessment have some drawbacks, which could be overcome with the use of computerised systems. With this aim, we present a system that automatically analyses the pain or discomfort levels of newborns. The proposed system allows the remote monitoring of newborns and raises alarms upon specific conditions. Hence, caregivers (e.g., nurses and their assistants) can act accordingly to help relieving the pain. Moreover, the remotely monitoring is also useful for parents, since they cannot stay close to their babies hospitalised in neonate Intensive Care Units.

Objective: The objective of this study was to investigate the prognostic significance of the wavelet decomposition (WD), when applied to single leads of the signal-averaged ECG (SAECG) of postinfarction patients, as well as to compare it with conventional time-domain (TD) analysis in order to optimize the utility of high resolution ECG techniques in risk stratification. Comparisons with clinical variables were also performed. Methods: SAECGs of 769 patients were analyzed (mean age 53 ± 7 years). A total of 42 arrhythmic events occurred within 54 months. For numerical calculations of WD, relative energies of the QRS complex were obtained in seven frequency bands. Conventional parameters of late potential analysis in TD were calculated at 25 and 40 Hz high pass filter. Results: No significant correlation was found between parameters of both methods. Several parameters of the WD of single leads showed slightly higher sensitivity (e.g., 52% vs 36%) and positive predictive values (e.g., 13.3% vs 10.2%) compared with those obtained with the QRS duration of TD analysis. In multivariate analysis, combination of QRS duration with WD parameters (relative risk [rr] =4.55, P < 0.0001), followed by the WD of single leads (rr = 4.19, P < 0.0001), nonsustained ventricular tachycardia in the long-term ECG (rr = 3.72, P = 0.0005) and the history of previous infarction (rr = 2.72, P = 0.0035) were the most significant predictors in risk stratification. Conclusion: Time domain and wavelet transform of SAECG resulted in an improvement in postinfarction risk stratification compared with the clinical variables included in this study. Wavelet parameters may not be vastly superior to QRS duration, but they are a new index measuring intra-QRS phenomena.

Atrial fibrillation (AF) is a very common arrhythmia characterized by chaotic electrical atrium activation reflected in the electrocardiogram by variable R-R intervals and absence of P waves.

Atrial fibrillation (AF) is an arrhythmia characterized by chaotic electrical activity in the atria, which causes asynchrony of atrial fibers excitation and contraction. Thus, the organized contractile capacity of the atrium for filling the ventricles is lost which diminishes the ventricular ejection, as well as, auricular blood stasis and turbulent flow favors thrombosis and consequent thromboembolism may develop. Therefore, this arrhythmia has an important clinical impact. This chapter summarizes the several unmet needs in AF, which still constitute a challenge for patients, physicians and health care managers because its medical, social and economic impact probably will worsen over the next decades. Therefore, research and future knowledge of AF will play a major role for modern societies.

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in clinical practice. It is not a benign disease because is associated to a significant increase in mortality and morbidity. Thus, being AF a potentially dangerous arrhythmia, it seems logical to use antiarrhythmic strategies to avoid, or at least control, this rhythm disturbance [1, 2].

