Objectives. Over the last few decades the number of temporary pacemaker placements has declined, while the number of operators has increased. The present study was undertaken in order to assess the quality of present day temporary pacing in Norwegian general hospitals. Design. Prospective, multi-center study from five general hospitals in Norway with a catchment area of 998,000 inhabitants. All temporary pacing procedures performed at these hospitals during a 1-year period should be registered. Results. Fifty patients were treated with temporary pacing and six repeated procedures were performed due to pacing failure. The yearly procedure-rate was five per 100,000 inhabitants. Twenty-nine physicians were involved in these procedures, of whom five were experienced implanters, and 18 physicians participated in only one procedure each. Following temporary pacing a permanent pacemaker was implanted in 60% of patients. In-hospital mortality was 18%, and the incidence of bacteremia was 6%. Conclusions. Temporary pacemaker treatment is currently performed with less than the required amount of skill, with a high number of complications. Cardiologists on call and the possibility of fast-track permanent implantation could improve the quality of care of patients with acute bradyarrhythmias.

The Working Group on Heart Failure of the Norwegian Society of Cardiology here presents a revised programme for the treatment of congestive heart failure. Possible surgical and percutaneous interventions should be considered, and non- pharmacological measures taken as indicated for each patient. ACE-inhibitors are the first-line pharmacological therapy in heart failure with reduced left ventricular ejection fraction (< 40%). Possible adverse effects on blood pressure, renal function and electrolytes necessitate close monitoring of these variables. Beta-blockers should be considered in patients with symptomatic heart failure. If ACE-inhibitors are not tolerated, an angiotensin- II-blocker can be the added. Diuretics should only be used as adjunctive therapy to ACE-inhibitors. Aldosterone antagonists have a proven effect on survival, but close monitoring of potassium levels is imperative. Especially in the elderly, the renal function and level of electrolytes must be monitored closely. Device therapy, such ac cardiac resynchronization therapy and implantable cardioverter defibrillators, are only indicated for selected patients. ACE-inhibitors, diuretics and beta-blockers are the drugs-of-choice for patients with congestive heart failure with preserved systolic function. Health care for patients with congestive heart failure must be well organized on different levels of care and with multidisciplinary teams involved. The goal is to reduce morbidity and mortality in the heart failure population. This programme is meant for primary, secondary and third line health care providers in Norway.

Congestive heart failure is a major health problem in the western world and the prevalence of patients with this diagnosis increases. About 2% of the adult population are affected; the majority are elderly, which represents a challenge when it comes to assessment and treatment. This article concerns the aetiology and diagnosis of congestive heart failure and provides a suggestion for guidelines. The proposed guidelines are aimed at primary, secondary and third line health care providers in Norway, and are based on previously published Norwegian guidelines and international guidelines. Hypertension and coronary artery disease account for 75-80% of known cases of congestive heart failure. The patient's history and risk factors must be investigated. Laboratory tests emphasising organ functions are important, and these should include measurement of B-type natriuretic peptide (BNP). Electrocardiograms and chest X-rays should be taken as well. All patients with suspected impaired left ventricular ejection fraction should undergo an echocardiographic examination. Invasive tests, and non-invasive imaging should be used for selected groups of patients only.

BACKGROUND:The use of thrombolysis in patients with acute myocardial infarction reduces mortality and morbidity. Rapid treatment after the onset of symptoms increases the benefit gained from thrombolysis.MATERIAL AND METHODS:The time delay in the administration of thrombolysis to 138 acute myocardial infarction patients in the hospital in Arendal, Norway was established with a retrospective chart review from January 1995 to December 1996. The results were published locally with a special focus on the time delay. To assess the effect of increased focus, a prospective registration of time delay was performed from November 1998 to December 2003. In this period, 356 acute myocardial infarctions were recorded. Second, the effect of changing the site of administering thrombolytic therapy from the coronary care unit to the emergency department was evaluated from January 2002 to December 2003.RESULTS:The time delay in administration of thrombolysis was reduced from a median delay of 54 minutes in the first period to a median delay of 27 minutes in the second period. No differences were found in time delay between the coronary care unit and the emergency department.INTERPRETATION:The time taken to administer thrombolysis to patients admitted with acute myocardial infarctions can be reduced by focusing on the delay. Changing site of treatment did not affect time delay.

