- Email: [email protected]
Lyme carditis: Sequential electrocardiographic changes in response to antibiotic therapy
Letters to the Editor
Acknowledgement The author of this manuscript has certified that he complies with the Principles of Ethical Publishing in the International Journal of Cardiology [3].
167
[2] Mettenleiter A. Adam Christian Thebesius (1686–1732) und die Entdeckung der Vasa Cordis Minima. Sudhoffs Arch Z Wiss Beih 2001;47: 3–580. [3] Coats AJ. Ethical authorship and publishing. Int J Cardiol 2009;131: 149–50.
References [1] Loukas M, Clarke P, Tubbs RS, Kolbinger W. Adam Christian Thebesius, a historical perspective. Int J Cardiol 2008;129:138–40. 0167-5273/$ - see front matter © 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2008.03.042
Lyme carditis: Sequential electrocardiographic changes in response to antibiotic therapy Kamran Manzoor a , Waqas Aftab b , Sonia Choksi c , Ijaz A. Khan d,⁎ a
Charleston Area Medical Center, Charleston, West Virginia, USA Community Regional Medical Center, Fresno, California, USA c North Central Bronx Hospital, Bronx, New York, USA d Good Samaritan Hospital, Baltimore, Maryland, USA
b
Received 27 January 2008; accepted 3 May 2008 Available online 5 August 2008
Abstract Lyme disease is a tick-borne spirochetal infection that may involve heart. The cardiac manifestations of Lyme disease including varying degrees of atrioventricular heart block occur within weeks to months of the infecting tick bite. This report describes a 43 year-old man with Lyme carditis who presented with complete heart block. The heart block resolved with ceftriaxone therapy. Lyme carditis should be considered in the differential diagnosis in patients who present with new onset advanced heart block. © 2008 Elsevier Ireland Ltd. All rights reserved. Keywords: Lyme carditis; Borrelia burgdorferi; Ixodes scapularis; Third degree heart block; Atrioventricular conduction block
Lyme carditis is one of the most challenging diagnoses if the presentation is atypical with no clear evidence of rash and arthritis. The cardiac involvement in early, disseminated disease usually presents with complaints of shortness of breath, palpitations, chest pain or syncope. The electrocardiographic manifestations of myocardial involvement include a varying degree of atrioventricular block or more diffuse signs of myocarditis. A high degree of atrioventricular block without cardiac risk factors may point towards a diagnosis of Lyme carditis. The micro⁎ Corresponding author. Division of Cardiology, Good Samaritan Hospital, 5601 Loch Raven Boulevard, Baltimore, Maryland 21239, USA. Tel.: +1 43 44 607; fax: +1 410 532 4606. E-mail address: [email protected] (I.A. Khan).
biological laboratory tests are insensitive initially and a negative serology does not exclude the diagnosis. The diagnosis is usually made on clinical grounds on admission, and antibiotics therapy is usually initiated even prior to the availability of serological results. The conduction abnormalities respond well to antibiotic treatment with an excellent prognosis. A 43-year-old man who worked in parks as a plumber in upstate New York presented initially with complaints of generalized tiredness, excessive sweating, resolving rash and itching over his back and lower extremities with no complaints of chest pain, fever or cough. The rash was attributed to non-specific allergy and he was treated with an antihistamine. One week later, he returned with shortness of breath, swelling of lower extremities, mild headache and
168
Letters to the Editor
Fig. 1. Electrocardiogram on day 1 showing complete heart block.
dizziness, but the rash had resolved. He denied blurred vision, neck stiffness, sore throat, chest pain, nausea, fever and joint pains. On admission, the patient was in respiratory distress. His pulse rate was 37 beats/min, blood pressure 136/67 mmHg, respiration rate 24/min, and body temperature was normal. Physical examination revealed jugular venous distension, normal heart sounds without murmur or gallop, and bilateral rales at both lung bases. No rash or palpable lymphadenoathy were detected. There was bilateral lower extremity pitting edema. Laboratory values were sig-
nificant for mild leukocytosis, with no bands or eosinophilia. The electrocardiogram on admission showed complete heart block with junctional escape rhythm (Fig. 1). Cardiac biomarkers were normal, and an echocardiogram revealed normal left ventricular ejection fraction with no wall motion abnormalities or pericardial effusion. Follow-up electrocardiogram after 30 min showed high degree atrioventricular block with 4:1 conduction (Fig. 2). A clinical diagnosis of Lyme carditis was made. Lyme serology was sent, and the patient was empirically started on intravenous ceftriaxone.
