Relationship between obstructive coronary artery disease and abnormal stress testing in patients with paroxysmal or persistent atrial fibrillation

Atrial fibrillation (AF) has been linked to the presence of underlying coronary artery disease (CAD). However, whether the higher burden of CAD observed in AF patients translates into higher burden of myocardial ischemia is unknown. In 87 patients (71% male, mean age 61 ± 10 years) with paroxysmal or persistent AF and without history of CAD, MSCT coronary angiography and stress testing (exercise ECG test or myocardial perfusion imaging) were performed. CAD was classified as obstructive (≥50% luminal narrowing) or not. Stress tests were classified as normal or abnormal. A population of 122 patients without history of AF, similar to the AF group as to age, gender, symptomatic status and pre-test likelihood, served as a control group. Based on MSCT, 17% of AF patients were classified as having no CAD, whereas 43% showed non-obstructive CAD and the remaining 40% had obstructive CAD. A positive stress test was observed in 49% of AF patients with obstructive CAD. Among non-AF patients, 34% were classified as having no CAD, while 41% showed non-obstructive CAD and 25% had obstructive CAD (P = 0.013 compared to AF patients). A positive stress test was observed in 48% of non-AF patients with obstructive CAD. In conclusion, the higher burden of CAD observed in AF patients is not associated to higher burden of myocardial ischemia.     

超声心动图评价冠心病合并房颤患者左房功能

目的：探讨应用超声心动图评价冠心病合并房颤患者左房功能的临床价值。方法：对冠心病合并房颤患者19例（心室律<120次/分）,窦性心律冠心病患者17例,及正常对照组20例健康人进行彩色多普勒超声检测。常规超声心动图测量参数包括左房大小（LAD）,双平面面积长度法测左房容量（LAVmax, LAVmin）;应用多普勒技术测量二尖瓣血流频谱参数：E峰、A峰及积分、E峰减速时间（DT）,计算E/A;肺静脉血流频谱收缩及舒张期速度和心房收缩期反流速度（S、D、Ar峰）及积分,计算S/D;左房射血分数（LAEF）;左房灌注分数（LAF）。结果：与对照组相比,冠心病合并房颤组左房收缩功能减低,冠心病组左房主动收缩增强（P<0.05）。冠心病伴房颤和不伴房颤患者左房舒张功能均减低,二组比较有明显差异（P<0.05）。结论：应用常规超声心动图能够评价冠心病合并房颤患者的左房功能。     

Antithrombotics in atrial fibrillation and coronary disease

Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia and approximately 18–45% of AF patients have concomitant coronary artery disease (CAD). Several studies have demonstrated that oral anticoagulation is the mainstay of therapy for stroke prevention in AF. Similarly, antiplatelet therapy including aspirin and P2Y12 inhibitor is recommended in the management of acute coronary syndrome and stable CAD. Despite the high prevalence of CAD with AF, practice guidelines are scarce on the appropriate antithrombotic regimen due to lack of large-scale randomized clinical trials. The use of direct thrombin and factor Xa inhibitors for stroke prevention in AF has also complicated the possible combinations of antithrombotic therapies. This review aims to discuss the available evidence regarding aspirin as an antithrombotic strategy, the role of novel anticoagulants and the specific clinical situations where aspirin may be beneficial in patients with AF and CAD.     

Doppler echocardiography during transesophageal atrial pacing in the detection of coronary artery disease

