In Consultation

IN CONSULTATION

tion consisted of medical history, esophageal manometry, endoscopy, and 24-h ambulatory monitoring of esophageal pH and pressure. Measurements and results: In five patients a diagnosis of ischemic coronary artery disease was made. In only two of these five patients, the cardiologic history strongly suggested a cardiac origin of the pain. Twelve patients had a pathologic 24-h pH profile, four of whom also had reflux esophagitis. Ten patients had symptomatic reflux. In only three of these ten patients, the history was judged to be indicative of an esophageal origin of the chest pain. No motility disorders were found. Conclusions: Thirty-six percent of the patients with chest pain newly referred to a cardiologic outpatient clinic have symptomatic gastroesophageal reflux. Neither cardiologic nor gastroenterologic history data have a high predictive value with respect to the origin of the chest pain.

Spontaneous Iliopsoas Hematoma in Patients With Unstable Coronary Syndromes Receiving Intravenous Heparin in Therapeutic Doses Z. Sasson, I. Mangat, K.A. Peckham. Mount Sinai Hospital, Toronto, Ont., Canada. Can J Cardiol 1996;12:490–4. Objective: To identify the relationship between the use of anticoagulants, specifically heparin, and the development of iliacus and psoas muscle hematoma. Three patients with unstable angina who developed groin pain while on heparin anticoagulation are presented. Patients who are anticoagulated with heparin are at increased risk of developing iliacus or psoas hematoma, manifesting a wide range of symptoms from groin pain to massive bleeding and shock. Identification of these patients is crucial in cardiology practice. Data sources: MEDLINE searches under “iliacus”, “psoas” and “iliopsoas hematoma” were conducted and cross referenced with patients on anticoagulant therapy. Only English language articles were included. Study selection: The search covered January 1966 to February 1995. Fifty-one articles were studied. Data synthesis: The current literature suggests that anticoagulation can cause iliacus or psoas muscle hematoma and usually presents as femoral neuropathy. However, the presented case reports provide evidence that an earlier manifestation of this entity is the development of groin pain, and that early identification is crucial to improving patient morbidity and mortality. Conclusions: Patients who are on heparin anticoagulation should be carefully monitored for development of groin pain or leg weakness. In such cases, early recognition of possible iliacus or psoas hematoma should be abdominal ultrasound or computed tomography, and heparin anticoagulation should be modified according to its clinical requirement.

Intermittent Pacemaker Dysfunction Caused by Digital Mobile Telephones B. Naegeli, S. Osswald, M. Deola, F. Burkart. Cardiac Unit, Department of Internal Medicine, University Hospital, Basel, Switzerland. J Am Coll Cardiol 1996;27:1471–7. Objectives: This study was designed to evaluate possible interactions between digital mobile telephones and implanted pacemakers. Background: Electromagnetic fields may interfere with normal pacemaker function. Development of bipolar sensing leads and modern noise filtering techniques have lessened this problem. However, it remains unclear whether these features also protect from high frequency noise arising from digital cellular phones. Methods: In 39 patients with an implanted pacemaker (14 dualchamber [DDD], 8 atrial-synchronized ventricular-inhibited [VDD(R)] and 17 ventricular-inhibited [VVI(R)] pacemakers), four mobile phones with different levels of power output (2 and 8 W) were tested in the standby, dialing and operating mode. During continuous electrocardiographic monitoring, 672 tests were performed in each mode with the phones positioned over the pulse generator, the atrial and the ventricular electrode tip. The tests were carried out at different sensitivity settings and, where possible, in the unipolar and bipolar pacing modes as well. Results: In 7 (18%) of 39 patients, a reproducible interference was induced during 26 (3.9%) of 672 tests with the operating phones in close proximity (,10 cm) to the pacemaker. In 22 dual-chamber (14 DDD, 8 VDD) pacemakers, atrial triggering occurred in 7 (2.8%) of 248 and ventricular inhibition in 5 (2.8%) of 176 tests. In 17 VVI (R) systems, pacemaker inhibition was induced in 14 (5.6%) of 248 tests. Interference was more likely to occur at high power output of the phone and at maximal sensitivity of the pacemakers (maximal vs. nominal sensitivity, 6% vs. 1.8% positive test results, p 5 0.009). When the bipolar and unipolar pacing modes were compared in the same patients, ventricular inhibition

