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13,100 | Predictive factors of sustained sinus rhythm and recurrent atrial fibrillation after the maze procedure. | We examined perioperative predictors of sustained sinus rhythm (SR) in patients undergoing the Cox maze operation and concomitant cardiac surgery for structural heart disease.</AbstractText>From October 1999 to December 2008, 90 patients with atrial fibrillation (AF) underwent the Cox maze operation and other concomitant cardiac surgery. Eighty-nine patients, all except for one postoperative death, were followed-up with serial electrocardiographic studies, 24-hour Holter monitoring tests, and regular echocardiographic studies.</AbstractText>Eighty-nine patients undergoing the maze operation were divided into two groups according to the presence of SR. At the time of last follow-up (mean follow-up period, 51.0±30.8 months), 79 patients (88.8%) showed SR (SR group) and 10 patients (11.2%) had recurrent AF (AF group). Factors predictive of sustained SR were the immediate postoperative conversion to SR (odds ratio, 97.2; p=0.001) and the presence of SR at the 6th month postoperatively (odds ratio, 155.7; p=0.002). Duration of AF, mitral valve surgery, number of valves undergoing surgery, left atrial dimension, and perioperative left ventricular dimensions and ejection fractions were not predictors of postoperative maintenance of SR.</AbstractText>Immediate postoperative SR conversion and the presence of SR at the 6th postoperative month were independent predictors of sustained SR after the maze operation.</AbstractText> |
13,101 | Transient J-Wave Appearance in the Inferior-Lateral Leads during Electrical Storm in a Patient with Brugada Syndrome. | A 67-year-old male patient was admitted with an abrupt sudden cardiac death. He represented with an extreme electrical storm of 30 times of ventricular fibrillation (VF) episodes on one day. External shocks were performed to terminate VF. Transient J-wave in the inferior-lateral leads and Brugada electrocardiography pattern on the right precordial leads appeared during the electrical storm. And J-wave disappeared after the termination of electrical storm. We report a case of the appearance of J-wave during electrical storm in a patient with Brugada syndrome. |
13,102 | Is a drug-challenge test with propafenone adequate to exclude Brugada syndrome? | Brugada syndrome is associated with sudden cardiac death in patients with a structurally normal heart. The electrocardiogram (ECG) pattern of Brugada syndrome is characterised by complete or incomplete right bundle branch block and ST-segment elevation in the right precordial leads. These ECG signs may not always be apparent but can be unmasked with certain anti-arrhythmia agents. We report here a case of a 26-year-old woman without detectable structural heart disease but with a history of syncope, cardiac arrest, intubation and defibrillation for ventricular fibrillation. We performed challenge tests with propafenone and ajmaline. After infusion of propafenone, there were minimal ECG changes which were not diagnostic for Brugada syndrome. One week later the provocation test was repeated with ajmaline. During infusion of ajmaline, prominent J waves and ST-segment elevation appeared in the right precordial leads (V1-3). Premature ventricular complexes were seen on a 12-lead ECG. The patient's ECG showed Brugada type 1 pattern. She received an internal cardioverter/defibrillator and was discharged with a beta-blocker. |
13,103 | Gender modulates the aging effects on different patterns of early repolarization. | Distinct patterns of early repolarization (ER) are associated with ventricular fibrillation and arrhythmic death. We evaluated whether gender modulated the aging effects on different ER patterns. We studied manifestations of ER in the anterior, inferior, and lateral leads on standard 12-lead electrocardiography from male (n = 1077) and female (n = 1170) individuals of young (≤44 years), middle-aged (45-64 years), and elderly (≥65 years) subjects. Among a total of 2247 individuals, 543 (24.2 %) subjects had ER and 417 (18.6 %) had single-location ER. Single-location ER occurred less in lateral leads than in anterior or inferior leads (2.1, 7.8, 8.6 %, respectively, p < 0.05). Subjects with inferior ER (n = 193) were older (61 ± 14, 49 ± 14, 54 ± 16 years, respectively, p < 0.05) than those with anterior (n = 176) or lateral (n = 48) ER. In males with ER, the elderly group (n = 22) had fewer instances of anterior ER (34, 59, 80 %, respectively, p < 0.05) than middle-aged (n = 76) or young (n = 59) groups. Elderly males (n = 37) and females (n = 48) had greater instances of inferior ER (57, 32, 19 %, p < 0.05; 86, 62, 46 %, respectively, p < 0.05) than middle-aged males (n = 41) and females (n = 41), and young males (n = 14) and females (n = 12), respectively. In conclusion, gender modulates the aging effects on the occurrences of anterior ER and inferior ER. |
13,104 | KATP channel opening accelerates and stabilizes rotors in a swine heart model of ventricular fibrillation. | The mechanisms underlying ventricular fibrillation (VF) are still disputed. Recent studies have highlighted the role of KATP-channels. We hypothesized that, under certain conditions, VF can be driven by stable and epicardially detectable rotors in large hearts. To test our hypothesis, we used a swine model of accelerated VF by opening KATP-channels with cromakalim.</AbstractText>Optical mapping, spectral analysis, and phase singularity tracking were performed in eight perfused swine hearts during VF. Pseudo-bipolar electrograms were computed. KATP-channel opening almost doubled the maximum dominant frequency (14.3 ± 2.2 vs. 26.5 ± 2.8 Hz, P < 0.001) and increased the maximum regularity index (0.82 ± 0.05 vs. 0.94 ± 0.04, P < 0.001), the density of rotors (2.0 ± 1.4 vs. 16.0 ± 7.0 rotors/cm²×s, P < 0.001), and their maximum lifespans (medians: 368 vs. ≥3410 ms, P < 0.001). Persistent rotors (≥1 movie = 3410 ms) were found in all hearts after cromakalim (mostly coinciding with the fastest and highest organized areas), but they were not epicardially visible at baseline VF. A 'beat phenomenon' ruled by inter-domain frequency gradients was observed in all hearts after cromakalim. Acceleration of VF did not reveal any significant regional preponderance. Complex fractionated electrograms were not found in areas near persistent rotors.</AbstractText>Upon KATP-channel opening, VF consisted of rapid and highly organized domains mainly due to stationary rotors, surrounded by poorly organized areas. A 'beat phenomenon' due to the quasi-periodic onset of drifting rotors was observed. These findings demonstrate the feasibility of a VF driven by stable rotors in hearts whose size is similar to the human heart. Our model also showed that complex fractionation does not seem to localize stationary rotors.</AbstractText> |
13,105 | Molecular basis of selective atrial fibrosis due to overexpression of transforming growth factor-β1. | Animal studies show that transforming growth factor-β1 (TGF-β1) is an important mediator of atrial fibrosis and atrial fibrillation (AF). This study investigated the role of TGF-β1 in human AF and the mechanism of atrial-selective fibrosis.</AbstractText>Atrial specimens from 17 open heart surgery patients and left atrial and ventricular specimens from 17 explanted hearts were collected to assess the relationship between TGF-β1, AF, and differential atrial vs. ventricular TGF-β1 levels. A transgenic mouse model overexpressing active TGF-β1 was used to study the mechanisms underlying the resultant atrial-selective fibrosis. Higher right atrial total TGF-β1 levels (2.58 ± 0.16-fold, P < 0.0001) and active TGF-β1 (3.7 ± 0.7-fold, P = 0.013) were observed in those that developed post-operative AF. Although no ventricular differences were observed, 11 explanted heart failure hearts exhibited higher atrial TGF-β1 levels than 6 non-failing hearts (2.30 ± 0.87 fold higher, P < 0.001). In the transgenic mouse, TGF-β1 receptor-1 kinase blockade resulted in decreased atrial expression of fibrosis-related genes. By RNA microarray analyses in that model, 80 genes in the atria and only 2 genes in the ventricle were differentially expressed. Although these mice atria, but not the ventricles, exhibited increased expression of fibrosis-related genes and phosphorylation of Smad2, there were no differences in TGF-β1 receptor levels or Smads in the atria compared with the ventricles.</AbstractText>TGF-β1 mediates selective atrial fibrosis in AF that occurs via TGF-β Receptor 1/2 and the classical Smad pathway. The differential atrial vs. ventricular fibrotic response occurs at the level of TGF-β1 receptor binding or phosphorylation.</AbstractText> |
13,106 | Nitric oxide regulates cardiac intracellular Na⁺ and Ca²⁺ by modulating Na/K ATPase via PKCε and phospholemman-dependent mechanism. | In the heart, Na/K-ATPase regulates intracellular Na(+) and Ca(2+) (via NCX), thereby preventing Na(+) and Ca(2+) overload and arrhythmias. Here, we test the hypothesis that nitric oxide (NO) regulates cardiac intracellular Na(+) and Ca(2+) and investigate mechanisms and physiological consequences involved. Effects of both exogenous NO (via NO-donors) and endogenously synthesized NO (via field-stimulation of ventricular myocytes) were assessed in this study. Field stimulation of rat ventricular myocytes significantly increased endogenous NO (18 ± 2 μM), PKCε activation (82 ± 12%), phospholemman phosphorylation (at Ser-63 and Ser-68) and Na/K-ATPase activity (measured by DAF-FM dye, western-blotting and biochemical assay, respectively; p<0.05, n=6) and all were abolished by Ca(2+)-chelation (EGTA 10mM) or NOS inhibition l-NAME (1mM). Exogenously added NO (spermine-NONO-ate) stimulated Na/K-ATPase (EC50=3.8 μM; n=6/grp), via decrease in Km, in PLM(WT) but not PLM(KO) or PLM(3SA) myocytes (where phospholemman cannot be phosphorylated) as measured by whole-cell perforated-patch clamp. Field-stimulation with l-NAME or PKC-inhibitor (2 μM Bis) resulted in elevated intracellular Na(+) (22 ± 1.5 and 24 ± 2 respectively, vs. 14 ± 0.6mM in controls) in SBFI-AM-loaded rat myocytes. Arrhythmia incidence was significantly increased in rat hearts paced in the presence of l-NAME (and this was reversed by l-arginine), as well as in PLM(3SA) mouse hearts but not PLM(WT) and PLM(KO). We provide physiological and biochemical evidence for a novel regulatory pathway whereby NO activates Na/K-ATPase via phospholemman phosphorylation and thereby limits Na(+) and Ca(2+) overload and arrhythmias. This article is part of a Special Issue entitled "Na(+) Regulation in Cardiac Myocytes". |
13,107 | Atrial fibrillation in endurance athletes. | There is a growing population of veteran endurance athletes, regularly participating in training and competition. Although the graded benefit of exercise on cardiovascular health and mortality is well established, recent studies have raised concern that prolonged and strenuous endurance exercise may predispose to atrial and ventricular arrhythmias. Atrial fibrillation (AF) and atrial flutter are facilitated by atrial remodelling, atrial ectopy, and an imbalance of the autonomic nervous system. Endurance sports practice has an impact on all of these factors and may therefore act as a promoter of these arrhythmias. In an animal model, long-term intensive exercise training induced fibrosis in both atria and increased susceptibility to AF. While the prevalence of AF is low in young competitive athletes, it increases substantially in the aging athlete, which is possibly associated with an accumulation of lifetime training hours and participation in competitions. A recent meta-analysis revealed a 5-fold increased risk of AF in middle-aged endurance athletes with a striking male predominance. Beside physical activity, height and absolute left atrial size are independent risk factors for lone AF and the stature of men per se may explain part of their higher risk of AF. Furthermore, for a comparable amount of training volume and performance, male non-elite athletes exhibit a higher blood pressure at rest and peak exercise, a more concentric type of left ventricular remodelling, and an altered diastolic function, possibly contributing to a more pronounced atrial remodelling. The sports cardiologist should be aware of the distinctive features of AF in athletes. Therapeutic recommendations should be given in close cooperation with an electrophysiologist. Reduction of training volume is often not desired and drug therapy not well tolerated. An early ablation strategy may be appropriate for some athletes with an impaired physical performance, especially when continuation of competitive activity is intended. This review focuses on the prevalence, risk factors, and mechanisms of AF in endurance athletes, and possible therapeutic options. |
13,108 | Mexiletine as an adjunctive therapy to amiodarone reduces the frequency of ventricular tachyarrhythmia events in patients with an implantable defibrillator. | The most effective pharmacological management of frequent ventricular tachyarrhythmia events in patients with an implantable defibrillator who failed or did not tolerate amiodarone is unknown. The aim of this retrospective cohort study was to assess the efficacy and tolerability of mexiletine in such patients. The patients served as self-controls. The number of treated ventricular tachyarrhythmia episodes (primary outcome); mortality, shocks from the defibrillator, and electrical storm events (secondary outcomes) during mexiletine therapy was compared with a matched duration of observation just before initiating mexiletine in 29 patients who were treated with a median dose of 300 mg/d of mexiletine and were followed for a median of 12 months. None of the patients had to stop mexiletine due to side effect. There was a significant reduction in the incidence of ventricular tachycardia/fibrillation episodes (median 2 vs. 12 events, P = 0.001) and shocks (median 0 vs. 2 events, P = 0.003) in the first 3 months of treatment, but long-term efficacy was only observed among patients who continued amiodarone therapy. In conclusion, mexiletine, when added to amiodarone in case of amiodarone inefficacy, reduces ventricular tachycardia/fibrillation events and appropriate therapies in patients with an implantable cardioverter defibrillator. A randomized trial should validate the efficacy and safety of mexiletine as an adjunctive therapy to amiodarone. |
13,109 | Impact of transesophageal electrophysiologic study to elucidate the mechanism of arrhythmia on children with supraventricular tachycardia and no preexcitation. | An electrophysiologic study (EPS) of children and teenagers with paroxysmal supraventricular tachycardia (SVT) and normal electrocardiography (ECG) in sinus rhythm was evaluated. Generally, EPS is performed only before paroxysmal SVT ablation in these patients. In this study, 140 patients (mean age, 15 ± 3 years) with normal ECG in sinus rhythm were studied for SVT by a transesophageal route in baseline state and after isoproterenol. Idiopathic left or right ventricular tachycardia was diagnosed in four patients (3 %). Anterograde conduction over an atrioventricular (AV) left lateral (n = 10) or septal (n = 9) accessory pathway (AP) was noted in 19 patients (13.5 %) at atrial pacing. Orthodromic AV reentrant tachycardia (AVRT) was induced in these children. Five of the patients had a high rate conducted over AP (>240 bpm in baseline state or >290 bpm after isoproterenol). Two of the patients (a 10-year-old girl with well-tolerated SVT and a 17-year-old with syncope-related SVT) had the criteria for a malignant form with the induction of atrial fibrillation conducted over AP at a rate exceeding 290 bpm in baseline state. Of the 140 patients, 74 (53 %) had typical AV node reentrant tachycardia (AVNRT), nine had atypical AVNRT (6 %), 1 had atrial tachycardia (0.7 %), and 33 (23.5 %) had AVRT related to a concealed AP with only retrograde conduction. Electrophysiologic study is recommended for children with paroxysmal SVT and normal ECG in sinus rhythm. The data are helpful for guiding the treatment. Ventricular tachycardia or atrial tachycardia can be misdiagnosed. Masked preexcitation syndrome with anterograde conduction through AP was present in 13.5 % of the patients, and 1.4 % had a malignant preexcitation syndrome. |
13,110 | Value of an automatic external defibrillator printout as a diagnostic tool after successful AED use on a child. | A 6-year-old girl without any medical history experienced a drowning incident for a duration of 2 min, according to witnesses. This was followed by cardiopulmonary resuscitation, during which the automatic external defibrillator (AED) detected a shockable rhythm and subsequently delivered a single electroshock. At the time of admission, her medical history was unclear, and as her chest had been wet, it was not clear if the AED had been capable of correctly analysing the rhythm. The AED printout, however, revealed ventricular fibrillation (VF), which proved to be a primary cardiac cause at the time of the incident. This case report confirms the assumption that the AED can adequately perform rhythm analysis on children and convert VF into sinus rhythm. Moreover, the AED printout can provide information about the rhythm that is necessary for the diagnosis of an underlying cardiac disease. |
13,111 | Tricuspid regurgitation after mitral valve repair for degenerative mitral regurgitation. | We examined changes of TR (tricuspid regurgitation) after mitral valve repair for degenerative mitral regurgitation (MR) and investigated their contributing parameters.</AbstractText>We divided 205 patients undergoing mitral valve repair for degenerative MR into 3 groups: up-grade (n = 65), down-grade (n = 29), and no-change (n = 111) of TR during postoperative follow-up. Preoperative, immediate postoperative, and mid-term postoperative parameters included MR grade, right ventricular (RV) pressure, RV Tei index, left ventricular Tei index, and presence of atrial fibrillation.</AbstractText>Preoperative incidence of atrial fibrillation in the down-grade group was lower (7%) than those in the other groups (37% and 34%). In the immediate postoperative stage, the TR grade of the up-grade group was significantly lower (p <0.001) and RV Tei index of the downgrade group was significantly lower (p = 0.049). In mid-term postoperative stage, the TR grade (p <0.001) and RV Tei index (p = 0.034) of the down-grade group were significantly lower, and the MR up-grade in the TR up-grade group was significantly frequent (p = 0.008).</AbstractText>TR became deteriorated even after the operation in about 30% and remained unchanged in about 50%. The RV Tei index can be a reliable parameter to predict postoperative improvement of TR. The postoperative MR up-grade was related to the TR up-grade.</AbstractText> |
