Journal of the American College of Cardiology
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J. Am. Coll. Cardiol. · Feb 1994
ReviewShould all patients undergo transesophageal echocardiography before electrical cardioversion of atrial fibrillation?
The management of anticoagulant therapy in patients with atrial fibrillation undergoing electrical cardioversion remains controversial, largely because of inadequate studies demonstrating risk or benefit, a relatively inconvenient anticoagulation management strategy and the increasing use of transesophageal echocardiography. Recent investigations into the potential mechanisms involved in the development of thrombus and systemic embolism in patients undergoing electrical cardioversion of atrial fibrillation may provide insight into underlying predisposing factors, with subsequent modification of management strategies. Conventional wisdom suggests that preexisting thrombus is responsible for thromboembolic events after cardioversion. ⋯ To protect against both potential mechanisms of embolization, these data support therapeutic anticoagulation for all patients with atrial fibrillation of > 2 days in duration from the time of, as well as after cardioversion for a total of 4 weeks, undergoing cardioversion, even in the absence of thrombus on echocardiography. Therefore, the role of transesophageal echocardiography in this setting should be to enable early cardioversion if atrial thrombus is excluded and to identify high risk patients with atrial thrombi so as to postpone cardioversion and avoid the risk of embolization. Ultimately, however, a controlled, randomized and prospective clinical trial will be required to compare conventional management with a transesophageal echocardiography-guided strategy.
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J. Am. Coll. Cardiol. · Feb 1994
Transesophageal echocardiography before and during direct current cardioversion of atrial fibrillation: evidence for "atrial stunning" as a mechanism of thromboembolic complications.
The purpose of this study was to evaluate the usefulness of transesophageal echocardiography before electrical cardioversion in patients with atrial fibrillation and to determine the mechanism of thromboembolism after cardioversion. ⋯ Transesophageal echocardiographic detection of left atrial thrombus before direct current cardioversion is important but infrequent in patients with predominantly nonvalvular atrial fibrillation. The occurrence of thromboembolic complications in the absence of demonstrable left atrial thrombus and the new development of spontaneous echo contrast in association with the transient atrial dysfunction ("stunning") caused by cardioversion suggest that cardioversion may promote new thrombus formation, in which case all patients should receive full anticoagulant therapy at the time of cardioversion.
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J. Am. Coll. Cardiol. · Feb 1994
Clinical TrialA new dosing regimen for esmolol to treat supraventricular tachyarrhythmia in Chinese patients.
The purpose of this study was to find a safe dosing regimen for esmolol infusion to rapidly control supraventricular tachyarrhythmia after cardiac surgery in Chinese patients. ⋯ The dosing regimen for esmolol infusion recommended in western studies is not suitable for Chinese patients. In this report we propose a new dosing regimen for esmolol infusion that is both safe and rapid in the treatment of supraventricular tachyarrhythmia in Chinese patients.
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J. Am. Coll. Cardiol. · Feb 1994
Comparative StudySelective aortic perfusion and oxygenation: an effective adjunct to external chest compression-based cardiopulmonary resuscitation.
The purpose of this study was to compare the perfusion pressure and rate of return of spontaneous circulation produced by standard advanced cardiac life support with that resulting from advanced cardiac life support with simultaneous aortic occlusion and proximal infusion with oxygenated fluid. ⋯ The use of selective aortic perfusion and oxygenation increases aortic and coronary perfusion pressures during cardiopulmonary resuscitation, resulting in a large increase in the rate of return of spontaneous circulation. This technique may be an effective adjunct to advanced cardiac life support based on any method of external chest compression and may improve the poor prognosis of patients with cardiac arrest.
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J. Am. Coll. Cardiol. · Jan 1994
Randomized Controlled Trial Clinical TrialA randomized trial of intravenous heparin in conjunction with anistreplase (anisoylated plasminogen streptokinase activator complex) in acute myocardial infarction: the Duke University Clinical Cardiology Study (DUCCS) 1.
We designed a randomized trial to evaluate the effects of heparin administration in conjunction with anistreplase (anisoylated plasminogen streptokinase activator complex [APSAC]) on arterial patency and clinical end points. ⋯ Weight-adjusted intravenous heparin therapy after APSAC in acute myocardial infarction does not reduce the combined incidence of death, reinfarction, recurrent ischemia and occlusion of the infarct-related artery. Furthermore, withholding intravenous heparin therapy is associated with a 46% reduction in bleeding complications. Our findings do not support the addition of intravenous heparin after APSAC therapy, as currently recommended, and suggest that a strategy of withholding heparin is simpler and safer and does not place the patient at increased risk for ischemic complications after myocardial infarction.