Prevalence of Esophageal Disorders in Patients With Chest Pain Newly Referred to the Cardiologist J.-H. Voskuil, M.J. Cramer, R. Breumelhof, R. Timmer, A.J.P.M. Smout. Department of Gastroenterology, St. Antonius Hospital, Nieuwegein, the Netherlands. Chest 1996;109: 1210–4. Study objective: The prevalence of esophageal disorders (dysmotility and/or gastroesophageal reflux) in patients with chest pain newly referred to a cardiologic clinic is unknown. The aims of our study were to investigate the prevalence of esophageal abnormalities in these patients and to assess the value of medical history in predicting the origin of the patient’s chest pain. Design: We evaluated 28 consecutive patients who were newly referred to the cardiologist because of angina-like chest pain. Patients with evidence of severe myocardial ischemia were excluded. Cardiologic evaluation included medical history, physical examination, ECG, and exercise testing; further cardiologic workup was carried out only when considered necessary. Gastroenterologic evalua-

ACC CURRENT JOURNAL REVIEW January/February 1997

87

IN CONSULTATION

was induced only in the unipolar mode (12.5% positive test results, p 5 0.0003). Conclusions: Digital mobile phones in close proximity to implanted pacemakers may cause intermittent pacemaker dysfunction with inappropriate ventricular tracking and potentially dangerous pacemaker inhibition.

ically significant cardiac arrhythmias. Twenty-four (29%) of the remaining 82 patients had a current psychiatric disorder, and 20 of these patients (83%) had major depression or panic disorder. These patients were significantly younger and more disabled, somatized more, and had more hypochondriacal concerns about their health than did patients who had no psychiatric disorder. Their palpitations were more likely to last longer than 15 minutes, were accompanied by more ancillary symptoms, and were described as more intense. At 3-month follow-up, about 90% of the patients in both groups continued to experience palpitations. Symptoms of somatization, hypochondriacal concerns, and impairment of intermediate activities had improved in both groups, but remained higher in patients with psychiatric disorder than in patients without psychiatric disorder. During the follow-up interval, patients with psychiatric disorder had more emergency department visits. The physicians of patients with psychiatric disorder were more likely to ascribe the palpitations to anxiety or depression, and ordered fewer laboratory tests on them, but few patients who had not already been in psychiatric treatment were referred or started on psychotropic medication. Conclusions: Physicians are aware of a psychiatric component to the clinical presentation of palpitation, but this observation does not result in psychiatric treatment or referral in most cases.

Cardiac Manifestations of Lyme Disease: A Review K.S. Nagi, R. Joshi, R.K. Thakur. Arrhythmia Service, Thoracic Cardiovascular Institute, Lansing, MI. Can J Cardiol 1996;12:503–6. Objective: To describe the clinical features of cardiac manifestations of Lyme disease, the most common vector-borne illness in North America, which occasionally results in cardiac involvement. Data sources: A review of the Englishlanguage clinical literature pertaining to Lyme disease and Lyme carditis indexed in MEDLINE from 1975 to 1995. Data extraction: Studies describing diagnosis, clinical features, treatment or outcome were reviewed. Data synthesis: Cardiac complications of Lyme disease may occur in up to 8% of patients. Cardiac manifestations occur in the early phase of the illness, at a median of 21 days from the onset of erythema migrans. Manifestations of Lyme carditis include atrioventricular block, myopericarditis, intraventricular conduction disturbances, bundle branch block and congestive heart failure. Temporary cardiac pacing may be required in up to a third of cases and complete recovery occurs in most (greater than 90%) patients. The overall prognosis of Lyme carditis is very good, although recovery may be delayed and late complications such as dilated cardiomyopathy may occur. Conclusion: Lyme disease is a tick-borne spirochetal infection caused by Borrelia burgdorferi. Cardiac complications of Lyme disease generally occur in the early phase and include conduction system disturbances, myopericarditis and congestive heart failure.