The aim of this study was to extract and combine non-invasive risk parameters from the signal-averaged electrocardiogram (SAECG) and heart rate variability (HRV) based on 24-hour ambulatory electrocardiography to optimize the prognostic value for arrhythmic events after acute myocardial infarction. A prospective series of 553 men < 66 years of age enrolled in the Post-Infarction Late Potential study were analyzed. Within 2 to 4 weeks after acute myocardial infarction, all patients underwent SAECG and 24-hour ambulatory electrocardiography before hospital discharge. During 6 months of followup, 25 patients (4.5%) experienced arrhythmic events (sustained ventricular tachycardia, n = 11; ventricular fibrillation, n = 7; sudden cardiac death, n = 7). The predictive power of SAECG and HRV parameters was assessed using a Cox proportional-hazards model. In HRV analysis, the most significant differences between patients with and without arrhythmic events were observed for the beat-to-beat parameter root-meansquare of successive RR differences [RMSSD]): 25.7 +/- 16.9 ms in patients with arrhythmic events versus 34.1 +/- 18.6 ms in patients free of arrhythmic events (p = 0.004). Time domain analysis of the SAECG showed the QRS duration to be most significantly different in both patient groups: 106.4 +/- 18.7 ms (arrhythmic events) versus 95.3 +/- 18.7 ms (no arrhythmic events) (p = 0.001). Based on the Cox regression model, RMSSD and QRS duration were demonstrated to be independent significant risk factors (regression coefficient for QRS duration: cq = 0.014 +/- 0.006 ms(-1), p = 0.014; for RMSSD: cr = -0.041 +/- 0.016 ms(-1), p = 0.009). Based on the regression coefficients, an analytic risk model was developed describing the arrhythmic risk as a function of QRS duration, RMSSD, and time after infarction. We conclude that the combination of beat-to-beat changes of heart rate measured by RMSSD and QRS duration from the SAECG enhances noninvasive risk stratification after myocardial infarction.

The effect of sotalol on the rate and the RR interval variability of induced ventricular tachycardia was studied in 26 patients. Sotalol increased the mean cycle length and irregularity of RR intervals, which may affect detection of ventricular tachycardia by implantable cardioverter-defibrillator devices.

Objectives.This study sought to evaluate the prognostic value of wavelet correlation functions of the signal-averaged electrocardiogram (ECG) for arrhythmic events in patients after myocardial infarction.Background.Wavelet transform of the signal-averaged ECG has been shown to be a nonstationary analysis technique describing the time evolution of frequency spectra throughout the QRS complex. To quantify the wavelet transform, we introduced the new concept of the wavelet correlation function.Methods.The relation among wavelet correlation functions, ventricular late potentials and the site of infarction was investigated in 769 men

A B S T R A C T Introduction and objectives: Assessment of the cost-effectiveness of dabigatran for the prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation in Spain, from the perspective of the National Health System. Methods: Adaptation of a Markov chain model that simulates the natural history of the disease over the lifetime of a cohort of 10 000 patients with non-valvular atrial fibrillation. Model comparators were warfarin in a first scenario, and a real world prescribing pattern in a second scenario, in which 60% of the patients were treated with vitamin K antagonists, 30% with acetylsalicylic acid, and 10% received no treatment. Deterministic and probabilistic sensitivity analyses were performed. Results: Dabigatran reduced the occurrence of clinical events in both scenarios, providing gains in quantity and quality of life. The incremental cost-effectiveness ratio for dabigatran compared to warfarin was 17 581 euros/quality-adjusted life year gained and 14 118 euros/quality-adjusted life year gained when compared to the real world prescribing pattern. Efficiency in subgroups was demonstrated. When the social costs were incorporated into the analysis, dabigatran was found to be a dominant strategy (ie, more effective and less costly). The model proved to be robust. Conclusions: From the perspective of the Spanish National Health System, dabigatran is an efficient strategy for the prevention of stroke in patients with non-valvular atrial fibrillation compared to warfarin and to the real-world prescribing pattern; incremental cost-effectiveness ratios were below the 30 000 euros/quality-adjusted life year threshold in both scenarios. Dabigatran would also be a dominant strategy from the societal perspective, providing society with a more effective therapy at a lower cost compared to the other 2 alternatives.

