- Email: [email protected]
Age- and anesthesia-related changes in accessory pathway conduction in children with Wolff-Parkinson-White syndrome
Age- and Anesthesia-Related Accessory Pathway Conduction Wolff -Parkinson-White
Chan es in in Chil %ren With Syndrome
Ruey-Kang R. Chang, MD, MPH, Glenn T. Wetzel, MD, PhD, Kevin M. Shannon, William G. Stevenson, MD, and Thomas S. Klitzner, MD, PhD t has been observed that accessorypathway conducItween tion changes over time.’ However, the relation beaccessory pathway conduction and age has not been established, particularly in a pediatric population. The anterograde accessorypathway effective refractory period (APERP) is a measureof accessorypathway conduction and has been proposed as a marker for risk of hypotensive tachyarrhythmias in patients with the WolffParkinson-White syndrome (WPW).2-4Michelucci et al5 found a significant direct correlation between anterograde APERP and age in a group of predominantly adult patients with WPW However, studies of accessorypathway conduction in children have been inconsistent regarding the effect of patient age on the anterograde APERE?6y7 We conducted a retrospective study to determine age-related changes in the anterograde APERP These results may have significance in determining the risk of life-threatening arrhythmias in children with WPW ... Seventy-qne consecutive patients aged cl8 years with WPW were evaluated by programmed electrical stimulation at the UCLA Medical Center between January 1982 and February 1994.All patients had an overt preexcitation pattern on the resting 1Zlead electrocardiogram, and spontaneousepisodesof orthodromic- or antidromic-reciprocating tachycardia,or atrial fibrillation. All patients were evaluated by echocardiographyfor cardiac anomalies. Three patients who had tricuspid atresia or other forms of single ventricle and underwent Fontan procedures were excluded from the study. Eight patients who had previously experienced rapid onset of symptomatic hypotension requiring emergent medical attention accompanying arrhythmias were suspected of having atria1 fibrillation with a rapid ventricular response and were excluded. The remaining 60 patients were considered to be typical “low-risk” pediatric patients. Anterograde APERP was not obtainable in 5 patients (age 10.8 to 13.1 years, mean 11.8)secondary to the initiation of tachycardia during atrial pacing at the basic drive cycle length. The remaining 55 patients formed the patient population for this study. Their ages ranged from 4 months to 17years (mean 9.8 years). There were 36 male From the Division of Cardiology, De rtment of Pediatrics, UCL4 School of Medicine, Los Angeles, CCI r.Iforma, and the CardiovascuIar Division, Brigham and Women’s Hospital, Boston, Massachusetts. This study was supported in part by Grant HL02723 from the National Institutes of Health, Bethesda, Maryland, and by Grant 940323 from the American Academy of Pediatrics, Elk Grove Village, Illinois. Dr. Klitzner’s address is: Division of Cardiology, Department of Pediatrics, UCLA School of Medicine, 10833 le Conte Avenue, los Angeles, California 90024. Manuscript received May 30, 1995; revised manuscript received and accepted August 12, 1995.