Fig. 2. Electrocardiogram 30 min later showing 4:1 heart block.
Letters to the Editor
169
Fig. 3. Electrocardiogram on day 2 showing 2:1 heart block.
During first 24 h, the heart rate remained between 30 and 40 beats/min with high degree atrioventricular block but normal blood pressure. On the next day, the electrocardiogram showed sequential improvement from high degree atrioventricular block to 2:1 atrioventricular block (Fig. 3). The Lyme serology and Western blot returned positive. After 5 days of ceftriaxone therapy, the patient's heart rate improved to around 60 beats/min, although he continued to have intermittent and first and second-degree atrioventricular blocks (Fig. 4). Holter monitoring on day 8 of ceftriaxine therapy showed sinus
rhythm with first-degree atrioventricular block. The atrioventricular block completely resolved after 14 days of ceftriaxone treatment. Lyme disease is caused by infection with the spirochete Borrelia burgdorferi that is acquired through the bite of the Ixodes scapularis tick [1]. The clinical spectrum is categorized into an early and late phases [1]. The early phase may show localized disease (erythema migrans with its associated signs and symptoms) or disseminated disease (multiple erythema migrans, cardiac manifestations, neurological manifestations including cranial and peripheral
Fig. 4. Electrocardiogram on day 5 showing Wenckebach phenomenon with 3:2 alternating with 2:1 heart blocks.
170
Letters to the Editor
neuropathies with or with out meningitis). Late phase presentation includes arthritis and central neurological dysfunctions, tertiary neuroborreliosis [2]. The typical skin lesions of erythema chronicum migrans can be absent in early disease and the presentation may include just nonspecific complaints including flu-like symptoms, fever without localizing symptoms, arthralgia, headache, or neck stiffness [3–5]. Furthermore, it is possible to have only the cardiac manifestations as a sole presentation [6]. The cardiac involvement of early, disseminated Lyme disease may present within few days to several months of the infecting tick bite [7]. About 4–10% of patients with Lyme disease have acute cardiac manifestations on initial presentation including dyspnea on exertion, palpitations, chest pain, or syncope [8–11]. These symptoms can be attributed to heart block, ventricular or supraventricular tachycardia, acute myocarditis, and acute pericarditis [8–11]. Conduction abnormalities with transient atrioventricular heart block are the most frequent cardiac manifestations. In an analysis of 105 cases reviewed by Van der Linde et al. [12], third degree heart block was present in 49% of the cases, while 16% had second degree and 12% had first-degree heart block. Other conduction abnormalities include junctional rhythm and asystolic pauses. Electrophysiological studies suggest that the heart block may be localized or diffuse within different levels of the conducting system, but involvement is usually above the bundle of His, typically within the atrioventricular node [13]. Other cardiac complications including myocarditis, left ventricular dysfunction and pericarditis are generally mild and self-resolving [14]. A number of non-invasive tests are being used to evaluate the myocardium for inflammatory response or myocardial damage in Lyme carditis, including gallium scanning and indium-labeled anti-myosin antibody scanning [15]. Magnetic resonance imaging scans have been shown to be helpful in the diagnosis of acute carditits with signal enhancement in positive cases [16]. Cardiac biomarkers are not usually elevated in patients with atrioventricular block presentation but may be useful as adjuvant markers in the diagnosis of acute myocarditis and pericarditis [17]. Echocardiography typically reveals normal ejection fraction, but may be helpful in chronic Lyme carditis for monitoring the development of dilated cardiomyopathy, although there is controversy of whether longstanding dilated cardiomyopathy may be associated with the chronic B. burgdorferi infection [18–20]. In patients with atrioventricular block with the PR-interval greater than 0.3 s, therapy with one of the intravenous antibiotics, ceftriaxone, cefotaxime or penicillin G is recommended along with cardiac monitoring. The usual response to treatment is within 1–2 weeks. Temporary cardiac pacing may be required in 30% of the patients but insertion of a permanent pacemaker is rarely needed [21]. Complete recovery of Lyme carditis is more than 90% with antibiotic treatment although there may be relapse or late complications [22].