The aim of this study was to assess the applicability of the Doppler echocardiogram (EchoKG) during transesophageal atrial pacing (TAP) with respect to the detection of coronary artery disease (CAD). Aortic flow peak velocity (PV), mean acceleration (MA), stroke distance (SD), minute distance (MD) and time to PV were measured using pulsed Doppler EchoKG during sinus rhythm and at pacing rates of 120 and 140 bpm in 11 patients, taken as subjects, with CAD defined by coronary arteriography and 15 patients without CAD (the control group). Similar changes of PV, SD, MD and time to PV during TAP were observed in subjects with and without CAD. Only changes of MA were different between subjects with and without CAD:MA during TAP remained unchanged in the control group and decreased from 1055.2±49.7 cm/s² (baseline) to 829.0±55.9 cm/s² at a pacing rate 140 bpm (p<0.05) in subjects with CAD. On the basis of these data we suggest a new criterion for the detection of hemodynamically significant CAD: decrease of MA at a pacing rate of 140 bpm>15% of initial value. Its specificity and sensitivity in the detection of CAD were respectively 87% and 82%. We conclude that the Doppler EchoKG during TAP is a relatively simple and reliable method for the diagnosis of CAD, and that the response of the Doppler EchoKG parameter of MA to TAP is a sensitive and specific index, useful for the detection of significant coronary artery stenosis.     

Amiodaron in atrial fibrillation: post coronary artery bypass graft

BACKGROUND: Atrial fibrilation (AF) is the most common complication following heart surgeries; it often occurs in patients after coronary artery bypass graft (CABG). The purpose of this review is to categorize prophylaxes or treatment by administration of Amiodaron in patients with CABG.DATA RESOURCES: We searched google scholar, pubmed, and Cochrane Library databases (the period 1970-2010) for articles on Amiodaron in CABG and cardiac surgery. A total of 1 561 articles were identified, and 30 articles met the criteria and were enrolled in this review.RESULTS: Most studies supported Amiodarone for prophylaxi purpose in patients who were performed with CABG; few papers supported Amiodaron as a drug for treating CABG. The prophylaxis can decrease the incidence rate of AF in CABG, but if it uses as a treatment, the side effect of Amiodaron will decrease because all of the patients will not get Amiodarone. In the other hand use of Amiodarone as a treatment does not influence the length of hospital stay significantly but these kinds of study are so few.CONCLUSION: No appropriate therapeutic method has been defined for AF. At present, the common way of treating AF following cardiac surgery is mainly based on prophylaxis in medical books and references.     

整体功能指数评价冠心病合并心房颤动患者左心室功能

目的 采用整体功能指数(GFI)评价冠状动脉性心脏病(CAD)合并心房颤动(AF)患者左心室功能的临床价值. 方法 对CAD合并AF组患者30例(心室律<120次/分)、CAD窦性心律组患者30例及正常对照组30名进行彩色多普勒超声检测.用双平面Simpson法计算检测左心室舒张末期容积指数(EDVI)、收缩末期容积指数(ESVI)、左心室射血分数(LVEF).测量二尖瓣舒张早期峰值速度(E)、心肌舒张早期峰值速度(Em)、收缩峰值速度(Sm).计算E/Em和GFI[(E/Em)/Sm]. 结果与正常对照组相比,CAD窦性心律组及CAD合并AF组E/Em增大、Em、Sm减低、GFI值增大(P<0.05).与CAD窦性心律组比较,CAD合并AF组E/Em、GFI值增大(P<0.05). 结论应用GFI能够评价CAD合并AF患者的左心室功能.     

Management of atrial fibrillation in patients with chronic obstructive pulmonary disease

Atrial fibrillation is the cardiac arrhythmia encountered most often in clinical practice. It is triggered by many conditions such as thyroid dysfunction, cardiac disease, alcohol, and pulmonary disease. Patients with chronic obstructive pulmonary disease (COPD) are susceptible to many insults that can lead to an acute deterioration superimposed on chronic disease. Changes in blood gases, abnormalities in pulmonary functions, and hemodynamic changes resulting from pulmonary hypertension can lead to the development of atrial fibrillation. Atrial fibrillation and COPD frequently coexist and complicate treatment of both conditions. The treatment of COPD exacerbation may include beta-adrenergic agonist and theophylline, which can precipitate atrial fibrillation with rapid ventricular response. Pharmacologic and electrical cardioversion may be ineffective in the management of atrial fibrillation in patients with COPD until respiratory decompensation has been corrected. This article focuses on the management of atrial fibrillation in patients with COPD.     

