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Showing papers by "Atlantic Health System published in 2002"


Journal ArticleDOI
TL;DR: Dual-site RA provides superior symptomatic and asymptomatic AF prevention compared with high RA in patients with symptomatic AF frequency of < or =1/week and is safe and better tolerated than high RA and SP.

180 citations


Journal ArticleDOI
TL;DR: An independent relationship found between nonwhite race and high preventable hospitalization may be in part the result of delays in seeking care affected by antecedent cultural factors.
Abstract: This research examines the effect of income, race, and cultural factors on preventable hospitalizations, using age and sex-adjusted preventable admissions from 53 contiguous zip codes in New Jersey from 1993 to 1995. Low income was strongly associated with high rates of preventable hospitalization in the study zip codes. Income is likely a proxy for education level, barriers to accessing primary care, and health insurance. A floor effect of income levels was present that may reflect a natural level of preventable hospitalization not affected by income, education, or health insurance status. An independent relationship found between nonwhite race and high preventable hospitalization may be in part the result of delays in seeking care affected by antecedent cultural factors. Removing financial barriers is critical but may be insufficient for reducing preventable hospitalizations if other barriers are not also addressed.

30 citations


Journal ArticleDOI
TL;DR: It is concluded that electrophysiologic studies can elicit latent atrial flutter or tachycardia in patients with refractory AF without spontaneous monomorphic atrial tachyarrhythmias.
Abstract: Atrial flutter or tachycardia may coexist with atrial fibrillation [AF] and can be treated with ablation techniques in attempt to reduce the total AF burden. The role of ablation of latent atrial tachyarrhythmias elicited at electrophysiologic study in conjunction with atrial pacing and antiarrhythmic drugs in patients with refractory AF has not been evaluated. We evaluated the efficacy of catheter ablation of electrically induced atrial flutter or atrial tachycardia in improving rhythm control in patients with refractory AF. Methods: Consecutive patients with refractory AF, and spontaneous atrial flutter (Group 1) or without spontaneous atrial flutter (Group 2) underwent programmed stimulation in a baseline drug-free state. All patients had electrically induced atrial flutter or tachycardia. Radiofrequency ablation of the arrhythmia substrate was performed in all patients. Primary endpoints evaluated for patient outcome in both groups included maintenance of rhythm control and freedom from recurrent atrial tachyarrhythmias. Results: Forty-three patients, with a mean age of 66±13 years were studied. Group 1 consisted of 22 patients while Group 2 had 21 patients. Ablation of the tricuspid valve-inferior venacaval isthmus was performed in 41 patients who had common atrial flutter induced at electrophysiologic study. Ablation of other atrial sites was performed in 8 patients with induced atypical flutter and 4 patients with induced atrial tachycardia. Ten of these patients had ablation of more than one arrhythmia. 17 patients (40%) had atrial pacing instituted and 28 patients remained on a class 1/3 antiarrhythmic drug. During a mean follow-up of 26±14 months, 33 patients (82.5%) remained in rhythm control. Actuarial analysis showed 96% of patients in rhythm control at 6 months, 94% at 12 months, and 90% at 24 months. Freedom from symptomatic AF recurrence was 64% at 6 months, 58% at 12 months, and 42% at 24 months. The outcome for both of these endpoints was similar for Group 1 and Group 2 (p = NS). The AF free interval increased significantly from 7±9 days to 172±121 days (p < 0.01) after ablation. This increase was again similar in both the groups. In the 14 patients were who did not receive atrial pacing and who remained on the same class 1/3 antiarrhythmic drug, the AF free interval increased from 18±17 days to 212±102 days (p < 0.01).

19 citations


Journal ArticleDOI
TL;DR: It is concluded that there are monthly and daily patterns in cardiac arrests, with more arrests in the colder months for those >or=65 years of age, and more for ages <65 on Saturdays and Mondays.
Abstract: Our objective was to determine whether monthly and daily patterns existed in cardiac arrests in a 7 emergency department (ED) cohorts in New Jersey. We conducted a retrospective analysis of a computerized database over an 11-year period containing 2,370,233 patient visits and 6,827 nontraumatic cardiac arrests. Time-series regression revealed colder months having more cardiac arrests, especially for patients ≥65 years of age. In that age group, December and March were highest with 17% more ( P =.002) than the average of nonsignificant months. August was the lowest with 19% ( P =.001) fewer cardiac arrests. Day-of-week variation was found only for patients P P =.01), respectively. We conclude that there are monthly and daily patterns in cardiac arrests, with more arrests in the colder months for those ≥65 years of age, and more for ages