In conclusion, in patients presenting with heart block and no known prior cardiac disease or risk factors, Lyme carditis should be considered in the differential diagnosis. Eliciting an appropriate history of environmental exposure to the infectious agent may provide an important clue. Early testing and initiation of empiric antimicrobial therapy while monitoring the patient's rhythm may improve the ultimate outcome and lead to complete resolution of the heart block. Acknowledgement The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [23]. References [1] Nadelman RB, Wormser GP. Lyme borreliosis. Lancet 1998;352:557–65. [2] Bagger-Sjoback D, Remahl S, Ericsson M. Long-term outcome of facial palsy in neuroborreliosis. Otol Neurotol 2005;26:790–5. [3] Sigal LH. Toward a more complete appreciation of the clinical spectrum of Borrelia burgdorferi infection: early Lyme disease without erythema migrans. Am J Med 2003;114:74–5. [4] Cameron D, Gaito A, Harris N, et al. Evidence-based guidelines for the management of Lyme disease. Expert Rev Anti Infect Ther 2004;2 (1 Suppl):S1–S13. [5] Swinnen J, Moerenhout C, Cools FJ. Cardiac conduction disturbances in Lyme disease. Acta Cardiol 2003;58:211–4. [6] Gildein HP, Gunther S, Mocellin R. Complete heart block in a 9 year old girl caused by borreliosis. Br Heart J 1993;70:88–90. [7] Steere AC, Batsford WP, Weinberg M, et al. Lyme carditis: cardiac abnormalities of Lyme disease. Ann Intern Med 1980;93:8–16. [8] Grzesik P, Oczko-Grzesik B, Kepa L. Cardiac manifestations of Lyme borreliosis. Przegl Epidemiol 2004;58:589–96. [9] Sigal LH. Early disseminated Lyme disease: cardiac manifestations. Am J Med 1995;98:25S–8S. [10] Franck H, Wollschlager H. Lyme carditis and symptomatic sinus node dysfunction. Z Kardiol 2003;92:1029–32. [11] Vlay SC, Dervan JP, Elias J, Kane PP, Dattwyler R. Ventricular tachycardia associated with Lyme carditis. Am Heart J 1991;121:1558–60. [12] Van der Linde MR. Lyme carditis: clinical characteristics of 105 cases. Scand J Infect Dis Suppl 1991;77:81–4. [13] Van der Linde MR, Crijns HJ, Lie KI. Transient complete AV block in Lyme disease: electrophysiologic observations. Chest 1989;96: 219–21. [14] Munk PS, Orn S, Larsen AI. Lyme carditis: persistent local delayed enhancement by cardiac magnetic resonance imaging. Int J Cardiol 2007;115:e108–10. [15] Bergler-Klein J, Sochor H, Stanek G, Globits S, Ullrich R, Glogar D. Indium 111 monoclonal antimyosin antibody and magnetic resonance imaging in the diagnosis of acute Lyme myopericarditis. Arch Intern Med 1993;153:2696–700. [16] Karadag B, Spieker LE, Schwitter J, Ruschitzka F, Lüscher TF, Noll G, Corti R. Lyme carditis: restitutio ad integrum documented by cardiac magnetic resonance imaging. Cardiol Rev Jul–Aug 2004;12(4): 185–7. [17] Sauvant G, Bossart W, Kurrer MO, Follath F. Diagnosis and course of myocarditis: a survey in the medical clinics of Zurich University Hospital 1980 to 1998. Schweiz Med Wochenschr 2000;130:1265–71. [18] Stanek G, Klein J, Bittner R, Glogar D. Borrelia burgdorferi as an etiologic agent in chronic heart failure. Scand J Infect Dis Suppl 1991;77: 85–7.
