Uncomplicated Atrial Fibrillation Research Articles

Major drivers of healthcare system costs and cost variability for routine atrial fibrillation ablation.

Catheter ablation is an effective treatment for atrial fibrillation (AF) but incurs significant financial costs to payers. Reducing variability may improve cost effectiveness. We aimed to measure (1) the components of direct and indirect costs for routine AF ablation procedures, (2) the variability of those costs, and (3) the main factors driving ablation cost variability. Using data from the University of Utah Health Value Driven Outcomes system, we were able to measure direct, inflation-adjusted costs of uncomplicated, routine AF ablation to the healthcare system. Direct costs were considered costs incurred by pharmacy, disposable supplies, patient labs, implants, and other services categories (primarily anesthesia support) and indirect costs were considered within imaging, facility, and electrophysiology lab management categories. A total of 910 patients with 1060 outpatient ablation encounters were included from January 1, 2013, to December 31, 2020. Disposable supplies accounted for the largest component of cost with 44.8 ± 9.7%, followed by other services (primarily anesthesia support) with 30.4 ± 7.7% and facility costs with 16.1 ± 5.6%; pharmacy, imaging, and implant costs each contributed <5%. Direct costs were larger than indirect costs (82.4 ± 5.6% vs 17.6 ± 5.6%). Multivariable regression showed that procedure operator was the primary factor associated with AF ablation overall cost (up to 12% differences depending on operator). Direct costs and other services (primarily anesthesia) drive the majority costs associated with AF ablations. There is significant variability in costs for these routine, uncomplicated AF ablation procedures. The procedure operator, and not patient characteristic, is the main driver for cost variability.

Effect of specialist consultation on emergency department revisits among patients with uncomplicated recent-onset atrial fibrillation or flutter.

To examine the association between specialist consultation and risk of 30-day ED revisit in emergency department (ED) patients with recent-onset uncomplicated atrial fibrillation or flutter (AF/AFL). As a secondary analysis of a previously published trial, clinical experts identified predictors of consultation including age and sex, ED sinus conversion, thromboembolic risk, heart rate, rate control medication use, coronary artery disease and anti-platelet use, and chronic obstructive pulmonary disease. These were included in a propensity-matched hierarchical Bayesian model accounting for hospital site as a random effect, with 30-day ED revisit as the primary outcome. We also measured ED length of stay for consulted and non-consulted patients. We analyzed data from 11 sites for 829 ED patients with AF/AFL, of whom 364 (44%) had specialist consultation. A total of 128 patients (15.4%) had an ED revisit, 78 (16.8%) from the no consult group and 50 (13.7%) from the consult group. Consultation rates ranged from 8.8 to 71% between sites. Median length of stay was 591min (interquartile range [IQR] 359-1024) for consulted patients and 300min (IQR 212-409) for patients without consultation. After propensity-matching, consulted patients had a 0.6% (IQR -4 to 3%) lower risk of 30-day revisits than non-consulted patients (probability of lower risk 55%). In ED patients with uncomplicated AF/AFL, there was substantial between-site variation in specialist consultations; such consultation was unlikely to influence revisits within 30days while ED length of stay was nearly double. ED specialist consultations may not be necessary for uncomplicated patients.

Effect of Air Quality on the Risk of Emergency Room Visits in Patients With Atrial Fibrillation.

Background: We investigated the effect of particulate matter with aerodynamic diameter <2.5 μm (PM2.5) and meteorological conditions on the risk of emergency room visits in patients with atrial fibrillation (AF) in Beijing, which is considered as a monsoon climate region.Methods: In this case-crossover design study, medical records from patients with AF who visited the Critical Care Center in the Emergency Department of Anzhen Hospital from January 2011 through December 2014 and air quality and meteorological data of Beijing during the same period were collected and analyzed using Cox regression and time-series autocorrelation analyses.Results: A total of 8,241 patients were included. When the average PM2.5 concentration was >430 μg/m3, the risk of emergency room visits for patients with uncomplicated AF, AF combined with cardiac insufficiency, and AF combined with rheumatic heart disease increased by 12, 12, and 40%, respectively. When the average PM2.5 concentration was >420 μg/m3, patients with AF combined with diabetes mellitus had a 75% increased risk of emergency room visits, which was the largest increase in risk among all types of patients with AF. When the average PM2.5 concentration was >390 μg/m3, patients with AF combined with acute coronary syndrome had an approximately 30% increased risk of emergency room visits, which was the highest and fastest increase in risk among all types of patients with AF. The risk of emergency room visits for patients with AF was positively correlated with air quality as the time lag proceeded, with an autocorrelation coefficient of 0.223 between the risk of emergency room visits and air quality in patients with AF on day 6 of the time lag.Conclusion: Exposure to certain concentrations of PM2.5 in a monsoon climate region significantly increased the risk of emergency room visits in patients with AF.