13,112 | Public access defibrillation improved the outcome after out-of-hospital cardiac arrest in school-age children: a nationwide, population-based, Utstein registry study in Japan. | The purpose of this study was to determine whether implementation of public access defibrillation (PAD) improves the outcome after out-of-hospital cardiac arrest (OHCA) in school-age children at national level.</AbstractText>We conducted a prospective, nationwide, population-based Japanese Utstein registry study of consecutive OHCA cases in elementary and middle school children (7-15 years of age) who had a bystander-witnessed arrest of presumed cardiac origin during 2005-09 and received pre-hospital resuscitation by emergency responders. The primary endpoint was a favourable neurological outcome 1 month after an arrest. Among 230 eligible patients enrolled, 128 had ventricular fibrillation (VF) as an initial rhythm. Among these 128 patients, 29 (23%) children received a first shock by a bystander. Among these 29 patients, the proportion of the favourable neurological outcome after OHCA was 55%. During the study period, the proportion of patients initially shocked by a bystander among eligible patients increased from 2 to 21% (P = 0.002 for trend). The proportion of patients with a favourable neurological outcome after OHCA increased from 12 to 36% overall (P = 0.006). The collapse to defibrillation time was shorter in bystander-initiated defibrillation when compared with defibrillation by emergency responders (3.3 ± 3.7 vs. 12.9 ± 5.8 min, P < 0.001), and was independently associated with a favourable neurological outcome after OHCA [P = 0.03, odds ratio (OR) per 1 min increase, 0.90 (95% confidence interval 0.82-0.99)]. A non-family member's witness was independently associated with VF as the initial rhythm [P < 0.001, OR 4.03 (2.08-7.80)].</AbstractText>Implementation of PAD improved the outcome after OHCA in school-age children at national level in Japan.</AbstractText> |
13,113 | A composite model of survival from out-of-hospital cardiac arrest using the Cardiac Arrest Registry to Enhance Survival (CARES). | Using CARES data, to develop a composite multivariate logistic regression model of survival for projecting survival rates for out-of-hospital arrests of presumed cardiac etiology (OHCA).</AbstractText>This is an analysis of 25,975 OHCA cases (from October 1, 2005 to December 31, 2011) occurring before EMS/first responder arrival and involving attempted resuscitation by responders from 125 EMS agencies.</AbstractText>The survival-at-hospital discharge rate was 9% for all cases, 16% for bystander-witnessed cases, 4% for unwitnessed cases, and 32% for bystander-witnessed pVT/VF cases. The model was estimated separately for each set of cases above. Generally, our first equation showed that joint presence of a presenting rhythm of pVT/VF and return of spontaneous circulation in the pre-hospital setting (PREHOSPROSC) is a substantial direct predictor of patient survival (e.g., 55% of such cases survived). Bystander AED use, and, for witnessed cases, bystander CPR and response time are significant but less sizable direct predictors of survival. Our second equation shows that these variables make an additional, indirect contribution to survival by affecting the probability of joint presence of pVT/VF and PREHOSPROSC. The model yields survival rate projections for various improvement scenarios; for example, if all cases had involved bystander AED use (vs. 4% currently), the survival rate would have increased to 14%. Approximately one-half of projected increases come from indirect effects that would have been missed by the conventional single-equation approach.</AbstractText>The composite model describes major connections among predictors of survival, and yields specific projections for consideration when allocating scarce resources to impact OHCA survival.</AbstractText>Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.</CopyrightInformation> |
13,114 | Clinical state transitions during advanced life support (ALS) in in-hospital cardiac arrest. | When providing advanced life support (ALS) in cardiac arrest, the patient may alternate between four clinical states: ventricular fibrillation/tachycardia (VF/VT), pulseless electrical activity (PEA), asystole, and return of spontaneous circulation (ROSC). At the end of the resuscitation efforts, either death has been declared or sustained ROSC has been obtained. The aim of this study was to describe and analyze the clinical state transitions during ALS among patients experiencing in-hospital cardiac arrest.</AbstractText>The defibrillator files from 311 in-hospital cardiac arrests at the University of Chicago Hospital (IL, USA) and St. Olav University Hospital (Trondheim, Norway) were analyzed (clinicaltrials.gov: NCT00920244). The transitions between clinical states were annotated along the time axis and visualized as plots of the state prevalence according to time. The cumulative intensity of the state transitions was estimated by the Nelson-Aalen estimator for each type of state transition, and for the intensities of overall state transitions. Between 70% and 90% of patients who eventually obtained sustained ROSC had progressed to ROSC by approximately 15-20 min of ALS, depending on the initial rhythm. Patients behaving unstably after this time period, i.e., alternating between ROSC, VF/VT and PEA, had a high risk of ultimately being declared dead.</AbstractText>We provide an overall picture of the intensities and patterns of clinical state transitions during in-hospital ALS. The majority of patients who obtained sustained ROSC obtained this state and stabilized within the first 15-20 min of ALS. Those who continued to behave unstably after this time point had a high risk of ultimately being declared dead.</AbstractText>Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.</CopyrightInformation> |
13,115 | A three-dimensional finite element model of human atrial anatomy: new methods for cubic Hermite meshes with extraordinary vertices. | High-order cubic Hermite finite elements have been valuable in modeling cardiac geometry, fiber orientations, biomechanics, and electrophysiology, but their use in solving three-dimensional problems has been limited to ventricular models with simple topologies. Here, we utilized a subdivision surface scheme and derived a generalization of the "local-to-global" derivative mapping scheme of cubic Hermite finite elements to construct bicubic and tricubic Hermite models of the human atria with extraordinary vertices from computed tomography images of a patient with atrial fibrillation. To an accuracy of 0.6 mm, we were able to capture the left atrial geometry with only 142 bicubic Hermite finite elements, and the right atrial geometry with only 90. The left and right atrial bicubic Hermite meshes were G1 continuous everywhere except in the one-neighborhood of extraordinary vertices, where the mean dot products of normals at adjacent elements were 0.928 and 0.925. We also constructed two biatrial tricubic Hermite models and defined fiber orientation fields in agreement with diagrammatic data from the literature using only 42 angle parameters. The meshes all have good quality metrics, uniform element sizes, and elements with aspect ratios near unity, and are shared with the public. These new methods will allow for more compact and efficient patient-specific models of human atrial and whole heart physiology. |
13,116 | Ulinastatin improved cardiac dysfunction after cardiac arrest in New Zealand rabbits. | The present study was designed to evaluate the effects of ulinastatin (UTI) on cardiac dysfunction after cardiopulmonary resuscitation (CPR).</AbstractText>A total of 48 healthy adult male New Zealand rabbits were untreated for 8 minutes after the induction of ventricular fibrillation (VF) by an external transthoracic alternating current and then treated by CPR. These rabbits were then randomly divided into the control and UTI groups after the return of spontaneous circulation (ROSC) and were observed for 8 hours after the ROSC. Before CPR and after ROSC at 2, 4, and 8 hours, blood samples were collected to determine the levels of tumor necrosis factor α (TNF-α), interleukin-6 (IL-6), malondialdehyde (MDA), cardiac troponin I (cTnI), and N-terminal probrain natriuretic peptide (NT-proBNP), and the left ventricular ejection fraction (EF) was measured by echocardiography.</AbstractText>Nineteen of 24 rabbits in the control group and 18 of 24 in the UTI group were successfully resuscitated. The plasma levels of TNF-α, IL-6, MDA, cTnI, and NT-proBNP were significantly increased, accompanying a deceased EF in the control group, but the cotreatment with UTI decreased the plasma levels of TNF-α, IL-6, MDA, cTnI, and NT-proBNP (P < .05), attenuating the myocardial injury and improving the EF in the UTI group. Only 9 of 19 animals in the control group but 14 of 18 animals in the UTI group survived longer than 8 hours (P = .011).</AbstractText>The progression of proinflammatory responses, oxidative stress, and myocardial injury have been linked to the reduced EF after VF/CPR, and the administration of UTI at a cardioprotective dosage preserved the cardiac function after VF/CPR.</AbstractText>Copyright © 2013 Elsevier Inc. All rights reserved.</CopyrightInformation> |
13,117 | New clinical and electrocardiographic classification in patients with idiopathic ventricular fibrillation. | The presence of early repolarization (ER) recently has been considered as a prognostic marker for sudden cardiac death in patients with idiopathic ventricular fibrillation (IVF), but there are certain numbers of IVF patients lacking ER. We aimed to clarify the clinical and electrocardiographic characteristics of the patients with IVF in the presence and absence of ER.</AbstractText>We studied 64 consecutive IVF patients from the Japan Idiopathic Ventricular Fibrillation Study (J-IVFS) registry, which subjected with at least one episode of documented VF in the absence of structural heart diseases and excluding Brugada syndrome. We assessed clinical and electrophysiological characteristics in the IVF patients with and without ER. ER was defined as J-point elevation of >0.1 mV in either inferior or lateral leads. Twelve-lead electrocardiogram (ECG) demonstrated 24 (38%) of 64 patients with ER (ER[+] group) and the remaining 40 (62%) patients without ER (ER[-] group ). ER[+] group had a male predominance (92% for males) and ER[-] group revealed nearly equal distribution in both sexes. While no patients in ER[+] group showed intraventricular conduction disturbance (CD) with abnormal axis deviation and/or bundle branch block in ECG, 9 in ER[-] group had signs of CD (ER[-]/CD[+] subgroup). ER[-]/CD[+] subgroup had prolonged P-R interval and QRS duration compared to other patient groups.</AbstractText>We found 3 distinct ECG patterns in IVF patients. In addition to the presence and absence of ER, there is a subgroup without ER demonstrating intraventricular CD, which represents a distinct clinical entity of IVF.</AbstractText>© 2013 Wiley Periodicals, Inc.</CopyrightInformation> |
13,118 | Improving depression and reducing cardiac events: which is the chicken and which is the egg? | To examine the assumption that depression leads to recurrent cardiac events and death in those with heart disease.</AbstractText>Consideration of alternative perspectives and discussion of the literature.</AbstractText>It is not clear from studies like MIND-IT, ENRICHD or SADHART whether depression treatment improves cardiac outcomes. In these studies, recurrent cardiac events and death were recorded 6months or more after study entry, but shorter-term cardiac outcomes (e.g., stabilization of plaque prone to rupture and thrombosis or changes in areas of myocardium prone to life-threatening arrhythmia) were not assessed. Although the prevailing view is that shorter-term improvement in depression is necessary to improve cardiovascular outcomes, the possibility that shorter-term improvement in cardiac status might result in reduced symptoms of depression has not been examined. If correct, this possibility might explain why studies have shown that patients whose depression improves also exhibit improved cardiovascular outcomes and lower mortality, even though randomization to the depression intervention in these studies had no effect.</AbstractText>It is not clear whether improving depression comes first and reduced cardiac events follows or whether patients whose cardiac status improves also exhibit improvement in depression. Which is the chicken and which the egg is more than just a philosophical question, since it may affect the direction of future research in this field, and even how we approach the care of patients with heart disease and depression.</AbstractText>Copyright © 2013 Elsevier Inc. All rights reserved.</CopyrightInformation> |
13,119 | Non-alcoholic fatty liver disease is associated with an increased prevalence of atrial fibrillation in hospitalized patients with type 2 diabetes. | NAFLD (non-alcoholic fatty liver disease) and AF (atrial fibrillation) are two pathological conditions that are highly prevalent in developed countries and share multiple risk factors. The relationship between NAFLD and AF in Type 2 diabetes is currently unknown. We studied a hospital-based sample of 702 patients with Type 2 diabetes discharged from our Division of Endocrinology during 2007-2011. The diagnosis of AF was confirmed in affected participants on the basis of ECGs and medical history by experienced cardiologists. NAFLD was defined by ultrasonographic detection of hepatic steatosis in the absence of other liver diseases. Of the 702 hospitalized patients included in the study, 514 (73.2%) of them had NAFLD and 85 (12.1%) had persistent or permanent AF. NAFLD was associated with an increased risk of prevalent AF {OR (odds ratio), 3.04 [95% CI (confidence interval), 1.54-6.02]; P<0.001}. Adjustments for age, sex, systolic BP (blood pressure), HbA1c, (glycated haemoglobin), estimated GFR (glomerular filtration rate), total cholesterol, electrocardiographic LVH (left ventricular hypertrophy), COPD (chronic obstructive pulmonary disease), and prior history of HF (heart failure), VHD (valvular heart disease) or hyperthyroidism did not attenuate the association between NAFLD and AF [adjusted OR, 5.88 (95% CI, 2.72-12.7); P<0.001]. In conclusion, our results show that ultrasound-diagnosed NAFLD is strongly associated with an increased prevalence of persistent or permanent AF in patients with Type 2 diabetes, independently of several clinical risk factors for AF. The potential impact of NAFLD on AF deserves particular attention, especially with respect to the implications for screening and surveillance strategies in the growing number of patients with NAFLD. |
13,120 | Electrophysiological effects of tamoxifen: mechanism of protection against reperfusion arrhythmias in isolated rat hearts. | Reperfusion arrhythmias are currently attributed to ionic imbalance and oxidative stress. Tamoxifen is a potent antioxidant that also modulates some ionic transport pathways. In this work, we tried to correlate the electrophysiological effects of 1, 2, and 5 µM of tamoxifen with the incidence and severity of arrhythmias appearing on reperfusion after 10 minutes of coronary occlusion in isolated hearts from female rats. All tamoxifen concentrations inhibited the action potential shortening observed in the control hearts during late ischemia (6-10 minutes), whereas 2 and 5 µM also reduced the resting membrane potential depolarization. The incidence of sustained ventricular tachycardia and/or ventricular fibrillation on reperfusion decreased from 10 of 12 (control group) to 5 of 10 (1 µM, P = 0.1718), 4 of 12 (2 µM, P = 0.0361), and 2 of 10 (5 µM, P = 0.0083). The possible role of chloride currents activated by cell swelling in these effects was explored in hearts submitted to a 10-minute hypotonic challenge, where tamoxifen (5 µM) blocked the action potential shortening and the late resting membrane potential depolarization produced by hypotonicity, mimicking its action in late ischemia. Tamoxifen produced a similar increase of the total antioxidant capacity of myocardial samples at all the concentration tested. In conclusion, our data strongly suggest that the antiarrhythmic action of this agent is mediated by its electrophysiological effect derived from modulation of chloride currents activated by cell swelling. |
13,121 | Risk assessment for incident heart failure in individuals with atrial fibrillation. | Atrial fibrillation (AF) is a strong risk factor for heart failure (HF); HF onset in patients with AF is associated with increased morbidity and mortality. Risk factors that predict HF in individuals with AF in the community are not well established.</AbstractText>We examined clinical variables related to the 10-year incidence of HF in 725 individuals (mean 73.3 years, 45% women) with documented AF in the Framingham Heart Study. Event rates for incident HF (n = 161, 48% in women) were comparable in women (4.30 per 100 person-years) and men (3.34 per 100 person-years). Age, body mass index, ECG LV hypertrophy, diabetes, significant murmur, and history of myocardial infarction were positively associated with incident HF in multivariable models (C-statistic 0.71; 95% confidence interval 0.67-0.75). We developed a risk algorithm for estimating absolute risk of HF in AF patients with good model fit and calibration (adjusted calibration χ2 statistic 7.29; P(χ2) = 0.61). Applying the algorithm, 47.6% of HF events occurred in the top tertile in men compared with 13.1% in the bottom tertile, and 58.4% in women in the upper tertile compared with 18.2% in the lowest category. For HF type, women had a non-significantly higher incidence of HF with preserved EF compared with men.</AbstractText>We describe advancing age, LV hypertrophy, body mass index, diabetes, significant heart murmur, and history of myocardial infarction as clinical predictors of incident HF in individuals with AF. A risk algorithm may help identify individuals with AF at high risk of developing HF.</AbstractText> |