History of Migraine and Risk of Cerebral Ischaemia in Young Adults A. Carolei, C. Marini, G. De Matteis. Dipt Medicina Intern Sanita Pubblica, Universita degli Studi di L’Aquila, L’Aquila-Collemaggio, Italy. Lancet 1996;347:103–6. Background: A history of migraine has been proposed as a risk factor for cerebral ischaemia in women under 45. Methods: To investigate the association between history of migraine and cerebral ischaemia, we performed a case-control study of 308 patients aged 15– 44, with either transient ischaemic attack (TIA) or stroke, and of 591 age- and sexmatched controls prospectively recruited in seven university hospitals. Crude and adjusted odds ratios were calculated using logistic regression analysis. Findings: A history of migraine was more frequent in patients than in controls (14.9% vs 9.1%; adjusted odds ratio 1.9, 95% confidence interval 1.1–3.1). In the prospectively designed subgroup analyses, a history of migraine reached the highest odds ratio (3.7, 95% CI 1.5–9) and was the only significant risk factor in women below age 35 (p 5 0.003); atherogenic risk factors were more relevant in men and in patients older than 35; previous migraine attacks with aura were more frequent in stroke patients (odds ratio 8.6, 95% CI 1–75). Interpretation: Our findings indicated that the rare association between migraine and cerebral ischaemia is limited to women below

Somatized Psychiatric Disorder Presenting as Palpitations A.J. Barsky, B.A. Delamater, S.A. Clancy, E.M. Antman, D.K. Ahern. Division of Psychiatry, Brigham and Women’s Hospital, Boston, MA. Arch Intern Med 1996;156: 1102–8. Background: Psychiatric disorder is underdiagnosed in primary care practice, often because it is somatized and the patient reports only physical symptoms. Palpitations are among the symptoms that often are somatized. Methods: We studied prospectively 125 consecutive medical outpatients referred for ambulatory electrocardiographic monitoring to evaluate a chief complaint of palpitations. They completed an in-person research interview at the time of monitoring and a telephone follow-up interview 3 months later. The referring physicians completed questionnaires about their patients before receiving the results of the monitoring and again 3 months later. Results: Forty-three patients had clin-

ACC CURRENT JOURNAL REVIEW January/February 1997

88

IN CONSULTATION

age 35, and suggest a need for careful clinical evaluation of comorbidity in the presence of migraine with aura.

mortality, however, was increased in the left BBB group when compared with their controls (p 5 0.01, log rank test). Left BBB, but not right BBB, was associated with an increased prevalence of cardiovascular disease at follow-up (21% vs 11%; p 5 0.04). In the absence of clinically overt cardiac disease, the presence of left BBB or right BBB is not associated with increased overall mortality. Isolated left BBB is associated with an increased risk of developing overt cardiovascular disease and increased cardiac mortality.

Electrocardiographic Abnormalities in Patients Receiving Hemodialysis S. Abe, M. Yoshizawa, N. Nakanishi, T. Yazawa, K. Yokota, M. Honda, G. Sloman. Department of Internal Medicine, Keio University, Tokyo, Japan. Am Heart J 1996; 131:1137–44. We assessed standard 12-lead and Holter electrocardiographic (ECG) abnormalities in maintenance hemodialysis (HD) patients. Of 221 outpatients receiving HD, 143 (65%) had ECG abnormalities. Rates were higher in male, elderly, hypertensive, and diabetic patients than in female, younger, normotensive, and nondiabetic patients. The prevalence of ECG changes correlated inversely with HD duration. Serial ECGs were compared in 87 patients whose average HD duration was 7.5 6 2.5 years. Thirty-four patients (39%) showed normal ECGs throughout, 27 (31%) relatively stable abnormalities, 22 (25%) worsening, and 4 (5%) reversion to normal. Age, hypertension, and diabetes are factors related to abnormal ECG findings. Among the 142 Holter recordings from 72 patients, 70 (97%) were basically in sinus rhythm, and 2 (3%) were in atrial fibrillation. The average frequency of supraventricular premature contractions (SVPCs) was 1597 6 9725 per 24 hours, and that of ventricular premature contractions (VPCs), 556 6 1415. VPCs were multifocal in 9%, runs in 25%, and early in 1%. In 29 (40%) of recordings, VPCs appeared mainly during and for several hours after HD. ST-T changes were seen in 43 (60%). In 11, ST depression occurred during and a few hours after HD. Patients receiving HD showed diverse ECG abnormalities. Holter ECGs revealed a high incidence of arrhythmias and ST-T changes, which frequently appeared in relation to HD timing.