Same-day discharge in selected patients undergoing atrial fibrillation ablation.

Atrial fibrillation (AF) ablation is a complex procedure, generally requiring at least one overnight hospital stay. We investigated the safety and feasibility of early mobilization and same-day discharge following streamlined peri-ablation management for AF. From 2014, we offered same-day discharge to selected patients who underwent uncomplicated AF ablation on the morning lists, with ultrasound-guided femoral access, uninterrupted warfarin or minimal interruption in novel oral anticoagulants, and reversal of intraprocedural heparin with protamine. Patients were discharged 6-8h postprocedure and offered access to a dedicated nurse helpline. Of 1599 AF ablation cases performed from April 2014 to March 2017, 811 (50.7%) were performed on the morning lists and 169/811 (20.8%) were discharged on the same day. Excluding 26 research cases, 1/143 (0.7%) had transient right phrenic nerve palsy and five (3.5%) cases experienced minor problems that did not preclude same-day discharge; three (2.1%) needed rehospitalization postdischarge: one for pericarditic chest pain and two for nausea/vomiting. Compared to 642 overnight cases, day-case procedures were shorter, more likely to be redos, to be performed under sedation rather than general anesthesia, and less likely to involve linear lesions and electrical cardioversion. There were no significant differences in patient age, gender, body mass index, CHA2 DS2 -VASc, in preprocedural anticoagulation regimen (warfarin vs novel anticoagulants vs no anticoagulation) and in choice of ablation method (cryoballoon vs radiofrequency). Selective same-day discharge after AF ablation is safe and feasible using a streamlined peri-procedural care protocol. Wider adoption can potentially reduce health-care costs while improving patient experience.

A Multicenter Randomized Trial to Evaluate a Chemical-first or Electrical-first Cardioversion Strategy for Patients With Uncomplicated Acute Atrial Fibrillation.

Emergency department (ED) patients with uncomplicated atrial fibrillation (AF) of less than 48 hours may be safely managed with rhythm control. Although both chemical-first and electrical-first strategies have been advocated, there are no comparative effectiveness data to guide clinicians. At six urban Canadian centers, ED patients ages 18 to 75 with uncomplicated symptomatic AF of less than 48 hours and CHADS2 score of 0 or 1 were randomized using concealed allocation in a 1:1 ratio to one of the following strategies: 1) chemical cardioversion with procainamide infusion, followed by electrical countershock if unsuccessful; or 2) electrical cardioversion, followed by procainamide infusion if unsuccessful. The primary outcome was the proportion of patients discharged within 4 hours of arrival. Secondary outcomes included ED length-of-stay (LOS); prespecified ED-based adverse events; and 30-day ED revisits, hospitalizations, strokes, deaths, and quality of life (QoL). Eighty-four patients were analyzed: 41 in the chemical-first group and 43 in the electrical-first group. Groups were balanced in terms of age, sex, vital signs, and CHADS2 scores. All patients were discharged home, with 83 (99%) in sinus rhythm. In the chemical-first group, 13 of 41 patients (32%) were discharged within 4 hours compared to 29 of 43 patients (67%) in the electrical-first group (p=0.001). In the chemical-first group, the median ED LOS was 5.1 hours (interquartile range [IQR]= 3.5 to 5.9 hours) compared to 3.5 hours (IQR= 2.4 to 4.6 hours) in the electrical-first group, for a median difference of 1.2 hours (95% confidence interval= 0.4 to 2.0 hours, p<0.001). No patients experienced stroke or death. All other outcomes, including adverse events, ED revisits, and QoL, were similar. In uncomplicated ED AF patients managed with rhythm control, chemical-first and electrical-first strategies both appear to be successful and well tolerated; however, an electrical-first strategy results in a significantly shorter ED LOS.

