Blockade of the human cardiac K+ channel Kv1.5 by the antibiotic erythromycin

The Internet, as a global computer network, provides opportunities to make available multimedia educational materials, such as teaching files and image databases, that can be accessed using "World-Wide Web" client browser to provide continuing medical education. Since August, 1995, at the Institute of Radiology-University of Palermo, we developed a World-Wide Web server on the Internet to provide a collection of interactive radiology educational resources such as teaching files and image database for continuing medical education in radiology. Our server is based on a UNIX workstation connected to the Internet via our campus Ethernet network and reachable at the uniform resource locator (URL) address: http:/(/)mbox.unipa.it/approximately radpa/ radpa.html. Digital CT and MR images for teaching files and image database are downloaded through an Ethernet local area network from a GE Advantage Windows workstation. US images will be acquired on-line through a video digitizing board. Radiographs will be digitized by means of a Charge Coupled Device (CCD) scanner. To set up teaching files, image database and all other documents, we use the standard "HyperText Markup Language" (HTML) to edit the documents, and the Graphics Interchange Format (GIF) or Joint Photographic Expert Group (JPEG) format to store the images. Nine teaching files are presently available on the server, together with 49 images in the database, a list of international radiological servers, a section devoted to the museum of radiology hosted by our Institute, the electronic version of the Journal Eido Electa. In the first 12 months of public access through the Internet, 12,280 users accessed the server worldwide: 45% of them to retrieve teaching files; 35% to retrieve images from the database; the remaining 20% to retrieve other documents. Placing teaching files and image database on a World-Wide Web server makes these cases more available to residents and radiologists to provide continuing medical education in radiology.     

Expression of Kv1.5 K+ channels in activated microglia in vivo

OBJECTIVES: This study evaluated postoperative weight gain in children who received albumin versus crystalloid prime for cardiopulmonary bypass (CPB). DESIGN: A retrospective case-controlled study. Children whose extracorporeal (EC) circuit prime contained albumin (group 1) were matched with those whose prime contained only crystalloid (group 2) on the basis of age, weight, and surgical repair. SETTING: A university-based medical center. PARTICIPANTS: Seventy-six children (newborn to 4 years of age) who underwent CPB for correction of a congenital heart anomaly from 1993 to 1995. Group 1 underwent surgery from October 1994 to September 1995, and group 2 from February 1993 to September 1994. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Group 1 had less weight gain on postoperative days (PODs) 1, 2 and 3 compared with group 2 (p = 0.04 on POD 1). Albumin (grams per milliliter) prime and prime volume in milliliters per kilogram were the best predictors of weight gain (p < 0.004), with prime volume being the more important. Children who weighed less than 7.5 kg received more prime volume and had greater weight gain than children who weighed 7.5 kg or greater on PODs 1, 2, and 3 (p < 0.02). CONCLUSION: Data suggest that adding albumin to the EC circuit prime and minimizing the prime volume will result in less postoperative weight gain. Further prospective study with a larger sample is warranted to determine whether albumin prime offers other clinical benefits.     

Expression environment determines K+ current properties: Kv1 and Kv4 alpha-subunit-induced K+ currents in mammalian cell lines and cardiac myocytes

Voltage-gated K+ channel (Kv) pore-forming (alpha) subunits of the Kv1 and Kv4 subfamilies have been cloned from heart cDNA libraries, and are thought to play roles in the generation of the transient outward K+ current, Ito. Heterologous expression of these subunits in Xenopus oocytes, however, reveals K+ currents that are quite distinct from Ito. In the experiments here, the detailed time- and voltage-dependent properties of the currents expressed in mammalian cell lines and in cardiac myocytes by Kv1.4 and Kv4.2 were examined and compared to previous findings in studies of oocytes, as well as to Ito characterized in various myocardial cells. As in oocytes, expression of Kv1.4 in HEK-293, Ltk- or neonatal rat ventricular cells reveals rapidly activating K+ currents. In contrast to the currents in oocytes, however, there are two components of inactivation of the Kv1.4-induced currents in mammalian cells, and both components are significantly slower in myocytes than in either HEK-293 or Ltk- cells. In addition, in all three cell types, recovery of Kv1.4 from steady-state inactivation is very slow, proceeding with mean time constants in the range of 6-8 s. The properties of Kv4.2-induced currents also vary with cell type and, importantly, the rates of activation, inactivation and recovery from inactivation are significantly faster in mammalian cells than in Xenopus oocytes. In HEK-293, Chinese hamster ovary (CHO) and neonatal rat ventricular cells, for example, the currents recover from steady-state inactivation with mean (+/-SD) time constants of 153+/-32 (n=12), 245+/-112 (n=10) and 86+/-38 (n=11) ms, respectively; therefore, recovery proceeds 5-10 times faster than observed for Kv4.2 in oocytes. These results emphasize the importance of the cellular expression environment in efforts to correlate endogenous K+ currents with heterologously expressed K+ channel subunits. In addition, the finding that Kv alpha subunits produce distinct K+ currents in different cells suggests that cell-type-specific associations with endogenous Kv alpha or accessory beta subunits and/or post-translational processing play roles in determining the properties of functional K+ channels.     