19 citations


Journal ArticleDOI
TL;DR: The relative effectiveness of the implantable cardioverter defibrillator and antiarrhythmic drugs (AADs) varies with left ventricular ejection fraction (LVEF), but once an ICD or AAD treatment strategy is chosen, the degree to which the LVEF influences survival is unknown.
Abstract: Survival with ICD or Antiarrhythmic Therapy.Introduction: The relative effectiveness of the implantable cardioverter defibrillator (ICD) and antiarrhythmic drugs (AADs) varies with left ventricular ejection fraction (LVEF). However, once an ICD or AAD treatment strategy is chosen, the degree to which the LVEF influences survival is unknown. This article addresses that question. Methods and Results: Using patient data from the Antiarrhythmics Versus Implantable Defibrillators (AVID) trial, the impact of LVEF on prognosis of patients who were treated with either an ICD or AAD was assessed. Survival within each quintile of LVEF was estimated by the method of Kaplan-Meier for patients treated with either the ICD or AADs. The Cox proportional hazards model was used to investigate the prognostic value of LVEF for estimating survival after adjustment for other baseline covariates among all patients in the subgroups treated by ICD or AAD. In the highest two quintiles of LVEF, survival was comparable in AAD-treated and ICD-treated patients. In the AAD-treated patients, higher LVEF was significantly and independently associated with survival free of all-cause mortality and arrhythmic death. In the ICD-treated patients, however, the statistical significance of the association was lost and only a trend toward greater survival was present. Death due to congestive heart failure remained independently and significantly associated with survival in both AAD-treated and ICD-treated patients. Conclusion: In patients treated with AADs but not patients treated with ICDs, survival is strongly associated with LVEF. The absence of a statistically significant association in the ICD patients is likely related to the effectiveness of the ICD in treating malignant ventricular arrhythmias, but a chance lack of association cannot be excluded.

15 citations


Journal ArticleDOI
TL;DR: The current status of different single-site and dual-site pacing modes for the prevention of atrial fibrillation are discussed and the mechanism of prevention of AF with these modes and the future directions these modes may take are discussed.
Abstract: Nonpharmacological methods are being evaluated for the prevention of atrial fibrillation. The role of atrial pacing has been extensively examined in a large number of retrospective and prospective studies, and recently in randomized multicenter trials. The populations examined have varied from patie

14 citations


Journal ArticleDOI
TL;DR: Optimal patient management requires intimate knowledge of these complex devices and of the diverse arrhythmias that may be treatable by a single multifaceted ICD device.
Abstract: Implantable cardioverter-defibrillator (ICD) devices were originally developed for prevention of sudden cardiac death (SCD). They are now widely regarded as the primary therapy for this condition. Clinical trials have led to a progressive expansion in indications for their use.1,2⇓ Recent clinical reports show effectiveness of these devices in patients with recurrent syncope, in the prevention of SCD in high-risk patients with coronary disease, and in the treatment of atrial fibrillation. Refinements in ICD technology have improved functionality and enhanced safety. Optimal patient management requires intimate knowledge of these complex devices and of the diverse arrhythmias that may be treatable by a single multifaceted ICD device. A 75-year-old man presented with near-syncope and ventricular arrhythmias. He had a past history of dilated cardiomyopathy, old cerebrovascular accident, symptomatic atrial flutter/fibrillation, and heart failure. He had been treated with anticoagulation and antiarrhythmic drugs, but it was noted on admission that he was in atrial flutter with a ventricular rate of 110 bpm. Electrophysiological evaluation revealed isthmus- (common or typical) and nonisthmus- (atypical) dependent atrial flutter and inducible hypotensive monomorphic sustained ventricular tachycardia. A linear ablation of the tricuspid valve-inferior vena cava isthmus interrupted common flutter, but atypical flutter persisted. The following day, a dual chamber ICD capable of defibrillation and antitachycardia, as well as standard demand pacing in both chambers, was inserted. An additional coronary sinus lead was placed to permit dual site right atrial pacing for prevention of atrial flutter and fibrillation (Figure 1A). The patient was given a handheld activator for termination of atrial fibrillation (AF) and flutter. Figure 1. A, Lateral radiograph of the chest showing the first dual chamber atrioventricular defibrillator inserted in patient with refractory atrial fibrillation. Note the distinct atrial and ventricular pacing and defibrillation leads. An additional coronary sinus pacing lead is placed …

11 citations


Journal ArticleDOI
TL;DR: The NICU nurse, often the first to notice an inguinal hernia in a premature infant, should understand the etiology, basic pathophysiology, and nursing care for this condition.
Abstract: Inguinal hernia repair is one of the most common surgical procedures performed on premature infants. Improved survival rates in the NICU have led to an increase in the incidence of premature infants with inguinal hernias. The NICU nurse, often the first to notice an inguinal hernia in a premature infant, should understand the etiology, basic pathophysiology, and nursing care for this condition.