Missed Opportunities for Appropriate Anticoagulation Among Emergency Department Patients With Uncomplicated Atrial Fibrillation or Flutter

Emergency department (ED) patients with atrial fibrillation or flutter are at risk of stroke, and guidelines recommend anticoagulation for patients with increased cardiovascular risk. Emergency physicians have a unique opportunity to provide appropriate anticoagulation for such patients, and we wished to investigate whether this was accomplished. This retrospective cohort study used a database from 2 urban EDs to identify consecutive patients with an ED discharge diagnosis of atrial fibrillation or flutter from April 1, 2006, to March 31, 2010, who were managed solely by the emergency physician. Comorbidities, rhythms, and management were obtained by chart review, and complicated patients (those with an acute underlying medical condition) were excluded by predefined criteria. Patient medications on ED presentations were obtained through the provincial Pharmanet database. Patients were stratified into CHADS 2 (congestive heart failure, hypertension, age > 75, diabetes, stroke/transient ischemic attack) scores, and the primary outcome was the proportion of higher-risk (CHADS 2 score >0) patients who were discharged home with the incorrect anticoagulation by the emergency physician. The secondary outcome was the number of lower-risk (CHADS 2=0) patients who began receiving warfarin by the emergency physician orders. The regional ED database was interrogated to ascertain the number of patients who had a stroke at 30 days. Consecutive patients (1,090) were enrolled and 732 were discharged home with no cardiology consultation (657 fibrillation and 75 flutter). Of 151 higher-risk (CHADS 2 score >0) patients who should have been anticoagulated, 80 (53.0%; 95% confidence interval 44.7% to 61.0%) were discharged home from the ED without appropriate anticoagulation. In this group, 1 patient had an ischemic stroke at 24 days. Among 300 lower-risk patients (CHADS 2 score=0), 25 (8.3%; 95% confidence interval 5.6% to 12.2%) had warfarin initiated. In this cohort of ED patients with uncomplicated atrial fibrillation or flutter who were discharged without cardiology involvement, many were not appropriately anticoagulated before ED arrival, and more than half of such patients did not appear to have corrective measures initiated by the emergency physician. This may represent a potential opportunity to improve patient care and outcomes.

Physician-controlled costs: the choice of equipment used for atrial fibrillation ablation

PurposeAtrial fibrillation (AF) ablation uses expensive technology and equipment. Physicians have considerable latitude over equipment choice. Average Medicare reimbursement is $10,338 for uncomplicated AF ablations. The purpose of this study is to evaluate the cost of special equipment chosen by physicians to perform AF ablation.MethodsWe obtained the list price cost of special capital equipment and of disposable equipment (intracardiac ultrasound probes, transseptal needles/sheaths, and ablation/recording catheters) commonly used for radiofrequency (RF) AF ablation. We also evaluated the equipment cost of using robotic magnetic navigation and cryoablation. Then we evaluated costs for several physician equipment choice scenarios.ResultsUsing open irrigated-tip catheters, the lowest estimated cost-per-case for manual RF ablation of AF was $6,637, and the highest estimated cost of manual RF ablation was $12,603. Assuming 200 AF ablations/year and a 6-year magnet life, the cost-per-case of using magnetic navigation ablation ranged from $12,261–$15,464. The cost-per-case using cryoballoons alone ranged from $12,847–$15,320, and if focal cryoablation or RF touch-up is needed, cryoablation cost increased to $15,942–$22,284.ConclusionsPhysicians have many choices in AF ablation equipment. Equipment costs in our arbitrary scenarios range from $6,637 to $22,284 per case. More important than the specific cost of each scenario is the concept that these are physician-driven costs, and as such, physicians will need to determine if more expensive technologies increase procedural efficacy and/or patient safety enough to justify the greater procedural equipment costs.

