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Patients who had cardiac arrest without ST-segment elevation were assigned to undergo either immediate coronary angiography or delayed coronary angiography (after neurologic recovery). All patients underwent PCI if indicated. There was no significant between-group difference in overall survival at 90 days.

This clinical trial of outcomes in patients with atrial fibrillation showed that lenient rate control (resting heart rate, <110 beats per minute) was not inferior to strict rate control (resting heart rate, <80 beats per minute). On the basis of the results, strict rate control may be abandoned as a therapeutic strategy in many patients with permanent atrial fibrillation. In patients with atrial fibrillation, lenient rate control (resting heart rate, <110 beats per minute) was not inferior to strict rate control (resting heart rate, <80 beats per minute). Atrial fibrillation is not a benign condition. 1 It may cause symptoms and is associated with stroke and heart failure. Previous studies have established that the rates of complications and death were similar in patients with atrial fibrillation receiving rate-control therapy and in those receiving rhythm-control therapy. 2 , 3 Therefore, rate control has become front-line therapy in the management of atrial fibrillation. The optimal level of heart-rate control, however, is unknown, as is whether strict rate control is associated with an improved prognosis as compared with a more lenient approach. 2 – 6 Guidelines, though empirical and not evidence-based, recommend the use of strict . . .

This study is the European counterpart of the North American study of atrial fibrillation reported in this issue of the Journal . Although the European study was smaller, the findings in the two studies were quite similar. Rate control was not inferior to rhythm control and should be regarded as appropriate for the management of persistent atrial fibrillation. Atrial fibrillation is not a benign condition. 1 , 2 For many clinicians, maintenance of sinus rhythm is the main therapeutic goal. In patients with persistent atrial fibrillation, repeated electrical cardioversion and prophylactic antiarrhythmic drugs are used to maintain sinus rhythm. 3 However, frequent recurrences of atrial fibrillation and adverse effects of drugs decrease the potential benefits of electrical cardioversion. 4 – 6 Also, the beneficial effects of rhythm control may be nullified by life-threatening cardiovascular events. Such events may be related not to the rhythm but, rather, to underlying cardiovascular abnormalities. 4 Since the rhythm is not the main determinant of the prognosis, it is . . .

Ischemic heart disease is a major cause of out-of-hospital cardiac arrest. The role of immediate coronary angiography (CAG) and percutaneous coronary intervention (PCI) after restoration of spontaneous circulation following cardiac arrest in the absence of ST-segment elevation myocardial infarction (STEMI) remains debated. We hypothesize that immediate CAG and PCI, if indicated, will improve 90-day survival in post–cardiac arrest patients without signs of STEMI. In a prospective, multicenter, randomized controlled clinical trial, 552 post–cardiac arrest patients with restoration of spontaneous circulation and without signs of STEMI will be randomized in a 1:1 fashion to immediate CAG and PCI (within 2 hours) versus initial deferral with CAG and PCI after neurological recovery. The primary end point of the study is 90-day survival. The secondary end points will include 90-day survival with good cerebral performance or minor/moderate disability, myocardial injury, duration of inotropic support, occurrence of acute kidney injury, need for renal replacement therapy, time to targeted temperature control, neurological status at intensive care unit discharge, markers of shock, recurrence of ventricular tachycardia, duration of mechanical ventilation, and reasons for discontinuation of treatment. The COACT trial is a multicenter, randomized, controlled clinical study that will evaluate the effect of an immediate invasive coronary strategy in post–cardiac arrest patients without STEMI on 90-day survival.

Diagnosing acute Stanford type A aortic dissection with the uncommon involvement of the left main coronary artery(LMCA) remains challenging for the emergency physician because it can resemble acute myocardial infarction with cardiogenic shock. The following case report illustrate this infrequent but critical situation. A 52-year-old woman with a history of hypertension awakened with acute retrosternal chest pain accompanied by nausea and vomiting. She was referred to our hospital for primary coronary intervention because of acute myocardial infarction with cardiogenic shock. Coronary angiography indeed revealed LMCA occlusion. Subsequently successful percutaneous coronary intervention with stent implantation was performed, followed by immediate clinical improvement of the patient. Soon after admission at the coronary care unit, severe chest pain, hypotension, and electrocardiographic signs of diffuse myocardial ischemia relapsed. Control coronary angiography,however, showed no in-stent thrombosis. Review of clinical examination revealed an aortic regurgitation murmur. Because of this dynamic pattern of (1) signs of acute myocardial ischemia, (2) relapse of hemodynamic collapse, and (3) unaltered control coronary angiography together with the confirmed aortic regurgitation at transthoracic echocardiography, the patient was suspected of having aortic dissection. Transesophageal echocardiography revealed Stanford type A aortic dissection with severe eccentric aortic regurgitation and no pericardial effusion. Emergent valve-sparing aortic replacement was performed. The patient recovered completely. In this case, the lifesaving element was primary coronary intervention with stenting of the LMCA preventing extensive myocardial damage followed by a surgical correction of the aorta.