782例心房颤动住院患者的病因学分析

目的 对心房颤动的病因进行分析,并比较房颤合并不同疾病患者栓塞并发症的发生率。方法 选择1997年至2005年在北京安贞医院住院并进行冠状动脉造影的房颤患者782例,其中风湿性心脏病273例,冠心病266例,非风湿瓣膜性心脏病69例,高血压63例,心肌病45例,特发性房颤39例,先天性心脏病17例。观察心电图、超声心动图及冠状动脉造影等进行回顾性分析。结果 器质性心脏病患者房颤,以风心病和冠心病最为常见,分别为34．9％和34．0％。风心病患者发生房颤的年龄较冠心病患者轻,风心病房颤患者占中年组（40～60岁）的85．9％,其中女性占54．6％,冠心病房颤患者占老年组（〉60岁）的70．4％,其中男性占73．9％,两者差异具有统计学意义,（P〈0．01）。而以房颤为首发症状就诊的89例患者中,冠心病仅占12．3％,特发性房颤占43．8％,高血压占31．4％,其他占12．5％。脑栓塞的发生率分别为风心病5．1％,冠心病2．2％,风心病合并冠心病11．7％,其他类型心脏病2．9％。左房血栓的检出率分别为风心病13．9％,冠心病3．1％,风心病合并冠心病15．1％,其他类型心脏病3．3％。结论 器质性心脏病并发房颤患者不同病因的年龄、性别的构成差异明显。冠心病房颤患者中,多合并有其他心脏病,如瓣膜性心脏病、高血压等。以房颤为首发症状的患者诊断冠心病应该谨慎。风心病患者合并冠心病并不少见,其栓塞的发生率明显升高,抗凝治疗后房颤患者栓塞并发症的发生率显著下降。     

静脉注射艾司洛尔治疗慢性阻塞性肺疾病合并快速心房颤动的疗效及安全性

目的 观察静脉注射艾司洛尔治疗慢性阻塞性肺疾病(COPD)合并快速心房颤动的临床疗效及安全性。方法 COPD急性加重合并快速心房颤动患者共58例,其中25例给予静脉注射艾司洛尔序贯口服倍他乐克,33例给予静脉注射胺碘酮序贯口服胺碘酮,观察两组心律失常疗效及对血压、心率、动脉血气的影响。结果 两组分别静脉注射艾司洛尔及胺碘酮后,心律失常明显减少,两组有效率分别为92.0%和93.9%,两组均会导致血压下降,但不需使用血管活性药物维持血压;艾司洛尔组未出现严重不良反应,胺碘酮组有2例出现严重心动过缓（<50次/min）,退出临床观察。治疗过程中两组呼吸衰竭没有明显加重。结论 艾司洛尔在COPD合并快速心房颤动治疗中安全有效,可有效控制心室率,不会导致呼吸衰竭加重。     

Characteristics of rapid rhythms recorded within pulmonary veins during atrial fibrillation

Rapid rhythms often arise in the pulmonary veins during atrial fibrillation (AF). The activation patterns within pulmonary veins during these rapid rhythms are not well described. In 39 patients with paroxysmal AF, ostial recordings were obtained during AF in 110 pulmonary veins with a decapolar distal ring catheter. Pulmonary vein tachycardia (PVT) was defined as a pulmonary vein (PV) rhythm that had a cycle length shorter than at the adjacent left atrium. During AF, PVT was recorded in 93% of PV's, usually in the form of intermittent bursts that had a mean duration of 1,325 +/- 647 ms and mean cycle length of 125 +/- 20 ms. The mean cycle length of continuous PVT's (141 +/- 25) was longer than the mean cycle length of intermittent bursts of PVT (P < 0.05). The intermittent PVT's were associated with a shorter left atrial cycle length than were the continuous PVT's. In 90% of PVTs, complex activation patterns attributable to simultaneous recordings from two or more overlapping fascicles were present at a segment of the pulmonary vein ostium, and the mean cycle length of these recordings was 80 +/- 32 ms. PVT during AF is much more often intermittent than continuous. The relationship between PVT cycle length and left atrial cycle length suggests that PVT's influence the left atrium during AF. PVT must be distinguished from recordings within PV's that have a short cycle length as a result of simultaneous recordings from two or more overlapping fascicles.     