Prehospital Atrial Fibrillation: Clinical and Economic Aspects

Objective: to retrospectively study the results of emergency medical care for patients with uncomplicated attacks of atrial fibrillation and to provide a clinical and economic assessment of their prehospital management tactics. Material and methods. A comparative retrospective study was conducted to examine the results of emergency medical care rendered to 1200 patients with uncomplicated atrial fibrillation attacks lasting as long as 24 hours. Ambulance call and outpatient cards and inpatient case reports were used. A clinical and economic assessment of the prehospital management tactics for the patients was made. Results. The prehospital therapy of atrial fibrillation was found to be ineffective in the first hour of observation. In more than 90% of cases, an atrial fibrillation attack was eliminated by the end of the first 24 hours regardless of which antiarrhythmic agent had been used. Conclusion. The proposed prehos-pital management tactics for patients with uncomplicated atrial fibrillation attacks lasting as long as 24 hours make it possible to decrease the length of stay of a called ambulance team and to enhance its efficiency, without reducing the clinical effect of performed antiarrhythmic therapy. Key words: atrial fibrillation, emergency medical care, prehospi-tal stage, clinical and economic analysis.

Peculiarities of the emergency care rendering for the patients with atrial fibrillation at a pre-admission stage: clinic-economic aspects

Comparative retrospective study of emergency care rendering results for 1200 patients with uncomplicated fibrillation attacks was carried out and their management tactics clinic-economic assessment at a pre-admission stage was done. It has been found that therapy for atrial fibrillation is unproductive in the first hour of observation at a pre-admission stage. Atrial fibrillation attack was eliminated to the end of the first day regardless of used antiarrhythmic preparation in more than 90% of the cases. Proposed management tactics for patients with uncomplicated atrial fibrillation attacks until 24 hours of duration at a pre-admission stage allows by cost lowering and clinical effect of conducting antiarrhythmic therapy maintenance to shorten an emergency team stay time and increase its operative turnover.

Intravenous diltiazem is superior to intravenous amiodarone or digoxin for achieving ventricular rate control in patients with acute uncomplicated atrial fibrillation*

To compare the clinical efficacy of intravenous diltiazem, digoxin, and amiodarone for acute ventricular rate (VR) control in patients with acute symptomatic atrial fibrillation (AF) necessitating hospitalization. Randomized control trial. Acute emergency medical admission unit in a regional teaching hospital in Hong Kong. One hundred fifty adult patients with acute AF and rapid VR (>120 bpm). Patients were randomly assigned in 1:1:1 ratio to receive intravenous diltiazem, digoxin, or amiodarone for VR control. The primary end point was sustained VR control (<90 bpm) within 24 hours; the secondary end points included AF symptom improvement and length of hospitalization. At 24 hours, VR control was achieved in 119 of 150 patients (79%). The time to VR control was significantly shorter among patients in the diltiazem group (log-rank test, p < 0.0001) with the percentage of patients who achieved VR control being higher in the diltiazem group (90%) than the digoxin group (74%) and the amiodarone group (74%). The median time to VR control was significantly shorter in the diltiazem group (3 hours, 1-21 hours) compared with the digoxin (6 hours, 3-15 hours, p < 0.001) and amiodarone groups (7 hours, 1-18 hours, p = 0.003). Furthermore, patients in the diltiazem group persistently had the lowest mean VR after the first hour of drug administration compared with the other two groups (p < 0.05). The diltiazem group had the largest reduction in AF symptom frequency score and severity score (p < 0.0001). In addition, length of hospital stay was significantly shorter in the diltiazem group (3.9 +/- 1.6 days) compared with digoxin (4.7 +/- 2.1 days, p = 0.023) and amiodarone groups (4.7 +/- 2.2 days, p = 0.038). As compared with digoxin and amiodarone, intravenous diltiazem was safe and effective in achieving VR control to improve symptoms and to reduce hospital stay in patients with acute AF.