Letters to the Editor [19] Sonnesyn SW, Diehl SC, Johnson RC, Kubo SH, Goodman JL. A prospective study of the seroprevalence of Borrelia burgdorferi infection in patients with severe heart failure. Am J Cardiol 1995;76:97–100. [20] Seinost G, Gasser R, Reisinger E, et al. Cardiac manifestations of Lyme borreliosis with specific reference to contractile dynfunction. Acta Med Austriaca 1998;25:44–50.
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[21] Pinto DS. Cardiac manifestations of Lyme disease. Med Clin North Am 2002;86:285–96. [22] Nagi KS, Joshi R, Thakur RK. Cardiac manifestations of Lyme disease: a review. Can J Cardiol 1996;12:503–6. [23] Coats AJ. Ethical authorship and publishing. Int J Cardiol 2009;131: 149–50.
0167-5273/$ - see front matter © 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2008.05.028
Behavioural interventions for smoking cessation in patients hospitalised for a major cardiovascular event Omer Aziz a , Petros Skapinakis b , Shamim Rahman a , Christopher Rao a , Hutan Ashrafian a , Sukhmeet Singh Panesar a , Ara Darzi a , Rodney Foale c , Thanos Athanasiou a,⁎ a
b
Department of Biosurgery and Surgical Technology, St. Mary's Hospital, Imperial College London, United Kingdom Academic Unit of Psychiatry, University of Bristol, UK & Department of Psychiatry, University of Ioannina School of Medicine, Greece c Department of Cardiology, St. Mary's Hospital, W2 1NY, London, United Kingdom Received 27 January 2008; accepted 3 May 2008 Available online 6 August 2008
Abstract The impact of cigarette smoking on progression of atherosclerosis in patients with known cardiovascular disease suggests a strong need for effective cessation interventions in this group. This letter compares and discusses smoking cessation outcomes following behavioural smoking cessation interventions versus usual care in hospitalised cardiovascular patients using meta-analysis of randomised controlled peerreviewed publications. It particularly focuses on the impact of intensity and duration of intervention on outcome. © 2008 Elsevier Ireland Ltd. All rights reserved. Keywords: Smoking cessation; Behavioural intervention; Cardiovascular; Hospitalised
1. Introduction Smoking increases the progression of atherosclerosis, angina, myocardial infarction (MI), and sudden cardiac death [1], with cessation thought to reduce the recurrence risk of coronary events to that of non-smokers within 3 years [2]. Helping a smoker who has had an MI achieve cessation reduces their mortality by up to 50% over the next 3 to 5 years [3]. Patients who have recently been hospitalised for a cardiovascular event represent a group who are likely to be more motivated to stop smoking, provided a focused approach is initiated and actively followed up [4]. Hospital initiated smoking cessation programs may vary in intensity (the number of cessation interventions in a
⁎ Corresponding author. Senior Lecturer & Consultant Cardiothoracic Surgeon, Department of Biosurgery & Surgical Technology, 10th Floor QEQM Building, St. Mary's Hospital, W2 1NY, London, United Kingdom. Tel.: +44 207 886 1310; fax: +44 207 886 1810. E-mail address: [email protected] (T. Athanasiou).
given period of time), duration, and the use of objective verification (urine, sputum, blood, or carbon monoxide breath testing) [5–7]. In addition, they may include the administration of either nicotine based pharmacotherapy (chewing gums, inhalers, and patches), [8–10] or nonnicotine based medication (buproprion) [11,12]. Although previous research has identified a high intensity of intervention as an important determinant of success [13], the impact of duration of intervention is not yet clear. Distinguishing between duration and intensity is important because longer lasting interventions may not necessarily need to be highly intensive to be effective, as shown in the treatment of other chronic conditions such as depression or diabetes [14,15]. Meta-analysis of randomised controlled trials offers a tool to compare behavioural interventions (BI) for smoking cessation programs versus usual care (UC) in patients hospitalised for cardiovascular diseases. It also allows us to examine the hypothesis that interventions of longer duration (N 3 months post-discharge) will be more effective compared to shorter ones.