Mid-term outcome after carotid artery stenting depends on presence of coronary artery disease

BACKGROUND: Longer-term outcome of patients following carotid artery revascularization depends predominantly on cardiac events rather than neurological events. AIM: To assess the longer-term outcomes of patients with known coronary artery morphology undergoing carotid artery stenting. METHOD: In a prospective observational study including 549 consecutive patients undergoing carotid artery stenting, a coronary angiography was performed in a single session unless a recent angiogram was available. Following the intervention, patients were followed prospectively to determine neurological events as well as major adverse coronary events (MACE) during long-term follow-up. RESULTS: Coronary artery disease was present in 378 patients including 92 patients without current significant stenosis. The MACE rate was 6.4% in patients without coronary artery disease compared to 28.3% in patients with coronary artery disease (P<0.00001). Cardiac and all-cause mortality were statistically significantly higher in patients with a significant coronary stenosis than in patients without coronary artery disease (P<0.001 and P<0.01). Cardiac mortality and all-cause mortality were 2.3% and 7.6% in patients without coronary artery disease (patient group I), 7.6% and 13.0% in patients with coronary artery disease but no current significant stenosis (patient group II), and 10.5% and 16.1% in patients with significant coronary stenosis (patient group III). Neurological events, however, were distributed equally among the three patient groups. CONCLUSIONS: In the longer term, outcomes in patients undergoing carotid artery stenting depend on concomitant coronary artery disease rather than neurological events, cardiac mortality and even all-cause mortality depending on a significant coronary artery stenosis.     

Predictors and impact of atrial fibrillation after isolated coronary artery bypass grafting

OBJECTIVE: Although an extensive number of studies have attempted to identify predictors of new-onset atrial fibrillation (AFIB) after coronary artery bypass grafting (CABG), a strong predictive model does not exist. Prior studies have included patients recruited from multiple centers with variant AFIB prevalence rates and those who underwent CABG in combination with other surgical procedures. Also, most studies have focused on pre- and perioperative characteristics, with less attention given to the initial postoperative period. The purpose of this study was to comprehensively examine pre-, peri-, and postoperative characteristics that might predict new-onset AFIB in a large sample of patients undergoing isolated CABG in a single medical center, utilizing data readily available to clinicians in electronic data repositories. In addition, length of stay and selected postoperative complications and disposition were compared in patients with AFIB and no AFIB. DESIGN: Retrospective, comparative survey. SETTING: University-affiliated tertiary care hospital. PATIENTS: Patients with new-onset AFIB who underwent isolated standard CABG or minimally invasive direct vision coronary artery bypass were identified from an electronic clinical data repository. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The prevalence of AFIB in the total sample (n = 814) was 31.9%. Predictors of AFIB included age (p =.0004), number of vessels bypassed (p =.013), vessel location (diagonal [p <.003] or posterior descending artery [p <.001]), and net fluid balance on the operative day (p =.015). Forward stepwise regression analysis produced a model that correctly predicted AFIB in only 24% of cases, with age (14%) and body surface area (9%) providing the most prediction. The incidence of embolic stroke was higher in AFIB (n = 8) vs. no AFIB (n = 4) patients, but stroke preceded AFIB onset in seven of eight cases. Subjects with AFIB had a longer stay (p =.0004), more intensive care unit readmissions (p =.0004), and required more assistance at hospital discharge (p =.017). CONCLUSIONS: Despite attempts to examine comprehensively predictors of new-onset AFIB, we were unable to identify a robust predictive model. Our findings, in combination with prior work, imply that it may not be feasible to predict the development of new-onset AFIB after CABG using data readily available to the bedside clinician. In this sample, stroke was uncommon and, when it occurred, preceded AFIB in all but one case. As anticipated, AFIB increased length of stay, and patients with this complication required more assistance at discharge.     

