Among patients undergoing percutaneous intervention for coronary artery disease, increased BMI was associated with improved 5 year survival. Among those with established coronary disease, the adverse effects of excess adipose tissue may be offset by beneficial vasoactive properties.

Since autonomic tone affects the likelihood of the occurrence and perpetuation of atrial fibrillation, variation of the rate of occurrence of attacks would be expected in parallel with the known diurnal variation of autonomic activity.5 In this study we noted the times of day that episodes of atrial fibrillation occurred. We also compared the ventricular rates at the onset of paroxysms, and noted the number of prolonged paroxysms, in patients with and without digoxin therapy. Patients and methodsWe selected Holter recordings showing paroxysmal atrial fibrillation in 72 consecutive patients who were being investigated for clinical reasons. All patients were in sinus rhythm at the start and end of the recordings, which lasted for 48 hours. For the purposes of this study paroxysmal atrial fibrillation was defined as the occurrence of at least five beats of supraventricular origin, with a totally irregular ventricular response, with no visible P or flutter waves, the arrhythmia lasting less than 24 hours. Seventy two patients (32 men and 40 women; mean age 72 (range 34-93) had arrhythmias which fulfilled these criteria. Associated diagnoses were as follows: none 45, ischaemic heart disease 12, sinoatrial disease 11, valvar heart disease two, hypertension two. Thirty one patients were taking digoxin, 11 were taking a ,B adrenergic blocker (five with digoxin), and nine were taking a calcium channel blocker (three with digoxin). We calculated the serum concentration of digoxin from the serum creatinine concentration and the body weight, using a nomogram based on the pharmacokinetics of digoxin.6 The calculated serum digoxin concentration was 0 ,ug/l in 41, up to 1 jg/l in 11, and over 1 jug/l in 20 patients.The time of onset of each paroxysm was noted together with the ventricular rate, calculated from the first 5-10 beats of each paroxysm. In the case of prolonged bouts of atrial fibrillation lasting 30 minutes or more, the duration of the attack and the ventricular rate immediately before it ended were noted.

Two and a half hours after the onset of chest pain he was admitted to hospital. The electrocardiogram showed evidence of an anterolateral myocardial infarction (figure). The chest radiograph was normal. He was treated with intravenous diamorphine 5 mg and' prochlorperazine 12 5 mg. Soon afterwards he had a cardiac arrest and the cardiac monitor showed ventricular fibrillation. He was successfully cardioverted by a single direct current shock of 400 J. He was subsequently given 15 megaunits of streptokinase. Over the ensuing 24 hours the electrocardiographic monitor showed frequent ventricular extrasystoles, several self-terminating runs of ventricular tachycardia, and intermittently a nodal rhythm. Thereafter he made an uncomplicated recovery. Blood taken after he was resuscitated showed a rise in serum alanine aminotransferase reaching a maximum of 224 U/l the day after admission, and in lactate dehydrogenase reaching a maximum of 556 U/l two days after admission. Gamma glutamyl transferase rose to 104 U/l two days after admission.

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Objective: To determine whether percutaneous coronary intervention (PCI) hospital volume of throughput is associated with periprocedural and medium-term events, and whether any associations are independent of differences in case mix. Design: Retrospective cohort study of all PCIs undertaken in Scottish National Health Service hospitals over a six-year period. Methods: All PCIs in Scotland during 1997-2003 were examined. Linkage to administrative databases identified events over two years' follow up. The risk of events by hospital volume at 30 days and two years was compared by using logistic regression and Cox proportional hazards models. Results: Of the 17 417 PCIs, 4900 (28%) were in low-volume hospitals and 3242 (19%) in high-volume hospitals. After adjustment for case mix, there were no significant differences in risk of death or myocardial infarction. Patients treated in high-volume hospitals were less likely to require emergency surgery (adjusted odds ratio 0.18, 95% confidence interval (CI) 0.07 to 0.54, p = 0.002). Over two years, patients in high-volume hospitals were less likely to undergo surgery (adjusted hazard ratio 0.52, 95% CI 0.35 to 0.75, p = 0.001), but this was offset by an increased likelihood of further PCI. There was no net difference in coronary revascularisation or in overall events. Conclusion: Death and myocardial infarction were infrequent complications of PCI and did not differ significantly by volume. Emergency surgery was less common in high-volume hospitals. Over two years, patients treated in high-volume centres were as likely to undergo some form of revascularisation but less likely to undergo surgery. W hen first introduced more than 20 years ago, percutaneous coronary intervention (PCI) was undertaken in only a few hospitals, with on-site cardiac surgical cover in case patients had coronary occlusion or dissection as a complication of PCI. With the development of coronary stents, the need for emergency referral for surgery fell dramatically, and PCI is now undertaken in an increasing number of sites.As with all interventions there is a balance to be struck. In low-volume centres, operators may find it more difficult to maintain their level of expertise and keep abreast of new advances. However, the likelihood has been well established that patients undergoing any procedure, including revascularisation, in part depends on their geographical distance from the intervention centre.1 Restricting interventions to fewer high-volume centres therefore inevitably leads to geographical inequalities in access to health care.It has been suggested that PCIs should be undertaken only in hospitals performing a minimum of 400 PCIs per annum. 2PCI volume of throughput has even been proposed as a generic marker of quality of care within hospitals.3 However, published studies have produced conflicting results on whether periprocedural complications are less likely to occur in higher-volume institutions.4-11 Furthermore, we are unaware of any studies published to date examining whether hospital vo...