Acknowledgement The author of this manuscript has certified that he complies with the Principles of Ethical Publishing in the International Journal of Cardiology [3].
167
[2] Mettenleiter A. Adam Christian Thebesius (1686–1732) und die Entdeckung der Vasa Cordis Minima. Sudhoffs Arch Z Wiss Beih 2001;47: 3–580. [3] Coats AJ. Ethical authorship and publishing. Int J Cardiol 2009;131: 149–50.
References [1] Loukas M, Clarke P, Tubbs RS, Kolbinger W. Adam Christian Thebesius, a historical perspective. Int J Cardiol 2008;129:138–40. 0167-5273/$ - see front matter © 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2008.03.042
Lyme carditis: Sequential electrocardiographic changes in response to antibiotic therapy Kamran Manzoor a , Waqas Aftab b , Sonia Choksi c , Ijaz A. Khan d,⁎ a
Charleston Area Medical Center, Charleston, West Virginia, USA Community Regional Medical Center, Fresno, California, USA c North Central Bronx Hospital, Bronx, New York, USA d Good Samaritan Hospital, Baltimore, Maryland, USA
b
Received 27 January 2008; accepted 3 May 2008 Available online 5 August 2008
Abstract Lyme disease is a tick-borne spirochetal infection that may involve heart. The cardiac manifestations of Lyme disease including varying degrees of atrioventricular heart block occur within weeks to months of the infecting tick bite. This report describes a 43 year-old man with Lyme carditis who presented with complete heart block. The heart block resolved with ceftriaxone therapy. Lyme carditis should be considered in the differential diagnosis in patients who present with new onset advanced heart block. © 2008 Elsevier Ireland Ltd. All rights reserved. Keywords: Lyme carditis; Borrelia burgdorferi; Ixodes scapularis; Third degree heart block; Atrioventricular conduction block
Lyme carditis is one of the most challenging diagnoses if the presentation is atypical with no clear evidence of rash and arthritis. The cardiac involvement in early, disseminated disease usually presents with complaints of shortness of breath, palpitations, chest pain or syncope. The electrocardiographic manifestations of myocardial involvement include a varying degree of atrioventricular block or more diffuse signs of myocarditis. A high degree of atrioventricular block without cardiac risk factors may point towards a diagnosis of Lyme carditis. The micro⁎ Corresponding author. Division of Cardiology, Good Samaritan Hospital, 5601 Loch Raven Boulevard, Baltimore, Maryland 21239, USA. Tel.: +1 43 44 607; fax: +1 410 532 4606. E-mail address: [email protected] (I.A. Khan).
biological laboratory tests are insensitive initially and a negative serology does not exclude the diagnosis. The diagnosis is usually made on clinical grounds on admission, and antibiotics therapy is usually initiated even prior to the availability of serological results. The conduction abnormalities respond well to antibiotic treatment with an excellent prognosis. A 43-year-old man who worked in parks as a plumber in upstate New York presented initially with complaints of generalized tiredness, excessive sweating, resolving rash and itching over his back and lower extremities with no complaints of chest pain, fever or cough. The rash was attributed to non-specific allergy and he was treated with an antihistamine. One week later, he returned with shortness of breath, swelling of lower extremities, mild headache and
168
Letters to the Editor
Fig. 1. Electrocardiogram on day 1 showing complete heart block.
dizziness, but the rash had resolved. He denied blurred vision, neck stiffness, sore throat, chest pain, nausea, fever and joint pains. On admission, the patient was in respiratory distress. His pulse rate was 37 beats/min, blood pressure 136/67 mmHg, respiration rate 24/min, and body temperature was normal. Physical examination revealed jugular venous distension, normal heart sounds without murmur or gallop, and bilateral rales at both lung bases. No rash or palpable lymphadenoathy were detected. There was bilateral lower extremity pitting edema. Laboratory values were sig-
nificant for mild leukocytosis, with no bands or eosinophilia. The electrocardiogram on admission showed complete heart block with junctional escape rhythm (Fig. 1). Cardiac biomarkers were normal, and an echocardiogram revealed normal left ventricular ejection fraction with no wall motion abnormalities or pericardial effusion. Follow-up electrocardiogram after 30 min showed high degree atrioventricular block with 4:1 conduction (Fig. 2). A clinical diagnosis of Lyme carditis was made. Lyme serology was sent, and the patient was empirically started on intravenous ceftriaxone.
