Cardiac arrhythmias in IHD as detected by Holter monitoring
Keywords:diabetes mellitus, ischemic heart disease, cardiac arrhythmia, Holter monitoring, myocardial infarction, chronic stable angina, atria fibrillation, ventricular ectopic, cardiomyopath, ECG, CAD
AbstractA retrospectives study for selected 96 patients with chronic IHD (chronic stable angina and old MI) referred to Holter unit in AL-Hussein teaching hospital between 20th June 2014 to 20th March 2015 for 24 hour ECG monitoring for different symptoms and 102 healthy control individuals .The age ,sex and the findings of Holter monitoring of control individuals are recorded .The age ,sex, smoking history, referred symptoms and findings of Holter monitoring are recorded. ECG findings of Holter are classified according to specific criteria. Results and discussion; In this study , IHD are common in male sex in comparison to control individuals[ 55% to 47%] and most patient with IHD aged more than 40 and 45% of them above 60, this agree with fact that the prevalence of IHD is higher in men than that in women, this partly due to protective effect of estrogen , Older patients, particularly beyond 70 years of age, have a higher risk for coronary disease and higher risk for adverse outcomes. Sinus tachycardia seen in 51% of control group and 1% of IHD group,[ p value less than 0.05] This is usually either catecholamine mediated in response to a physiologic state (e.g., exercise, anemia, hypotension, pain, fever, thyrotoxicosis) or pharmacologically induced by administration of exogenous stimulants or inhibitors of vagal tone (e.g., β-agonists, catecholamines, theophylline, cocaine, caffeine, atropine. Non-sustained AF is seen in34 patients [33%] of IHD and only in 6 [5%] of control group so there is significant correlation between IHD and AF [p value less than 0.05], some author describe that IHD is most common cause of atrial fibrillation (2) , mechanism behind that ventricular ischemia cause increased intra-atrial pressure and cause AF or less commonly due to atrial ischemia causing AF In this study: total PVC are significantly related to IHD [50 patient 53%] while it present in 18 individuals of control group [17%] and the frequent PVC are seen commonly in IHD than control group [26 patients (27%) to 10 individuals (9%).[p value less than 0.05 In the absence of underlying cardiac disease, VPCs are probably of no prognostic importance. In the presence of cardiac disease, especially ischemic cardiac disease, VPCs predict an increased risk of cardiac death.. However, no study has documented that elimination of VPCs with antiarrhythmic drug therapy reduces the risk of arrhythmic death in patients with severe structural heart disease. In fact, drug therapies that slow myocardial conduction and/or enhance dispersion of refractoriness can actually increase the risk of life-threatening arrhythmias (drug-induced QT prolongation and TDP) despite being effective at eliminating VPCs .Ventricular tachycardia [VT] are closely related to IHD [4 patients (4%)] to non of control group [p value less than 0.05]. In some patients who have non sustained VTs initially, sustained episodes or ventricular fibrillation later develop(s). More than 50% of patients treated for symptomatic recurrent VT have ischemic heart disease. The next largest group has cardiomyopathy ,with lesser percentages divided among those with primary electrical disease, such as inherited ion channel abnormalities , mitral valve prolapse, valvular heart disease, congenital heart disease, and miscellaneous causes. Most patients with IHD in this study have old MI [64 (66%)] and 32 are have chronic stable angina [33%]. Non-sustained AF , PVC and non-sustained VT are frequently seen in those with old MI [25%,34% and 4% respectively] than with stable angina [10%,19% and 0% respectively]P value less than 0.05,patient with a history of previous MI at high risk of sudden arrhythmic due to a combination of scar-related arrhythmia and ischemia. Patients at greatest risk are those with poor left ventricular function. .AF increasing as age advance as seen in table 4 [19% for those 60 and above and 16% for those less than 60 with p value 0.05]Atrial fibrillation is a common arrhythmia that is found in 1 percent of persons older than 60 years to more than 5 percent of patients older than 69 years]Atrial arrhythmia are common seen in female with IHD[PAC 3% and AF in 22%] while ventricular arrhythmia are common seen in male sex[ PVC in 34% and VT in 4%] Estimates are that 2.2 million Americans have atrial fibrillation, which occurs more commonly in men than in women. The prevalence of premature V complexes increases with age; they are associated with male gender and a reduced serum potassium concentration. PVCs are more frequent in the morning in patients after myocardial infarction, but this circadian variation is absent in patients with severe LV dysfunction]
- Elliott M. Antman, et al,: Ischemic Heart Disease, :chapter 243. HARRISON'S Principles of internal medicine 18th edition 2012:
- D.E.Newby, et al: cardiovascular disease: chapter 18. Davidson's principle and practice of medicine 22nd edition 20141-:
- Jeffery E.Olgin ;cardiac arrhythmia ; cardiovascular disease ;Cecil text book of medicine;24th edition 2011.
- Jeffrey E. Olgin Douglas P. Zipes ;specific arrhythmia ;Braunwold,s heart disease 9th edition 2011
- Lawrence Rosenthal, MD, PhD, FACC, FHRS; Chief Editor: Jeffrey N Rottman, MD :Atrial fibrillation: Mediscape references ;2014
- Mueller C, Neumann FJ, Roskamm H, et al: Women do have an improved long-term outcome after non-ST-elevation acute coronary syndromes treated very early and predominantly with percutaneous coronary intervention: A prospective study in 1,450 consecutive patients. J Am Coll Cardiol 2002; 40:245-250.
- Bach RG, Cannon CP, Weintraub WS, et al: The effect of routine, early invasive management on outcome for elderly patients with non-ST-segment elevation acute coronary syndromes. Ann Intern Med 2004; 141:186-195
- Brady PA, Low PA, Shen WK: Inappropriate sinus tachycardia, postural orthostatic tachycardia syndrome, and overlapping syndromes. Pacing Clin Electrophysiol 2005; 28:1112
- Zipes DP, Camm AJ, Borggrefe M, et al: ACC/AHA/ESC Guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. J Am Coll Cardiol 2006; 48:247-346.Consensus guidelines with a comprehensive review of the literature
- Buxton AE, Lee KL, Fisher JD, et al: A randomized study of the prevention of sudden death in patients with coronary artery disease. Multicenter Unsustained Tachycardia Trial Investigators.
- N Engl J Med 1999; 341:1882 61. McKenzie JP, Frazier DW, Smith JM, et al: Successful radio frequency ablation of inappropriate sinus tachycardia (abstr). Circulation 92:I, 1995
- Eric H. Awtry. Joseph Loscalzo cardiac arrhythmia cardiovascular disease:-Cecil essential of medicine:7th edition
- Ischemic stroke phenotype in patients with nonsustained atrial fibrillation. - PubMed – NCBI