24-hour Ambulatory Monitoring Research Articles

Videofluoroscopic Modified Barium Swallow Study for Premature Ventricular Complexes–Associated Dysphagia

An 18-year-old white female with a body mass index of 28 kg/m2 presented with a 6-month history of intermittent esophageal dysphagia, dizziness, and heavy vomiting associated with frequent premature ventricular complexes (PVCs). Her echocardiogram was normal, and serial 24-hour ambulatory Holter monitoring documented between 100 and 5000 monomorphic PVCs. A 12-lead ECG obtained during an emergency department visit revealed monomorphic single PVC, as well as pairs and triplets with inferior axis and left bundle-branch block pattern. Upper endoscopy and chest x-ray did not reveal any pathologies. Videofluoroscopic modified barium swallow study with simultaneous ECG monitoring …

Distress and Affective Dysregulation in Patients With Borderline Personality Disorder

Borderline personality disorder (BPD) is characterized by enduring psychological distress and affective dysregulation. Several models have linked both phenomena, but are lacking empirical support. To investigate the relation between psychological distress and components of affective dysregulation (especially inability to label emotions, conflictive emotions, and physiological hyperarousal), we repeatedly assessed these components using a 24-hour ambulatory monitoring approach in a group of 50 BPD patients and 50 healthy controls. Hierarchical linear model analyses identified a clear relation between inability to label emotions and distress in the BPD group (p = 0.0009) but not across all subjects (p = 0.6492). Conflictive emotions were related to psychological distress in both groups (p < 0.0001). This relation is, however, most pertinent to the BPD group who experienced conflicting emotions more frequently. Physiological arousal (heart rate) was related to distress in both groups. Our empirical findings emphasize training in labeling emotions and distress tolerance interventions in treatment for BPD.

Incidence and clinical significance of ventricular arrhythmias in dilated cardiomyopathy

The diagnosis of dilated (congestive) cardiomyopathy was made in 75 patients on the basis of clinical, ECG, echo and angiographic-haemodynamic findings. Ambulatory 24-hour monitoring was undertaken in all patients. Nearly all of them (93%) had ventricular extrasystoles (VES), 35% more often than 1000/24 h. In 15% VES occurred in pairs, in 44% as ventricular tachycardia. In general, frequent VES (greater than 30/h) also came in pairs and/or as ventricular tachycardia. On the other hand, not all patients with such complex arrhythmias also had frequent VES. In about 70% of all patients with ventricular tachycardia such episodes were registered repeatedly, in more than 40% more than five tachycardia episodes per 24 hours. In the majority of patients the tachycardia consisted of three (33%), four (12%) or five (18%) consecutive ventricular complexes. All episodes of ventricular tachycardia ended spontaneously and were clinically largely silent. Apparently there was no clinically relevant correlation between frequency and severity of the arrhythmia, on the one hand, and extent of abnormal ventricular function, on the other. These findings indicate that frequent and complex ventricular arrhythmias are a characteristic feature of dilated (congestive) cardiomyopathy. If they occur in heart disease of seemingly unknown aetiology, dilated cardiomyopathy should be suspected. Preliminary findings of long-term observation indicate that patients with frequent ventricular tachycardias have a higher risk of sudden death.

Sleep-Wakefulness Variations in Arterial Stiffness: Assessment Using Ambulatory Recording of Arterial Pulse Transit Time

The incidence of cardiovascular events is related to the sleep-wakefulness cycle. In particular, the magnitude and speed of the changes in hemodynamic variables that occur during transitions between wakefulness and sleep and between sleep and wakefulness are regarded as factors that either predict or determine target organ damage and cardiovascular risk. Although increased arterial stiffness (AS) is associated with the development of cardiovascular abnormalities, it is not known whether there exist any changes in AS that are associated with circadian variations in the incidence of cardiovascular events. The aims of this study were to assess AS in healthy subjects over a 24-hour period, to characterize any differences that occur between sleep and wakefulness, and to investigate any changes in AS that occur during the transition from wakefulness to sleep or from sleep to wakefulness. Twenty healthy volunteers with a dipper circadian blood pressure pattern underwent 24-hour ambulatory monitoring of blood pressure, heart rate and AS. In practice, AS was determined using the aorta-brachial pulse transit time and fractional pulsatility indices. Myocardial oxygen consumption was quantified using the double product (DP). An average was calculated for all variables for periods of sleep (23:00 to 06:00) and wakefulness (8:00 to 21:00) and for transitions from wakefulness to sleep (20:00 vs. 02:00) and from sleep to wakefulness (06:00 vs. 10:00 hours). In complete contrast to DP, AS was greater during sleep than wakefulness (P< .05). Moreover, the changes in AS that occurred during transitions from wakefulness to sleep and from sleep to wakefulness were the opposite of those observed in DP (P< .05). Arterial stiffness was greater during sleep than wakefulness, increased during the transition from wakefulness to sleep, and decreased during the transition from sleep to wakefulness.