Background— Inflammation and matrix degradation may play a pathogenic role in chronic heart failure (CHF), and therefore, we examined whether thalidomide, a drug with potential immunomodulating and matrix-stabilizing properties, could improve left ventricular (LV) function in patients with CHF secondary to idiopathic dilated cardiomyopathy (IDCM) or coronary artery disease (CAD). Methods and Results— Fifty-six patients with CHF and an LV ejection fraction (LVEF) <40% who were already on optimal conventional cardiovascular treatment were randomized to thalidomide (25 mg QD increasing to 200 mg QD) or placebo and followed up for 12 weeks. Our main findings were as follows: (1) During thalidomide treatment but not during placebo, there was a marked increase in LVEF (&7 EF units) along with a significant decrease in LV end-diastolic volume and heart rate. (2) This improvement in LVEF was accompanied by a decrease in matrix metalloproteinase-2 without any changes in its endogenous tissue inhibitor, suggesting a matrix-stabilizing net effect. (3) Thalidomide also induced a decrease in total neutrophil count and an increase in plasma levels of tumor necrosis factor-α, suggesting both proinflammatory and antiinflammatory effects. (4) The effect of thalidomide on LVEF was more marked in IDCM than in CAD, possibly partly reflecting that the former group was able to tolerate a higher thalidomide dosage. Conclusions— Although our results must be confirmed in larger studies that also examine the effects on morbidity and mortality, our findings suggest a role for thalidomide in the management of CHF in addition to traditional cardiovascular medications.

Long-term treatment with timolol in patients ages 65-75 years who survived myocardial infarction was related to a significant reduction, compared with placebo, in overall mortality (p < 0.05), total cardiac death (p < 0.01), sudden death (p < 0.05) and reinfarction (p < 0.01). The analyses were based on 732 patients (384 taking placebo and 348 timolol) from a cohort of 1884 patients in the Norwegian multicenter timolol study. The dosage of timolol was 10 mg twice daily and the patients were followed for 12-33 months (mean 17 months). There were 83 deaths in the placebo group and 52 deaths in the timolol group, a reduction of 35.5%. There were 69 initial reinfarctions in the placebo group and 38 in the timolol group, a reduction of 39.2%. There was no difference in the reduction of mortality and reinfarction between patients 65-75 years of age and patients less than 65 years of age. The incidence of side effects, the number of withdrawals and the reasons for withdrawal were similar in older and younger patients. We conclude that age should not be a decision-making factor concerning timolol therapy in postinfarct patients.

To test the hypothesis that a statin could reduce the recurrence rate of atrial fibrillation after electrical cardioversion (EC), we performed an open, controlled multicenter study. Patients (n = 114) who had atrial fibrillation >48 hours and who were scheduled for EC were randomized to receive 40 mg of pravastatin once daily for 3 weeks before and 6 weeks after EC or no drug in addition to standard therapy. Pravastatin did not reduce the recurrence rate of atrial fibrillation after EC.

The assessment of quality of life (QoL) has become recognized as an important tool for evaluating heart failure therapy. The angiotensin-converting enzyme inhibitor ramipril (mean dose 8 mg) was evaluated in 223 patients with moderate chronic congestive heart failure at 24 centers in 4 Nordic countries following a randomized, double-blind, placebo-controlled, parallel group design. The follow-up period was 12 weeks. QoL was evaluated using a questionnaire with 47 items, including the disease-specific Severe Heart Failure Questionnaire, the Sleep Dysfunction Scale, and the Psychological General Well-Being Index. In both treatment groups the total score increased from baseline to 12 weeks for both the Severe Heart Failure Questionnaire and for the Psychological Well-Being Index, reflecting relief of symptoms and improved well-being. However, no significant differences between the placebo and ramipril groups could be detected. Only a trend toward improvement in sleep on ramipril compared with placebo therapy was observed. In conclusion, in this placebo-controlled trial no significant effects of 12-week ramipril treatment of QoL could be demonstrated in patients with moderate congestive heart failure.