1074
THE AMERICAN
JOURNAL
OF CARDIOLOGY@
VOL. 76
MD,
(65%) and 19 female (35%) patients. Twenty-seven patients (49%, mean age 9.2 years) underwent electrophysiologic study with local anesthesiaand intramuscular injection of a combination of meperidine-promethazine with or without chlorpromazine. The remaining 28 patients (mean age 10.4 years) underwent electrophysiologic study and radiofrequency ablation of accessory pathwaysunder general anesthesiawith isoflurane or enflurane inhalation. All antiarrhythmic medications were discontinued 2.5 half-lives before electrophysiologic study. Parental consent was obtained prior to electrophysiologic study. Multipolar electrode catheters were inserted percutaneously and advanced to the right ventricular apexand His bundle position. In patients younger than age 3 years, the right ventricular apex catheter was moved to the high right atrium for atria1pacing studies. In patients aged ~3 years, 4 catheters were used (high right atrium, His bundle, right ventricular apex, and coronary sinus). The anterograde APERP was the longest coupling interval measured at a site near the origin of the accessorypathway that failed to conduct through the accessory pathway. Anterograde APERPs were measured at a paced cycle length of 400 ms. Three regression models were used to determine the correlation between ageand anterogradeAPERP.Anterograde APERP was the dependent and age the independent variable in all 3 models. In the first regression model, the correlation was examined by simple linear regression in the 27 patients who received only local anesthetics and parenteral sedation. The secondregression model included all 55 patients. In the third regression model, a qualitative independent variable GA was added to the second model to account for the possibility that isoflurane or enflurane inhalation may increasethe anterogradeAPERP.8 GA was set equal to 1 for the 28 patients who received general anesthesia and to 0 for the 27 patients who received parenteral sedation and local anesthesia.Statistical analysis was conducted using the software package Statistica (StatSoft Inc., Tulsa, Oklahoma, 1993). Standard linear regression was used to determine correlation coefficients and regression coefficients. All p values were calculated as 2-tailed and p co.05 was considered statistically significant. The anterogradeAPERP ranged from 185to 320 ms for the 27 patients who received parenteral sedation and local anesthesia, and from 185 to 360 ms for all 55 patients in the study.The mean anterogradeAPERP was 254 -t 35 ms (mean 2 1 SD) for the 27 patients in the first regression model, and 274 + 41 ms for all 55 patients, Results of the regressionanalysis for the 3 models are summarized in Table I. A significant correlation was found between age and anterogradeAPERP in patients who received sedation and local anesthesia (r = NOVEMBER
15,
1995
0.75, p cO.0001). The regression sugTABLEI Regression Models of Age Versus Anterograde Accessory Pathway Effective gested a 4.7 ms/year increase in the Refractory Period (APERP) anterograde APERP in this group of Patients Regression Equation r p Value patients. When considering all 55 patients, there was a 4.0 ms/year increase Patients with parenteral APERP (ms) = 211 + 4.7 x age (yr) 0.75 <0.0001 sedation (n = 27) in the anterogradeAPERP, but the corAll patients (n = 55) 0.001 APERP (ms] = 236 + 4.0 x age (yr] 0.42 relation coefficient decreasedto 0.42 (p All patients (n = 55) APERP (ms) = 223 + 3.4 x age (yr) 0.61f <0.0001 = 0.0013). The third regression model +36.1 x GA* suggesteda 3.4 mslyear increasein age *GA = 1 for 28 patients who received general anesthesia; GA = 0 for 27 patients who received and a 36.1 ms increasein patients who parer&ml sedation ond local anesthesia. received general anesthesia.The over+P= 0.36 for age (p = 0.002). and 0.44 for GA (p
0
0
350
Cl
0 0
FIGURE 1. Scatter pbt of all 55 patients in this shuly, including those who received local anesthetics and renteral sedation (n = 27; fil&&) and those receiving general anesthesia [open circles~. The regression line (GA = 0) indicab35 palients who received local anesthesia and parentera sedation. The 2 regression lines have the same slope of 3.4 ms/year. The differenceintheintercepbofihese2 parallel lines is 36.1 ms.