Ambulatory arterial blood pressure monitoring in patients before and after thyroidectomy

[corrected] Increased values of thyroid hormones in the clinical syndrome of hyperthyreosis affect blood pres sure values and its circadial variation. The aim of this study was to define the influence of hyperthyreosis on the values and circadial variations of arterial blood pressure, as well as to investigate the effect of thyroid surgery on blood pressure values. We compared the 24-hour averages of systolic and diastolic blood pressure, their variations and their reduction during the night between 20 female patients with hyperthyroidism and hypertension de novo and 20 healthy females. We compared the values of 24-hour ambulatory monitoring performed before the surgery with the values gathered two weeks after the surgery. The 24-hour average systolic and diastolic blood pressure values were higher in the patients with hyperthyroidism than in the control group (p < 0.001). In the group of patients, the variations in blood pressure were significantly higher than they were in the group of healthy people (p < 0.001). The amplitude of the nocturnal reduction of blood pressure was also significantly lower in the patients with hyperthyroid status and hypertension, in comparison to the healthy persons (p < 0.001). Two weeks after the surgery, a significant reduction of blood pressure values (both for systolic and diastolic) appeared. The patients with hyperthyroidism caused hypertension had higher systolic and dia stolic blood pressure, higher variations in blood pressure and lower nocturnal reduction of blood pressure than healthy subjects. Thyroid surgery, as a control of thyroid function, optimised blood pressure very rapidly.

Monitorização eletrocardiográfica ambulatorial por 24-horas em cães com cardiomiopatia dilatada idiopática

Caracterizou-se monitorização eletrocardiográfica ambulatorial por 24 horas (ou monitorização Holter) em cães com cardiomiopatia dilatada idiopática, visando principalmente à detecção de arritmias ventriculares não detectadas pela eletrocardiografia convencional (de repouso). Para tanto, avaliaram-se 40 pacientes com diagnóstico de cardiomiopatia dilatada idiopática, por meio de exame físico e mensuração indireta da pressão arterial, além de exames eletrocardiográfico, ecocardiográfico, radiográfico de tórax e da monitorização Holter. Extra-sístoles ventriculares foram detectadas, por monitorização Holter, em 97,5% dos animais e taquicardia ventricular, em 45%. Não houve correlação entre o número de extra-sístoles ventriculares e a fração de encurtamento. Considerando as manifestações clínicas, apenas houve associação entre presença de taquicardia ventricular e histórico de síncopes. Conclui-se que a incidência de arritmias ventriculares em cães com cardiomiopatia dilatada idiopática é bastante alta, sendo a taquicardia ventricular relativamente freqüente, ocorrendo mais sob a forma não sustentada.

Evaluation and Treatment of Chagas Disease in the United States

Because of population migration from endemic areas and newly instituted blood bank screening, US clinicians are likely to see an increasing number of patients with suspected or confirmed chronic Trypanosoma cruzi infection (Chagas disease). To examine the evidence base and provide practical recommendations for evaluation, counseling, and etiologic treatment of patients with chronic T cruzi infection. Evidence Acquisition Literature review conducted based on a systematic MEDLINE search for all available years through 2007; review of additional articles, reports, and book chapters; and input from experts in the field. The patient newly diagnosed with Chagas disease should undergo a medical history, physical examination, and resting 12-lead electrocardiogram (ECG) with a 30-second lead II rhythm strip. If this evaluation is normal, no further testing is indicated; history, physical examination, and ECG should be repeated annually. If findings suggest Chagas heart disease, a comprehensive cardiac evaluation, including 24-hour ambulatory ECG monitoring, echocardiography, and exercise testing, is recommended. If gastrointestinal tract symptoms are present, barium contrast studies should be performed. Antitrypanosomal treatment is recommended for all cases of acute and congenital Chagas disease, reactivated infection, and chronic T cruzi infection in individuals 18 years or younger. In adults aged 19 to 50 years without advanced heart disease, etiologic treatment may slow development and progression of cardiomyopathy and should generally be offered; treatment is considered optional for those older than 50 years. Individualized treatment decisions for adults should balance the potential benefit, prolonged course, and frequent adverse effects of the drugs. Strong consideration should be given to treatment of previously untreated patients with human immunodeficiency virus infection or those expecting to undergo organ transplantation. Chagas disease presents an increasing challenge for clinicians in the United States. Despite gaps in the evidence base, current knowledge is sufficient to make practical recommendations to guide appropriate evaluation, management, and etiologic treatment of Chagas disease.