13,122 | A nonsynonymous polymorphism in semaphorin 3A as a risk factor for human unexplained cardiac arrest with documented ventricular fibrillation. | Unexplained cardiac arrest (UCA) with documented ventricular fibrillation (VF) is a major cause of sudden cardiac death. Abnormal sympathetic innervations have been shown to be a trigger of ventricular fibrillation. Further, adequate expression of SEMA3A was reported to be critical for normal patterning of cardiac sympathetic innervation. We investigated the relevance of the semaphorin 3A (SEMA3A) gene located at chromosome 5 in the etiology of UCA. Eighty-three Japanese patients diagnosed with UCA and 2,958 healthy controls from two different geographic regions in Japan were enrolled. A nonsynonymous polymorphism (I334V, rs138694505A>G) in exon 10 of the SEMA3A gene identified through resequencing was significantly associated with UCA (combined P = 0.0004, OR 3.08, 95%CI 1.67-5.7). Overall, 15.7% of UCA patients carried the risk genotype G, whereas only 5.6% did in controls. In patients with SEMA3A(I334V), VF predominantly occurred at rest during the night. They showed sinus bradycardia, and their RR intervals on the 12-lead electrocardiography tended to be longer than those in patients without SEMA3A(I334V) (1031±111 ms versus 932±182 ms, P = 0.039). Immunofluorescence staining of cardiac biopsy specimens revealed that sympathetic nerves, which are absent in the subendocardial layer in normal hearts, extended to the subendocardial layer only in patients with SEMA3A(I334V). Functional analyses revealed that the axon-repelling and axon-collapsing activities of mutant SEMA3A(I334V) genes were significantly weaker than those of wild-type SEMA3A genes. A high incidence of SEMA3A(I334V) in UCA patients and inappropriate innervation patterning in their hearts implicate involvement of the SEMA3A gene in the pathogenesis of UCA. |
13,123 | A randomized study of cardiac resynchronization therapy defibrillator versus dual-chamber implantable cardioverter-defibrillator in ischemic cardiomyopathy with narrow QRS: the NARROW-CRT study. | Current recommendations require a QRS duration of ≥120 ms as a condition for prescribing cardiac resynchronization therapy (CRT). This study was designed to test the hypothesis that patients with heart failure (HF) of ischemic origin, current indications for defibrillator implantation, and QRS <120 ms may benefit from CRT in the presence of marked mechanical dyssynchrony.</AbstractText>Patients with intraventricular dyssynchrony on echocardiography were randomly assigned to CRT or dual-chamber defibrillator implantation (CRT defibrillator and dual-chamber implantable cardioverter-defibrillator arm, respectively). The primary end point was the HF clinical composite response, which scores patients as improved, unchanged, or worsened. The secondary end point was the cumulative survival from HF hospitalization and HF death. An additional secondary end point was the composite of HF hospitalization, HF death, and spontaneous ventricular fibrillation. Twenty-three of 56 patients with CRT defibrillator showed an improvement in their clinical composite response at 1 year, compared with 9 of 55 patients with dual-chamber implantable cardioverter-defibrillator (41% versus 16%; P=0.004). After a median follow-up of 16 months, the CRT defibrillator arm showed a nonsignificant higher survival from HF hospitalization and HF death (P=0.077), and a significantly higher survival from the combined end point of HF hospitalization, HF death, and spontaneous ventricular fibrillation (P=0.028).</AbstractText>In this comparison of CRT defibrillator and dual-chamber implantable cardioverter-defibrillator, CRT improved clinical status in some patients with ischemic cardiomyopathy, mild-to-moderate symptoms, narrow QRS duration, and mechanical dyssynchrony on echocardiography.</AbstractText>URL: http://clinicaltrials.gov. Unique identifier: NCT01577446.</AbstractText> |
13,124 | The use of neuromuscular blocking agents in the ICU: where are we now? | Intensivists use neuromuscular blocking agents for a variety of clinical conditions, including for emergency intubation, acute respiratory distress syndrome, status asthmaticus, elevated intracranial pressure, elevated intra-abdominal pressure, and therapeutic hypothermia after ventricular fibrillation-associated cardiac arrest. The continued creation and use of evidence-based guidelines and protocols could ensure that neuromuscular blocking agents are used and monitored appropriately. A collaborative multidisciplinary approach coupled with constant review of the pharmacology, dosing, drug interactions, and monitoring techniques may reduce the adverse events associated with the use of neuromuscular blocking agents. |
13,125 | Quantitative assessment of brain microvascular and tissue oxygenation during cardiac arrest and resuscitation in pigs. | Cardiac arrest is associated with a very high rate of mortality, in part due to inadequate tissue perfusion during attempts at resuscitation. Parameters such as mean arterial pressure and end-tidal carbon dioxide may not accurately reflect adequacy of tissue perfusion during cardiac resuscitation. We hypothesised that quantitative measurements of tissue oxygen tension would more accurately reflect adequacy of tissue perfusion during experimental cardiac arrest. Using oxygen-dependent quenching of phosphorescence, we made measurements of oxygen in the microcirculation and in the interstitial space of the brain and muscle in a porcine model of ventricular fibrillation and cardiopulmonary resuscitation. Measurements were performed at baseline, during untreated ventricular fibrillation, during resuscitation and after return of spontaneous circulation. After achieving stable baseline brain tissue oxygen tension, as measured using an Oxyphor G4-based phosphorescent microsensor, ventricular fibrillation resulted in an immediate reduction in all measured parameters. During cardiopulmonary resuscitation, brain oxygen tension remained unchanged. After the return of spontaneous circulation, all measured parameters including brain oxygen tension recovered to baseline levels. Muscle tissue oxygen tension followed a similar trend as the brain, but with slower response times. We conclude that measurements of brain tissue oxygen tension, which more accurately reflect adequacy of tissue perfusion during cardiac arrest and resuscitation, may contribute to the development of new strategies to optimise perfusion during cardiac resuscitation and improve patient outcomes after cardiac arrest. |
13,126 | Complex inheritance for susceptibility to sudden cardiac death. | Sudden cardiac death (SCD) from ventricular fibrillation during myocardial infarction is a leading cause of total and cardiovascular mortality. It has a multifactorial, complex nature and aggregates in families, implicating the involvement of heritable factors in the determination of risk. During the last few years, genome-wide association studies have uncovered common genetic variants modulating risk of SCD. We here review the current insight on genetic determinants of SCD in the community and describe the genome-wide association approaches undertaken thus far in uncovering genetic determinants of SCD risk. |
13,127 | The cellular autophagy markers Beclin-1 and LC3B-II are increased during reperfusion in fibrillated mouse hearts. | Autophagy is an intracellular bulk degradation process for elimination of damaged macromolecules and organelles. In the past decades, the scientific community has gained increasingly detailed understanding of the role of autophagy in myocardial homeostasis, although still many controversies remain. In the ischemic myocardium, autophagy appears to be beneficial for survival, whereas upon reperfusion the process may induce cell death. However, the overall effect of autophagy seems to depend on the duration and intensity of stress, as along with the extent of autophagy within myocardial tissue. Reperfusion of an ischemic heart maybe harmful, but it is an essential process for myocardial survival. One of the major adverse consequences of reperfusion is the occurrence of ventricular fibrillation (VF). In the present study, we investigated the possible connection between autophagy and VF. Isolated mouse hearts were subjected to ischemia/reperfusion (I/R) and divided into two groups based on the development of VF at the beginning of reperfusion. Western blot analysis was conducted for autophagy-associated proteins LC3B, ATG-5, ATG-7, ATG-12, Bcl-2 and Beclin-1 proteins. Significantly higher level of Beclin-1 and LC3B-II/LC3B-I ratio (both definitive autophagy biomarkers) was observed in the fibrillated myocardium, versus tissue from the nonfibrillated hearts. Interestingly, although Bcl-2 is a major regulator of Beclin-1, level of this protein was not significantly altered in tissue from fibrillated, versus non-fibrillated hearts. Moreover, Atg7 expression showed a trend, albeit nonsignificant, towards elevation in fibrillated versus non-fibrillated hearts. Results of the present investigation demonstrate a possible link between VF and autophagy. Studies by authors of this report to evaluate potential etiologic relationships between the two processes are ongoing. |
13,128 | Predicting factors, incidence and prognosis of cardiac arrhythmia in medical, non-acute coronary syndrome, critically ill patients. | Cardiac arrhythmia is an important complication of critically ill patients, especially in perioperative period and early after myocardial infarction. However, the information regarding this condition in medical critically ill without active coronary artery disease patients is limited.</AbstractText>To identify the predictive factors, incidence, and prognosis of tachyarrhythmia and bradyarrhythmia in non-coronary critically ill medical patients.</AbstractText>A single center prospective cohort study, included medical critically ill patients, age > or = 18 year-old, admitted in a 15-bed medical ICU between September 2010 and August 2011. The patients with active coronary artery disease, end stage organ failure and not expected to survive > or = 48 hours were excluded. The patients' baseline characteristic, APACHE II score, laboratory investigations in the first 24 hours and treatment modalities were recorded. Continuous electrocardiographic monitoring was performed during ICU admission. The arrhythmic event, requiring treatment, was recorded.</AbstractText>A total of 247 patients were included, the mean age was 58.5 +/- 20.0 year-old and mean APACHE II score was 20.1 +/- 9.8. Most of them had septic shock (57.1%) and respiratory failure (55.1%). The incidence of arrhythmia was 39.7%. Of 45 patients (18.2%) who had tachyarrhythmia, new onset atrial fibrillation was demonstrated in 34 patients (13.8%), following by ventricular fibrillation (9 patients, 3.6%) and supraventricular tachycardia (2 patients, 0.8%). Bradyarrhythmia was noted in 53 patients (21.5%). Of these, junctional bradycardia was witnessed in 34 patients (13.8%), followed by symptomatic bradycardia (15 patients, 6.1%) and atrioventricular blockage (4 patients, 1.60%). The multivariate by logistic regression analysis revealed the receiving of norepinephrine and APACHE II > or = 25 as an independent predictor for tachyarrhythmia, while the receiving of norepinephrine, arterial pH < 7.3 and HCO3 > or = 18 were associated with bradyarrhythmia. The presence of arrhythmia, especially ventricular fibrillation, symptomatic sinus bradycardia and junctional bradycardia in medical ICU is associated with higher hospital mortality (bradyarrhythmia 88. 7%, tachyarrhythmia 66.70%) than the absent group (18.1%, p < 0.001).</AbstractText>Arrhythmia is a serious complication of medical critically ill patients and associated with high mortality rate. Appropriate shock management together with proper metabolic support may prevent this condition.</AbstractText> |
13,129 | Primary prevention of sudden cardiac death in a nonischemic dilated cardiomyopathy population: reappraisal of the role of programmed ventricular stimulation. | We considered the role of programmed ventricular stimulation in primary prevention of sudden cardiac death in an idiopathic dilated cardiomyopathy population.</AbstractText>One hundred fifty-eight patients with idiopathic dilated cardiomyopathy underwent programmed ventricular stimulation. Ventricular tachycardia/ventricular fibrillation was triggered in 44 patients (group I, 27.8%) versus 114 patients (group II), where ventricular tachycardia/ventricular fibrillation was not induced. Sixty-nine patients with idiopathic dilated cardiomyopathy underwent implantable cardioverter-defibrillator (ICD) implantation: 41/44 in group I and 28/114 in group II. The major end points of the study were overall mortality and appropriate ICD activation. Overall mortality during the 46.9 months of mean follow-up was not significantly different between the 2 groups. Patients with left ventricular ejection fraction ≤35% (n=119) demonstrated a higher overall mortality rate compared with the patients with left ventricular ejection fraction >35% (n=39; 16.8% versus 10.3%, log-rank P=0.025). Advanced New York Heart Association class (III and IV versus I and II) was the single independent and strongest prognostic factor of overall mortality (hazard ratio, 11.909; P<0.001; confidence interval, 3.106-45.65), as well as of cardiac mortality (hazard ratio, 14.787; P=0.001; confidence interval, 2.958-73.922). Among ICD recipients, ICD activation rate was significantly higher in group I compared with group II (30 of 41 patients-73.2% versus 5 of 28 patients-17.9%; log-rank P=0.001), either in the form of antitachycardia pacing (68.3% versus 17.9%; log-rank P=0.001) or in the shock delivery form (51.2% versus 17.9%; log-rank P=0.05). Induction of ventricular tachycardia/ventricular fibrillation during programmed ventricular stimulation in contrast to left ventricular ejection fraction was the single independent prognostic factor for future ICD activation (hazard ratio, 4.195; P=0.007; confidence interval, 1.467-11.994).</AbstractText>Inducibility of ventricular tachycardia/ventricular fibrillation was associated with an increased likelihood of subsequent ICD activation and sudden cardiac death surrogate.</AbstractText> |
13,130 | Prognostic significance of early repolarization in inferolateral leads in Brugada patients with documented ventricular fibrillation: a novel risk factor for Brugada syndrome with ventricular fibrillation. | Little is known about the clinical and prognostic impact of early repolarization (ER) on patients with Brugada syndrome (BrS), especially those with documented ventricular fibrillation (VF).</AbstractText>To investigate the prevalence and prognostic significance of ER in inferolateral leads in patients with BrS and documented VF.</AbstractText>We investigated 10 different 12-lead electrocardiograms (ECGs) recorded on different days to identify the presence of ER, which was defined as J-point elevation ≥0.1 mV in inferior (II, III, aVF) or lateral leads (I, aVL, V₄-V₆), in 49 individuals (46 men; age 46 ± 13 years) with a type 1 ECG of BrS and previous history of VF.</AbstractText>ER was observed persistently (in all ECGs) in 15 patients (31%; P group), intermittently (in at least one but not in all ECGs) in 16 patients (33%; I group), and not observed in 18 patients (37%; N group), yielding an overall ER incidence of 63% (31/49). During the follow-up period (7.7 years), recurrence of VF was documented in all 15 patients (100%) in the P group, and less in 12 patients (75%) in the I group and in 8 patients (44%) in the N group. The P group showed a worse prognosis than N group (P = .0001) by Kaplan-Meier analysis. Either persistent or intermittent ER in an inferolateral lead was an independent predictor of fatal arrhythmic events (hazard ratio 4.88, 95% confidence interval 2.02-12.7, P = .0004; and hazard ratio 2.50, 95% confidence interval 1.03-6.43, P = .043, respectively).</AbstractText>The prevalence of ER in inferolateral leads was high and an especially persistent form of ER was associated with a worse outcome in BrS patients with documented VF.</AbstractText>Copyright © 2013 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
13,131 | Mitral valve reoperation under ventricular fibrillation through right mini-thoracotomy using three-dimensional videoscope. | Conventional reoperative mitral valve surgery by median sternotomy has several difficulties. We performed mitral valve replacement (MVR) under ventricular fibrillation (VF) through right mini-thoracotomy with three-dimensional videoscope for avoiding the problems.</AbstractText>Between 2006 and 2011, we performed 257 cases of MVR, in which 125 cases underwent isolated MVR. Ten cases of patients underwent reoperative MVR under VF through thoracotomy with three-dimensional videoscope (Group I), and 27 cases of patients underwent reoperative conventional MVR through median sternotomy (Group II). We retrospectively reviewed the outcomes and compared Group I with Group II. Preoperative left ventricular ejection fraction (LVEF) was significantly lower (50.5 ± 19.8% vs 64.4 ± 12.0%; p = 0.046), and significantly higher Euro SCORE was found in Group I (4.8 ± 2.0 vs 3.8 ± 2.4; p = 0.037).</AbstractText>Although Group I required cooling and rewarming time, average operative times was significantly shorter in Group I (262 ± 46 min vs 300 ± 57 min; p = 0.044), and cardiopulmonary bypass times and average VF times in Group I and aortic cross-clamp times in Group II were equivalent. There was no significant difference in the average of postoperative maximum creatine kinase (CK)-MB. In-hospital mortality was 0/10 (0%) and 1/27 (3.7%), and postoperative paravalvular leakage occurred in 0/10 (0%) and 1/27 (3.7%), and stroke occurred in 1/10 (10%) and 1/27 (3.7%) for Groups I and II. Two patients underwent reoperation for bleeding in Group II. Intensive care unit stay in Group I was significantly shorter than in Group II (1.8 ± 0.6 days vs 3.0 ± 1.7 days; p = 0.025).</AbstractText>The higher risk of preoperative background in Group I had no effect on the operation. Mitral valve surgery under VF through right mini-thoracotomy can be an alternative procedure for reoperation after conventional various cardiothoracic surgeries.</AbstractText> |