0
GA=1
8Q)300 E 2 g 250
200
150 0
2
4
6
6
10
12
14
16
AGE (years)
BRIEF REPORTS 1075
described in pediatric patients, our results suggest that anterograde APERP increases with age. Thus, a single cutoff value of anterogradeAPERP may not be an adequate predictor of risk for patients of all ages. The cutoff value of APERP used to identify high-risk patients should be adjusted for age. In addition, our results also suggestthat younger children more frequently have short APERPs. Although young children tend to have short APERPs, this may not indicate an increased risk of hypotensive tachyarrhythmias, becausefaster rates may be better tolerated with a lower risk of ventricular fibrillation, or atria1fibrillation may be less common in this age group. This is consistent with published reports stating that atria1fibrillation with 1:1 conduction to the ventricle is rare in young children.h,7We also found an effect of general anesthesiaon the interpretation of age-related changesin accessorypathway conduction. When patients who received general anesthesiawere addedto the regression analysis, the correlation coefficient decreased to 0.42 (Table I). Subsequentinclusion of general anesthesia as an independent variable increased the correlation coefficient to 0.61. This is consistent with the effect of inhalational anesthetics on the anterograde APERP, which we have previously reported.8General anesthesia is now frequently used for patients with WPW undergoing transcatheterablation of accessorypathways. It is important to recognize that general anesthesiamay cloud the interpretation of the age dependency of anterograde APERP and the assessmentof a patient’s long-term risk of life-threatening arrhythmias. The anterograde effective refractory period of the accessory pathway is age-dependent in pediatric patients with the WPW syndrome. Thus, age should
Breath Acetone Markku
Kupari,
be considered when developing electrophysiologic criteria for the risk of hypotensive arrhythmias in these patients. In addition, general anesthesia must also be considered in interpreting age-related changes in the anterograde APERP, especially in children. Acknowledgment: We wish to thank Sarah M. Warren for her help with the preparation of this manuscript. 1. Klein GJ. Yee R. Shama AD. L*mgirudmal elecrrophyticll(~pic awssment of asymptomatic patienb with the Wolff-Parkinson-White elcctnrardiographic pattern. N Engl J Med lY89;320:12?9-1233. 2. Wcllens HJJ. Durrer D. Wolff-Parkinson-White ryndrume and aria1 fibrillation. Relation between refracrory period of accessory pathway and rentricular rate during atrial fihrillalion. Am J Cardiol 1974:.34:777-7X2. 3. Waspe LE. Brodman R. Kim SC;. Fisher JD. Suscepfihdiry tu atnal lihnllarion and venuicular lachyarrhylhmia in rhe Wolff-Parkinson-White syndrome: role of the accessory pathway. Am Heart J 19X6; I 12: I I4 I-I 152. 4. Bella PD. Brugada P. Talajic M, Lcmery R. Turner P. Le~aun R. Dugemirr 1‘. Wellens HJJ. Avial fibrillation in parienrs wirh an accessory pathway: importance of the conduction prupenies of tie accessory pathway. J Am Co// Curdiol lYY1:17:1352-1356. 5. Michelucci A, Padeletti I.. Meuani A. Relationship hctwecn age and antegrade refractoriness of the accessory pathway in Wolff-Parkinson-While patients. Cardiology 1989:76:270-273. 6. Gillette PC. C&on A, Kugkr JD. Wolff-Parkinson-White syndrome m chddmn: electrophysiologic and @armacologic characteristics. Ckuhion lY79:M): 14X7- 1495. 7. Perry JC. Carson A Jr. Supraventricular tachycardia due to Wolff-ParkinsonWhite syndrome in children: early ditippcxance and la~e recurrence. J Am Co/l Cardiol 1990:16:1215-1220. 8. Chane R-KR. Srewwn WG. Wet/cl GT. Shannon K. Baum VC. Khrmer TS. Effects ‘;f irofl;rane on elecrrophysiologic mcawrcments in children with the PACE 11)95: in press. Wolff-Parkinson-While syndrome. 9. DuBrow 1W. Asher EA. Amat-y-Lcun F. Dcne, P. Wu D. Rosen K. Hasrn~rer AR. Comparison of cardiac refrdc~ory periods in children and adults. C‘ircuhfh 1975;51:485+91. 10. Deal BJ. Keane JF. Gillette PC Carson A Jr. Wolff-Parkinson-WhItr syndrome and supravenvlcular tachycardia during infancy: management and follow-up. J Am Cd Cardiol 1985;5: 13&135.