A pilot study to test the effect of pulsatile insulin infusion on cardiovascular mechanisms that might contribute to attenuation of renal compromise in type 1 diabetes mellitus patients with proteinuria

We hypothesized that correction of insulin deficiency by pulsatile intravenous insulin infusion in type 1 diabetes mellitus patients with nephropathy preserves renal function by mechanisms involving cardiac autonomic function, cardiac mass, or efficiency, or by hemostatic mechanisms. The control group (8 patients) received subcutaneous insulin (3-4 injections per day). The intravenous infusion group (10 patients) received three 1-hour courses of pulsed intravenous insulin infusion on a single day per week in addition to subcutaneous insulin. Laboratory measurements included 2-dimensional Doppler echocardiography, 24-hour ambulatory monitoring with heart rate variation analysis, platelet aggregation and adhesion, plasma fibrinogen, factor VII, von Willebrand factor, fibrinolytic activity, plasminogen activator inhibitor, and viscosity measured at baseline and 12 months. Blood pressure control was maintained preferentially with angiotensin-converting enzyme inhibitors. Ratio of carbon dioxide production to oxygen utilization was measured with each infusion and showed rapid increase from 0.8 to 0.9 ( P = .005) at weekly treatments through 12 months. We observed an annualized decrease in creatinine clearance of 9.6 mL/min for controls vs 3.0 mL/min for infusion patients. Annualized fall in blood hemoglobin was 1.9 vs 0.8 g/dL, respectively ( P = .013). There were no differences between the control and infusion group with respect to glycohemoglobin, advanced glycated end products, cholesterol, or triglycerides. No differences between the study groups for hemodynamic or hemostatic factors were evident. Blood pressures were not significantly different at baseline or 12 months. We conclude that although preservation of renal function with attenuation of loss of blood hemoglobin during 12 months of intravenous insulin infusion was associated with improvement in the efficiency of fuel oxidation as measured by respiratory quotient, this occurred without differences in metabolic/hemostatic factors, cardiac autonomic function, cardiac wall, or chamber size. Our hypothesis that preservation of renal function in type 1 diabetes mellitus patients with proteinuria by weekly pulsed insulin infusion involves mechanisms from the autonomic nervous system, cardiac size, and function, or elements of hemostasis was not confirmed.

Impact of aortic stenting on peripheral vascular function and daytime systolic blood pressure in adult coarctation

Objectives:To determine the relation of ambulatory systolic blood pressure to aortic obstruction and more extensive vascular dysfunction, assessed by central aortic, peripheral conduit arterial and resistance vessel function.Methods:12 adults (5...

Distinct Clinical Characteristics Between Patients With Nonerosive Reflux Disease and Those With Reflux Esophagitis