13,132 | Thromboembolic event rate in paroxysmal and persistent atrial fibrillation: data from the GISSI-AF trial. | Few data on the thromboembolic (TE) risk of paroxysmal and persistent atrial fibrillation (AF) are available. This study aimed to assess the incidence of TE events in paroxysmal and persistent AF.</AbstractText>We performed a subset post hoc analysis of 771 patients with paroxysmal and 463 with persistent AF enrolled in the multicenter, prospective, randomized, double-blind, placebo-controlled GISSI-AF trial - comparing the efficacy of valsartan versus placebo in preventing AF recurrences - where the choice of antithrombotic treatment was left to the judgment of the referring physician. TE and major outcome events were centrally validated. AF recurrences were detected by frequent clinic visits and a transtelephonic monitoring device with weekly and symptomatic transmissions.</AbstractText>Eighty-five percent of patients had a history of hypertension, and the 7.7% had heart failure, left ventricular dysfunction, or both. The mean CHADS2 score was 1.41±0.84. TE and major bleeding events were observed at a low incidence among the overall population at 1-year follow-up (0.97% and 0.81%, respectively). The univariate and multivariable analyses revealed no statistically significant differences in the incidence of TE, major bleeding events or mortality in paroxysmal and persistent AF patients. TE events were more common among women than men (p=0.02). The follow-up examination showed under- or overtreatment with warfarin in many patients, according to guideline suggestions. Warfarin was more frequently prescribed to patients with persistent AF (p<0.0001) and patients with AF recurrences (p<0.0001). AF recurrences were noninvasively detected in 632 (51.2%) patients. In patients without AF recurrences, the TE event rate was 0.5% versus 1.74%, 1.28%, and 1.18% for those with only symptomatic, only asymptomatic or both symptomatic and asymptomatic AF recurrences, respectively, but the difference was not statistically significant, even after adjusting for warfarin treatment and the CHADS2 score (HR 2.93; CI 95%; 0.8-10.9; p=0.11).</AbstractText>TE and major bleeding events showed a very low incidence in the GISSI-AF trial population, despite under- or overtreatment with warfarin in many patients. TE events had a similar rate in paroxysmal and persistent AF.</AbstractText>NCT00376272.</AbstractText> |
13,133 | Reduced diurnal variation of heart rate is associated with increased plasma B-type natriuretic peptide level in patients with atrial fibrillation. | The plasma B-type natriuretic peptide (BNP) level has been shown to be increased in patients with chronic atrial fibrillation (AF) independent of left ventricular ejection fraction (LVEF). The purpose of this study is to evaluate the relationship between the plasma BNP level and heart rate variation in patients with AF.</AbstractText>The plasma BNP level is associated with heart rate variation in patients with AF.</AbstractText>A total of 102 patients with AF and preserved LVEF were included from 2 hospitals. The ambulatory electrocardiographic recording and measurement of plasma BNP levels were performed simultaneously. Echo-Doppler parameters were measured as the average of 10 consecutive cardiac cycles.</AbstractText>A difference in the mean heart rate between night and day (DIFF) and the standard deviation of the 5-miniute mean R-R interval (SDARR) were significantly associated with log-transformed BNP levels (r = -0.411, P < 0.001 and r = -0.243, P = 0.049, respectively). In echocardiography, the ratio of E velocity to early diastolic velocity, which reflects left ventricular (LV) filling pressure, was significantly correlated with the DIFF and SDARR, along with the log-transformed BNP level. Stepwise multiple linear regression analysis revealed that the DIFF and age were independent factors related with the BNP level (P < 0.01).</AbstractText>The reduced diurnal variation of heart rate was significantly associated with increased BNP, which is linked to LV diastolic dysfunction in patients with AF.</AbstractText>© 2013 Wiley Periodicals, Inc.</CopyrightInformation> |
13,134 | Assessment of optimal right ventricular pacing site using invasive measurement of left ventricular systolic and diastolic function. | Right ventricular apical pacing has a detrimental effect on left ventricular (LV) function. More optimal pacing site may be found by invasive measurement of LV mechanical performance during pacing from different RV pacing sites. We aimed to investigate the effect of RV pacing lead location on invasive indices of LV mechanical performance.</AbstractText>Patients undergoing catheter ablation for persistent atrial fibrillation were enrolled. Single-site endocardial pacing from the lateral LV region was periodically switched to pacing from the mapping catheter navigated to different RV sites within the three-dimensional electroanatomical RV map. SystIndex, DiastIndex, and PPIndex were defined as the ratio of LV dP/dtmax, LV dP/dtmin, and arterial pulse pressure during RV pacing to corresponding values from adjacent periods of LV pacing. Haemodynamic data were analysed in 18 RV segments created by dividing RV horizontally (basal, mid, and apical portion), vertically (inferior, mid, and superior portion) and frontally (septum and free wall). Eight patients (58 ± 7 years; 2 females; 26 ± 4 RV pacing sites per patient) were enrolled into the study. Compared with LV pacing, the best RV pacing values of SystIndex and DiastIndex were achieved in basal-mid-septal segment (+6.9%, P = 0.02 and +3.4%, P = 0.36, respectively) while the best PPIndex was obtained in superior-mid-septal segment of RV (+4.5%, P = 0.02). All indices were fairly concordant showing significant improvement of haemodynamics during RV pacing in the direction from free wall to septum, from apex to base, and from inferior to superior segments.</AbstractText>The best LV mechanical performance was achieved by RV septal pacing in the non-apical mid-to-superior segments.</AbstractText> |
13,135 | Catheter ablation in selected patients with depressed left ventricular ejection fraction and persistent atrial fibrillation unresponsive to current cardioversion. | In congestive heart failure (CHF) patients with persistent atrial fibrillation (AF), direct current cardioversion (DCC) may reveal participation of tachycardiamediated process to left ventricular (LV) dysfunction by restoring sinus rhythm (SR). However, if DCC fails to restore SR, patients' management remains challenging. The aim of the study was to assess the AF catheter ablation benefit in a selected group of CHF patients with LV ejection fraction (LVEF) <40% and persistent AF unresponsive to DCC, in whom a tachycardia-mediated process is thought to be predominant.</AbstractText>Between January 2008 and September 2011, among 129 CHF patients with persistent AF referred to our institution, 34 (63.8 ± 9-year old, 24 men) presented AF refractory to DCC with an estimated high likelihood of tachycardia-mediated LV dysfunction according to a specific set of criteria. These 34 patients underwent stepwise AF ablation and were closely followed up. After a mean 1.9 AF ablation procedures per patient and 17.6 ± 7 months after the last procedure, all patients were in SR. The New York Heart Association class improved from 2.8 ± 0.3 to 1 ± 0.2 (P< 0.001) and the LVEF increased from 30.4 ± 6 to 54.6 ± 6% (P< 0.0001) after 3-6 months of SR, with a persistent benefit as long as the SR was maintained.</AbstractText>Atrial fibrillation catheter ablation in selected CHF patients with persistent AF refractory to DCC and without any other evidence for secondary LV dysfunction leads to a substantial LVEF improvement in the majority of them. However, redo procedures are frequent in order to achieve mid-term SR maintenance.</AbstractText> |
13,136 | Dissociation of hemodynamic and electrocardiographic indexes of myocardial ischemia in pigs with hibernating myocardium and sudden cardiac death. | Many survivors of sudden cardiac death (SCD) have normal global ventricular function and severe coronary artery disease but no evidence of symptomatic ischemia or infarction before the development of lethal ventricular arrhythmias, and the trigger for ventricular tachycardia (VT)/ventricular fibrillation (VF) remains unclear. We sought to identify the role of spontaneous ischemia and temporal hemodynamic factors preceding SCD using continuous telemetry of left ventricular (LV) pressure and the ECG for periods up to 5 mo in swine (n = 37) with hibernating myocardium who experience spontaneous VT/VF in the absence of heart failure or infarction. Hemodynamics and ST deviation at the time of VT/VF were compared with survivors with hibernating myocardium as well as sham controls. All episodes of VT/VF occurred during sympathetic activation and were initiated by single premature ventricular contractions, and the VT degenerated into VF in ∼ 30 s. ECG evidence of ischemia was infrequent and no different from those that survived. Baseline hemodynamics were no different among groups, but LV end-diastolic pressure during sympathetic activation was higher at the time of SCD (37 ± 4 vs. 26 ± 4 mmHg, P < 0.05) and the ECG demonstrated QT shortening (155 ± 4 vs. 173 ± 5 ms, P < 0.05). The week before SCD, both parameters were no different from survivors. These data indicate that there are no differences in the degree of sympathetic activation or hemodynamic stress when VT/VF develops in swine with hibernating myocardium. The transiently elevated LV end-diastolic pressure and QT shortening preceding VT/VF raises the possibility that electrocardiographically silent subendocardial ischemia and/or mechanoelectrical feedback serve as a trigger for the development of SCD in chronic ischemic heart disease. |
13,137 | [Efficacy and safety of ibutilide for conversion of atrial fibrillation/flutter]. | To investigate the efficacy and safety of intravenous ibutilide for conversion of atrial fibrillation (AF) and flutter (AFL) to sinus rhythm.</AbstractText>Ninety-nine consecutive patients aged 18-75 y with AF/AFL were included. The duration of arrhythmia was <90 d (1 h-90 d) and ventricular rate was >60 beats/min. Patients were assigned randomly into two groups: 49 patients in ibutilide group received ibutilide 1 mg, then repeated if AF/AFL was not converted after 10 min; 50 patients in propafenone group received propafenone 70 mg, then repeated if AF/AFL persisted after 10 min. Two drugs were diluted by 50 ml of 5% glucose and injected intravenously within 10 min.</AbstractText>Ventricular rates were decreased in both groups. AF/AFL were converted in 34 of 49 patients (69.4 % ) in ibutilide group and in 22 of 50 patients (44.0 %) in propafenone group (P <0.05). The converting time of ibutilide was significantly shorter than that of propafenone [(16.79 ± 12.31) min compared with (36.92 ± 11.38)min, P <0.01]. The most serious adverse effect of ibutilide was non-sustained monomorphic ventricular tachycardia (3/49,6.12 %). Transient hypotension and heart pause were the main adverse events in patients who received propafenone, acute left heart failure occurred in one patient of propafenone group.</AbstractText>Intravenous ibutilide is a safe and effective agent for cardioversion of recent-onset AF/AFL. Furthermore,strict processing under electrocardio-monitoring is important.</AbstractText> |
13,138 | Increases in survival from out-of-hospital cardiac arrest: a five year study. | This study reports improvements in survival from out-of-hospital cardiac arrest in London over a five year period from 2007 to 2012 and explores the potential reasons for the very striking increases observed.</AbstractText>Data from the London Ambulance Service's cardiac arrest registry from 2007 to 2012 were analysed retrospectively for all patients who met the Utstein comparator group criteria (an arrest of a presumed cardiac cause that was bystander witnessed with an initial rhythm of VF/VT).</AbstractText>We observed an increase in survival from out-of-hospital cardiac arrest during the five year period, with incremental improvements each year from 12% to 32% for the Utstein comparator group of patients.</AbstractText>We suggest that a range of important changes made to pre-hospital cardiac care in London over the last five years have contributed to the observed increase in survival over the study period. In addition we advocate a range of further initiatives to continue improving survival from out-of-hospital cardiac arrest.</AbstractText>Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.</CopyrightInformation> |
13,139 | Quinidine, a life-saving medication for Brugada syndrome, is inaccessible in many countries. | The aim of this study was to determine the availability of quinidine throughout the world.</AbstractText>Quinidine is the only oral medication that is effective for preventing life-threatening ventricular arrhythmias due to Brugada syndrome and idiopathic ventricular fibrillation. However, because of its low price and restricted indication, this medication is not marketed in many countries.</AbstractText>We conducted a survey of the availability of quinidine by contacting professional medical societies and arrhythmia specialists worldwide. Physicians were e-mailed questionnaires requesting information concerning the quinidine preparation available at their hospital. We also requested information concerning cases of adverse arrhythmic events resulting from unavailability of quinidine.</AbstractText>A total of 273 physicians from 131 countries provided information regarding the availability of quinidine. Quinidine was readily available in 19 countries (14%), not accessible in 99 countries (76%), and available only through specific regulatory processes that require 4 to 90 days for completion in 13 countries (10%). We were able to gather information concerning 22 patients who had serious arrhythmias probably related (10 cases) or possibility related (12 cases) to the absence of quinidine, including 2 fatalities possibly attributable to the unavailability of quinidine.</AbstractText>The lack of accessibility of quinidine is a serious medical hazard at the global level.</AbstractText>Copyright © 2013 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
13,140 | Huge ST elevation and ventricular arrhythmias in vasospastic angina diagnosed by Holter monitoring. | We report a case of a 67year old man with a recent history of sporadic chest pain and palpitations. After a normal, maximal stress test he underwent 24-hours Holter monitoring that showed two short periods of huge ST segment elevation associated with non sustained ventricular tachycardia and chest pain, referable to coronary spasm. Coronary angiogram showed significant atherosclerotic stenosis in the right coronary artery treated by angioplasty and bare metal stent implantation. Holter monitoring is a non-invasive and low-cost examination that can give valuable informations; it should be reserved for selected patients when vasospastic angina is suspected. |
13,141 | Clinical impact of the implantable loop recorder in patients with isolated syncope, bundle branch block and negative workup: a randomized multicentre prospective study. | Few studies have compared conventional testing with prolonged monitoring using an implantable loop recorder (ILR) following the first syncope episode in patients with bundle branch block (BBB) and negative workup.</AbstractText>To compare two syncope evaluation strategies-primary use of an ILR (Group 1) versus conventional testing (Group 2)-and to estimate the prevalence of significant arrhythmias in the ILR patient subset.</AbstractText>From January 2005 to December 2010, 78 patients admitted after one syncope episode were randomized to ILR (n=41) or conventional follow-up (n=37). Mean follow-up was 27 ± 12 months.</AbstractText>Mean age was 76 ± 8 years and 30 patients were women (38.5%); 18 presented cardiomyopathy (23%) and 12 had a history of atrial fibrillation (15.4%). Mean left ventricular ejection fraction was 56.5 ± 11% and mean His-to-ventricle interval was 55 ± 6ms based on negative electrophysiological study (EPS). Electrocardiogram abnormalities involved: 34 left bundle branch blocks (BBBs); 11 right BBBs; and 33 bifascicular blocks. Overall, 21 patients (27%) developed significant arrhythmic events: ventricular tachycardia (n=1; 1.3%); sudden death (n=2; 2.6%); third-degree atrioventricular (AV) block (n=14; 18%); sick sinus syndrome (n=4; 5.1%). In 19 (24.4%) patients, relevant arrhythmias were detected, with a significant difference between the ILR group (n=15/41; 36.6%) and the conventional follow-up group (n=4/37; 10.8%) (P=0.02). Eighteen patients were implanted with pacemakers; one received an implantable defibrillator. No predictors of AV block were identified in the ILR group.</AbstractText>In this randomized prospective study, the ILR strategy proved largely superior to conventional follow-up in detecting recurrent events, with a potential impact on therapeutic management. This observation highlights the usefulness of early monitoring in patients with BBB and negative EPS even after the first syncope episode but an empiric pacemaker strategy remains to be validated in this selected population.</AbstractText>Copyright © 2013. Published by Elsevier Masson SAS.</CopyrightInformation> |