in Congestive
MD, Jyri Lommi, MD, Markku
Heart
Failure
Ventilti, MSc, and Ulla Karjalainen,
PhD
patients with CHF and in control groups consisting of healthy persons and cardiac patients free of CHE ... We studied 31 patients with chronic CHF, 19cardiac increased,3and malnutrition is not uncommon.4 These abnormalities are able to augment lipolysis and use of patients without U-IF, and 24 healthy persons.The CHF peripheral fat in general energy metabolism.5,6 The group was selected from among consecutive patients resulting increased supply of circulating free fatty acids admitted to our department for evaluation or treatment should, in theory, boost ketone body production,6*7but between May 25 and November II, 1994. Criteria for whether CHF really leads to ketosis-pronenesshas not the diagnosis of CHF were the presenceof heart disease been studied. To test the hypothesis that CHF is a keto- and at least 3 of the following 4 signs: (I) dyspnea or sis-prone state, we measuredbreath acetone concentra- fatigue on ordinary effort, (2) either audible third heart tions by gas chromatography after an overnight fast in sound or heart rate >90 beats/min at rest, (3) enlarged relative heart volume on chest x-rays8 or (4) either pulmonary venous congestion on chest x-rays or abnormal From the Drvrsion of Cardiology (Defxxtment of Medicrne) and the neck vein distention at clinical examination. The neck Deportment of Clrnrcol Chemistry, Helsrnki University Central Hos iveins were studied by estimating the supraclavicular tal, Helsrnki, Finland. Thus work was supported by grants from tEe Finnrsh Academv ISA 7 135). Finnish Heart Association [ 19th Febru height (cm) of the blood column in the right internal ary Fund). Foundation for Cardrovascular Research, and Paavo Nurjugular vein with the patient breathing quietly in the sitmi Foundation. Helsrnki. Finland. Dr. Kuwn’s oddress is: Division of ting position. Any venous bulging abovethe clavicle was Cardiology, Helsinki University Central Hosprtal, FIN00290 Helsinconsideredabnormal. Patientswere excluded if they had ki, Finland Manuscript received May 30, 1995; revised manuscript received ond accepted August 8, 199.5 endocrine, renal, infectious, gastrointestinal, or connec-
congestive heart failure (CHF), the circulating conof stresshormones and tumor necrosisfacItorncentrations are frequently elevated,1.2basal metabolism can be
1076
THE AMERICAN
JOURNAL
OF CARDIOLOGY’
VOL. 76
NOVEMBER
15,
1995
Chan es in in Chil %ren With Syndrome
Ruey-Kang R. Chang, MD, MPH, Glenn T. Wetzel, MD, PhD, Kevin M. Shannon, William G. Stevenson, MD, and Thomas S. Klitzner, MD, PhD t has been observed that accessorypathway conducItween tion changes over time.’ However, the relation beaccessory pathway conduction and age has not been established, particularly in a pediatric population. The anterograde accessorypathway effective refractory period (APERP) is a measureof accessorypathway conduction and has been proposed as a marker for risk of hypotensive tachyarrhythmias in patients with the WolffParkinson-White syndrome (WPW).2-4Michelucci et al5 found a significant direct correlation between anterograde APERP and age in a group of predominantly adult patients with WPW However, studies of accessorypathway conduction in children have been inconsistent regarding the effect of patient age on the anterograde APERE?6y7 We conducted a retrospective study to determine age-related changes in the anterograde APERP These results may have significance in determining the risk of life-threatening arrhythmias in children with WPW ... Seventy-qne consecutive patients aged cl8 years with WPW were evaluated by programmed electrical stimulation at the UCLA Medical Center between January 1982 and February 1994.All patients had an overt preexcitation pattern on the resting 1Zlead electrocardiogram, and spontaneousepisodesof orthodromic- or antidromic-reciprocating tachycardia,or atrial fibrillation. All patients were evaluated by echocardiographyfor cardiac anomalies. Three patients who had tricuspid atresia or other forms of single ventricle and underwent Fontan procedures were excluded from the study. Eight patients who had previously experienced rapid onset of symptomatic hypotension requiring emergent medical attention accompanying arrhythmias were suspected of having atria1 fibrillation with a rapid ventricular response and were excluded. The remaining 60 patients were considered to be typical “low-risk” pediatric patients. Anterograde APERP was not obtainable in 5 patients (age 10.8 to 13.1 years, mean 11.8)secondary to the initiation of tachycardia during atrial pacing at the basic drive cycle length. The remaining 55 patients formed the patient population for this study. Their ages ranged from 4 months to 17years (mean 9.8 years). There were 36 male From the Division of Cardiology, De rtment of Pediatrics, UCL4 School of Medicine, Los Angeles, CCI r.Iforma, and the CardiovascuIar Division, Brigham and Women’s Hospital, Boston, Massachusetts. This study was supported in part by Grant HL02723 from the National Institutes of Health, Bethesda, Maryland, and by Grant 940323 from the American Academy of Pediatrics, Elk Grove Village, Illinois. Dr. Klitzner’s address is: Division of Cardiology, Department of Pediatrics, UCLA School of Medicine, 10833 le Conte Avenue, los Angeles, California 90024. Manuscript received May 30, 1995; revised manuscript received and accepted August 12, 1995.