This study was conducted to compare rate- and rhythm-control therapy in patients with persistent atrial fibrillation (AF) and mild to moderate chronic heart failure (CHF). Rate control is not inferior to rhythm control in preventing mortality and morbidity in patients with AF. In CHF, this issue is still unsettled. In this predefined analysis of the RACE study, a total of 261 patients were in New York Heart Association (NYHA) classes II and III at baseline. These patients were analyzed. The primary end point was a composite of cardiovascular mortality, hospitalization for CHF, thromboembolic complications, bleeding, pacemaker implantation, and life-threatening drug side effects. Furthermore, quality of life was compared. After 2.3 ± 0.6 years, the primary end point occurred in 29 (22.3%) of the 130 rate-control patients and in 32 (24.4%) of the 131 rhythm-control patients. More cardiovascular deaths, hospitalization for CHF, and bleeding occurred under rate control. Thromboembolic complications, drug side effects, and pacemaker implantation were more frequent under rhythm control. Quality of life did not differ between strategies. In patients successfully treated with rhythm control, the prevalence of end points was not different from those who were in AF at study end. However, the type of end point was different: mortality, bleeding, hospitalization for heart failure, and pacemaker implantation occurred less frequently. In patients with mild to moderate CHF, rate control is not inferior to rhythm control. However, if sinus rhythm can be maintained, outcome may be improved. A prospective randomized trial is necessary to confirm these results.

Recent studies demonstrated that rate control is an acceptable alternative for rhythm control in patients with persistent atrial fibrillation (AF). However, optimal heart rate during AF is still unknown. To show that in patients with permanent AF, lenient rate control is not inferior to strict rate control in terms of cardiovascular mortality, morbidity, neurohormonal activation, New York Heart Association class for heart failure, left ventricular function, left atrial size, quality of life, and costs. The RACE II study is a prospective multicenter trial in The Netherlands that will randomize 500 patients with permanent AF (≤12 months) to strict or lenient rate control. Strict rate control is defined as a mean resting heart rate <80 beats per minute (bpm) and heart rate during minor exercise <110 bpm. After reaching the target, a 24-hour Holter monitoring will be performed. If necessary, drug dose reduction and/or pacemaker implantation will be performed. Lenient rate control is defined as a resting heart rate <110 bpm. Patients will be seen after 1, 2, and 3 months (for titration of rate control drugs) and yearly thereafter. We anticipate a 25% 2.5-year cardiovascular morbidity and mortality in both groups. Enrollment started in January 2005 in 29 centers in The Netherlands and is expected to be concluded in June 2006. Follow-up will be at least 2 years with a maximum of 3 years. This study should provide data how to treat patients with permanent AF.

Beat gestures—spontaneously produced biphasic movements of the hand—are among the most frequently encountered co-speech gestures in human communication. They are closely temporally aligned to the prosodic characteristics of the speech signal, typically occurring on lexically stressed syllables. Despite their prevalence across speakers of the world's languages, how beat gestures impact spoken word recognition is unclear. Can these simple ‘flicks of the hand' influence speech perception? Across a range of experiments, we demonstrate that beat gestures influence the explicit and implicit perception of lexical stress (e.g. distinguishing OBject from obJECT ), and in turn can influence what vowels listeners hear. Thus, we provide converging evidence for a manual McGurk effect: relatively simple and widely occurring hand movements influence which speech sounds we hear.

The perception of temporal contrasts in speech is known to be influenced by the speech rate in the surrounding context. This rate-dependent perception is suggested to involve general auditory processes because it is also elicited by nonspeech contexts, such as pure tone sequences. Two general auditory mechanisms have been proposed to underlie rate-dependent perception: durational contrast and neural entrainment. This study compares the predictions of these two accounts of rate-dependent speech perception by means of four experiments, in which participants heard tone sequences followed by Dutch target words ambiguous between /ɑs/ “ash” and /a:s/ “bait”. Tone sequences varied in the duration of tones (short vs. long) and in the presentation rate of the tones (fast vs. slow). Results show that the duration of preceding tones did not influence target perception in any of the experiments, thus challenging durational contrast as explanatory mechanism behind rate-dependent perception. Instead, the presentation rate consistently elicited a category boundary shift, with faster presentation rates inducing more /a:s/ responses, but only if the tone sequence was isochronous. Therefore, this study proposes an alternative, neurobiologically plausible account of rate-dependent perception involving neural entrainment of endogenous oscillations to the rate of a rhythmic stimulus.

Temporal contrasts in speech are perceived relative to the speech rate of the surrounding context. That is, following a fast context sentence, listeners interpret a given target sound as longer than following a slow context, and vice versa. This rate effect, often referred to as “rate-dependent speech perception,” has been suggested to be the result of a robust, low-level perceptual process, typically examined in quiet laboratory settings. However, speech perception often occurs in more challenging listening conditions. Therefore, we asked whether rate-dependent perception would be (partially) compromised by signal degradation relative to a clear listening condition. Specifically, we tested effects of white noise and reverberation, with the latter specifically distorting temporal information. We hypothesized that signal degradation would reduce the precision of encoding the speech rate in the context and thereby reduce the rate effect relative to a clear context. This prediction was borne out for both types of degradation in Experiment 1 , where the context sentences but not the subsequent target words were degraded. However, in Experiment 2 , which compared rate effects when contexts and targets were coherent in terms of signal quality, no reduction of the rate effect was found. This suggests that, when confronted with coherently degraded signals, listeners adapt to challenging listening situations, eliminating the difference between rate-dependent perception in clear and degraded conditions. Overall, the present study contributes towards understanding the consequences of different types of listening environments on the functioning of low-level perceptual processes that listeners use during speech perception.