Circulating endothelial cells in atrial fibrillation with and without acute cardiovascular disease

Normal adults have very few circulating endothelial cells (CECs) in their blood, but increased levels have been shown in association with conditions associated with endothelial damage such as myocardial infarction and stroke. As atrial fibrillation (AF) is associated with a hypercoagulable state and abnormalities of plasma indices of endothelial damage/dysfunction, we hypothesised that CECs would also be raised in this condition, and would correlate with these plasma markers. We measured CECs (by immunofluoresence) as an indicator of frank endothelial damage, alongside 3 plasma indices of endothelial perturbation: von Willebrand factor (vWf), soluble E-selectin and soluble thrombomodulin (sTM) (all ELISA) in 28 patients with chronic 'stable' AF, 63 patients with AF plus an acute cardiovascular or cerebrovascular event as positive controls, and 20 healthy subjects in sinus rhythm as negative controls. Chronic 'stable' AF patients had significantly higher levels of plasma vWf (p<0.001 ), but comparable numbers of CECs (p=0.1638) in comparison to healthy controls. In patients with AF associated with an acute cardiovascular or cerebrovascular event, levels of CECs (p<0.0001) and sTM (p=0.004), but not vWf or sEsel, were significantly increased in comparison to chronic 'stable' AF patients. Patients with uncomplicated AF have abnormal systemic endothelial damage/dysfunction, as evident by increased plasma vWf levels, but normal numbers of CECs, compared to subjects in sinus rhythm. However, following clinical complications, such as stroke or significant haemodynamic compromise, further endothelial disturbance (as indicated by high levels of sTM and CECs) suggests additional endothelial damage.

Low Molecular Weight Heparin in Atrial Fibrillation Management: Facts, Fiction, Future

Atrial fibrillation (AF) is the most common sustained arrhythmia and various AF disease management strategies can be utilized. A prospective, randomized pilot study of two AF disease management strategies was conducted at a single university hospital in patients newly diagnosed with AF. The impact of low molecular weight heparin (LMWH) on AF management strategies is discussed with respect to the current guidelines for AF management, existing data on LMWH for AF, and recent investigations pertaining to AF. 18 patients were enrolled. The accelerated emergency department based strategy utilizing LMWH resulted in a significant reduction in length of stay (2.1 +/- 2.3 versus <1 day) and a trend toward lower costs (1,706 +/- 1,512 dollars versus 879 +/- 394 dollars; p = 0.15) when compared to the more traditional strategy of hospital admission. Measured clinical outcomes were similar for both treatment strategies. The investigation showed that an outpatient, emergency department based disease management strategy for new, uncomplicated AF could result in clinically acceptable, cost-effective innovations in AF treatment strategies. LMWH is an example of an agent allowing innovations in disease management strategies.

A prospective, randomized, controlled trial of an emergency department–based atrial fibrillation treatment strategy with low-molecular-weight heparin

Study objective: We assess an alternative accelerated clinical pathway approach to the management of patients with newly diagnosed or new-onset atrial fibrillation (AF). Methods: A prospective, randomized pilot study of 2 AF disease-management strategies was conducted at a single university hospital. A traditional approach of hospital admission versus an accelerated emergency department–based strategy with low-molecular-weight heparin and early cardioversion to sinus rhythm was assessed in a cohort of patients with uncomplicated AF. The primary end points were length of stay and total actual direct costs. Results: Eighteen patients were randomized over a 15-month period. The accelerated treatment strategy in the ED resulted in a substantial decrease in length of stay (2.1±2.3 versus <1 day) and a favorable trend toward mean cost reduction ($1,706±$1,512 versus $879±$394; P =.15). The clinical outcomes (rate of sinus rhythm at discharge and follow-up and complications caused by AF) related to AF were similar in the 2 groups. Conclusion: A disease-management strategy for new, uncomplicated AF that uses an ED-outpatient treatment pathway results in a shorter length of stay at potentially lower cost. The results of this pilot study warrant further investigation. [Kim MH, Morady F, Conlon B, Kronick S, Lowell M, Bruckman D, Armstrong WF, Eagle KA. A prospective, randomized, controlled trial of an emergency department–based atrial fibrillation treatment strategy with low-molecular-weight heparin. Ann Emerg Med. August 2002;40:187-192.]