Fig. 2. Electrocardiogram 30 min later showing 4:1 heart block.
Letters to the Editor
169
Fig. 3. Electrocardiogram on day 2 showing 2:1 heart block.
During first 24 h, the heart rate remained between 30 and 40 beats/min with high degree atrioventricular block but normal blood pressure. On the next day, the electrocardiogram showed sequential improvement from high degree atrioventricular block to 2:1 atrioventricular block (Fig. 3). The Lyme serology and Western blot returned positive. After 5 days of ceftriaxone therapy, the patient's heart rate improved to around 60 beats/min, although he continued to have intermittent and first and second-degree atrioventricular blocks (Fig. 4). Holter monitoring on day 8 of ceftriaxine therapy showed sinus
rhythm with first-degree atrioventricular block. The atrioventricular block completely resolved after 14 days of ceftriaxone treatment. Lyme disease is caused by infection with the spirochete Borrelia burgdorferi that is acquired through the bite of the Ixodes scapularis tick [1]. The clinical spectrum is categorized into an early and late phases [1]. The early phase may show localized disease (erythema migrans with its associated signs and symptoms) or disseminated disease (multiple erythema migrans, cardiac manifestations, neurological manifestations including cranial and peripheral
Fig. 4. Electrocardiogram on day 5 showing Wenckebach phenomenon with 3:2 alternating with 2:1 heart blocks.
170
Letters to the Editor
neuropathies with or with out meningitis). Late phase presentation includes arthritis and central neurological dysfunctions, tertiary neuroborreliosis [2]. The typical skin lesions of erythema chronicum migrans can be absent in early disease and the presentation may include just nonspecific complaints including flu-like symptoms, fever without localizing symptoms, arthralgia, headache, or neck stiffness [3–5]. Furthermore, it is possible to have only the cardiac manifestations as a sole presentation [6]. The cardiac involvement of early, disseminated Lyme disease may present within few days to several months of the infecting tick bite [7]. About 4–10% of patients with Lyme disease have acute cardiac manifestations on initial presentation including dyspnea on exertion, palpitations, chest pain, or syncope [8–11]. These symptoms can be attributed to heart block, ventricular or supraventricular tachycardia, acute myocarditis, and acute pericarditis [8–11]. Conduction abnormalities with transient atrioventricular heart block are the most frequent cardiac manifestations. In an analysis of 105 cases reviewed by Van der Linde et al. [12], third degree heart block was present in 49% of the cases, while 16% had second degree and 12% had first-degree heart block. Other conduction abnormalities include junctional rhythm and asystolic pauses. Electrophysiological studies suggest that the heart block may be localized or diffuse within different levels of the conducting system, but involvement is usually above the bundle of His, typically within the atrioventricular node [13]. Other cardiac complications including myocarditis, left ventricular dysfunction and pericarditis are generally mild and self-resolving [14]. A number of non-invasive tests are being used to evaluate the myocardium for inflammatory response or myocardial damage in Lyme carditis, including gallium scanning and indium-labeled anti-myosin antibody scanning [15]. Magnetic resonance imaging scans have been shown to be helpful in the diagnosis of acute carditits with signal enhancement in positive cases [16]. Cardiac biomarkers are not usually elevated in patients with atrioventricular block presentation but may be useful as adjuvant markers in the diagnosis of acute myocarditis and pericarditis [17]. Echocardiography typically reveals normal ejection fraction, but may be helpful in chronic Lyme carditis for monitoring the development of dilated cardiomyopathy, although there is controversy of whether longstanding dilated cardiomyopathy may be associated with the chronic B. burgdorferi infection [18–20]. In patients with atrioventricular block with the PR-interval greater than 0.3 s, therapy with one of the intravenous antibiotics, ceftriaxone, cefotaxime or penicillin G is recommended along with cardiac monitoring. The usual response to treatment is within 1–2 weeks. Temporary cardiac pacing may be required in 30% of the patients but insertion of a permanent pacemaker is rarely needed [21]. Complete recovery of Lyme carditis is more than 90% with antibiotic treatment although there may be relapse or late complications [22].