Long-Term Outcome of Mothers of Children With Complete Congenital Heart Block J. Press, Y. Uziel, R.M. Laxer, L. Luy, R.M. Hamilton, E.D. Silverman. Division of Rheumatology, Hospital for Sick Children, Toronto, Ont., Canada. Am J Med 1996; 100:328–32. Objectives: To determine the health of mothers of offspring with complete congenital heart block (CHB) both at the time of delivery of the affected child and in the long-term, and the percentage of mothers of children with CHB who had antiSSA/Ro and/or SSB/La antibodies. Patients and methods: Sixtyfour mothers of 64 children with CHB (seen between 1964 and 1993) were identified through the Cardiology database of The Hospital for Sick Children, Toronto, Canada. Medical information from these of children with CHB was evaluated. Data were obtained from the mothers by mailed questionnaire, telephone interview, and/or from the attending physicians. The presence of anti-Ro antibodies and anti-La antibodies were evaluated by ELISA assay. Results: The mean age at the time of delivery of the first child with CHB was 28 6 6 years. At the time of delivery 42 (66%) mothers were healthy, 2 (3%) had systemic lupus erythematosus (SLE), 2 (3%) had linear scleroderma, 2 (3%) had rheumatoid arthritis; 3 (5%) had a history of rheumatic fever (but were otherwise well), 1 (2%) had Sjogren’s syndrome (SS), and 12 (19%) had an undifferentiated autoimmune syndrome (UAS) (arthralgia, myalgia, photosensitivity, skin vasculitis, Raynaud’s phenomenon). The mean time to follow-up from delivery to study was 121 6 88 months. The mean maternal age at study was 38 6 9 years. Three of 12 mothers who initially had a UAS progressed to SLE (average follow-up time of 80 months, median 96), and 2 developed SS (with average follow-up time 140 months, median 132) and 1 went into remission. The mean follow-up time for the other mothers who did not develop an autoimmune disease was 150 6 102 months. Thirty-six of the 42 initially healthy mothers remained well. One mother developed SLE; 1 developed hyperthyroidism; 1 developed ankylosing spondylitis; and 3 developed an UAS. The mean follow-up time of the 36 mothers who remained healthy was similar (123 6 97 months) to the 6 initially healthy mothers who developed an autoimmune disease (121 6 36 months). Anti-Ro and/or

Natural History of Isolated Bundle Branch Block G.J. Fahy, S.L. Pinski, D.P. Miller, N. McCabe, C. Pye, M.J. Walsh, K. Robinson. Department of Cardiology F15, Cleveland Clinic Foundation, Cleveland, OH. Am J Cardiol 1996;77:1185–90. The purpose of this study was to determine the long-term outcome of patients with bundle branch block (BBB) who have no clinical evidence of cardiovascular disease. Among 110,000 participants in a screening program, 310 subjects with BBB without apparent or suspected heart disease were identified. Their outcome after a mean follow-up of 9.5 years was compared with that of 310 similarly screened age- and sex-matched controls. Among the screened population, isolated right BBB was more prevalent than isolated left BBB (0.18% vs 0.1%, respectively; p , 0.001), and the prevalence of each abnormality increased with age (p , 0.001). Total actuarial survival was no different for those with left BBB or right BBB and their respective controls. Cardiac

ACC CURRENT JOURNAL REVIEW January/February 1997

89

IN CONSULTATION

anti-La antibodies were positive in 32 of 53 (60%) mothers tested. Fourteen of the 53 mothers were symptomatic at the time of delivery and 39 were asymptomatic. Anti-Ro and/or anti-La antibodies were positive in 12 of 13 mothers tested at the time of delivery. Conclusions: The long-term maternal outcome in our cohort was very good as most of the initially healthy mothers remained well at follow-up. Twenty-five percent of the mothers with a UAS and only 2% of the initially healthy mothers developed SLE. The development of an autoimmune disease in an asymptomatic mother identified by the birth of a child with CHB was less common in our study than in previous studies. However, close follow-up of mothers with UAS is warranted.