1074
THE AMERICAN
JOURNAL
OF CARDIOLOGY@
VOL. 76
MD,
(65%) and 19 female (35%) patients. Twenty-seven patients (49%, mean age 9.2 years) underwent electrophysiologic study with local anesthesiaand intramuscular injection of a combination of meperidine-promethazine with or without chlorpromazine. The remaining 28 patients (mean age 10.4 years) underwent electrophysiologic study and radiofrequency ablation of accessory pathwaysunder general anesthesiawith isoflurane or enflurane inhalation. All antiarrhythmic medications were discontinued 2.5 half-lives before electrophysiologic study. Parental consent was obtained prior to electrophysiologic study. Multipolar electrode catheters were inserted percutaneously and advanced to the right ventricular apexand His bundle position. In patients younger than age 3 years, the right ventricular apex catheter was moved to the high right atrium for atria1pacing studies. In patients aged ~3 years, 4 catheters were used (high right atrium, His bundle, right ventricular apex, and coronary sinus). The anterograde APERP was the longest coupling interval measured at a site near the origin of the accessorypathway that failed to conduct through the accessory pathway. Anterograde APERPs were measured at a paced cycle length of 400 ms. Three regression models were used to determine the correlation between ageand anterogradeAPERP.Anterograde APERP was the dependent and age the independent variable in all 3 models. In the first regression model, the correlation was examined by simple linear regression in the 27 patients who received only local anesthetics and parenteral sedation. The secondregression model included all 55 patients. In the third regression model, a qualitative independent variable GA was added to the second model to account for the possibility that isoflurane or enflurane inhalation may increasethe anterogradeAPERP.8 GA was set equal to 1 for the 28 patients who received general anesthesia and to 0 for the 27 patients who received parenteral sedation and local anesthesia.Statistical analysis was conducted using the software package Statistica (StatSoft Inc., Tulsa, Oklahoma, 1993). Standard linear regression was used to determine correlation coefficients and regression coefficients. All p values were calculated as 2-tailed and p co.05 was considered statistically significant. The anterogradeAPERP ranged from 185to 320 ms for the 27 patients who received parenteral sedation and local anesthesia, and from 185 to 360 ms for all 55 patients in the study.The mean anterogradeAPERP was 254 -t 35 ms (mean 2 1 SD) for the 27 patients in the first regression model, and 274 + 41 ms for all 55 patients, Results of the regressionanalysis for the 3 models are summarized in Table I. A significant correlation was found between age and anterogradeAPERP in patients who received sedation and local anesthesia (r = NOVEMBER
15,
1995
0.75, p cO.0001). The regression sugTABLEI Regression Models of Age Versus Anterograde Accessory Pathway Effective gested a 4.7 ms/year increase in the Refractory Period (APERP) anterograde APERP in this group of Patients Regression Equation r p Value patients. When considering all 55 patients, there was a 4.0 ms/year increase Patients with parenteral APERP (ms) = 211 + 4.7 x age (yr) 0.75 <0.0001 sedation (n = 27) in the anterogradeAPERP, but the corAll patients (n = 55) 0.001 APERP (ms] = 236 + 4.0 x age (yr] 0.42 relation coefficient decreasedto 0.42 (p All patients (n = 55) APERP (ms) = 223 + 3.4 x age (yr) 0.61f <0.0001 = 0.0013). The third regression model +36.1 x GA* suggesteda 3.4 mslyear increasein age *GA = 1 for 28 patients who received general anesthesia; GA = 0 for 27 patients who received and a 36.1 ms increasein patients who parer&ml sedation ond local anesthesia. received general anesthesia.The over+P= 0.36 for age (p = 0.002). and 0.44 for GA (p
0
0
350
Cl
0 0
FIGURE 1. Scatter pbt of all 55 patients in this shuly, including those who received local anesthetics and renteral sedation (n = 27; fil&&) and those receiving general anesthesia [open circles~. The regression line (GA = 0) indicab35 palients who received local anesthesia and parentera sedation. The 2 regression lines have the same slope of 3.4 ms/year. The differenceintheintercepbofihese2 parallel lines is 36.1 ms.