Objectives. The aim of this study was to analyze the relations between the presence of ventricular conduction delay and the necessary coupling intervals for the induction of sustained ventricular tachyarrhythmias. Methods. The electrophysiologic and signal-averaged electrocardiographic (ECG) data from 83 patients with previous myocardial infarction and inducible sustained mononomorphic ventricular tachycardia (n = 71) and ventricular fibrillation (n = 12) were analyzed. Results. The sum of the coupling intervals needed for inducing ventricular tachycardia and ventricular fibrillation was 485 ± 59 ms and 387 ± 36 ms, respectively (p < 0.001). The mean difference between the effective refractory period and the second coupling interval for the induction of ventricular tachycardia and ventricular fibrillation was −3 ± 40 ms and 24 ± 29 ms, respectively (p < 0.02). QRS duration and duration of terminal low amplitude signals of the QRS complex (p < 0.004) were longer in patients with inducible ventricular tachycardia than in patients with inducible ventricular fibrillation. The root mean square of the voltage during the last 40 ms of QRS complex was lower in patients with inducible ventricular tachycardia than in patients with inducible ventricular fibrillation (p < 0.007). Patients with inducible ventricular tachycardia presented with a greater prevalence of ventricular late potentials than that of patients with inducible ventricular fibrillation (p < 0.007). For arrhythmia induction, significantly shorter coupling intervals were necessary in patients without than in patients with ventricular late potentials. A positive correlation was found between the cycle length of the induced ventricular tachycardia and the filtered QRS duration as well as with the sum of the coupling intervals. Conclusions. Induction of ventricular fibrillation requires shorter coupling intervals than does induction of ventricular tachycardia. The presence of ventricular conduction delay seems to be a marker of facilitated induction of sustained monomorphic ventricular tachycardia rather than of ventricular fibrillation. The coupling intervals required to induce ventricular tachycardia or fibrillation are longer in patients with than in those without an abnormal signal-averaged ECG.

We assessed the diagnostic yield of axillary ultrasound, alone or in combination with fine-needle aspiration axillary biopsy and magnetic resonance imaging in patients with invasive breast carcinoma compared with final axillary histology by sentinel node biopsy or by axillary lymph node dissection. From January 2003 to March 2009, 520 axillary ultrasound examinations and 105 axillary magnetic resonance imaging studies were included. Compared with final axillary histology, ultrasound fine-needle aspiration showed positive predictive value of 87%, negative predictive value of 82%, sensitivity of 53% and specificity of 100%. In cases of negative ultrasound, the rate of positive nodes was 17% (micro-metastases excluded). Ultrasound examination of the axilla, combined with fine-needle aspiration as appropriate must be included in the preoperative work-up of patients considered for sentinel node biopsy to definitively establish such an indication while minimizing the risk of false-negative sentinel node. Axillary magnetic resonance imaging did not improve the preoperative work-up.

The class Ic antiarrhythmic agent propafenone was studied by repeated electrophysiologic testing in 54 patients (43 male, aged 54 +/- 10 years, mean ejection fraction of 37.3 +/- 16.9%) with ventricular tachyarrhythmias. Forty patients (74%) had coronary artery disease. Programmed ventricular stimulation (S2, S2S3 during sinus rhythm and/or during S1S1 = 500, 430, 370, and 330 ms) off antiarrhythmic drugs induced sustained ventricular tachycardia, flutter, or fibrillation in all patients. After 450-900 mg of oral propafenone/day for 4-7 days, 51 patients were restudied. In the remaining three patients, spontaneous ventricular tachycardia occurred on drug therapy. Tachycardia induction was suppressed in 9 of 51 patients restudied (18%) and rendered more difficult to induce (basic stimulation drive greater than or equal to 40 beats/min higher than at control study) in another 7 patients (14%) (overall efficacy of 31%). The tachycardia rate decreased from 220 +/- 43 to 177 +/- 44 beats/min (p less than 0.01). The right ventricular effective refractory period increased from 232 +/- 22 to 252 +/- 22 ms (p less than 0.001). Responders to propafenone therapy had higher rates of inducible ventricular tachycardia at control (greater than 230 beats/min: 43%; less than or equal to 230 beats/min: 21%; p less than 0.05), higher ejection fractions, and lower left ventricular end-diastolic pressures than nonresponders. Eleven of the 16 patients showing a positive response to propafenone therapy in electrophysiologic testing were discharged on propafenone alone. During follow-up (17 +/- 12 months), nine patients remained free from ventricular tachycardia, one patient had a relapse, and one patient died of noncardiac death.(ABSTRACT TRUNCATED AT 250 WORDS)