13,142 | Echocardiographic left ventricular end-diastolic pressure volume loop estimate predicts survival in congestive heart failure. | The left ventricular end-diastolic pressure-volume relationship (LV-EDPVR) is a measure of LV distensibility, conveying the size the LV will assume at a given LV end-diastolic pressure (LV-EDP). Measurement of LV-EDPVR requires invasive testing with specialized equipment. Echocardiography can be used to measure LV end-diastolic volume (EDV) and to grossly estimate LV-EDP noninvasively. We therefore hypothesized that categorization of patients based on these parameters to create an estimate of the end-diastolic pressure-volume loop position (EDPVE) could predict congestive heart failure (CHF) prognosis.</AbstractText>Echocardiograms from 968 CHF clinic patients were reviewed. LV-EDP was considered to be elevated if mitral filling pattern was pseudo-normal or restrictive. EDPVE was categorized into 3 groups. EDPVE was considered to have evidence of rightward shift if the LV was severely dilated (>97 mL/m(2)). EDPVE was considered to have evidence of leftward shift if the LV was normal size (<76 mL/m(2)) and there was Doppler evidence of increased LV-EDP. Patients who did not meet criteria for leftward or rightward shift were classified as "intermediate." Using the intermediate group for comparison, those with evidence of leftward shift in EDPVE had increased mortality (hazard ratio [HR] 1.77; 95% confidence interval [CI]: 1.23-2.54). Rightward shift only correlated with increased mortality in those older than age 70 years. Leftward shift remained an independent predictor of mortality even after adjusting for LV ejection fraction, atrial fibrillation, mitral regurgitation, and Doppler indices of diastolic dysfunction.</AbstractText>EDPVE is a strong predictor of CHF survival which is independent of LV ejection fraction and traditional Doppler indices of LV diastolic function.</AbstractText>Copyright © 2013 Elsevier Inc. All rights reserved.</CopyrightInformation> |
13,143 | [Cardiac arrest and cardial insuffiency as result of thyrotoxicosis]. | A 52-year-old woman, who had an out-of-hospital cardiac arrest, was resuscitated, intubated and transferred with cardiogenic shock to angioplasty of the right coronary artery. Afterwards the patient had normal biventricular function, but four days later she developed atrial fibrillation and recurrent cardiogenic shock with a left ventricular ejection fraction of 20%. Thyrotoxic crisis was determined as the underlying cause; and antithyroid treatment stabilised the patient's haemodynamics completely within 24 hours. The importance of high thyroxine levels in patients with ischaemic heart disease is discussed. |
13,144 | Anomalous left coronary artery arising from the pulmonary artery. | A 13-year-old boy was found unconscious. Ventricular fibrillation was seen in his admission to the emergency room. Dilated right coronary artery and increased coronary arterial flow were seen in echocardiography. In the angiography, left coronary artery abnormally arising from pulmonary artery and aneursymatic dilatation in the right coronary artery was seen. <<b>Learning objective:</b> Anomalous left coronary artery arising from pulmonary artery is one of the rare reasons for myocardial ischemia in childhood. Life expectancy can be normal which depends largely on the number of collaterals that are present between right and left coronary arteries. However, sudden death risk always exists.>. |
13,145 | A 1.5T MRI-conditional 12-lead electrocardiogram for MRI and intra-MR intervention. | High-fidelity 12-lead electrocardiogram (ECG) is important for physiological monitoring of patients during MR-guided intervention and cardiac MRI. Issues in obtaining noncorrupted ECGs inside MRI include a superimposed magneto-hydro-dynamic voltage, gradient switching-induced voltages, and radiofrequency heating. These problems increase with magnetic field. The aim of this study is to develop and clinically validate a 1.5T MRI-conditional 12-lead ECG system.</AbstractText>The system was constructed with transmission lines to reduce radiofrequency induction and switching circuits to remove induced voltages. Adaptive filters, trained by 12-lead measurements outside MRI and in two orientations inside MRI, were used to remove the magneto-hydro-dynamic voltage. The system was tested on 10 (one exercising) volunteers and four arrhythmia patients.</AbstractText>Switching circuits removed most imaging-induced voltages (residual noise <3% of the R-wave). Magneto-hydro-dynamic voltage removal provided intra-MRI ECGs that varied by <3.8% from those outside the MRI, preserving the true S-wave to T-wave segment. In premature ventricular contraction (PVC) patients, clean ECGs separated premature ventricular contraction and sinus rhythm beats. Measured heating was <1.5°C. The system reliably acquired multiphase (steady-state free precession) wall-motion-cine and phase-contrast-cine scans, including subjects in whom 4-lead gating failed. The system required a minimum repetition time of 4 ms to allow robust ECG processing.</AbstractText>High-fidelity intra-MRI 12-lead ECG is possible.</AbstractText>Copyright © 2013 Wiley Periodicals, Inc.</CopyrightInformation> |
13,146 | Ventricular arrhythmias and left ventricular hypertrophy in hypertrophic cardiomyopathy. | In hypertrophic cardiomyopathy (HCM), the degree of left ventricular hypertrophy (LVH) could influence the development of ventricular arrhythmias.</AbstractText>In HCM, analyze the association between the occurrence of ventricular arrhythmias determined by Holter electrocardiogram (ECG-Holter) and the degree of LVH determined by maximum wall thickness (MWT) in echocardiography and body mass index (BMI).</AbstractText>Fifty-four consecutive patients with HCM underwent 24-hour ECG-Holter and echocardiography for assessment of level of LVH through MWT and BMI. Two levels were established for the occurrence of Ventricular Arrhythmias: I - alone or paired extrasystoles and II - Non- Sustained Ventricular Tachycardia (NSVT).</AbstractText>In 13 patients (24%) with NSVT (level II), there was a higher frequency of MWT of the left ventricle (LV) > 21 mm (n = 10, 77%, 25 ± 4 mm) and LLLV = 144 g/m² (n = 10, 77%, 200 ± 30 g/m²), in comparison with those presenting with extrasystole arrhythmias (level I) (n = 41, 76%), in which these measures were identified in, respectively, 37 % (n= 15, 23 ± 1 mm), p = 0.023, and 39% (n = 16, 192 ± 53 g / m²) of the cases (p = 0.026). The cut-off values mentioned were determined by the ROC curve with a confidence interval of 95%. NSVT was more common in patients with MWTLV > 21 mm and LLLV > 144 g/m² (8 of 13, 62%) than in those with (4 of 13, 31%) or without (1 of 13; 8%) echocardiographic variables above cut-off values (p = 0.04).</AbstractText>In HCM, occurrence of ventricular arrhythmias by Holter was associated with the degree of LVH assessed by echocardiography through MWT and BMI.</AbstractText> |
13,147 | Dyssynchrony and the risk of ventricular arrhythmias. | The aim of our study was to evaluate the relationship between left ventricular (LV) dyssynchrony and the risk of ventricular tachycardia (VT) or ventricular fibrillation (VF) in patients enrolled in the MADIT-CRT (Multicenter Automatic Defibrillator Implantation Trial-Cardiac Resynchronization Therapy) trial.</AbstractText>Intraventricular mechanical dyssynchrony might be an important factor in ventricular arrhythmogenesis by enhancing electrical heterogeneity in heart failure patients. The effects of dyssynchrony have not yet been evaluated in a large cohort of implantable cardioverter-defibrillator (ICD) and cardiac resynchronization therapy with defibrillator (CRT-D) patients.</AbstractText>LV dyssynchrony was measured at baseline and at 12-months by speckle-tracking echocardiography, defined as the standard deviation of time to peak systolic strain in 12 LV myocardial segments. The endpoint was the first VT/VF/death or VT/VF. LV dyssynchrony was evaluated in 764 left bundle branch block (LBBB) patients and in 312 non-LBBB patients.</AbstractText>Baseline LV dyssynchrony was not predictive of VT/VF/death or VT/VF in LBBB or non-LBBB patients in either treatment arm. In CRT-D patients with LBBB, improvement in LV dyssynchrony over a year was associated with significantly lower incidence of VT/VF/death (p < 0.001) and VT/VF (p < 0.001) compared to ICD patients and to CRT-D patients with unchanged or worsening dyssynchrony. Among LBBB patients, 15% decrease in LV dyssynchrony was associated with lower risk of VT/VF/death (hazard ratio: 0.49, 95% confidence interval: 0.24 to 0.99, p = 0.049) and VT/VF (hazard ratio: 0.30, 95% confidence interval: 0.12 to 0.77, p = 0.009) as compared to ICD patients. Patients without LBBB receiving CRT-D did not show reduction in VT/VF/death or in VT/VF in relation to improving dyssynchrony when evaluating cumulative event rates or risk of events.</AbstractText>Baseline LV dyssynchrony did not predict VT/VF/death or VT/VF in mild heart failure patients with or without LBBB. CRT-induced improvement of LV dyssynchrony was associated with significant reduction of ventricular arrhythmias in patients with LBBB.</AbstractText>Copyright © 2013 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
13,148 | Prognosis in the hospitalized very elderly: the PROTEGER study. | It was reported that many recognized cardiovascular risk factors were no longer valid in the very elderly and, sometimes, even act in the opposite direction. It remains unclear which cardiovascular risk factors are still vital for death prediction in the oldest-old population.</AbstractText>We assessed cardiac abnormalities and dysfunction by ultrasonography and electrocardiography, blood pressure and arterial stiffness by BP monitor and tonometry, and biochemical parameters by routine laboratory assay, and investigated their associations with all-cause mortality in 331 hospitalized elderly patients (mean age ± standard deviation: 87 ± 7 years). After a mean follow-up of 378 days, 110 deaths occurred.</AbstractText>As compared with survivals, patients with all-cause mortality had significantly lower left ventricular ejection fraction (LVEF) (57.5 ± 13.8% vs 62.4 ± 11.2%, P = 0.002), low-density lipoprotein (LDL) (3.13 ± 0.98 vs 3.56 ± 0.98 mmol/L, P<0.001) and high-density lipoprotein (HDL) cholesterol (1.06 ± 0.30 vs 1.14 ± 0.32 mmol/L, P = 0.04), albumin (33.1 ± 5.4 vs 35.1 ± 4.5 g, P = 0.002), and creatinine clearance rate (Ccr) (42.4 ± 19.4 vs 55.8 ± 28.2 mL/min, P<0.001), and higher incidence of atrial fibrillation (26.4% vs 12.7%, P = 0.002). In multivariate Cox regression model, LVEF, atrial fibrillation, LDL cholesterol, albumin and Ccr were significant and independent death predictors with hazard ratios of 0.82 (0.70, 0.97), 1.74 (1.11, 2.74), 0.70 (0.57, 0.87), 0.66 (0.54, 0.82) and 0.57 (0.44, 0.75), respectively.</AbstractText>In the last stage of lifespan, cardiac systolic dysfunction and atrial fibrillation, as well as malnutrition and renal insufficiency, are crucial risk factors, which should be fully considered in the risk assessment strategy of the hospitalized elderly with cardiovascular diseases.</AbstractText>Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.</CopyrightInformation> |
13,149 | Advantages of a subcutaneous implantable cardioverter-defibrillator in LAMP2 hypertrophic cardiomyopathy. | Danon disease is a rare X-linked lysosomal disease causing severe hypertrophic cardiomyopathy (LAMP2 cardiomyopathy) and an extremely poor prognosis in males, with several reported cases of sudden cardiac death despite the use of transvenous implantable cardioverter defibrillators (TV-ICD). We describe a case in which a TV-ICD was unable to defibrillate induced ventricular fibrillation (VF), but a wholly subcutaneous system (S-ICD) was successful in terminating induced VF and spontaneous ventricular tachycardia. These findings have relevance to the selection of device therapy in the management of these individuals and a wider group of young patients with severe hypertrophic cardiomyopathy. |
13,150 | Significance of intraoperative testing in right-sided implantable cardioverter-defibrillators. | Implantation of implantable cardioverter-defibrillators (ICD) from the left pectoral region is the standard therapeutical method. Increasing numbers of system revisions due to lead dysfunction and infections will consecutively increase the numbers of right-sided implantations. The reliability of devices implanted on the right pectoral side remains controversially discussed, and the question of testing these devices remains unanswered.</AbstractText>In a prospectively designed study all 870 patients (60.0 ± 14  years, 689 male) who were treated with a first ICD from July 2005 until May 2012 and tested intraoperatively according to the testing protocol were analyzed. The indication for implantation was primary prophylactic in 71.5%. Underlying diseases included ischemic cardiomyopathy (50%), dilative cardiomyopathy (37%), and others (13%). Mean ejection faction was 27 ± 12%. Implantation site was right in 4.5% and left in 95.5%.</AbstractText>Five patients supplied with right-sided ICD (13%, p = 0.02 as compared to left-sided) failed initial intraoperative testing with 21 J. 3 patients were male. The age of the patients failing intraoperative testing with right-sided devices appeared higher than of patients with left-sided devices (p = 0.07). The ejection fraction was 28 ± 8%. All patients reached a sufficient DFT ≤ 21 J after corrective procedures.</AbstractText>Implantation of ICDs on the right side results in significantly higher failure rate of successful termination of intraoperatively induced ventricular fibrillation. The data of our study suggest the necessity of intraoperative ICD testing in right-sided implanted ICDs.</AbstractText> |
13,151 | Improved neuroprotective effect of methylene blue with hypothermia after porcine cardiac arrest. | Induced mild hypothermia and administration of methylene blue (MB) have proved to have neuroprotective effects in cardiopulmonary resuscitation (CPR); however, induction of hypothermia takes time. We set out to determine if MB administered during CPR could add to the histologic neuroprotective effect of hypothermia.</AbstractText>A piglet model of extended cardiac arrest (12 min of untreated cardiac arrest and 8 min of CPR) was used to assess possible additional neuroprotective effects of MB when administered during CPR before mild therapeutic hypothermia induced 30 min after restoration of spontaneous circulation (ROSC). Three groups were compared: C group (n = 8) received standard CPR; PH group (n = 8) received standard CPR but 30 min after ROSC these piglets were cooled to 34°C; the PH+MB group (n = 8) received an MB infusion 1 min after commencement of CPR and the same cooling protocol as the PH group. Three hours later, the animals were killed. Immediately after death, the brains were harvested pending histological and immunohistological analysis.</AbstractText>Circulatory variables were similar in the groups except that cardiac output was greater in the PH+MB group 2-3 h after ROSC. Cerebral cortical neuronal injury and blood-brain barrier disruption was greatest in the C group and least in the MB group. The neuroprotective effect of MB and hypothermia was significantly greater than that of delayed hypothermia alone.</AbstractText>Administration of MB during CPR added to the short term neuroprotective effects of induced mild hypothermia induced 30 min after ROSC.</AbstractText>© 2013 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.</CopyrightInformation> |
13,152 | [Pseudo-PJRT in an 8 year-old boy with severe decompensated heart failure and recurrent episodes of ventricular fibrillation]. | We present a case of 8 year-old boy with several episodes of ventricular fibrillation in the course of tachycardia-mediated cardiomyopathy and severe decompensated heart failure. The cardiomyopathy was caused by incessant long-RP tachycardia that was resistant to pharmacotherapy. Despite initial suspition that the arrhythmia was permanent junctional reciprocating tachycardia (PJRT) electrophysiology study revealed atypical atrioventricular nodal reentrant tachycardia. Due to clinical and electrocardiographical presentation mimicking PJRT such arrhythmia merits the name 'pseudo PJRT'. |
13,153 | [QTc variability. Is a single measurement of QT/QTc interval enough to perform risk stratification and therapeutic decisions in a patient with long QT syndrome?]. | We described a case of 30 year-old woman with episodes of syncope primarily diagnosed as epilepsy, and finally recognised as long QT syndrome. Based on QTc prolongation > 600 ms in series of electrocardiograms and Holter monitoring the patient was implanted with cardioverter-defibrillator (ICD). During follow-up many appropriate ICD shocks due to ventricular fibrillation occurred. |