0
GA=1
8Q)300 E 2 g 250
200
150 0
2
4
6
6
10
12
14
16
AGE (years)
BRIEF REPORTS 1075
described in pediatric patients, our results suggest that anterograde APERP increases with age. Thus, a single cutoff value of anterogradeAPERP may not be an adequate predictor of risk for patients of all ages. The cutoff value of APERP used to identify high-risk patients should be adjusted for age. In addition, our results also suggestthat younger children more frequently have short APERPs. Although young children tend to have short APERPs, this may not indicate an increased risk of hypotensive tachyarrhythmias, becausefaster rates may be better tolerated with a lower risk of ventricular fibrillation, or atria1fibrillation may be less common in this age group. This is consistent with published reports stating that atria1fibrillation with 1:1 conduction to the ventricle is rare in young children.h,7We also found an effect of general anesthesiaon the interpretation of age-related changesin accessorypathway conduction. When patients who received general anesthesiawere addedto the regression analysis, the correlation coefficient decreased to 0.42 (Table I). Subsequentinclusion of general anesthesia as an independent variable increased the correlation coefficient to 0.61. This is consistent with the effect of inhalational anesthetics on the anterograde APERP, which we have previously reported.8General anesthesia is now frequently used for patients with WPW undergoing transcatheterablation of accessorypathways. It is important to recognize that general anesthesiamay cloud the interpretation of the age dependency of anterograde APERP and the assessmentof a patient’s long-term risk of life-threatening arrhythmias. The anterograde effective refractory period of the accessory pathway is age-dependent in pediatric patients with the WPW syndrome. Thus, age should
Breath Acetone Markku
Kupari,
be considered when developing electrophysiologic criteria for the risk of hypotensive arrhythmias in these patients. In addition, general anesthesia must also be considered in interpreting age-related changes in the anterograde APERP, especially in children. Acknowledgment: We wish to thank Sarah M. Warren for her help with the preparation of this manuscript. 1. Klein GJ. Yee R. Shama AD. L*mgirudmal elecrrophyticll(~pic awssment of asymptomatic patienb with the Wolff-Parkinson-White elcctnrardiographic pattern. N Engl J Med lY89;320:12?9-1233. 2. Wcllens HJJ. Durrer D. Wolff-Parkinson-White ryndrume and aria1 fibrillation. Relation between refracrory period of accessory pathway and rentricular rate during atrial fihrillalion. Am J Cardiol 1974:.34:777-7X2. 3. Waspe LE. Brodman R. Kim SC;. Fisher JD. Suscepfihdiry tu atnal lihnllarion and venuicular lachyarrhylhmia in rhe Wolff-Parkinson-White syndrome: role of the accessory pathway. Am Heart J 19X6; I 12: I I4 I-I 152. 4. Bella PD. Brugada P. Talajic M, Lcmery R. Turner P. Le~aun R. Dugemirr 1‘. Wellens HJJ. Avial fibrillation in parienrs wirh an accessory pathway: importance of the conduction prupenies of tie accessory pathway. J Am Co// Curdiol lYY1:17:1352-1356. 5. Michelucci A, Padeletti I.. Meuani A. Relationship hctwecn age and antegrade refractoriness of the accessory pathway in Wolff-Parkinson-While patients. Cardiology 1989:76:270-273. 