To evaluate the prevalence of tinea capitis, tinea pedis, and tinea unguium in children from several schools of Barcelona city.During the period of 2003-2004, a prospective cross-sectional study was carried out in 1,305 children (9% immigrant population) between the ages 3 and 15 in 17 schools in Barcelona. A systematic examination of the feet, (including nails and scalp), was performed to identify lesions compatible with tinea. Cultures of scalp and feet samples were done and analysis of environmental samples was performed for dermatophyte isolation.Dermatophytes were isolated in 2.9% of the samples with a prevalence of 2.5% in feet, 0.23% in scalp, and 0.15% in nails of the feet. The predominant etiologic agents in feet were Trichophyton mentagrophytes in 45.7% of the cases and Trichophyton rubrum in 31.4%. In the nails, T. rubrum and Trichophyton tonsurans were isolated, while T. mentagrophytes (2 cases) and Trichophyton violaceum (1 case) were identified in scalp samples. Forty-five per cent of dermatophytes were isolated from healthy feet, the majority of cases in children 13- 15-years-old (p0.05). Microsporum gypseum was the only agent identified in the environmental samples, and was also found in one of the cases of tinea pedis.The results of this study demonstrate a low prevalence of tinea capitis and tinea unguium in school children of Barcelona. On the contrary, high prevalence of dermatophytes in feet was found. It highlights the high prevalence of healthy carriers of dermatophytes in feet.

Malignant cardiac tumors are very uncommon. Among metastatic tumors involving the heart, lung, breast and melanoma are the most frequent primary tumors. Clinical manifestations of metastatic cardiac disease are unspecific. We describe the case of a patient who had oral cavity cancer 3 years before and presented with ventricular tachycardia due to metastatic myocardial invasion. The patient, a 49-year-old man, former smoker, had an infiltrating squamous cell carcinoma of the tonsil (cT4N3M0) 3 years before. He was treated with local radiotherapy and

Sudden cardiac death is an unresolved problem which causes significant mortality and morbidity in both the community and in-hospital setting. Cardiac arrest is often caused by ventricular tachyarrhythmias which may be mostly interrupted by cardioversion or defibrillation. The single most critical factor for survival is the response time. Over the last 30 years, there have been virtually no procedural changes in the way hospitals address in-hospital resuscitation. A unique device has been developed that eliminates human intervention and assures defibrillation therapy is administered in seconds. This is accomplished with a fully automatic, external bedside monitor defibrillator designed to be prophylactically attached to hospitalized patients at risk of ventricular tachyarrhythmia. The safety and efficacy of the device has been demonstrated in multicenter US and European trials. Thus, this device allows a new scenario which may increase survival and enables meaningful redistribution of health resources.

After abnormal head-up tilt test (HUT), several trials have evaluated treatment strategies for vasovagal syncope (VVS). However, few unequivocal results have been obtained. The aim of the study was to prospectively analyze the natural history of patients with VVS who did not undergo specific treatment but received education for avoiding syncope after an abnormal HUT.From 1996, 334 consecutive patients with VVS and an abnormal HUT result were followed. All of them received education for avoiding syncope as first-line therapy.During 30.4 +/- 21 months, there were no cardiac deaths. However, 101 patients (30.2%) had recurrences (1 recurrence, n = 64;or =2, n = 37), which were not influenced by the type of response during HUT or by age. Time to first recurrence was correlated with the number of recurrences (r: -0.34, P =.0001). Mean recurrence-free time was 50.1 months (95% CI 46-54) and the cumulative probability of no recurrence was 69.8%. Receiver operator character curve analysis, demonstrated significant differences in the recurrence rate between patients with5 oror =5 previous episodes of syncope (25.1% vs 44%; P =.001). In addition, the mean recurrence-free time of patients with5 episodes was significantly longer (54.1 months) than in patients withor =5 episodes (39.6 months; P =.0005). Multivariate logistic regression identified the previous number of episodes as an independent risk marker of recurrences (odds ratio 2.34, 95% CI 1.4-3.8, P =.001). Age (at HUT performance) as a continuous variable was not a predictor of outcome.Survival of patients with VVS presenting after an abnormal HUT is excellent. Although the broad majority of those patients do not suffer recurrences after education, the number of previous syncopal episodes critically influences the recurrence rate.