13,154 | Acute hyperglycaemia and inflammation in patients with ST segment elevation myocardial infarction. | Acute hyperglycaemia in patients with acute coronary syndromes (ACS) is associated with increased cardiovascular (CV) risk among both diabetic and non-diabetic patients although the mechanisms underlying this association are not clearly understood. Acute hyperglycaemia in patients with ACS may be associated with increased systemic inflammation. Leukocytes are the major cellular mediators of inflammation and their elevated count is associated with higher CV event rate in ACS patients. Thus, it is possible that there is a relationship between acute hyperglycaemia and high leukocyte count and concomitant presence of these two conditions may contribute to increased CV risk among patients with ST segment elevation myocardial infarction (STEMI).</AbstractText>To investigate the relationship between acute hyperglycaemia and high leukocyte count and to evaluate its association with outcomes in patients with STEMI.</AbstractText>Glucose level and leukocyte count on admission were measured in 246 patients with STEMI admitted in 2004- -2007 to the First Department of Cardiology and Hypertension at the University Hospital in Cracow who were treated with an early invasive management strategy. Patients were divided into two groups, with acute hyperglycaemia (glycaemia on admission ≥ 7.8 mmol/L) and with normoglycaemia (glycaemia on admission < 7.8 mmol/L). Leukocyte count was defined as high when it was greater than or equal to the median in the overall study group.</AbstractText>Acute hyperglycaemia was noted in 136 (55.3%) patients. Median leukocyte count on admission in the overall study group was 10.8 × 103/mm3 (interquartile range: 8.5-13.0). Significantly higher in-hospital mortality (11.8% vs. 1.8%, p = 0.0029) and higher rates of cardiogenic shock (10.3% vs. 0.9%, p = 0.0022), Killip class > 1 heart failure (HF; 44.1% vs. 20.0%, p < 0.0001), atrial fibrillation (11.0% vs. 3.6%, p = 0.0308), ventricular fibrillation (5.9% vs. 0.9%, p = 0.0389), repeated percutaneous coronary angioplasty (5.2% vs. 0.0%, p = 0.0158), the primary endpoint defined as death and/or cardiogenic shock (16.9% vs. 1.8%, p = 0.0001), and the secondary endpoint defined as atrial fibrillation and/or second or third degree atrioventricular block and/or HF and/or stroke/transient ischaemic attack (53.7% vs. 23.6%, p < 0.0001) were noted in the acute hyperglycaemia group in comparison with the normoglycaemic group. Adverse events were associated with high leukocyte count in all patients and in both diabetic and non-diabetic subgroups. Mean leukocyte count was higher in patients who died (13.3 ± 4.01 vs. 11.0 ± 3.56 [103/mm3], p = 0.0115; 14.2 ± 1.59 vs. 10.8 ± 3.18 [103/mm3], p = 0.0210; and 13.5 ± 4.79 vs. 11.1 ± 3.72 [103/mm3], p = 0.0363 in the overall study group, diabetics and non-- diabetics, respectively), in patients with cardiogenic shock (14.0 ± 4.56 vs. 11.0 ± 3.52 [103/mm3], p = 0.0019; and 15.4 ± 4.93 vs. 11.0 ± 3.66 [103/mm3], p = 0.0007 in the overall study group and non-diabetics, respectively), and in patients with HF (12.1 ± 3.78 vs. 10.8 ± 3.51 [103/mm3], p = 0.0083; and 12.1 ± 3.39 vs. 10.3 ± 2.90 [103/mm3], p = 0.0159 in the overall study group and diabetics, respectively) as compared to patients without respective adverse events. Glucose level on admission correlated positively with the on-admission leukocyte count. This correlation was statistically significant in the overall study group (r = 0.25, p < 0.0001), in diabetics (r = 0.27, p = 0.021), and in non-diabetics (r = 0.35, p < 0.0001). Patients with both acute hyperglycaemia and the leukocyte count greater than or equal to the median in the overall study group had a higher in-hospital risk of death and/or cardiogenic shock (odds ratio 17.6, 95% CI 1.9-165.3, p = 0.0122).</AbstractText>Acute hyperglycaemia is associated with worse in-hospital outcomes in patients with STEMI. More severe inflammation (defined as leukocyte count on admission) is noted in STEMI patients with adverse events. A significant positive correlation can be seen between glucose level and leukocyte count on admission, and concomitant presence of both acute hyperglycaemia and more severe inflammation in patients with STEMI was found to be an independent predictor of poor in-hospital outcomes.</AbstractText> |
13,155 | Evaluation of factors affecting persistence of atrial fibrillation in patients with concomitant atrial flutter treated with percutaneous radiofrequency current ablation of the right atrial cavotricuspid isthmus. | Atrial fibrillation (AF) and atrial flutter (AFL) often coexist. In some patients, AF remission is seen after successful percutaneous radiofrequency current ablation of the cavotricuspid isthmus (CTI).</AbstractText>To evaluate factors affecting AF remission in patients with typical AFL and concomitant AF who underwent CTI ablation.</AbstractText>The study included consecutive 69 patients with typical AFL and concomitant clinically documented AF who underwent successful CTI ablation in 2003-2010. Based on the follow-up data from medical records and telephone interviews, the patients were divided into two groups: with persistent AF (group A) and with remission of AF (group B). This distinction was based on arrhythmia symptoms reported by the patient, such as palpitation or irregular heartbeat, and confirmed electrocardiographically (12-lead ECG or Holter monitoring).</AbstractText>Group A included 47 patients, and group B included 22 patients. The two groups did not differ significantly in regard to the New York Heart Association (NYHA) functional class and concomitant diseases including diabetes, ischaemic heart disease, previous myocardial infarction and arterial hypertension. The two groups also did not differ by echocardiographically determined mean left ventricular ejection fraction (LVEF) and left atrial dimension (43.5 ± 9.27 vs. 39.27 ± 5.76, p = 0.075). Multivariate logistic regression did not identify any independent risk factors of AF persistence after CTI ablation. Univariate logistic regression also did not show arterial hypertension, type 2 diabetes, previous myocardial infarction, LVEF, left ventricular dimension or age to affect AF persistence after successful ablation.</AbstractText>Based on the results of our study, we were unable to identify factors determining remission of AF coexisting with AFL in patients after percutaneous CTI ablation. These findings may indicate the need for complex ablation procedure (involving both CTI and pulmonary venous ostia ablation) in patients in whom these two arrhythmias coexist.</AbstractText> |
13,156 | [Electrical storm in patients with implantable cardioverter-defibrillator]. | 76 years old patient after the ICD implantation as a primary prevention of sudden cardiac death was admitted to the hospital because of the electrical storm which presented in ECG as a variety ventricular arrhythmia. Because of patients&rsquo; resistance for pharmacological treatment and antiarrhythmic therapies delivered from ICD, we performed an ablation and implemented the resynchronization therapy of the heart. |
13,157 | [Giant thrombus in the left atrium after mitral bioprosthesis implantation: is standard oral anticoagulation always sufficient?]. | We present a case of 70-year old male after coronary by-pass surgery and mitral bioprosthesis implantation due to infective endocarditis, with continuous atrial fibrillation, who was admitted to the hospital due to the worsening of the heart failure. He was on oral antivitamine K agents with therapeutic value of INR. On echocardiography we found enlargement of all cavities with extremely big left atrium (9.5 cm) and poor contractile left ventricular function (EF 25%). An enormously big old thrombus was found in the left atrium. The patient was disqualified from surgical treatment. Treatment with unfractionated heparin was unsuccessful. We discuss if standard antithrombotic treatment is always sufficient in such unusual cases. |
13,158 | L-type calcium channel mutations in Japanese patients with inherited arrhythmias. | Mutations in genes encoding the L-type cardiac calcium channel (LTCC) are associated with various types of inherited arrhythmias, including Brugada syndrome (BrS). However, the frequency in Asian populations remains unknown. This study aimed to elucidate disease-causing mutations in LTCC-related genes in Japanese patients diagnosed as BrS or idiopathic ventricular fibrillation (IVF), early repolarization syndrome, short QT syndrome, and compare them with those carrying SCN5A mutations.</AbstractText>We screened CACNA1C and CACNB2b in 312 probands and compared the clinical characteristics between probands with gene mutations in CACNA1C or SCN5A. In results, we identified 6 CACNA1C mutations in 7 unrelated probands and SCN5A mutations in 20 probands. There were no CACNB2b mutation carriers. In topology, half of the mutations were located in the C-terminus. Among 7 CACNA1C mutation carriers, 2 were female and 3 were symptomatic; 2 patients were resuscitated from ventricular fibrillation, and 1 patient had syncope. Compared with SCN5A mutation carriers, there were no significant differences in the ECG characteristics. 2 of 3 symptomatic CACNA1C patients were female, but all female SCN5A mutation carriers remained asymptomatic.</AbstractText>We identified 6 CACNA1C mutations in BrS and IVF patients and their phenotypes were varied. Although mutation frequency was not high, screening of LTCC channel genes may be clinically important to prevent unexpected sudden death.</AbstractText> |
13,159 | Left ventricular systolic dysfunction, heart failure, and the risk of stroke and systemic embolism in patients with atrial fibrillation: insights from the ARISTOTLE trial. | We examined the risk of stroke or systemic embolism (SSE) conferred by heart failure (HF) and left ventricular systolic dysfunction (LVSD) in the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation Trial (ARISTOTLE), as well as the effect of apixaban versus warfarin.</AbstractText>The risk of a number of outcomes, including the composite of SSE or death (to take account of competing risks) and composite of SSE, major bleeding, or death (net clinical benefit) were calculated in 3 patient groups: (1) no HF/no LVSD (n=8728), (2) HF/no LVSD (n=3207), and (3) LVSD with/without symptomatic HF (n=2736). The rate of both outcomes was highest in patients with LVSD (SSE or death 8.06; SSE, major bleeding, or death 10.46 per 100 patient-years), intermediate for HF but preserved LV systolic function (5.32; 7.24), and lowest in patients without HF or LVSD (1.54; 5.27); each comparison P<0.0001. Each outcome was less frequent in patients treated with apixaban: in all ARISTOTLE patients, the apixaban/warfarin hazard ratio for SSE or death was 0.89 (95% confidence interval, 0.81-0.98; P=0.02); for SSE, major bleed, or death it was 0.85 (0.78-0.92; P<0.001). There was no heterogeneity of treatment effect across the 3 groups.</AbstractText>Patients with LVSD (with/without HF) had a higher risk of SSE or death (but similar rate of SSE) compared with patients with HF but preserved LV systolic function; both had a greater risk than patients without either HF or LVSD. Apixaban reduced the risk of both outcomes more than warfarin in all 3 patient groups.</AbstractText>URL: http://www.clinicaltrials.gov. Unique identifier: NCT00412984.</AbstractText> |
13,160 | Percutaneous stellate ganglion block suppressing VT and VF in a patient refractory to VT ablation. | Electrical storm is a condition characterized by multiple episodes of ventricular tachycardia (VT) or ventricular fibrillation (VF) in a short period of time.</AbstractText>An 80-year-old male with a history of ischemic cardiomyopathy presented with multiple ICD shocks. As a last resort, he underwent percutaneous left, followed by right, stellate ganglion block under fluoroscopic guidance. Since his discharge, he has been managed with alternating, biweekly left and right stellate ganglion blocks, and he has received no ICD shocks.</AbstractText>This case illustrates the potential of ongoing, temporary percutaneous stellate ganglion blockade in suppressing ventricular arrhythmogenesis.</AbstractText>© 2013 Wiley Periodicals, Inc.</CopyrightInformation> |
13,161 | Effects of mechano-electric feedback on scroll wave stability in human ventricular fibrillation. | Recruitment of stretch-activated channels, one of the mechanisms of mechano-electric feedback, has been shown to influence the stability of scroll waves, the waves that underlie reentrant arrhythmias. However, a comprehensive study to examine the effects of recruitment of stretch-activated channels with different reversal potentials and conductances on scroll wave stability has not been undertaken; the mechanisms by which stretch-activated channel opening alters scroll wave stability are also not well understood. The goals of this study were to test the hypothesis that recruitment of stretch-activated channels affects scroll wave stability differently depending on stretch-activated channel reversal potential and channel conductance, and to uncover the relevant mechanisms underlying the observed behaviors. We developed a strongly-coupled model of human ventricular electromechanics that incorporated human ventricular geometry and fiber and sheet orientation reconstructed from MR and diffusion tensor MR images. Since a wide variety of reversal potentials and channel conductances have been reported for stretch-activated channels, two reversal potentials, -60 mV and -10 mV, and a range of channel conductances (0 to 0.07 mS/µF) were implemented. Opening of stretch-activated channels with a reversal potential of -60 mV diminished scroll wave breakup for all values of conductances by flattening heterogeneously the action potential duration restitution curve. Opening of stretch-activated channels with a reversal potential of -10 mV inhibited partially scroll wave breakup at low conductance values (from 0.02 to 0.04 mS/µF) by flattening heterogeneously the conduction velocity restitution relation. For large conductance values (>0.05 mS/µF), recruitment of stretch-activated channels with a reversal potential of -10 mV did not reduce the likelihood of scroll wave breakup because Na channel inactivation in regions of large stretch led to conduction block, which counteracted the increased scroll wave stability due to an overall flatter conduction velocity restitution. |
13,162 | Results from a single-blind, randomized study comparing the impact of different ablation approaches on long-term procedure outcome in coexistent atrial fibrillation and flutter (APPROVAL). | This study examined the impact of different ablation strategies on atrial fibrillation (AF) recurrence and quality of life in coexistent AF and atrial flutter (AFL).</AbstractText>Three-hundred sixty enrolled patients with documented AF and AFL were blinded and randomized to group 1, AF±AFL ablation (n=182), or group 2, AFL ablation only (n=178). AF recurrence was evaluated with event recording and 7-day Holter at 3, 6, 9, and 12-month follow-ups. Quality of life was assessed at baseline and at the 12-month follow-up with 4 questionnaires: the Medical Outcome Study Short Form, the Hospital Anxiety and Depression Score, the Beck Depression Inventory, and the State-Trait Anxiety Inventory. Of the 182 patients in group 1, 58 (age, 63±8 years; 78% male; left ventricular ejection fraction, 59±8%) had AF+AFL ablation and 124 (age, 61±11 years; 72% male; left ventricular ejection fraction, 59±7%) had AF ablation only. In group 2 (age, 62±9 years; 76% male; left ventricular ejection fraction, 58±10%), only AFL was ablated by achieving bidirectional isthmus conduction block. Baseline characteristics were not different across groups. At 21±9 months of follow-up, 117 in group 1 (64%) and 34 in group 2 (19%) were arrhythmia free (P<0.001). In group 1, scores on most quality-of-life subscales showed significant improvement at follow-up, whereas group 2 patients derived relatively minor benefit.</AbstractText>In coexistent AF and AFL, lower recurrence rate and better quality of life are associated with AF ablation only or AF+AFL ablation than with lone AFL ablation. Furthermore, quality of life directly correlates with freedom from arrhythmia, as shown in this study for the first time in patients blinded to the procedure.</AbstractText>URL: http://www.clinicaltrial.gov/. Unique identifier: NCT01439386.</AbstractText> |
13,163 | [An apparent life threatening secondary to long Qt syndrome]. | We report the case of an infant with an episode of loss of consciousness, in whom ventricular fibrillation was diagnosed. He was successfully defibrillated and long QT syndrome was diagnosed as his baseline disease. This case constitutes a documented example of this entity as a cause of the sudden infant death syndrome. |
13,164 | Chronic myocardial infarction promotes atrial action potential alternans, afterdepolarizations, and fibrillation. | Atrial fibrillation (AF) is increased in patients with heart failure resulting from myocardial infarction (MI). We aimed to determine the effects of chronic ventricular MI in rabbits on the susceptibility to AF, and underlying atrial electrophysiological and Ca(2+)-handling mechanisms.</AbstractText>In Langendorff-perfused rabbit hearts, under β-adrenergic stimulation with isoproterenol (ISO; 1 µM), 8 weeks MI decreased AF threshold, indicating increased AF susceptibility. This was associated with increased atrial action potential duration (APD)-alternans at 90% repolarization, by 147%, and no significant change in the mean APD or atrial global conduction velocity (CV; n = 6-13 non-MI hearts, 5-12 MI). In atrial isolated myocytes, also under β-stimulation, L-type Ca(2+) current (I(CaL)) density and intracellular Ca(2+)-transient amplitude were decreased by MI, by 35 and 41%, respectively, and the frequency of spontaneous depolarizations (SDs) was substantially increased. MI increased atrial myocyte size and capacity, and markedly decreased transverse-tubule density. In non-MI hearts perfused with ISO, the I(CaL)-blocker nifedipine, at a concentration (0.02 µM) causing an equivalent I(CaL) reduction (35%) to that from the MI, did not affect AF susceptibility, and decreased APD.</AbstractText>Chronic MI in rabbits remodels atrial structure, electrophysiology, and intracellular Ca(2+) handling. Increased susceptibility to AF by MI, under β-adrenergic stimulation, may result from associated production of atrial APD alternans and SDs, since steady-state APD and global CV were unchanged under these conditions, and may be unrelated to the associated reduction in whole-cell ICaL. Future studies may clarify potential contributions of local conduction changes, and cellular and subcellular mechanisms of alternans, to the increased AF susceptibility.</AbstractText> |
13,165 | Analysis of QRS-T subtraction in unipolar atrial fibrillation electrograms. | This paper presents a QRS-T subtraction approach for atrial fibrillation (AF) intracardiac atrial electrograms (AEG). It also presents a comparison between the proposed method and two alternative ventricular subtraction techniques: average beat subtraction (ABS) using a fixed length window and an approach based on flat interpolation for QRS cancellation. Areas of the atrium close to the mitral valve showed stronger ventricular influence on the AEGs when compared with the remaining atrial regions. Ventricular influence affects the spectral power distribution of the AEG and can also affect the estimation of the dominant frequency unless the whole ventricular activity influence (QRS-T) is removed. The average power after QRS-T subtraction is significantly reduced for frequencies above 10 Hz (mostly associated with QRS complexes), as well as for frequencies between 3 and 5.5 Hz, (mostly related to T waves). The results indicate that the proposed approach removes ventricular influence on the AF AEGs better than the QRS cancellation method. Spectral analysis showed that both the ABS and the proposed method do well and no method should be preferred to the other. In the time domain, the proposed approach is matched to the lengths and timings of onset and offset for individual QRS-T segments while the ABS approach uses an arbitrary length around the QRS for the pattern used for QRS-T removal. |