It has been postulated that nonerosive reflux disease (NERD) and erosive reflux disease (ERD) are 2 distinct entities of gastroesophageal reflux disease. The aim of this study was to compare the clinical characteristics between patients with NERD and those with ERD. We prospectively recruited consecutive patients presenting with weekly attacks of heartburn or acid regurgitation. Exclusion criteria included gastric surgery, recent use of nonsteroidal anti-inflammatory drug or proton pump inhibitor, and peptic ulcer disease. Concomitant functional dyspepsia, irritable bowel syndrome, and psychological disorders were documented. Endoscopy, esophageal manometry, acid perfusion test, and 24-hour ambulatory pH monitoring were performed. Risk factors of NERD were determined by multivariate analysis. Two hundred fourteen patients (NERD, 113; ERD, 111) were studied. NERD patients were characterized by higher prevalence of Helicobacter pylori (36.3% vs 18%, P = .005), functional dyspepsia (64.6% vs 42.3%, P = .003), irritable bowel syndrome (44.2% vs 15.3%, P < .001), psychological disorders (9% vs 0.9%, P = .04), and positive acid perfusion test (40.7% vs 19.8%, P = .004). ERD patients had more hiatal hernias (35.1% vs 17.1%, P = .009), higher esophageal acid exposure (total time esophageal pH <4, 4.2% +/- 2.1% vs 5.9% +/- 2.3%; P = .01), and esophageal dysmotility (P < .05). With multivariate analysis, H pylori (odds ratio, 1.8; 95% confidence interval [CI], 1.1-3.2), irritable bowel syndrome (odds ratio, 2.8; 95% CI, 1.6-5.3), and positive acid perfusion test (odds ratio, 1.9; 95% CI, 1.4-2.8) were independent risk factors for NERD. Patients with NERD and ERD have distinct differences in clinical characteristics. NERD is characterized by higher prevalence of functional gastrointestinal disorders and esophageal acid hypersensitivity.

Psychophysiological ambulatory assessment of affective dysregulation in borderline personality disorder

Many experts now believe that pervasive problems in affect regulation constitute the central area of dysfunction in borderline personality disorder (BPD). However, data is sparse and inconclusive. We hypothesized that patients with BPD, in contrast to healthy gender and nationality-matched controls, show a higher frequency and intensity of self-reported emotions, altered physiological indices of emotions, more complex emotions and greater problems in identifying specific emotions. We took a 24-hour psychophysiological ambulatory monitoring approach to investigate affect regulation during everyday life in 50 patients with BPD and in 50 healthy controls. To provide a typical and unmanipulated sample, we included only patients who were currently in treatment and did not alter their medication schedule. BPD patients reported more negative emotions, fewer positive emotions, and a greater intensity of negative emotions. A subgroup of non-medicated BPD patients manifested higher values of additional heart rate. Additional heart rate is that part of a heart rate increase that does not directly result from metabolic activity, and is used as an indicator of emotional reactivity. Borderline participants were more likely to report the concurrent presence of more than one emotion, and those patients who just started treatment in particular had greater problems in identifying specific emotions. Our findings during naturalistic ambulatory assessment support emotional dysregulation in BPD as defined by the biosocial theory of [Linehan, M.M., 1993. Cognitive–Behavioral Treatment of Borderline Personality Disorder. The Guildford Press, New York.] and suggest the potential utility for evaluating treatment outcome.

Gastroesophageal reflux in patients with idiopathic pulmonary fibrosis referred for lung transplantation

The association between gastroesophageal reflux disease and idiopathic pulmonary fibrosis has not been fully characterized. The aims of this study were to determine in patients with idiopathic pulmonary fibrosis (1) the prevalence of reflux symptoms, (2) the esophageal manometric profile, and (3) the prevalence of proximal and distal esophageal reflux. Between May 1999 and March 2006, 30 patients with idiopathic pulmonary fibrosis were referred to the Swallowing Center at the University of California San Francisco. Each patient underwent a structured symptom assessment, esophageal manometry, and 24-hour dual sensor ambulatory pH monitoring. Twenty (67%) patients had abnormal esophageal reflux. Typical reflux symptoms, although more common in those with reflux, were not reliable as a screening test (sensitivity 65%, specificity 71%). Sixty-five percent of patients with abnormal reflux had a hypotensive lower esophageal sphincter. Abnormal esophageal peristalsis was more common among those with reflux (50% vs 10%; P = .03). In 9 (30%) patients, acid refluxed into the proximal esophagus for over 1% of the study time. A majority of patients with idiopathic pulmonary fibrosis have pathologic reflux. Symptoms do not distinguish between those with and without reflux. In these patients, reflux is associated with a hypotensive lower esophageal sphincter and abnormal esophageal peristalsis, and often extends into the proximal esophagus.