CONSULTATION

The Utility of Echocardiography in Cardiac Tamponade William C. Maxted, Jr, MD and Douglas S. Segar, MD, Krannert Institute of Cardiology, Indianapolis, Indiana

Air Travel and Adults With Cyanotic Congenital Heart Disease

The Utility of Echocardiography in Cardiac Tamponade ardiac tamponade refers to the hypotension that results from extrinsic compression of one or more cardiac chambers. It is not a discrete event, but it represents a continuum from a clinically nonsignificant occurrence to hemodynamic collapse. This is commonly attributable to elevated intrapericardial pressure with equilibration of the intrapericardial and intracavitary enddiastolic pressures (1). The common echocardiographic features of tamponade, including the limitations of transthoracic echocardiography will be discussed.

E. Harinck, P.A. Hutter, T.M. Hoorntje, M. Simons, A.A. Benatar, J.C. Fishcer, D. De Bruijn, E.J. Meijboom. Wilhelmina University Children’s Hospital, Utrecht, the Netherlands. Circulation 1996;93:272–6. Background: Concern has been expressed that a reduction of partial oxygen pressure during flight in commercial aircraft may induce dangerous hypoxemia in patients with cyanotic congenital heart disease. Methods and Results: To evaluate the validity of this concern, the transcutaneous SaO2 was measured in 12 adults with this type of heart disease and 27 control subjects during simulated commercial flights of 1.5 and 7 hours in a hypobaric chamber. Ten of those patients and 6 control subjects also were evaluated during two actual flights of approximately 2.5 hours in a DC-10 and an A-310, respectively. During the prolonged simulated and actual flights, the capillary blood pH, gases, and lactic acid were analyzed in the patients and during one of the actual flights also in the control subjects. During the simulated flights the SaO2 was at all times lower in the patients than in the control subjects. However, the maximal mean actual percentage decrease, as compared with sea level values, did not exceed 8.8% in either patients or control subjects. During the actual flights, this maximal decrease in the patients was 6%. Inflight reduction of the capillary PO2 was considerable in the control subjects but not in the patients. It is our hypothesis that the hick of a significant decrease of the PO2 in the patients might possibly be due to a high concentration of 2.3 diphosphoglycerate in the red cells. The flights had no influence on the capillary blood pH, PCO2, bicarbonate, or lactic acid levels in either patients or control subjects. Conclusions: Atmospheric pressure changes during commercial air travel do not appear to be detrimental to patients with cyanotic congenital heart disease.

Echocardiographic Determination of Tamponade 2-D echocardiography Findings on two-dimensional (2-D) echocardiogram equated with the diagnosis of tamponade include swinging of the heart in a pericardial effusion, respiratory variation in left and right ventricular sizes and right atrial and right ventricular diastolic collapse. The swinging motion of the heart signifies a large pericardial effusion but does not denote hemodynamic significance. During inspiration, the right ventricle (RV) enlarges because of augmentation of venous return. During tamponade, the RV free wall excursion is limited by the increased pericardial pressure; consequently, the septum may bulge further into the left ventricle. This results in a decreased left ventricular size during inspiration (2,3) and is the 2-D echocardiographic correlate of pulsus paradoxus (4). Right ventricular size during tamponade will generally be smaller than it is without extrinsic compression. Hence, comparison to previous echocardiograms may be useful in diagnosis. Two-dimensional echocardiograms reliably demonstrate right ventricular and right atrial diastolic collapse (Figure 1). Right atrial diastolic collapse is more sensitive but less specific than right ventricular collapse. A method described to increase the specificity and predictive value of right atrial collapse involves determining the relative amount of time during the cardiac cycle that the right atrium is collapsed (right atrial time inversion index) (5). A right atrial inversion time index of 0.34 was found to be consistent with tamponade with both a sensitivity and specificity of .90%. This was not affected by atrial fibrillation or flutter (5). The area of right atrial inversion is not predictive of tamponade (5). Right ventricular collapse most commonly occurs along

C

ACC CURRENT JOURNAL REVIEW January/February 1997 © 1997 by the American College of Cardiology Published by Elsevier Science Inc.

90

1062-1458/97/$17.00 PII S1062-1458(96)00135-3