Decreased expression of Kv4.2 and novel Kv4.3 K+ channel subunit mRNAs in ventricles of renovascular hypertensive rats

Hypertension-induced cardiac hypertrophy is associated with alterations in ventricular action potentials. To understand molecular mechanisms underlying this electrical abnormality, expression of cardiac voltage-gated K+ channel subunit genes was examined in ventricles of renovascular hypertensive rats. While generating a rat Kv4.3 probe, we discovered a previously unreported 19-amino acid insertion in the C-terminal intracellular region of the channel subunit. RNase protection assays indicated that this novel isoform is predominant in rat lung and heart. Effects of renovascular hypertension were then determined by using renal artery clipping models: two-kidney, one clip (2K-1C) rats, a model of high-renin hypertension with a normal plasma volume, and one-kidney, one clip (1K-1C) rats, a model of normal renin with a raised plasma volume. Expression of Kv4.2 and Kv4.3 mRNAs was diminished by > 50% in ventricles of 2K-1C rats; however, no changes in the expression of Kv1.2, Kv1.4, Kv1.5, Kv2.1, or KvLQT1 mRNAs were detected. Similar downregulation of Kv4.2 and Kv4.3 mRNAs was detected in 1K-1C rats. Chronic administration of captopril, an angiotensin-converting enzyme inhibitor, blocked the development of hypertension and the suppression of Kv4 subfamily channel mRNA expression in 2K-1C rats. Furthermore, captopril administration to sham-operated rats significantly increased Kv4.2 mRNA. These results indicate that renovascular hypertension causes specific reductions in Kv4 subfamily channel mRNA expression and that this effect is likely to be mediated primarily by an increase in cardiac afterload.     

Regulation of Kv4.2 and Kv1.4 K+ channel expression by myocardial hypertrophic factors in cultured newborn rat ventricular cells

Postnatal development and myocardial hypertrophy are associated with alterations in cardiac voltage-gated K+ channels. To investigate mechanisms underlying this K+ channel remodeling, expression of Kv4.2 and Kv1.4 K+ channel alpha-subunits was examined in cultured newborn rat ventricular myocytes by Western blot analysis using polyclonal antibodies against each of the subunits. At day 5 of cell culture, Kv1.4 protein was expressed at higher level than Kv4.2; as the age of culture progressed, Kv1.4 was significantly diminished while Kv4.2 increased with time in culture and became the predominant K+ channel protein. Such K+ channel isoform switch from Kv1.4 to Kv4.2 resembles that of the development in vivo. A 72-h treatment with exogenous triiodothyronine (T3, 0.1 microM) to cultured neonatal myocytes enhanced the expression of Kv4.2 by 73% and decreased the Kv1.4 expression by 22%. The effects of T3 were associated with an increase in the protein-to-DNA ratio indicating myocyte hypertrophy. On the other hand, a 72-h treatment with cardiac non-myocyte cell (NMC)-conditioned growth medium (NCGM) or phenylephrine (20 microM) induced similar cell hypertrophy, but in sharp contrast to T3, both markedly suppressed the Kv4.2 channel protein level. In addition, the trophic and the Kv4.2-downregulating effects of NCGM could be mimicked by exogenous endothelin-1 (0.1 microM), a paracrine factor secreted from cardiac NMCs. Our observations for the first time suggest that cardiac Kv4.2 and Kv1.4 K+ channel alpha-subunits are differentially regulated by a variety of myocardial hypertrophic factors. That T3 accelerated the developmental K+ channel isoform switch from Kv1.4 to Kv4.2 in vitro indicates the critical importance of thyroid hormone in postnatal K+ channel remodeling. Cardiac NMCs and alpha-adrenoceptor activation may contribute to the reduced outward K+ channel density in hypertrophied cardiomyocytes.     