Prognostic value of Poincare plot as nonlinear parameter of chaos theory in patients with myocardial infarction

There are different proofs about association of autonomic nervous system dysfunction, especially nonlinear parameters, with higher mortality after myocardial infarction. The objective of the study was to determine predictive value of Poincaré plot as nonlinear parameter and other significant standard risk predictors: ejection fraction of the left ventricle, late potentials, ventricular arrhythmias, and QT interval. The study included 1081 patients with mean follow-up of 28 months (ranging from 0-80 months). End-point of the study was cardiovascular mortality. The following diagnostic methods were used during the second week: ECG with commercial software Schiller AT-10: short time spectral analysis of RR variability with analysis of Poincaré plot as nonlinear parameter and late potentials; 24-hour ambulatory ECG monitoring: QT interval, RR interval, QT/RR slope, ventricular arrhythmias (Lown > II); echocardiography examinations: systolic disorder (defined as EF < 40%). There were 103 (9.52%) cardiovascular deaths during the follow-up. In univariate analysis, the following parameters were significantly correlated with mortality: mean RR interval < 800 ms, QT and RR interval space relationship as mean RR interval < 800 ms and QT interval > 350 ms, positive late potentials, systolic dysfunction, Poincaré plot as a point, ventricular arrhythmias (Lown > II). In multivariate analysis, the significant risk predictors were: Poincaré plot as a point and mean RR interval lower than 800 ms. Mean RR interval lower than 800 ms and nonlinear and space presentation of RR interval as a point Poincaré plot were multivariate risk predictors.

“Ratchet” syndrome, another etiology for pacemaker lead dislodgement: A case report

Our patient was diagnosed with familial 2:1 atrioventricularblock and had initially presented with bradycardia and as-sociated shortness of breath and decreased exercise toler-ance at the age of 7. She subsequently underwent an epi-cardial DDD pacemaker implantation with immediateimprovement in symptoms.At age 11, she was noted to have loss of sensing andcapture due to a ventricular lead fracture. Additionally, thegenerator was approaching elective replacement time. Sheunderwent placement of a transvenous DDDR pacemaker.The pocket was created beneath the pectoralis muscle. Us-ing a venogram as a “roadmap”, the axillary vein wasentered at two separate sites through the pocket. Medtronic3830 active fixation leads were placed into the mid septalarea of the right ventricle, and near the right atrial append-age. Additional slack was advanced on both the atrial andventricular lead to allow for growth. Pacing and sensingthresholds were established and adequate values were ob-tained. The proximal end of the lead was secured using thesewing sleeve with 2-0 Prolene (monofilament nonabsorb-able suture) and was then attached to the underlying fascia.The pacemaker generator was placed in the pocket withleads attached. With pacemaker interrogation appropriatepacemaker function was noted without diaphragmatic stim-ulation. The pacemaker was sutured to the underlying fasciawithin the pocket with the 2-0 Prolene, and the pocket wasclosed in three layers.A chest x-ray the following morning showed stable leadplacement with appropriate slack of the lead within theventricle (Figure 1). The pacemaker interrogation prior todischarge demonstrated appropriate pacemaker and leadfunction and a 24-hour ambulatory ECG monitor was es-sentially unremarkable. A sling was worn for the next 3–4days and the patient was instructed not to raise her armabove her shoulder for the next 6 weeks.Five weeks after implantation, the patient noted that herheart rate was low and she experienced twitching of her armthat seemed to coincide with her pacemaker rate. No othersymptoms were reported. She and her mother indicated shehad been compliant with the arm restrictions. She deniedmanipulating the pacemaker area, the device, or the lead.She stated that the incision had itched, but she had been verycareful not to scratch “hard”. Axillary and pocket stimula-tion were noted on physical exam. Device interrogationdemonstrated complete lack of sensing and pacing withnormal lead impedance values. The chest x-ray demonstratedthat the lead had retracted completely out of the heart andappeared to be wrapped around the pacemaker (Figure 2). Thetip of the ventricular lead was at the anterior axillary linewhile the atrial lead remained in place.The ventricular lead was removed and a new lead wasplaced in the manner previously described. During the ven-tricular lead replacement, the sewing sleeve was noted to bein the same position as originally placed, but with the leadpulled completely out of the sleeve. There were no visibleabnormalities of the lead. Since replacement of the lead, nosubsequent lead problems have been found, and the pace-maker system was functioning normally at both her one andthree month follow-up visits.

