Objective-To investigate a population of elderly people for atrial fibrillation and to determine how many of the cases identified might benefit from treatment with anticoagulants. Methods-From a practice of four primary care physicians, 1422 patients aged 65 years and over were identified, of whom 1207 (85% of the total population) underwent electrocardiographic screening to detect the presence of atrial fibrillation. Patients with the arrhythmia were further evaluated by echocardiography and interview, to stratify their risk of stroke based on echocardiographic and clinical risk factors, their perceived risk from anticoagulation, and their attitude towards this treatment. Their primary care physician was also interviewed to determine the factors influencing the prescription of anticoagulants. Results-The arrhythmia occurred in 65 patients (5.4% overall), its prevalence increasing markedly with age (2.3% in 65 to 69 years age group; 8.1% in those over 85). Warfarin was being prescribed to 21.4% of these patients, although the findings of the study indicate that a further 20% were eligible for this treatment. Symptoms suggestive of cardiac failure were common (32.1%) and coexisting pathology was often identified by cardiac ultrasound in these patients (left ventricular hypertrophy, 32.1%; impaired left ventricular contractility, 21.4%; left atrial dilatation, 80.4%; mitral annular calcification, 42.9%; mitral stenosis, 7.1%; mitral regurgitation, 48.2%; aortic stenosis, 8.9%). In all but one case, the decision to anticoagulate was based on the clinical rather than the echocardiographic findings. Conclusions-Individual risk-benefit assessment in elderly patients with atrial fibrillation suggests that almost half (41.4%) are eligible for full anticoagulation with warfarin, whereas presently only one fifth are receiving this treatment. The decision to anticoagulate can be made on clinical grounds in most cases. If these results are confirmed, a doubling of the current number of patients taking anticoagulants can be anticipated. (Heart 1998;79:50-55)

EIT images have been recorded from the upper thorax of 10 normal subjects and from two patients with pulmonary emboli. The Sheffield Mk2 system was used to obtain the EIT images during quiet tidal breathing and the images were then analysed to extract the cardiac and respiratory related components. In the 10 normal subjects the mean measured change in resistivity during tidal breathing was 9% (SD 3%) with no significant difference in four lung regions. The mean changes during the cardiac cycle were different in the four regions, ranging from -0.9% to -2.6%. The two patients showed very different cardiac related changes from those found in the normals in the posterior lung regions. The sign of the changes was positive, whereas it was negative in the normals. The changes in the anterior lung regions were within the range found in our normal group.

Of 2886 patients monitored during acute myocardial infarction, 500 were observed within one hour of the onset of symptoms. Half of the early admission group were admitted in response to emergency 999 calls and 435 of them travelled in resuscitation ambulances, where surveillance for arrhythmias was instituted. Pulmonary oedema occurred in 130 patients (26%), cardiogenic shock supervened in 60 (12%), and 115 (23%) died in hospital. Ventricular fibrillation was observed in 98 patients (20%). Forty two of them survived to be discharged, including 20 of the 24 with primary fibrillation which had occurred first in hospital. In only one case did primary ventricular fibrillation occur after the first 10 hours of onset of illness. Sinus bradycardia, atrial fibrillation, ventricular tachycardia, and ventricular fibrillation were all observed more frequently in patients admitted within one hour after the onset of symptoms than in those admitted later.An element of selection is inevitable when early admission is encouraged by the existence of a resuscitation ambulance system; this will depend in part on the early recognition of risk and the geographical location of the attack. These factors may bias the group towards relatively high risk. Nevertheless, prompt admission after myocardial infarction should improve survival by permitting successful management both of ventricular fibrillation and of other arrhythmias which may influence short term and long term prognosis. IntroductionLittle information is available in world reports on the complications of myocardial infarction when patients come under observation very early after the onset of symptoms. A series representing an unselected population cannot be obtained because data are collected only from those who seek treatment. In 1971 Adgey and colleagues reported' on the incidence of arrhythmias among 284 patients observed within one hour in a mobile coronary care unit manned by medical staff and, at that time, intended to operate in response to calls from general practitioners. Selection may not necessarily be similar in a community encouraged to make use of the emergency (999) telephone system for patients with severe chest pain or collapse; the Belfast results may also have been influenced by the availability of medical skills.Information on the results of early intervention is of particular value because of a resurgence of interest in prehospital care and early hospital admission. In Britain the Department of Health no longer actively discourages the creation of new coronary care and resuscitation ambulance programmes.2 3 District health authorities considering setting up such schemes within financial constraints will wish to know the potential benefits of early intervention.Taking advantage of data collected since the creation of an ambulance system4 -6 based on emergency services without direct medical intervention, we have reviewed retrospectively the records of 500 patients with confirmed myocardial infarction observed within 60 minutes of the onset of chest ...

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