Objectives The purpose of this study was to prospectively analyze the performance and safety of a new programmable, fully automatic external cardioverter-defibrillator (AECD) in a European multicenter trial. Background Although, the response time to cardiac arrest (CA) is a major determinant of mortality and morbidity, in-hospital strategies have not significantly changed during the last 30 years. Methods Patients (n = 117) at risk of CA in monitored wards (n = 51) and patients undergoing electrophysiologic testing or implantable cardioverter-defibrillator (ICD) implantation (n = 66) were enrolled. The accuracy of the automatic response of the device to any change of rhythm (lasting >1 s and >4 beats) was confirmed by reviewing the simultaneously recorded Holter data and the programmed parameters. Results During 1,240 h, 1,988 episodes of rhythm changes were documented. A total of 115 episodes lasted ≥10 s or needed treatment (pacing, n = 32; ICD, n = 51; AECD, n = 35) for termination. The device detected ventricular tachyarrhythmias with a sensitivity of 100% and specificity of 97.6% (true negatives, n = 1,454; true positives, n = 499; false positives, n = 35; false negatives, n = 0). The false positives were all caused by T-wave oversensing during ventricular pacing. There were no complications or adverse events. The mean response time was 14.4 s for those episodes needing a full charge of the capacitor. Conclusions This new AECD is safe and effective in detecting, monitoring, and treating spontaneous arrhythmias. This fully automatic device shortens the response time to treatment, and it is likely that it will significantly improve the outcome of patients with in-hospital CA.

Background Chest pain is a frequent symptom in the emergency department and often presents a diagnostic challenge. Because coronary thrombosis is a hallmark of acute ischemic syndromes, the substrates of the coagulation and fibrinolysis cascades may be markers of coronary ischemia. The objective of this study was to determine the diagnostic value of several hemostatic markers in patients presenting to the emergency department (ED) with chest pain syndromes. Methods Two hundred fifty-seven consecutive patients with acute chest pain were studied in this prospective study conducted in an urban ED. D- Dimer levels were measured at admission to the ED in all patients. We also measured thrombin-antithrombin complexes, prothrombin fragment 1+2, activated factor VII, and fibrinogen. We used regression analysis to estimate the likelihood of myocardial infarction and the diagnostic value of D -dimer. Results D -Dimer and fibrinogen levels were significantly higher in patients with acute ischemic events (myocardial infarction and unstable angina) than in nonischemic patients ( P P =.02, respectively). The other hemostatic markers were not significantly elevated in patients with ischemic events. D -Dimer level >500 μg/L had an independent diagnostic value for myocardial infarction and increased the diagnostic sensitivity of the electrocardiogram and history from 73% to 92%. Conclusion D -Dimer, an expression of ongoing thrombus formation and lysis, is a marker of substantial incremental value for the early diagnosis of acute coronary syndromes presenting with chest pain. It adds independent information to the traditional assessment for myocardial infarction. D -Dimer can be incorporated into clinical decision models in the ED. (Am Heart J 2000;140:379-84.)

Animal studies1–3 have shown that increased basic dispersion of repolarisation lowers the ventricular fibrillation threshold and facilitates induction of reentrant ventricular arrhythmias.