Long-term functional results after laparoscopic surgery for esophageal achalasia

Background Evidence on the long-term outcome of laparoscopic Heller–Dor surgery is limited. The aim of this study was to assess the long-term outcome of achalasic patients after surgery, particularly in relation to the radiologic preoperative stage of the disease. Methods Sixty-eight patients with achalasia were assessed clinically and by esophageal radiology, manometry, and 24-hour ambulatory esophageal pH monitoring before and at 3 months, 1, 1 to 3, 3 to 5, and 5 to 8 years after a laparoscopic Heller-Dor procedure. Results At 1 year after surgery the symptom score was significantly lower than the preoperative score ( P < .001), and a satisfactory clinical outcome was seen in more than 90% of the patients with stage I, II, and III disease at the preoperative radiologic assessment. Only 50% of stage IV patients reported satisfactory results. An adequate opening of the lower esophageal sphincter (LES) and LES resting pressure of less than 8 mm Hg was achieved in all patients, and esophageal emptying was accelerated significantly ( P < .001). At the consecutive follow-up evaluation (1–8 y), a satisfactory outcome was maintained in all stage I, II, and III responders. Stage IV patients with initially unsatisfactory results reported a worsening of symptoms ( P < .02). Patients with pseudodiverticulum had a higher symptom score ( P < .01). LES opening and resting pressure remained at levels of the 1-year follow-up evaluation. Esophageal emptying remained satisfactory in stage I, II, and III responders, but deteriorated in stage IV nonresponders and in 6 of the 10 patients with a pseudodiverticulum. Conclusions A satisfactory outcome of the laparoscopic Heller–Dor procedure in stage I, II, and III achalasic patients seems to last. Stage IV nonresponders tend to deteriorate over time. The development of pseudodiverticulum is associated with an increased symptom score.

Obesity Is Associated With Increased Transient Lower Esophageal Sphincter Relaxation

Obesity has been associated with gastroesophageal reflux disease (GERD) and its complication, but the mechanism is unclear. We evaluated the association between obesity and function of lower esophageal sphincter (LOS) in subjects without GERD. We prospectively recruited consecutive obese (BMI >30) patients referred for weight reduction procedure and age- and sex-matched overweight (BMI 25-30) and normal weight (BMI > or =20 and <25) subjects. Exclusion criteria included esophagitis, reflux symptoms, use of proton pump inhibitor, hiatus hernia >2 cm, and diabetes mellitus with microvascular complication. All participants underwent combined 2-hour postprandial esophageal manometry and pH monitoring after a standard test meal followed by 24-hour ambulatory pH monitoring. Eighty-four subjects (obese, 28; overweight, 28; normal weight, 28) were studied. All 3 groups had comparable mean LOS pressure, LOS length, and peristaltic function. During the postprandial period, both obese and overweight groups had substantial increase in 2-hour rate of transient lower esophageal sphincter relaxation (TLOSR) (normal weight: 2.1 +/- 1.2 vs overweight: 3.8 +/- 1.6 vs obese: 7.3 +/- 2.0, P < .001), proportion of TLOSR with acid reflux (normal weight: 17.6% +/- 22.0% vs overweight 51.8% +/- 22.5% vs obese: 63.5% +/- 21.7%, P < .001), and gastroesophageal pressure gradient (GOPG) (normal weight: 4.5 +/- 1.2 mm Hg vs overweight: 7.1 +/- 1.4 mm Hg vs obese: 10.0 +/- 1.5 mm Hg, P < .001). Using multiple regression model, BMI (r(2): 0.70, B: 0.28, 95% CI: 0.24-0.33, P < .001) and waist circumference (r(2): 0.65, unstandardized regression coefficient [B]: 0.10, 95% CI: 0.08-0.11, P < .001) were significantly correlated with TLOSR. Obesity is associated with increased TLOSR and acid reflux during the postprandial period in subjects without GERD. Abnormal postprandial LOS function may be an early event in the pathogenesis of obesity-related GERD.