In conclusion, in patients presenting with heart block and no known prior cardiac disease or risk factors, Lyme carditis should be considered in the differential diagnosis. Eliciting an appropriate history of environmental exposure to the infectious agent may provide an important clue. Early testing and initiation of empiric antimicrobial therapy while monitoring the patient's rhythm may improve the ultimate outcome and lead to complete resolution of the heart block. Acknowledgement The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [23]. References [1] Nadelman RB, Wormser GP. Lyme borreliosis. Lancet 1998;352:557–65. [2] Bagger-Sjoback D, Remahl S, Ericsson M. Long-term outcome of facial palsy in neuroborreliosis. Otol Neurotol 2005;26:790–5. [3] Sigal LH. Toward a more complete appreciation of the clinical spectrum of Borrelia burgdorferi infection: early Lyme disease without erythema migrans. Am J Med 2003;114:74–5. [4] Cameron D, Gaito A, Harris N, et al. Evidence-based guidelines for the management of Lyme disease. Expert Rev Anti Infect Ther 2004;2 (1 Suppl):S1–S13. [5] Swinnen J, Moerenhout C, Cools FJ. Cardiac conduction disturbances in Lyme disease. Acta Cardiol 2003;58:211–4. [6] Gildein HP, Gunther S, Mocellin R. Complete heart block in a 9 year old girl caused by borreliosis. Br Heart J 1993;70:88–90. [7] Steere AC, Batsford WP, Weinberg M, et al. Lyme carditis: cardiac abnormalities of Lyme disease. Ann Intern Med 1980;93:8–16. [8] Grzesik P, Oczko-Grzesik B, Kepa L. Cardiac manifestations of Lyme borreliosis. Przegl Epidemiol 2004;58:589–96. [9] Sigal LH. Early disseminated Lyme disease: cardiac manifestations. Am J Med 1995;98:25S–8S. [10] Franck H, Wollschlager H. Lyme carditis and symptomatic sinus node dysfunction. Z Kardiol 2003;92:1029–32. [11] Vlay SC, Dervan JP, Elias J, Kane PP, Dattwyler R. Ventricular tachycardia associated with Lyme carditis. Am Heart J 1991;121:1558–60. [12] Van der Linde MR. Lyme carditis: clinical characteristics of 105 cases. Scand J Infect Dis Suppl 1991;77:81–4. [13] Van der Linde MR, Crijns HJ, Lie KI. Transient complete AV block in Lyme disease: electrophysiologic observations. Chest 1989;96: 219–21. [14] Munk PS, Orn S, Larsen AI. Lyme carditis: persistent local delayed enhancement by cardiac magnetic resonance imaging. Int J Cardiol 2007;115:e108–10. [15] Bergler-Klein J, Sochor H, Stanek G, Globits S, Ullrich R, Glogar D. Indium 111 monoclonal antimyosin antibody and magnetic resonance imaging in the diagnosis of acute Lyme myopericarditis. Arch Intern Med 1993;153:2696–700. [16] Karadag B, Spieker LE, Schwitter J, Ruschitzka F, Lüscher TF, Noll G, Corti R. Lyme carditis: restitutio ad integrum documented by cardiac magnetic resonance imaging. Cardiol Rev Jul–Aug 2004;12(4): 185–7. [17] Sauvant G, Bossart W, Kurrer MO, Follath F. Diagnosis and course of myocarditis: a survey in the medical clinics of Zurich University Hospital 1980 to 1998. Schweiz Med Wochenschr 2000;130:1265–71. [18] Stanek G, Klein J, Bittner R, Glogar D. Borrelia burgdorferi as an etiologic agent in chronic heart failure. Scand J Infect Dis Suppl 1991;77: 85–7.