Clinical outcomes and costs associated with a first episode of uncomplicated atrial fibrillation presenting to the emergency room

A trial fibrillation (AF) is a frequent reason for emergency room visits.1 Traditional practice has been to admit patients with new AF for management.2 Despite this widespread practice pattern, the clinical utility of this approach is uncertain, as evidenced by a recent retrospective review of patients with acute, uncomplicated AF.3 A retrospective chart review was performed on all patients presenting with AF to the emergency room at a university hospital from September 1997 to November 1998, to assess the impact of a first episode of uncomplicated AF on clinical outcomes, length of stay, and actual direct costs. • • • Patients meeting the following eligibility criteria had data abstracted: (1) newly diagnosed or new onset AF; (2) uncomplicated clinical status at initial presentation, with no indication for hospital admission other than AF; (3) age between 18 and 75 years; (4) no contraindications to anticoagulation; and (5) no symptomatic congestive heart failure or known left ventricular ejection fraction ,30%. Forty-seven patients were identified. AF was confirmed in each case and the records were abstracted for baseline clinical and demographic information, clinical outcomes, medical management, length of stay, and clinical follow-up after initial presentation. Actual direct costs were calculated using the Transition Systems, Inc., cost allocation system (Eclipsys Corporation, Delray Beach, Florida). The costs of diagnostic testing (echocardiography, stress testing) related to AF after discharge performed on an outpatient basis were included. Subgroup analyses were performed based on the disposition of the patient after emergency room evaluation and on the presence or absence of spontaneous conversion of AF to sinus rhythm. Bivariate comparisons were made using Fisher’s exact test, chi-square test, or Pearson’s chi-square test, and means were compared across groups using Student’s t test. SAS version 6.2 (SAS Institute, Cary, North Carolina) was used for analyses. A p value ,0.05 was considered significant. The study group consisted of 47 patients with a mean age of 57 6 16 years (range 18 to 75). Baseline clinical and demographic characteristics are listed in Table 1. The use of rate control, anticoagulation, and resource utilization after initial presentation are shown in Table 2. The mean length of stay was 1.72 6 0.99 days (range 1 to 5) and the mean actual direct cost was $1,989 6 $1,583 dollars (range $202 to $4,430). The 25th and 75th percentiles for length of stay were 1 and 2 days, and for actual direct costs were $1,171 and $2,443. Among the 47 patients, 39 patients (83%) were admitted to the hospital and 8 patients (17%) were discharged from the emergency room. Mean age and gender ratio did not differ between the admitted paFrom the Cardiovascular Division, Washington University, St. Louis, Missouri; the Heart Care Program, Consortium for Health Outcomes, Innovation, and Cost Effectiveness Studies, and the Department of Emergency Medicine, University of Michigan Health System, Ann Arbor, Michigan. Drs. Kim and Eagle were supported by a research grant from Pharmacia-Upjohn Pharmaceuticals, Kalamazoo, Michigan. Dr. Kim’s address is: Campus Box 8086, Cardiovascular Division,Washington University in St. Louis, 660 S. Euclid Ave., St. Louis, Missouri 63110. E-mail: mkim@im.wustl.edu. Manuscript received September 14, 2000; revised manuscript received and accepted January 24, 2001. TABLE 1 Clinical Features of the Study Group (n 5 47)

Perioperative management of the chronically anticoagulated patient.

Common indications for chronic anticoagulation include mechanical prosthetic heart valve, non-rheumatic atrial fibrillation, and venous thromboembolism. Perioperative management of the chronically anticoagulated patient is a complex medical problem, and includes the following issues: urgency of surgery, risk of thromboembolism in the absence of anticoagulation, bleeding risk, consequences of bleeding, ability to control bleeding physically, and duration of bleeding risk after the procedure. Most patients can be managed safely by stopping oral anticoagulants 4-5 days before surgery and restarting anticoagulation after the procedure at the patient's usual daily dose. In general, dental procedures and cataract extraction can be performed without interrupting anticoagulation. Most other procedures can be safely performed with an INR < or = 1.4. For patients with double-wing prosthetic valves (e.g., St. Jude, Carbomedics) in the aortic position, uncomplicated atrial fibrillation, or a remote (>3 months) history of venous thromboembolism, oral anticoagulants can be stopped 4-5 days before surgery and restarted at the usual daily dose immediately after surgery. For other patients at higher risk of thrombosis, "bridging therapy" with outpatient low molecular weight heparin is safe and effective. For urgent procedures, a small dose of oral vitamin K usually will reduce the INR within 24-36 hours to a level sufficient for surgery and avoids exposure to transfused blood products.