Response to Abraham

More than 4000 patients have been evaluated in randomized controlled trials of cardiac resynchronization therapy (CRT). These studies have demonstrated that CRT with or without an implantable cardioverter-defibrillator (ICD) consistently improves quality of life, functional status, exercise capacity, and cardiac structure and function and reduces morbidity and mortality in heart failure patients with ventricular dyssynchrony. The magnitude of benefit seen with CRT is comparable to or exceeds that seen with evidence-based drug therapies for heart failure but occurs in patients who are already receiving such medications. Thus, CRT has been added to the list of evidence-based therapies that make heart failure patients feel better and live longer (the Table). Consequently, a strong ethical mandate exists for the use of CRT in heart failure. This mandate is reflected in our current practice guidelines for the management of chronic heart failure, which state that all eligible patients should receive CRT unless contraindicated.1,2 End of debate! CRT should be a routine part of any evidence-based treatment regimen for heart failure. View this table: Major Benefits of Evidence-Based Heart Failure Therapies Of course, things are never quite so simple, so let us take a look at the evidence supporting this clinical mandate for CRT and address patient selection, some of the limitations of CRT, and some of the unanswered questions about the use of CRT in heart failure. None of this discussion will lessen the role of CRT in the treatment of heart failure; rather, it will guide the selection of appropriate patients and speculate on the future application of CRT to an even broader group of heart failure patients. Response by Greenberg and Mehra p 2698 Approximately one third of patients with systolic heart failure exhibit ventricular dyssynchrony, defined as a QRS duration >120 ms on the surface ECG.3,4 Ventricular dyssynchrony produces suboptimal ventricular …

Panic Attacks, Daily Life Ischemia, and Chest Pain in Postmenopausal Women

Chest pain is a common symptom of panic attacks, but little is known about the relationship in older women among panic attacks, chest pain, and daily life ischemia. The authors conducted a cross-sectional survey of 3063 community-dwelling, generally healthy postmenopausal women enrolled between 1997 and 2000 in the Myocardial Ischemia and Migraine Study in 10 clinical centers of the 40-center Women's Health Initiative. Participants, ages 50 to 79 years, completed a questionnaire about occurrence of panic attacks in the previous 6 months and underwent 24-hour ambulatory electrocardiogram monitoring (AECG); 2705 women had valid AECG recordings and panic attack questionnaires. ST depression on AECG, heart rate variability (HRV), and chest pain episodes were compared among women with and without a 6-month history of panic attack. There was no difference in overall prevalence of ischemic episodes during AECG between women with and without panic attacks. Women with a recent history of panic were more likely to experience chest pain during AECG after controlling for potential confounders (odds ratio [OR] = 2.01; 95% confidence interval [CI] = 1.40-2.88), including both nonischemic (OR = 1.83; 95% CI = 1.26-2.65) and ischemic chest pain (OR = 4.94; 95% CI = 1.41-17.30). Although mean HRV was lower in those with panic attacks (p = .017), this was not significant after controlling for confounders. Postmenopausal women with a recent history of panic attacks do not appear to have more daily life ischemia as measured by occurrence of ST depression during 24-hour monitoring, but do have more chest pain and possibly lower HRV, suggesting that even sporadic panic attacks may be related to cardiovascular risk.

Potential Relationship Between Gastroesophageal Reflux Disease and Atrial Arrhythmias

A potential reduction in symptoms related to atrial fibrillation after treatment of gastroesophageal reflux disease symptoms with proton pump inhibitor therapy has been previously described. However, illustration of this relationship by combined 24-hour pH and ambulatory Holter monitoring has not been performed. We report 3 patients with symptoms of both palpitations and reflux who underwent simultaneous Holter and 24-hour ambulatory pH monitoring off of antireflux therapy. All of the patients reported a reduction in arrhythmia symptoms on proton pump inhibitor therapy. The findings from this preliminary series suggest a potential relationship between gastroesophageal reflux disease and atrial arrhythmias that might improve with antireflux therapy. Patients with documentation of both atrial arrhythmias and reflux should have a trial of aggressive acid suppressive therapy To further confirm this relationship, larger prospective studies are needed to assess whether maximal acid suppression improves arrhythmias.

A Valence-Dependent Group-Specific Recall Bias of Retrospective Self-Reports

Recall is an active reconstruction process likely to distort past experiences. This distortion, known as recall bias, seems to manifest itself differently in sick and healthy people. A recall bias has been documented in several disorders, but never investigated in borderline personality disorder (BPD). To determine recall bias in BPD, we assessed momentary and retrospective ratings of specific emotions in 50 patients with BPD and 50 healthy controls (HCs), using the methodology of 24-hour ambulatory monitoring. Our data reveal a group-specific valence-dependent recall bias of retrospective self-report, indicated by a different overall recall pattern in HCs and BPD. BPD patients show an overall negative recall pattern, whereas HCs show a positive recall pattern. A traditional questionnaire approach does not distinguish between symptoms of the disorder and recall bias, although the pathological mechanisms underlying them as well as the appropriate treatment strategies may be different.