4 citations




Journal ArticleDOI
TL;DR: The effect of natural disasters is often chronicled, and sometimes scientifically well studied as discussed by the authors, and with more frequency, we are encountering unnatural disasters such as the recent event in New York City and Washington DC on September 11, 2001 that can produce extraordinary mortality, often to the exclusion of comparable morbidity.
Abstract: The expression of human disease states at times of disasters has been a subject of intense but often intermittent study. These studies provide important insights into the medical condition and its interaction with its environment. The effect of natural disasters is often chronicled, and sometimes scientifically well studied. Regrettably, and with more frequency, we are encountering unnatural disasters such as the recent event in New York City and Washington DC on September 11, 2001 that can produce extraordinary mortality, often to the exclusion of comparable morbidity. In a metropolis with more state-of-the-art medical care than any in the world, only a few remained alive to benefit from the available care. At such times, we can harken back to prior calamities in search of guidance to mount an appropriate medical response. Almost sixteen years ago to the day, on September 19, 1985 an earthquake registering 8.1 on the Richter scale hammered Mexico City. More than 9,000 people died or disappeared in Mexico City, possibly 30,000 more were injured and over 95,000 became homeless. At the Benito Juarez Hospital, over a thousand doctors, nurses and patients were buried alive. Only a few scrambled out of the of demolished buildings alive. In fact, in both disasters ministering to the responders to the tragedy and survivors often occupied most of the medical rescue efforts. In an another man-made event, the raging oil fires of Kuwait in February 1991 produced an massive environmental and ecological disaster with vast, unknown and lingering health consequences. What do such events have to do with the art and science of cardiac arrhythmology? For starters, the classic triad of arrhythmogenesis has as one of its three founding elements, autonomic modulation. Even more fundamental is the involvement of autonomic nervous influences on the normal cardiac rhythm which has been long recognized. However, the processes by which such effects are achieved are poorly understood. For example, periodic oscillation of arterial pressure, heart rate and muscle sympathetic nerve activity and its relation to respiratory activity has been intensively studied. Initially thought to be secondary to baroreceptor reflexes, mounting evidence now suggests that these oscillations result from fluctuations in instantaneous sympatho-vagal balance [1]. In patients with atrial fibrillation (AF), an increase in adrenergic drive preceding a shift to vagal tone predominance has occurred immediately before AF onset. Two types of AF initiation depending on sympathetic or vagal tone enhancement have been reported [2,3]. In patients with implantable defibrillators at the onset of ventricular tachycardia (VT) or ventricular fibrillation (VF) heart rate variability findings are consistent with the shift of sympatho-vagal balance towards sympathetic predominance and a reduction in vagal tone [4,5]. In a large clinical trial, this sympathetic dependence was more commonly seen in VT events that were unrelated to early cycle triggering ectopics [6]. In the aftermath of a natural disaster it has been reasonable to speculate that such autonomic mechanisms could mediate increased density of arrhythmic events leading to clustering. Indeed, an increased incidence of sudden death or VT events have been observed after earthquakes and other disasters. It will remain to be seen if epidemiologic data substantiate such clustering after the New York & Washington DC disasters. There are however specific effects of environmental toxins related to individual disaster circumstances. Air pollution has been shown to have harmful cardiovascular effects with increased mortality and morbidity with long-term exposure. While deleterious effects of air pollution usually involve the respiratory system, immune system activation and coagulation abnormalities, the cardiovascular system is also affected by these actions. Cardiac arrhythmias may result from the autonomic impact on a preexisting diseased substrate and myocardial vulnerability [7]. Chronic exposure to metallic toxins such as lead in environmental disasters can lead to intraventricular conduction disturbances due to cumulative effects of such toxins [8]. Linkage between chronic fatigue syndrome and the raging oil fires in Gulf war veterans remains an active subject of investigation. Individuals with propensity to such disorders may have environmental precipitants. Cardiac dysfunction after smoke inhalation includes response to burn-related hypovolemia with a sec-

Book ChapterDOI
01 Jan 2002
TL;DR: Analysis of the benefit of atrial pacing is complicated by the interactions of this apparently simple intervention with a heterogeneous AF population and the authors' limited knowledge of the natural history of the arrhythmia in its different substrates.
Abstract: Atrial pacing has been widely but intermittently reported to reduce the recurrence of atrial fibrillation (AF) and progression to permanent AF in a wide variety of observational reports, with the vast majority of these involving retrospective analyses [1–3]. In addition, a variable patient population with respect to AF and underlying cardiac disease has often characterized these reports. The subject has received substantial attention since the follow-up report of the Danish Trial of Physiologic Pacing in sick sinus syndrome reported reduction in the incidence of persistent or permanent AF with atrial-based pacing in patients with sick sinus syndrome [4]. Clinical investigation of atrial pacing techniques for management of AF in symptomatic or high-risk populations has been examined in a series of prospective clinical trials [5–9]. Serious investigative interest has now focused on the electrophysiologic effects of different atrial pacing methods in experimental and clinical laboratory AF models. Analysis of the benefit of atrial pacing is complicated by the interactions of this apparently simple intervention with a heterogeneous AF population and our limited knowledge of the natural history of the arrhythmia in its different substrates. Finally, the appropriate endpoints for demonstration of device clinical efficacy and safety have been unclear, leading to increasing difficulty in defining and quantifying clinical benefit [10, 11].