Letters to the Editor [19] Sonnesyn SW, Diehl SC, Johnson RC, Kubo SH, Goodman JL. A prospective study of the seroprevalence of Borrelia burgdorferi infection in patients with severe heart failure. Am J Cardiol 1995;76:97–100. [20] Seinost G, Gasser R, Reisinger E, et al. Cardiac manifestations of Lyme borreliosis with specific reference to contractile dynfunction. Acta Med Austriaca 1998;25:44–50.
171
[21] Pinto DS. Cardiac manifestations of Lyme disease. Med Clin North Am 2002;86:285–96. [22] Nagi KS, Joshi R, Thakur RK. Cardiac manifestations of Lyme disease: a review. Can J Cardiol 1996;12:503–6. [23] Coats AJ. Ethical authorship and publishing. Int J Cardiol 2009;131: 149–50.
0167-5273/$ - see front matter © 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2008.05.028
Behavioural interventions for smoking cessation in patients hospitalised for a major cardiovascular event Omer Aziz a , Petros Skapinakis b , Shamim Rahman a , Christopher Rao a , Hutan Ashrafian a , Sukhmeet Singh Panesar a , Ara Darzi a , Rodney Foale c , Thanos Athanasiou a,⁎ a
b
Department of Biosurgery and Surgical Technology, St. Mary's Hospital, Imperial College London, United Kingdom Academic Unit of Psychiatry, University of Bristol, UK & Department of Psychiatry, University of Ioannina School of Medicine, Greece c Department of Cardiology, St. Mary's Hospital, W2 1NY, London, United Kingdom Received 27 January 2008; accepted 3 May 2008 Available online 6 August 2008
Abstract The impact of cigarette smoking on progression of atherosclerosis in patients with known cardiovascular disease suggests a strong need for effective cessation interventions in this group. This letter compares and discusses smoking cessation outcomes following behavioural smoking cessation interventions versus usual care in hospitalised cardiovascular patients using meta-analysis of randomised controlled peerreviewed publications. It particularly focuses on the impact of intensity and duration of intervention on outcome. © 2008 Elsevier Ireland Ltd. All rights reserved. Keywords: Smoking cessation; Behavioural intervention; Cardiovascular; Hospitalised
1. Introduction Smoking increases the progression of atherosclerosis, angina, myocardial infarction (MI), and sudden cardiac death [1], with cessation thought to reduce the recurrence risk of coronary events to that of non-smokers within 3 years [2]. Helping a smoker who has had an MI achieve cessation reduces their mortality by up to 50% over the next 3 to 5 years [3]. Patients who have recently been hospitalised for a cardiovascular event represent a group who are likely to be more motivated to stop smoking, provided a focused approach is initiated and actively followed up [4]. Hospital initiated smoking cessation programs may vary in intensity (the number of cessation interventions in a
⁎ Corresponding author. Senior Lecturer & Consultant Cardiothoracic Surgeon, Department of Biosurgery & Surgical Technology, 10th Floor QEQM Building, St. Mary's Hospital, W2 1NY, London, United Kingdom. Tel.: +44 207 886 1310; fax: +44 207 886 1810. E-mail address: [email protected] (T. Athanasiou).
given period of time), duration, and the use of objective verification (urine, sputum, blood, or carbon monoxide breath testing) [5–7]. In addition, they may include the administration of either nicotine based pharmacotherapy (chewing gums, inhalers, and patches), [8–10] or nonnicotine based medication (buproprion) [11,12]. Although previous research has identified a high intensity of intervention as an important determinant of success [13], the impact of duration of intervention is not yet clear. Distinguishing between duration and intensity is important because longer lasting interventions may not necessarily need to be highly intensive to be effective, as shown in the treatment of other chronic conditions such as depression or diabetes [14,15]. Meta-analysis of randomised controlled trials offers a tool to compare behavioural interventions (BI) for smoking cessation programs versus usual care (UC) in patients hospitalised for cardiovascular diseases. It also allows us to examine the hypothesis that interventions of longer duration (N 3 months post-discharge) will be more effective compared to shorter ones.