In patients surviving acute MI, identification of those at high risk for life-threatening ventricular tachyarrhythmias and/or sudden death is of great importance. Numerous strategies based on indices such as the degree of left ventricular dysfunction, complex ventricular arrhythmias, or parameters of autonomic dysfunction have not yet led to an effective identification of the individual patient at risk. During the past decade, many investigators have recorded low amplitude, high frequency components in the terminal QRS complex (so-called late potentials) from patients prone to sustained ventricular tachycardia. The SAECG has been used to predict life-threatening tachyarrhythmias in patients after acute MI and to screen for inducible ventricular tachycardia in patients with unexplained syncope or sustained ventricular tachycardia. This review article describes the most frequently applied methodology and clinical applications of the SAECG in post-MI patients and discusses the usefulness of noninvasive recordings in various other clinical settings.

Background Programmed ventricular stimulation is commonly used to guide therapy in post–myocardial infarction patients with sustained monomorphic ventricular tachycardia (VT) or ventricular fibrillation (VF). In patients with valvular heart disease presenting with spontaneous VT, VF, or syncope, the usefulness of this technique is still unclear. The aim of the study was to analyze whether programmed ventricular stimulation was helpful in guiding therapy and determining prognosis in 97 patients with valvular heart disease presenting with VT (60%), VF (18%), or syncope (22%). Methods and Results Patients were classified as having either predominant ventricular pressure or volume overload or no significant pressure or volume overload. Overall, sustained VT or VF was inducible in 38 (39%) and 19 (20%) patients, respectively. Forty-six (47%) patients were discharged on antiarrhythmic drugs, 29 (30%) received an implantable cardioverter-defibrillator, and 22 (23%) remained without therapy. With serial drug testing, inducibility was completely or partially suppressed in 18 (19%) and 9 (9%) patients, respectively. During a mean follow-up of 51 months (n=97), 17 patients (18%) died (sudden death, n=7; heart failure, n=4; noncardiac causes, n=6). One-, 2- and 3-year event-free survival for sudden death, sustained VT, or VF was 77%, 68%, and 61%, respectively. Only inducibility of VT during baseline study ( P P Conclusions Although programmed ventricular stimulation seems to predict adverse outcome, serial drug testing is unreliable in guiding therapy. The type of workload imposed on the ventricles influences outcome, being worse in patients with left ventricular volume overload. Therefore, implantation of a cardioverter-defibrillator should be considered early for the management of these patients.

The aim of this study was to analyze the ability of the multiresolution decomposition of the signal-averaged electrocardiogram (ECG) to discriminate between patients who develop life-threatening ventricular arrhythmias after myocardial infarction and those who do not and to compare the predictive values of this approach with those obtained from the analysis of ventricular late potentials in the time domain. Signal-averaged ECGs of 769 prospectively included patients were analyzed. A total of 42 arrhythmic events occurred during the follow-up period. For numerical calculations of wavelet analysis, the total and relative energies of the QRS complex were obtained in seven frequency bands. The combination of the relative energy in the frequency bands 7.8–15.6 Hz and 62.5–125 Hz enhanced statistical performance as compared with the time-domain parameters (positive predictive accuracy, 11.3 vs 8.2%). Combining wavelet transform and time-domain parameters enhanced the predictive values even more (positive predictive accuracy, 14.3%) compared with applying each method alone.

The prognostic significance of heart rate variability derived from 24-hour electrocardiographic recordings was investigated in 250 patients with acute myocardial infarction. During a follow-up of 6 months 15 patients experienced a serious arrhythmic event. These patients showed a significantly reduced beat to beat variability (p = 0.006), a slightly reduced 5-min variability (p = 0.04) and no significant differences in the 24-hour variability compared to the patients free of arrhythmic events. Based on Cox proportional hazard analysis, beat to beat variability remained an independent risk factor (p = 0.0036) in addition to the presence or absence of ventricular late potentials (p = 0.0004) and history of previous infarction (p = 0.04).