Cholinergic short-term conditioning and activation of ATP-sensitive K+ current in cat atrial myocytes

In atrial myocytes, an initial exposure to acetylcholine (ACh1) exerts a short-term conditioning effect such that a second ACh exposure (ACh2) activates ATP-sensitive K+ current (IK,ATP). The purpose of the present study was to determine the mechanism underlying the short-term conditioning induced by ACh that results in subsequent ACh-induced activation of IK.ATP. Cat atrial myocytes were studied using a nystatin-perforated patch whole cell recording method. Changes in L-type Ca2+ current (ICa,L) amplitude were used as an index of relative changes in cyclic AMP (cAMP). The results show that when atrial myocytes are treated with two consecutive exposures to 10 microM ACh separated by a recovery interval, ACh2 activates a larger increase in potassium conductance (gK+) than ACh1. The additional ACh2-induced increase in gK+ is selectively blocked by 10 microM glibenclamide, identifying the current as IK,ATP. Moreover, ICa,L activated immediately after the withdrawal of ACh1 exhibited a transient increase in amplitude above control (+ 76%), consistent with rebound stimulation of cAMP. Rp-cAMPs (50 microM), a selective antagonist of cAMP-dependent protein kinase A, blocked the rebound stimulation of ICa,L and abolished ACh2-induced activation of IK,ATP. Thapsigargin (5 microM), an inhibitor of Ca2+ ATPase in the sarcoplasmic reticulum (SR), abolished ACh2-induced activation of IK,ATP without decreasing rebound stimulation of ICa,L. Rebound stimulation of ICa,L and ACh2-induced activation of IK,ATP both varied as a function of ACh1 duration. We conclude that withdrawal of an initial ACh exposure elicits a rebound cAMP-mediated stimulation of SR Ca2+ uptake. This mechanism induces a short-term conditioning in atrial myocytes such that a subsequent ACh exposure activates IK,ATP. The present results demonstrate novel cholinergic signaling mechanisms in the regulation of IK,ATP.     

Heart failure and atrial fibrillation: current concepts and controversies

OBJECTIVE: Leptin is the product of ob gene shown to regulate body fat in mice. It is produced by human adipose tissue as well, but its physiological functions in man are not known. We explored if there is a relationship in obese humans with serum leptin and energy and fuel metabolism. DESIGN: Cross-sectional study including 45 obese (10 men, 35 women; age and body mass index: 42 +/- 7 y and 35.1 +/- 3.6 kg/m2, respectively). MEASUREMENTS: Food intake by a four-day-food record, blood samples for serum leptin concentrations and resting energy expenditure by indirect calorimetry. RESULTS: Leptin concentrations showed an inverse association (adjusted for fat mass, age and sex) with resting energy expenditure, respiratory quotient and carbohydrate oxidation rate (r = -0.324, P < 0.05; r = -0.420, P < 0.01; r = 0.478, P = < 0.01, respectively), and interestingly, also with dietary fat intake (unadjusted r = -0.30, P < 0.05). Especially, leptin concentrations were elevated in those with low resting energy expenditure and respiratory quotient (below the median). CONCLUSION: Serum leptin concentrations in obese subjects showed an inverse association with resting energy expenditure, respiratory quotient and carbohydrate oxidation rate. The physiological significance of these associations is unclear at the moment but could indicate that obese subjects show resistance to the actions of leptin also outside the brain in terms of regulating metabolic rate and fuel metabolism.     

Left atrial isolation for chronic atrial fibrillation caused by mitral valvular stenosis and regurgitation

Surgical isolation of the left atrium was performed for the treatment of chronic atrial fibrillation secondary to mitral valvular disease in a 65-year-old woman who underwent mitral valvular replacement. Left atrial isolation was simple procedure, prolonging the usual paraseptal atriotomy toward the both mitral valvular commissures anteriorly and posteriorly. The incision was conducted two centimeters apart from the mitral valve annulus, and cryoablation was added at the edges to ensure isolation of the residual left atrium. We suggest performing this simple procedure in patients with chronic atrial fibrillation undergoing mitral valvular replacement, in whom correction of irregular beat and compromised hemodynamics can be obtained.     