13,166 | Comparison between normothermic and mild hypothermic cardiopulmonary bypass in myocardial revascularization of patients with left ventricular dysfunction. | The aim of this study was to investigate whether normothermic bypass is superior to mild hypothermia in patients with poor left ventricular function. This was achieved by studying defibrillation rates, postoperative requirements of cardiac pacing or other morbidity issues and mortality in patients with left ventricular dysfunction operated upon for elective coronary revascularization.</AbstractText>Data were collected retrospectively from 252 consecutive patients with left ventricular dysfunction (ejection fraction ≤35%) undergoing coronary revascularization between January 2005 and January 2011. Patients operated upon under mild hypothermia (32 ºC) were placed in Group 1 and under normothermia (≥35 ºC) were placed in Group 2. Comorbidities and postoperative complications were recorded.</AbstractText>There were 128 patients in Group 1 and 124 patients in Group 2. Plasma concentrations of CK-MB and troponin T peaked at 6 hours postoperatively, with no significant difference between the groups. Despite longer aortic cross-clamp time and total bypass time in Group 2, significantly less defibrillation requirement rates after aortic declamping was observed. Hospital mortality occured in 16 patients; 8 patients in each group.</AbstractText>Normothermia enables less requirement for defibrillation after aortic declamping and postoperative cardiac pacing in patients with left ventricular dysfunction, which may be interpreted as better myocardial protection under normothermic bypass. However, maintaining normothermia had no effect on postoperative stroke, postoperative atrial fibrillation, renal failure development and mortality.</AbstractText> |
13,167 | Malignant bileaflet mitral valve prolapse syndrome in patients with otherwise idiopathic out-of-hospital cardiac arrest. | The aim of this study was to investigate the prevalence of mitral valve prolapse (MVP) and its association with ventricular arrhythmias in a cohort with "unexplained" out-of-hospital cardiac arrest.</AbstractText>Ventricular arrhythmias are an important cause of sudden unexpected death in the young. The role of MVP in sudden unexpected death remains controversial.</AbstractText>Of 1,200 patients evaluated between July 2000 and December 2009 in the Mayo Clinic's Long QT Syndrome/Genetic Heart Rhythm Clinic, all 24 (16 women, median age 33.5 years) with idiopathic out-of-hospital cardiac arrest (i.e., negative for ischemia, cardiomyopathy, and channelopathy) were reviewed.</AbstractText>All 24 patients had implantable cardioverter-defibrillators (ICDs). Out-of-hospital cardiac arrest was the sentinel event in 22 (92%). Bileaflet MVP was found in 10 (42%). Compared with patients with normal mitral valves, patients with bileaflet MVP: 1) were over-represented by women (9 of 10 [90%] vs. 7 of 14 [50%], p = 0.04); 2) had a higher prevalence of biphasic or inverted T waves (7 of 9 [77.8%] vs. 4 of 14 [29%], p = 0.04); and 3) on Holter interrogation had higher prevalence of ventricular bigeminy (9 of 9 [100%] vs. 1 of 10 [10%], p < 0.0001), ventricular tachycardia (7 of 9 [78%] vs. 1 of 10 [10%], p = 0.006), and premature ventricular contractions originating from the outflow tract alternating with the papillary muscle or fascicular region (7 of 9 [78%] vs. 2 of 10 [20%], p = 0.02). Over a median 1.8 years (range: 0.1 to 11.9 years) from ICD placement, 13 of 24 patients (54%) received appropriate ventricular fibrillation-terminating ICD shocks. Only bileaflet MVP was associated with ventricular fibrillation recurrences requiring ICD therapy on follow-up (logistic regression odds ratio: 7.2; 95% confidence interval: 1.1 to 48; p = 0.028).</AbstractText>The authors describe a "malignant" subset of patients with MVP who experienced life-threatening ventricular arrhythmias. This phenotype is characterized by bileaflet MVP, female sex, and frequent complex ventricular ectopic activity, including premature ventricular contractions of the outflow tract alternating with papillary muscle or fascicular origin.</AbstractText>Copyright © 2013 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
13,168 | Circulating levels of persistent organic pollutants (POPs) are associated with left ventricular systolic and diastolic dysfunction in the elderly. | Major risk factors for congestive heart failure (CHF) are myocardial infarction, hypertension, diabetes, atrial fibrillation, smoking, left ventricular hypertrophy (LVH) and obesity. However, since these risk factors only explain part of the risk of CHF, we investigated whether persistent organic pollutants (POPs) might also play a role.</AbstractText>In the Prospective Investigation of the Vasculature in Uppsala Seniors (PIVUS) study, left ventricular ejection fraction, (EF), E/A-ratio and isovolumic relaxation time (IVRT), were determined by echocardiography and serum samples of 21 POPs were analyzed in serum measured by high-resolution chromatography coupled to high-resolution mass spectrometry (HRGC/HRMS) in 998 subjects all aged 70 years.</AbstractText>In this cross-sectional analysis, high levels of several of the polychlorinated biphenyls (PCB congeners 99, 118, 105, 138, 153, and 180) and octachlorodibenzo-p-dioxin (OCDD) were significantly related to a decreased EF. Some POPs were also related to a decreased E/A-ratio (PCBs 206 and 209). All the results were adjusted for gender, hypertension, diabetes, smoking, LVH and BMI, and subjects with myocardial infarction or atrial fibrillation were excluded from the analysis.</AbstractText>Circulating levels of POPs were related to impairments in both left ventricular systolic and diastolic function independently of major congestive heart failure risk factors, suggesting a possible role of POPs in heart failure.</AbstractText>Copyright © 2013 Elsevier Inc. All rights reserved.</CopyrightInformation> |
13,169 | The association between asymptomatic coronary artery disease and CHADS2 and CHA2 DS2 -VASc scores in patients with stroke. | CHADS2 and CHA2 DS2 -VASc scores are measurement tools that stratify thromboembolic risk in patients with non-valvular atrial fibrillation, and are predictive of cerebral atherosclerosis, fatal stroke and ischaemic heart disease. Patients with higher CHADS2 and CHA2 DS2 -VASc scores are more likely to have had an akinetic/hypokinetic left ventricular segment or a recent myocardial infarction, all of which are associated with coronary artery disease (CAD). Most of the CHADS2 score components are also risk factors for atherosclerosis. Thus, CHADS2 and CHA2 DS2 -VASc scores may be predictive of CAD.</AbstractText>In all, 1733 consecutive patients with acute ischaemic stroke who underwent multi-slice computed tomography coronary angiography were enrolled. The association of CHADS2 and CHA2 DS2 -VASc scores with the presence and severity of CAD was investigated.</AbstractText>Of the 1733 patients, 1220 patients (70.4%) had any degree of CAD and 576 (33.3%) had significant CAD (≥ 50% stenosis in at least one coronary artery). As the CHADS2 and CHA2 DS2 -VASc scores increased, the presence of CAD also increased (P < 0.001). The severity of CAD was correlated with CHADS2 score (Spearman coefficient 0.229, P < 0.001) and CHA2 DS2 -VASc score (Spearman coefficient 0.261, P < 0.001). In multivariate analysis, after adjusting for confounding factors, CHADS2 and CHA2 DS2 -VASc scores ≥2 were independently associated with CAD. The CHA2 DS2 -VASc score was a better predictor of the presence of CAD than the CHADS2 score on area under the curve analysis.</AbstractText>CHADS2 and CHA2 DS2 -VASc scores were predictive of the presence and severity of CAD in patients with stroke. When a patient has high CHADS2 or CHA2 DS2 -VASc scores, physicians should consider coronary artery evaluation.</AbstractText>© 2013 The Author(s) European Journal of Neurology © 2013 EFNS.</CopyrightInformation> |
13,170 | Three-Dimensional Transoesophageal Echocardiography in Electrophysiology Laboratory. | Percutaneous electrophysiological interventions such as atrial fibrillation and ventricular tachycardia ablation are usually monitored by fluoroscopy and electroanatomical mapping systems. Electroanatomical mapping systems lacks soft tissue contrast and adequate visualization of the target area such as right ventricular out-flow tract and left atrium. Recently, real-time 3D transoesophageal echocardiography (RT-3D TEE) has emerged as an important method for visualizing cardiac structures such as left atrium, left atrial appendix, interatrial septum, pulmonary veins, Marshall ligament and mitral valve annulus during invasive procedures. This review aims to describe the RT-3D TEE for the guidance of percutaneous interventional electrophysiological study especially at atrial fibrillation in the cardiac electrophysiology laboratory. |
13,171 | Role of Atrio-Ventricular Junction Ablation in Symptomatic Atrial Fibrillation for Optimization of Cardiac Resynchronization Therapy. | Cardiac resynchronization (CRT) therapy is indicated in patients with at least mildly symptomatic heart failure, left ventricular ejection fraction ≤35% and wide QRS, and has been associated with decreased morbidity and mortality. Unfortunately, approximately 30% of the patients appropriately selected for therapy do not respond to CRT. Among the reasons for non-response, atrial fibrillation (AF) plays a prominent role. AF limits the degree of biventricular pacing during CRT, not only when the ventricular rate is fast and highly irregular, but also during periods of of relatively constant rate, by causing fusion and pseudo-fusion complexes. Importantly, achievement of nearly 100% biventricular pacing is necessary to derive benefit from CRT. A simple, albeit irreversible, method to maximize biventricular pacing in patients with AF who are otherwise eligible for CRT is atrioventricular junction (AVJ) ablation. In this review, we discuss the role of AVJ ablation in CRT optimization in patients with AF. The available evidence from observational non-randomized studies suggests that AVJ ablation in patients with AF qualifying for CRT may offer improvement in heart failure symptoms, better survival, and better cardiac function. In light of the inherent limitations of non-randomized studies, further randomized studies are needed to support this treatment option. |
13,172 | Dronedarone: Where Does it Fit in the AF Therapeutic Armamentarium? | Dronedarone is a derivative of amiodarone with similar mechanisms of action (blocking calcium, potassium and sodium channels in addition to having anti-adrenergic effects). Compared to amiodarone it has fewer drug interactions (though it can interact with all current anticoagulants), more limited risk of organ toxicity, a much shorter half-life with no need for a loading regimen, but lower efficacy. Dronedarone is approved for the treatment of atrial fibrillation; has had limited studies for other arrhythmias; and has no adverse drug-ICD interactions reported. Clinical trials have resulted in only one dosing regimen (400 mg bid, to be taken with food) and have demonstrated both rate and rhythm effects in atrial fibrillation (AF). Dronedarone slows the ventricular response, can prolong the time to/reduce recurrences of/ reduce progression of AF, and reduce the incidence of hospitalization in AF patients with risk-prone markers. However, trials have also revealed an increased risk of mortality and other adverse cardiovascular outcomes from dronedarone when given to patients in heart failure. The details of these trials, additional pharmacokinetic and pharmacodynamic information, and recommendations concerning the use of dronedarone are provided in the full manuscript that follows. |
13,173 | Can multi-slice computed tomography of the heart be useful in patients with epicardial leads? | New visualization methods are helpful in the noninvasive diagnosis of heart diseases. However, sometimes epicardial and endocardial leads can cause problems due to a large number of artifacts. Based on the presented case, we conclude that it is possible to perform multi-slice computed tomography of coronary arteries despite the coexistence of transvenous and epicardial leads. |
13,174 | Exendin-4 attenuates ischemia-induced ventricular arrhythmias in rats. | Glucagon-like peptide-1 and its receptor agonist-exendin-4 (Ex-4) have been shown to provide beneficial effects for cardiovascular diseases. This study investigated the effects of Ex-4 on ischemia-induced ventricular arrhythmias in rats.</AbstractText>Anesthetized male rats were once treated with Ex-4 (5 μg/kg, i.v.) 1 h before ischemia in the absence and/or presence of 5-hydroxydecanoic acid (5-HD, 10 mg/kg, i.v., a specific inhibitor of mitochondrial ATP-sensitive potassium [KATP] channels) which were once injected 10 min before ischemia. And then subjected to ischemia for 30 min. Ventricular arrhythmias were assessed.</AbstractText>During the 30-min ischemia, Ex-4 significantly reduced the incidence of ventricular fibrillation (VF) (p < 0.05). The duration of ventricular tachycardia (VT) + VF, the number of VT + VF episodes and the severity of arrhythmias were all significantly reduced by Ex-4 compared to those in myocardial ischemia group (p < 0.05 for all). Administration of 5-HD abolished the protective effects of Ex-4 on VF incidence, the duration of VT + VF, the number of VT + VF episodes and the severity of arrhythmias (p < 0.05 for all).</AbstractText>This study suggested that Ex-4 could attenuate ischemia-induced ventricular arrhythmias in rats in which mitochondrial KATP channels may be involved.</AbstractText> |
13,175 | Effectiveness of percutaneous coronary intervention within 12 hours to 28 days of ST-elevation myocardial infarction in a real-world Chinese population. | Percutaneous coronary intervention( PCI) for ST-elevation myocardial infarction (STEMI) has been widely accepted for patient who come within 12 hours, but for those who come to the hospital late (12 hours to 28 days) the long-term data and possible predictors are limited regarding 'hard' endpoints in 'real world'.</AbstractText>The registry data of all 5523 consecutive patients admitted due to an incident STEMI (12 hours to 28 days) in our center were analyzed. Patients were divided into 3 age groups (age<65; age = 65-74; age ≥75) and two therapeutic groups including conservative and PCI group. The primary endpoints included 30-day mortality and 1-year mortality.</AbstractText>The clinical characteristics include female gender; history of diabetes mellitus, previous myocardial infarction, cerebral vascular disease, chronic renal failure, atrial fibrillation, hypertension, anemia, gastric bleeding; presentation of ventricular tachycardia/ventricular fibrillation, pneumonia, heart failure, multiple organ failure and cardiogenic shock. The ratio of all the above factors increased with the age getting older (all p<0.05), while that of the PCI decreased significantly with ageing (53.9%, 36.3% and 21.7%). Except hypertension, all the other factors were less seen in the PCI group than in the conservative group (p<0.01). Pooled estimates, based on type of therapy and age groups, PCI resulted in significantly lower 30-day and 1-year mortality. Cox analysis showed the positive predictors for 30 days and 1 year mortality were heart failure, cerebral vascular disease, chronic renal failure, ventricular tachycardia/ventricular fibrillation, age, female, gastric intestinal bleeding, cardiogenic shock, multiple organ failure, while PCI was a negative predictor. ROCs analysis showed AUCs were always higher for PCI group.</AbstractText>The elderly have more comorbidities and higher rates of mortality, mandating thorough evaluation before acceptance for PCI. PCI between 12 hours to 28 days in all ages of patients including the elderly with STEMI is significantly more effective than conservative therapy.</AbstractText> |
13,176 | Antipsychotics and torsadogenic risk: signals emerging from the US FDA Adverse Event Reporting System database. | Drug-induced torsades de pointes (TdP) and related clinical entities represent a current regulatory and clinical burden.</AbstractText>As part of the FP7 ARITMO (Arrhythmogenic Potential of Drugs) project, we explored the publicly available US FDA Adverse Event Reporting System (FAERS) database to detect signals of torsadogenicity for antipsychotics (APs).</AbstractText>Four groups of events in decreasing order of drug-attributable risk were identified: (1) TdP, (2) QT-interval abnormalities, (3) ventricular fibrillation/tachycardia, and (4) sudden cardiac death. The reporting odds ratio (ROR) with 95 % confidence interval (CI) was calculated through a cumulative analysis from group 1 to 4. For groups 1+2, ROR was adjusted for age, gender, and concomitant drugs (e.g., antiarrhythmics) and stratified for AZCERT drugs, lists I and II (http://www.azcert.org , as of June 2011). A potential signal of torsadogenicity was defined if a drug met all the following criteria: (a) four or more cases in group 1+2; (b) significant ROR in group 1+2 that persists through the cumulative approach; (c) significant adjusted ROR for group 1+2 in the stratum without AZCERT drugs; (d) not included in AZCERT lists (as of June 2011).</AbstractText>Over the 7-year period, 37 APs were reported in 4,794 cases of arrhythmia: 140 (group 1), 883 (group 2), 1,651 (group 3), and 2,120 (group 4). Based on our criteria, the following potential signals of torsadogenicity were found: amisulpride (25 cases; adjusted ROR in the stratum without AZCERT drugs = 43.94, 95 % CI 22.82-84.60), cyamemazine (11; 15.48, 6.87-34.91), and olanzapine (189; 7.74, 6.45-9.30).</AbstractText>This pharmacovigilance analysis on the FAERS found 3 potential signals of torsadogenicity for drugs previously unknown for this risk.</AbstractText> |