The importance of the conus artery in patients with obstructive coronary artery disease

It is well-known that collateral circulation is important in preserving ventricular functions, especially in coronary artery disease with total occlusion. The conus branch is distinct in having notable capacity of angiogenesis and arteriogenesis. We intend to emphasize the clinical importance of the conus branch by presenting two cases in which it supplied the distal regions of total occlusion.     

冠心病并发抑郁的研究进展

综述了抑郁症致冠心病发生、发展的可能机制有炎症学说、血小板聚集增强、脂质代谢紊乱和心率变异性下降,冠心病致抑郁的机制有社会心理因素及生理机制五大学说;对冠心病并发抑郁的干预也进行了阐述.     

Resource utilization related to atrial fibrillation after coronary artery bypass grafting.

BACKGROUND: Studies of resource utilization by patients with new-onset atrialfibrillation after coronary artery bypass grafting have addressed only length of stay and bed charges. OBJECTIVE: To compare resource utilization between patients with new-onset atrial fibrillation and patients without atrialfibrillation after isolated coronary artery bypass grafting. METHODS: Retrospective review of clinical and administrative electronic databases for 720 subjects who underwent isolated coronary artery bypass grafting with cardiopulmonary bypass in 25 months at one medical center The prevalence of atrial fibrillation was determined, and resource utilization in various hospital cost centers was compared between subjects with and without atrialfibrillation. RESULTS: The prevalence of new-onset atrial fibrillation was 33.1%. Compared with subjects without atrialfibrillation, subjects with atrialfibrillation had a longer stay (5.8 +/- 2.4 vs. 4.4+/-1.2 days, P<.001), more days receiving mechanical ventilation (P =.002) and oxygen therapy (P<.001), and higher rates of readmission to the intensive care unit (4.6% vs. 0.2%, P<.001). Subjects with atrial fibrillation also had more laboratory tests (P<.001) and more days receiving cardiac drugs, heparin, diuretics, and electrolytes. Subjects with atrialfibrillation had higher total postoperative charges ($57261 +/- $17101 vs. $50905 +/- $10062, P = .001), a mean difference of $6356. The mean differences were greatest for bed charges ($1642), laboratory charges ($1215), pharmacy ($989), and respiratory care ($582). CONCLUSION: The economic impact of atrialfibrillation after coronary artery bypass grafting has been underestimated.     

Diagnostic performance of CT coronary angiography for the detection of obstructive coronary artery disease

CT coronary angiography (CTCA) is emerging as the most promising imaging modality for noninvasive detection of atherosclerotic disease of the coronary arteries. The possibility to identify or rule out significant coronary stenosis, to measure atherosclerotic plaque burden, and to characterize plaque components makes this imaging modality very enticing. This review briefly summarizes CTCA’s technical aspects, limitations, and pitfalls, as well as different methods of analyses of diagnostic performance of CTCA. It also provides clinical indications for the use of CTCA and discusses its use in patients with prior coronary stent placement and coronary artery bypass grafting.     

Clinical hypnosis for reduction of atrial fibrillation after coronary artery bypass graft surgery

The belief that postoperative atrial fibrillation (PAF) results from transient autonomic dysfunction suggests that interventions such as clinical hypnosis may reduce the incidence of PAF. To explore this hypothesis, we retrospectively compared outcomes between two groups of patients undergoing coronary artery bypass graft surgery: 50 consecutive patients who received preoperative hypnoidal explanation of the surgical procedure and 50 case-matched historical controls who received no clinical hypnosis. The patients who received hypnosis were significantly less likely to experience an episode of PAF (P = .003) and showed nonsignificant trends toward superior outcomes in terms of length of stay, narcotic use, and total hospital charges. Our findings indicate that prospective randomized trials are warranted to further delineate the potential benefit of clinical hypnosis for prevention of PAF.