Anticoagulation in chronic nonvalvular atrial fibrillation: a critical appraisal and meta-analysis

OBJECTIVE: To assess the outcomes associated with warfarin treatment of patients with chronic nonvalvular atrial fibrillation (CNVAF) for prevention of primary stroke. DATA SOURCES: MEDLINE was searched for literature published from 1987 to August 1996. Search terms used were 'atrial fibrillation' and 'anticoagulants'. STUDY SELECTION: Five published randomized controlled trials concerning primary stroke prevention. DATA EXTRACTION: Data were pooled across trials to estimate the magnitude of the effect for each of nine reported end-points. The annual probability of occurrence of each outcome was calculated, including standard errors and Mantel-Haenszel significance tests with 95% CIs. DATA SYNTHESIS: In view of the lack of blinded assessment and documented low inter-rater reliability of soft neurological end-points, the analysis was limited to the relatively objective end-points of major strokes, fatal strokes, major bleeding and fatal bleeding. Warfarin did not reduce the incidence of fatal strokes to a statistically significant extent, nor was incidence of fatal bleeding increased significantly. Warfarin reduced the absolute annual incidence of major strokes in patients with CNVAF by 0.89%, while at the same time it increased the absolute annual risk of major bleeding incidents by 1.8%. Though small, these differences were statistically significant. CONCLUSIONS: On balance, the margin between expected benefit and harm for warfarin prophylaxis in patients with CNVAF is uncomfortably thin. These results and conclusions differ from those of a previously published meta-analysis of these same studies.     

Non-invasive assessment of magnitude and dispersion of atrial cycle length during chronic atrial fibrillation in man

AIMS: Atrial fibrillation cycle lengths can be assessed from right precordial ECG leads and the unipolar oesophageal ECG using a non-invasive method called Frequency Analysis of Fibrillatory ECG. The purpose of this report is to present the results from application of this method in a large group of patients with long-term atrial fibrillation and to examine the differences between patients with 'coarse' and 'fine' atrial fibrillation. METHODS AND RESULTS: Simultaneous 15 min recordings from V1, V2 and an oesophageal lead at a position behind the posterior atrium were obtained in 28 patients, aged 41 to 78 years, with long-term (> 1 month) atrial fibrillation. In each lead, using the time averaging technique, the QRST complexes were suppressed. Thereafter, the frequency distribution of the residual ECG was estimated by means of Fast Fourier Transform. In the 3-12 Hz range of each lead, the dominant atrial cycle length, the power maximum and the spectral width were calculated. In 26 patients (93%), frequency spectra in the 3-12 Hz range could be obtained. The dominant atrial cycle length ranged from 120 to 175 ms, mean 150+/-16 (SD) ms in V1, and from 120 to 190 ms, mean 150+/-16 in an oesophageal lead (ns). The absolute difference in the dominant atrial cycle length between V1 and the oesophageal lead was 10.4+/-7.7 ms. There was no significant difference in the dominant atrial cycle length in V1 between patients with coarse and fine atrial fibrillation. The power maximum in V1 was significantly greater in patients with coarse compared to fine atrial fibrillation (P=0.01). The spectral widths ranged from 10 to 55 ms and demonstrated significantly higher mean values in lead V2 compared to V1 (P=0.001). Compared to V1, the mean values tended to be smaller in the oesophageal lead (P=0.05). CONCLUSIONS: Using the Frequency Analysis of Fibrillatory ECG method, the dominant atrial cycle length, power maximum and spectral width can be estimated from the frequency spectra in the majority of patients with atrial fibrillation. Spatial dispersion of the dominant atrial cycle length occurs in some patients and may be an important proarrhythmic marker. The distinction between coarse and fine atrial fibrillation cannot be used as a marker of the atrial cycle length.     

Anticoagulation in chronic nonvalvular atrial fibrillation: appraisal of two meta-analyses

Five randomized trials of warfarin stroke prophylaxis in atrial fibrillation have undergone meta-analyses by the Atrial Fibrillation Investigators (AFI) and by the British Columbia Office of Health Technology Assessment (BCOHTA), with differing conclusions. The AFI, using the original data, applied a consistent definition of 'major' bleeding (intracranial, hospitalization or transfusion of at least 2 U of blood) and found an excess of six major bleeding events. The BCOHTA used the definitions used in the studies, including "any medical intervention", and counted an excess of 21 'major' bleeding events. They then compared these with only the most severe one-third of the strokes. The BCOHTA were concerned that lack of blinding may have influenced the diagnosis of mild stroke, but the data do not suggest diagnostic bias. The risk reduction in the BCOHTA analysis of the most severe one-third of strokes was almost identical to that in the remaining strokes. The value of treatment is best assessed by comparing good with bad events of similar impact, and eliminating strokes from analysis does not eliminate them from patients. The BCOHTA analysis confirms the risk reduction demonstrated by the AFI.     