Influence of Metoprolol CR/ZOK on Plasminogen Activator Inhibitor (PAI‐1) in Man: A Pilot Study

Recent primary and secondary preventive trials have shown that long-term metoprolol therapy reduces the risk of acute cardiovascular complications. To test whether part of this beneficial long-term effect may be due to effects on the fibrinolytic system, three pilot studies were performed; two in healthy individuals, and one in patients with mild hypertension or uncomplicated atrial fibrillation. The effect of metoprolol CR/ZOK (controlled release) 100-200 mg daily, on plasminogen activator inhibitor activity (PAI-1) in plasma was measured. In addition serum triglycerides and orosomucoid were analyzed. All the individuals were included in double-blind placebo controlled cross-over trials with treatment periods ranging from 4 days to 3 weeks. During metoprolol therapy PAI-1 values were reduced, while orosomucoid and triglyceride levels were unchanged. A linear inverse correlation was found between fibrinolysis and PAI-1 activity in plasma, indicating that PAI-1 activity serves as an indicator of fibrinolysis. PAI-1 activity and triglycerides were significantly correlated during placebo and metoprolol therapy. In conclusion, our results in these pilot studies suggest that metoprolol enhances fibrinolytic activity as seen by reduced PAI-1 activity. These results should be further confirmed and put into relation of clinical effects of the therapy.

Hepatic disease during long-lasting atrial fibrillation.

Long-standing ascites of benign nature, associated with Peripheral edema and minimal liver functioin disturbance was observed in 15 cases of 472 patients suffering from atrial fibrillation without any other apparent signe of cardiac disease. The duration of ascites and edema correlated with the durationof uncomplicated atrial fibrillation.

A recognition of digitalis intoxication in the presence of atrial fibrillation.

In the presence of atrial fibrillation, digitalis toxicity can produce A-V nodal escape rhythm or non-paroxysmal A-V nodal tachycardia, and both of these are characterized by a regular ventricular rhythm. Non-paroxysmal A-V nodal tachycardia with exit block or the intermittent appearance of A-V nodal tachycardia, A-V nodal escape rhythm or ventricular premature contractions can produce an irregular rhythm which simulates uncomplicated atrial fibrillation. These digitalis-induced arrhythmias are not frequently associated with gastrointestinal symptoms and therefore an electrocardiogram is essential for diagnosis.

Atrial dissociation due to unilateral atrial fibrillation

A case of atrial dissociation due to unilateral atrial fibrillation is presented. Transitional changes from sinus rhythm to atrial dissociation due to unilateral atrial fibrillation followed by uncomplicated atrial fibrillation clearly demonstrated a true existence of such rare and interesting arrhythmia. This patient had irreversible congestive heart failure presumably due to idiopathic cardiomyopathy and expired shortly after the arrhythmia developed. The possible mechanism of atrial dissociation is described. All patients with atrial dissociation should be observed closely because the arrhythmia frequently appeared shortly before death.

Digitalis-induced cardiac arrhythmias: a report of 180 cases.

Digitalis is an essential drug in the treatment of congestive heart failure and various supraventricular arrhythmias. However, digitalis may produce or aggravate congestive heart failure and almost every known cardiac arrhythmia. A recognition of digitalis-induced arrhythmias is extremely important because cardiac arrhythmias may often indicate digitalis intoxication without any other signs.One hundred and eighty patients with digitalis intoxication studied by this author were presented. The total incidence of digitalis-induced arrhythmias was 346 episodes. The overall incidence of ventricular arrhythmias was highest (104 patients) and, among these, ventricular premature contractions predominated. The basic rhythm was atrial fibrillation in 87 patients and almost all of these patients showed either nonparoxysmal A-V nodal tachycardia or A-V nodal escape rhythm. This information is extremely important since A-V nodal arrhythmia in the presence of atrial fibrillation are frequently misinterpreted as uncomplicated atrial fibrillation. Frequent occurrence of A-V dissociation with A-V nodal arrhythmias was emphasized. Nineteen patients had atrial tachycardia and A-V conduction disturbances were encountered in 64 patients.Sudden appearance of rapid or slow heart action during digitalization should make one suspect digitalis toxicity rather than need for increased digitalis. Immediate recognition of digitalis toxicity particularly digitalisinduced arrhythmias and withdrawal of digitalis are essential to minimize the relatively high mortality.