6. Gillette PC. C&on A, Kugkr JD. Wolff-Parkinson-White syndrome m chddmn: electrophysiologic and @armacologic characteristics. Ckuhion lY79:M): 14X7- 1495. 7. Perry JC. Carson A Jr. Supraventricular tachycardia due to Wolff-ParkinsonWhite syndrome in children: early ditippcxance and la~e recurrence. J Am Co/l Cardiol 1990:16:1215-1220. 8. Chane R-KR. Srewwn WG. Wet/cl GT. Shannon K. Baum VC. Khrmer TS. Effects ‘;f irofl;rane on elecrrophysiologic mcawrcments in children with the PACE 11)95: in press. Wolff-Parkinson-While syndrome. 9. DuBrow 1W. Asher EA. Amat-y-Lcun F. Dcne, P. Wu D. Rosen K. Hasrn~rer AR. Comparison of cardiac refrdc~ory periods in children and adults. C‘ircuhfh 1975;51:485+91. 10. Deal BJ. Keane JF. Gillette PC Carson A Jr. Wolff-Parkinson-WhItr syndrome and supravenvlcular tachycardia during infancy: management and follow-up. J Am Cd Cardiol 1985;5: 13&135.
in Congestive
MD, Jyri Lommi, MD, Markku
Heart
Failure
Ventilti, MSc, and Ulla Karjalainen,
PhD
patients with CHF and in control groups consisting of healthy persons and cardiac patients free of CHE ... We studied 31 patients with chronic CHF, 19cardiac increased,3and malnutrition is not uncommon.4 These abnormalities are able to augment lipolysis and use of patients without U-IF, and 24 healthy persons.The CHF peripheral fat in general energy metabolism.5,6 The group was selected from among consecutive patients resulting increased supply of circulating free fatty acids admitted to our department for evaluation or treatment should, in theory, boost ketone body production,6*7but between May 25 and November II, 1994. Criteria for whether CHF really leads to ketosis-pronenesshas not the diagnosis of CHF were the presenceof heart disease been studied. To test the hypothesis that CHF is a keto- and at least 3 of the following 4 signs: (I) dyspnea or sis-prone state, we measuredbreath acetone concentra- fatigue on ordinary effort, (2) either audible third heart tions by gas chromatography after an overnight fast in sound or heart rate >90 beats/min at rest, (3) enlarged relative heart volume on chest x-rays8 or (4) either pulmonary venous congestion on chest x-rays or abnormal From the Drvrsion of Cardiology (Defxxtment of Medicrne) and the neck vein distention at clinical examination. The neck Deportment of Clrnrcol Chemistry, Helsrnki University Central Hos iveins were studied by estimating the supraclavicular tal, Helsrnki, Finland. Thus work was supported by grants from tEe Finnrsh Academv ISA 7 135). Finnish Heart Association [ 19th Febru height (cm) of the blood column in the right internal ary Fund). Foundation for Cardrovascular Research, and Paavo Nurjugular vein with the patient breathing quietly in the sitmi Foundation. Helsrnki. Finland. Dr. Kuwn’s oddress is: Division of ting position. Any venous bulging abovethe clavicle was Cardiology, Helsinki University Central Hosprtal, FIN00290 Helsinconsideredabnormal. Patientswere excluded if they had ki, Finland Manuscript received May 30, 1995; revised manuscript received ond accepted August 8, 199.5 endocrine, renal, infectious, gastrointestinal, or connec-
congestive heart failure (CHF), the circulating conof stresshormones and tumor necrosisfacItorncentrations are frequently elevated,1.2basal metabolism can be
1076
THE AMERICAN
JOURNAL
OF CARDIOLOGY’
VOL. 76
NOVEMBER
15,
1995