Value of cardiac ultrafast computed tomography for detecting right atrial thrombi in chronic atrial fibrillation

We evaluated the accuracy of cardiac ultrafast computed tomography in diagnosing atrial thrombi in 70 patients with chronic atrial fibrillation, and identified the predictors of atrial thrombi from among clinical, echocardiographic, and ultrafast computed tomographic features. Ultrafast computed tomography identified 11 atrial thrombi in 9 patients: 4 patients had thrombi in the left atrium, 3 in the right, and 2 in both. Transthoracic echocardiography detected only 4 left atrial thrombi, and enlargement of the left or right atrium was associated with atrial thrombi (p <0.05).     

Electrophysiologic characteristics of the atrium during chronic atrial fibrillation in man

Acorn tannins may affect food preferences and foraging strategies of squirrels through effects on acorn palatability and digestibility and squirrel physiology. Captive eastern gray squirrels (Sciurus carolinensis) were fed 100% red oak (Quercus rubra) or white oak (Quercus alba) acorn diets to determine effects on intake, digestion, and detoxification activity. Red oak acorns had higher phenol and tannin levels, which may explain the lower dry matter intakes and apparent protein digestibilities and the higher glucuronidation activities observed in squirrels. Although the white oak acorn diet had lower apparent protein digestibilities than the reference diet, it did not suppress dry matter intake for a prolonged period or stimulate glucuronidation. Negative physiological effects of a 100% red oak acorn diet suggest gray squirrels may require other foods to dilute tannin intake and provide additional nutrients. To distinguish the roles of different tannin types in the observed effects of acorn diets on squirrels, squirrels were fed rat chow containing no tannins, 4% or 8% tannic acid (hydrolyzable tannin), or 3% or 6% quebracho (condensed tannin). Apparent protein digestibilities were reduced by tannic acid and quebracho diets. Only the 8% tannic acid diet tended to increase glucuronidation. Specific effects of tannins may largely depend on tannin type, composition, and source and on other nutritional and physiological factors.     

Suppression of the voltage-gated K+ current of human megakaryocytes by thrombin and prostacyclin

We examined the effects of platelet activators and inhibitors of platelet function on the voltage-gated delayed rectifier K+ current of human megakaryocytes. We found that both the activators such as thrombin, the thrombin receptor peptide (TRP42-47) and ADP and the inhibitors such as prostacyclin suppressed the delayed rectifier current through two different mechanisms. The cAMP dependent protein kinase (A-kinase) inhibitor IP20 blocked the suppression of the delayed rectifier current by prostacyclin and failed to block the suppression by thrombin, TRP42-47 and ADP. The effects of IP20 suggest that the action of prostacyclin is mediated by A-kinase and the action of the three activators is not mediated by A-kinase. Pertussis toxin (PTX) an inhibitor of the inhibitory GTP-binding proteins (Gi) blocked the suppression of the delayed rectifier current by thrombin, TRP42-47 and ADP and failed to block the suppression by prostacyclin. The effects of PTX suggests that the action of the three activators is mediated by Gi or some other PTX-sensitive GTP-binding protein. We speculate that thrombin and other platelet activators that activate Gi may be suppressing the delayed rectifier current via a direct interaction of Gi or a subunit of it with the delayed rectifier potassium channel itself.     

Efficacy of serial electrical cardioversion therapy in patients with chronic atrial fibrillation after valve replacement and implications for surgery to cure atrial fibrillation

In April 1993, a 51-year-old woman had a fever, and an infiltrative shadow was seen in the left upper lobe on a chest X-ray film. Repeated sputum cultures were positive for Mycobacterium avium complex. She underwent antituberculosis therapy consisting of pyrazinamide, ofloxacin, and streptomycin. Her symptom disappeared and the abnormal shadow resolved. In January 1994, she was admitted to the hospital because of bloody sputum and abnormal chest X-ray findings consisting of a left hilar mass and atelectasis of the left upper lobe. Bronchoscopy revealed multiple polypoid lesions without necrosis in the left upper-lobe bronchus. Histological examination showed that the tumor consisted of an aggregation of lymphocytes and plasma cells, and was positive for Ziehl-Neelsen stain. The acid-fast bacillus was identified as Mycobacterium avium by the DNA probe method. Anti-tuberculosis treatment was given: rifampicin, isoniazid, sparfloxacin, and clarithromycin. Three months later, the atelectasis and the polypoid mass in the left upper-lobe bronchus had disappeared. We believe that the polypoid lesions in the left upper-lobe bronchus were due to infection by Mycobacterium avium. The patient was HIV-negative and immunocompetent. Such endobronchial lesions caused by Mycobacterium avium are rare in HIV-negative hosts.     

Electrophysiological properties in patients undergoing atrial compartment operation for chronic atrial fibrillation with mitral valve disease

AIMS: Surgical treatment for atrial fibrillation is now feasible in selective cases. The aim of this study was to assess the electrophysiological properties of patients undergoing atrial compartment operation for chronic atrial fibrillation. METHODS AND RESULTS: Electrophysiological studies were performed in 20 mitral valve patients with atrial fibrillation who had been maintained in sinus rhythm for more than 1 year after atrial compartment operation. Intra-cardiac recording and programmed electrical stimulation were performed in various atrial compartments. The parameters studied included sinus node function, atrial conduction and refractoriness, atrioventricular conduction function and inducible arrhythmias if any. Intra-cardiac recordings showed that the rhythm was of sinus origin in all cases, with the earliest atrial activity located in the high right atrium. The mean sinus cycle length was 750 +/- 110 ms, AH time 106 +/- 29 ms, and HV time 53 +/- 7 ms. The sinus node function was normal in 18 patients (90%), and only two patients had prolonged sinus node recovery and sino-atrial conduction. The right atrial appendage compartment was driven by the sinus node in all patients. However, the conduction time from the high right atrium to the right atrial appendage compartment was markedly prolonged in 12 of 15 patients (80%) undergoing the three-compartment operation in which an incision was placed between the high right atrium and right atrial appendage compartments. On the other hand, the electrical activities in the left atrial compartment were much more varied. In 13 of 20 patients (65%), the left atrial compartment was driven by the sinus node; 11 of the 13 patients had a normal or mildly prolonged conduction time (ranged 75 to 146 ms), whereas two patients had a marked delay in conduction (200 ms and 266 ms, respectively). In the remaining seven patients, the left atrial compartments were dissociated from the rest of the heart; five of them had a quiescent left atrium, one a fluttering left atrial rhythm, and one a slow left atrial rhythm. The effective refractory period was longer in the left atrial compartment (242 +/- 47 ms) as compared to that of the high right atrium (224 +/- 26 ms, P < 0.01) and right atrial appendage compartments (219 +/- 25 ms, P < 0.01). Programmed electrical stimulation could not induce atrial fibrillation in any patient, whereas two patients had inducible atrial flutter and three repetitive atrial responses. CONCLUSIONS: (1) Atrial compartment operation does not impair sinus node function in most cases. (2) Elimination of atrial fibrillation while maintaining the electrical connection between different atrial compartments is feasible.     

Beta-adrenergic blockade as adjunctive oral therapy in patients with chronic atrial fibrillation

In many patients with chronic atrial fibrillation, it is difficult to prevent an excessive ventricular rate under stress, even with high levels of digoxin in the blood. The effect of adding beta-adrenergic blockade with practolol to digoxin on the heart rate at rest and during low-grade controlled exercise was investigated in 28 patients with chronic atrial fibrillation and in ten normal control subjects who were receiving maintenance dosages (0.25 to 0.75 mg) of digoxin. In atrial fibrillation, therapy with practolol decreased the mean heart rate at rest from 99.8 beats per minute to 77.5 beats per minute (23 percent reduction; P less than 0.01) and during mild exercise from 148.9 beats per minute to 105.4 beats per minute (29 percent) reduction (P less than 0.001). Fifteen patients had clinically significant heart failure; therapy with practolol did not worsen it. Reversible side effects were detected in two patients. When therapy with digoxin is not sufficient to control atrial fibrillation, the addition of a beta-adrenergic blocking agent is recommended as adjunctive treatment in selected patients.