13,177 | Early enhanced external counter pulsation improves neurological recovery after the return of spontaneous circulation in a mongrel dog cardiac arrest model*. | The aim of this study was to investigate whether early enhanced external counter pulsation therapy after cardiopulmonary resuscitation improved neurological outcome in a mongrel dog cardiac arrest model.</AbstractText>Randomized, animal study.</AbstractText>Assisted circulation laboratory.</AbstractText>Twenty-four healthy male adult dogs (12-14 kg).</AbstractText>After minutes of untreated ventricular fibrillation followed by 2 minutes of cardiopulmonary resuscitation, the dogs were randomized to receive 4 hours of enhanced external counter pulsation therapy, to receive 4 hours of hypertension with over 140 mm Hg or to be a control.</AbstractText>Blood pressure and left ventricular ejection fraction were recorded. Cerebral flow was assessed using magnetic resonance imaging. Arterial blood gases and endothelium-derived vasoactive substances were assessed before cardiac arrest and 4 hours after the return of spontaneous circulation. Neurological outcome was assessed by the neurologic deficit score and terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling staining.</AbstractText>Enhanced external counter pulsation significantly improved the left ventricular ejection fraction and increased common carotid artery blood flow and shear stress. Enhanced external counter pulsation increased both relative cerebral blood volume (RCBV, p = 0.043) and relative cerebral blood flow (RCBF, p = 0.012) in animals 4 hours after return of spontaneous circulation. Enhanced external counter pulsation therapy promoted the production of nitric oxide and tissue plasminogen activator and decreased the release of endothelin-1 (p = 0.013) after return of spontaneous circulation. Treatment with norepinephrine in the high mean artery pressure also increased common carotid artery blood flow and shear stress. However, no effects on the left ventricular ejection fraction, the production of nitric oxide and tissue plasminogen activator, or the release of endothelin-1 were found. The neurologic deficit scores of the animals were significantly lower at 24, 48, 72, and 96 hours in the enhanced external counter pulsation group, as well as at 24, 72, and 96 hours compared with animals in the control group after return of spontaneous circulation. Fewer apoptotic neurons were observed in the animals in the enhanced external counter pulsation group compared with the animals in the control and hypertension groups.</AbstractText>These data indicated that the treatment of early enhanced external counter pulsation improved neurological outcome by both increasing cerebral blood flow and improving the recovery of microcirculation after return of spontaneous circulation. The treatment of early enhanced external counter pulsation can be a good option for protecting the brain after return of spontaneous circulation.</AbstractText> |
13,178 | Echocardiographic assessment of ventricular synchrony in congenital and acquired heart disease in children. | Electromechanical dyssynchrony is an important consequence of and contributor to ventricular dysfunction. Echocardiography can be useful to assess the mechanisms underlying mechanical dyssynchrony, to evaluate the impact of mechanical dyssynchrony on ventricular function, and to try to predict the therapeutic response to cardiac resynchronization therapy (CRT). Mechanical dyssynchrony has been demonstrated in several pediatric acquired and congenital cardiac conditions, but experience is still limited. Moreover, the optimal method to identify dyssynchrony remains unclear, and data predicting the response to CRT in pediatrics are lacking. Understanding mechanisms of electromechanical dyssynchrony by echocardiography seems promising, at least in left bundle branch block (LBBB), but may be limited in children due to the uncommon occurrence of LBBB in this population. This review addresses the commonly used methods to diagnose mechanical dyssynchrony, discusses the emerging concepts on the mechanisms of the various types of mechanical dyssynchrony, and discusses the possible significance of mechanical synchrony in pediatric and acquired congenital heart disease. |
13,179 | Characteristics of atrial fibrillation and comorbidities in familial atrial fibrillation. | One-third of lone atrial fibrillation (AF) presents as familial disorder. Heterogeneity of both genetic background and clinical manifestations remains largely uncharacterized. We aimed to evaluate the clinical characteristics and especially the triggering factors of familial AF.</AbstractText>Probands were screened from 84 consecutive lone AF patients seen in our tertiary hospital arrhythmia clinic. Those confirmed to have at least 1 first-degree relative with lone AF were included. 12-lead ECG, Holter recording, and cardiac ultrasound were performed. Data concerning arrhythmias and other medical history were collected. Altogether 17 kindreds with 59 AF patients, 52 of whom had lone AF, were identified. Initiation of AF was atrial extrasystolia (PACs) related in 35%, and vagal or sympathetic in 30% of cases. Within any given family, the characteristics related to AF initiation were the same in two-thirds of kindreds. AV conduction abnormalities were found in 2 families, sinus node dysfunction in 2 families, and both in 3 families. Frequent premature ventricular complexes (>1,000/24 hours) were observed in 9 families. Additional comorbidities included dilative cardiomyopathy and sudden death in 3 families.</AbstractText>In familial AF the proportion of PACs-related AF is lower than expected. The arrhythmia triggers for lone AF in general are heterogeneous but often family specific. Concomitant rhythm disorders, as well as cardiomyopathies, are common in patients with familial AF. A positive family history for AF in an apparently lone AF patient may be a marker for wider spectrum of cardiac pathology.</AbstractText>© 2013 Wiley Periodicals, Inc.</CopyrightInformation> |
13,180 | Factors influencing outcome in patients with cardiac arrest in the ICU. | Post-arrest variables associated with long-term survival after cardiopulmonary resuscitation (CPR) in intensive care unit (ICU) patients remain unclear. This study was designed to identify pre- and intra-arrest factors associated with survival 3 months after CPR in ICU patients and to identify post-arrest factors associated with long-term survival in those who survived 24 h after CPR.</AbstractText>A total of 131 ICU patients undergoing CPR from January 2009 to June 2010 were included. Data were retrospectively analysed and categorized based on the Utstein template.</AbstractText>The overall survival rate 3 months after CPR was 20.6%. Logistic regression analysis revealed that acute physiology and chronic health evaluation (APACHE) II score (odds ratio, 95% confidence interval, 0.87 [0.83-0.93]; P < 0.001), ventricular tachycardia/ventricular fibrillation (VT/VF, 5.55 [1.55-19.83]; P = 0.032), and normoxia during CPR (4.45 [1.34-14.71]; P = 0.045) were significant independent pre- and intra-arrest predictors of 3-month survival after CPR in ICU patients. Fifty-seven patients survived 24 h after CPR, and their 3-month survival rate was 47.4%. Early enteral nutrition (9.94 [1.96-50.43]; P = 0.030) and normoxia after return of spontaneous circulation (10.75 [2.03-55.56]; P = 0.030) were predictive of 3-month survival in patients who survived 24 h after CPR.</AbstractText>Normoxia during CPR and VT/VF were predictors of long-term survival after CPR in ICU patients. In patients surviving 24 h after CPR, initiation of enteral nutrition within 48 h and maintenance of normoxia were associated with a positive outcome.</AbstractText>© 2013 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.</CopyrightInformation> |
13,181 | [Hypertrophic cardiomyopathy: current aspects and new developments]. | Hypertrophic cardiomyopathy (HCM) is a myocardial disorder characterized by left ventricular hypertrophy with no apparent cause (such as severe hypertension, aortic valve stenosis, etc.). The clinical diagnosis is based on cardiac imaging, commonly using 2D echocardiography and increasingly CMR. HCM is the leading cause of sudden death in young people, especially on the sports field. Many patients remain asymptomatic throughout life, while others develop heart failure, atrial fibrillation and stroke. HCM is the most common genetic (autosomal dominant) cardiovascular disease, with variable penetrance and expression. It is caused by mutations in genes coding for cardiac sarcomeric proteins. Genetic counseling and clinical risk stratification are crucial for all patients. Medical treatment with B-blockers or verapamil improves symptoms but has not been show to modify the clinical course. Patients with outflow obstruction and severe symptoms unresponsive to medical therapy are candidates for alcohol septal ablation or surgical myectomy. Current approaches focus on the prevention of sudden death by means of implantable defibrillators in high-risk patients. |
13,182 | ECG of the month. Irregular rhythm in a 25-year-old man with three prior cardiac operations. Coarse atrial fibrillation with a rapid ventricular response, left anterior fascicular block, left ventricular hypertrophy with repolarization abnormality. | The patient underwent closure of an atrial septal defect at age 3, had a leaking "mitral" valve repaired at age 9, and at age 13 had a "mitral" valve replacement. He began taking warfarin sodium at that time and remained symptom-free until 10 days before his initial visit here when he presented to another hospital with dyspnea and palpitations. Treatment there consisted of lisinopril 10 mg qd, carvedilol 6.25 mg bid, aldactone 25 mg qd, furosemide 40 mg qd, digoxin 0.25 mg qd, and a continuation of warfarin sodium 7.5 mg qd. An echocardiogram showed a left ventricular ejection fraction of 20%. After diuresis, he was referred to our cardiology clinic. On his initial visit here, his heart rate was an irregular 120 beats/min, his blood pressure was 106/77 mmHg, and closing and opening snaps of a normally functioning mechanical mitral valvular prosthesis were heard. He was obese (height, 5' 9"; weight, 272 lbs). An electrocardiogram was recorded (Figure 1). |
13,183 | Radiofrequency ablation for atrial fibrillation during concomitant cardiac surgery. Mid-term results. | Atrial fibrillation is found in an increasing number of patients undergoing open heart surgery. It is associated with higher mortality rates, risk of stroke and left ventricular dysfunction. Surgical ablation for atrial fibrillation has evolved from the complex"cut and sew" Maze procedure to less invasive techniques, utilizing alternative energy sources. We present our experience with left atrial radiofrequency ablation during cardiac surgery, outlining the technical aspects of the procedure and postoperative outcomes, with emphasis on mid-term freedom from atrial fibrillation.</AbstractText>The study included 93 consecutive patients with history of atrial fibrillation scheduled for cardiac surgery between January 2008 and December 2011. Concomitant left atrial radiofrequency ablation was performed using monopolar (endocardial) or bipolar (epicardial) systems, depending on the type of underlying cardiac pathology. Duration of the atrial fibrillation, re-do surgery, low ejection fraction, advanced age, or giant left atria were not considered as contraindications.</AbstractText>Of the included patients, 73.1 % were discharged in stable sinus rhythm. Overall freedom from atrial fibrillation was 69.6 % at late follow-up, which ranged from 12 to 48 months (median, 22 months) and did not differ for the two approaches (epicardial vs. endocardial). The presence of early atrial tachyarrhythmia was a predictor of atrial fibrillation recurrence (p = 0.026). Age was also associated with higher recurrence rates during hospital stay (p = 0.04), but not for late atrial fibrillation.</AbstractText>Concomitant left atrial radiofrequency ablation conveyed satisfactory early and mid-term rhythm control, with acceptable postoperative outcomes, given the risk profile of our patient cohort.</AbstractText> |
13,184 | Approach to reduction of ventricular arrhythmias and implantable cardioverter-defibrillator therapies in patients with heart failure. | Prevention of ventricular arrhythmias and implantable cardioverter-defibrillator (ICD) therapies in patients with heart failure will be reviewed.</AbstractText>ICD utilization in patients with heart failure has resulted in significantly improved long-term survival. However, there is growing evidence that ICD shocks are associated with increased morbidity and mortality. As a result, there is increasing emphasis on the treatment strategies to avoid ICD therapies. Optimal heart failure management with medical as well as cardiac resynchronization therapy when indicated is an essential part of treatment; however, adjunctive measures may be necessary to suppress ventricular arrhythmias, prevent unnecessary shocks, and improve quality of life.</AbstractText>Device programming can help avoid ICD therapies by delaying time to detection, increasing detection rate cutoffs, and discriminating between supraventricular and ventricular arrhythmias. Still, as patients live longer with advanced stages of heart failure, there will be a need to suppress sustained ventricular arrhythmias that would otherwise require ICD therapy. Antiarrhythmic drugs offer a noninvasive option to help suppress ventricular arrhythmias. With more experience and better catheter mapping and ablation techniques, there is a movement toward an early invasive strategy for ventricular tachycardia management in patients with heart failure.</AbstractText> |
13,185 | Atrial fibrillation and heart failure: beyond the heart rate. | Atrial fibrillation and heart failure are two of the most prevalent cardiovascular disease conditions. They often coexist and lead to significant morbidity and mortality. Adequate management strategies for this dual epidemic continue to be the subject of many research studies.</AbstractText>Recent clinical trials suggest that a rhythm control strategy for atrial fibrillation does not offer a survival advantage over rate control in heart failure patients with reduced systolic function. Rhythm control in these trials was achieved using antiarrhythmic drugs, with evidence of increased mortality associated with certain agents. Catheter ablation is a more effective and increasingly used approach to maintain sinus rhythm in atrial fibrillation patients, with promising results in the heart failure population. Late-gadolinium-enhancement cardiac MRI (LGE-MRI) assessment of atrial fibrosis helps in selecting the better candidates for atrial fibrillation ablation. AV nodal ablation and bi-ventricular pacing remains another viable option. Atrial fibrillation patients with heart failure and preserved systolic function are another group in whom maintenance of sinus rhythm is thought to be advantageous.</AbstractText>Patients with atrial fibrillation and heart failure are a heterogeneous group and require a personalized treatment approach. Catheter ablation to restore and maintain sinus rhythm is a modality that promises to be advantageous beyond rate control.</AbstractText> |
13,186 | Myocardial protection against global ischemia with Krebs-Henseleit buffer-based cardioplegic solution. | The Krebs-Henseleit buffer is the best perfusion solution for isolated mammalian hearts. We hypothesized that a Krebs-Henseleit buffer-based cardioplegic solution might provide better myocardial protection than well-known crystalloid cardioplegic solutions because of its optimal electrolyte and glucose levels, presence of buffer systems, and mild hyperosmolarity.</AbstractText>Isolated Langendorff-perfused rat hearts were subjected to either global ischemia without cardioplegia (controls) or cardioplegic arrest for either 60 or 180 min, followed by 120 min of reperfusion. The modified Krebs-Henseleit buffer-based cardioplegic solution (mKHB) and St. Thomas' Hospital solution No. 2 (STH2) were studied. During global ischemia, the temperatures of the heart and the cardioplegic solutions were maintained at either 37°C (60 min of ischemia) or 22°C (moderate hypothermia, 180 min of ischemia). Hemodynamic parameters were registered throughout the experiments. The infarct size was determined through histochemical examination.</AbstractText>Cardioplegia with the mKHB solution at moderate hypothermia resulted in a minimal infarct size (5 ± 3%) compared to that in the controls and STH2 solution (35 ± 7% and 19 ± 9%, respectively; P < 0.001, for both groups vs. the mKHB group). In contrast to the control and STH2-treated hearts, no ischemic contracture was registered in the mKHB group during the 180-min global ischemia. At normothermia, the infarct sizes were 4 ± 3%, 72 ± 6%, and 70 ± 12% in the mKHB, controls, and STH2 groups, respectively (P < 0.0001). In addition, cardioplegia with mKHB at normothermia prevented ischemic contracture and improved the postischemic functional recovery of the left ventricle (P < 0.001, vs. STH2).</AbstractText>The data suggest that the Krebs-Henseleit buffer-based cardioplegic might be superior to the standard crystalloid solution (STH2).</AbstractText> |
13,187 | Implantable cardioverter-defibrillator shocks: epidemiology, outcomes, and therapeutic approaches. | Implantable cardioverter-defibrillators (ICDs) have revolutionized the approach to the prevention of sudden cardiac death and are commonly used in a wide range of high-risk patients, including the large population of patients with severe left ventricular systolic dysfunction. The benefit of these devices derives from their therapies, including both antitachycardia pacing and high-energy shocks. However, although these therapies may be life saving, devices can also deliver inappropriate shocks.</AbstractText>To review ICD therapies (shocks and antitachycardia pacing), their effects on health outcomes, and current methods to reduce these therapies.</AbstractText>We reviewed clinical evidence on ICD shocks and reference lists of retrieved articles. We also examined literature about the methods of reducing ICD therapy.</AbstractText>Both appropriate and inappropriate ICD shocks are common and are associated with an adverse effect on health outcomes, quality of life, and mortality. Several methods are available to reduce the risk of inappropriate ICD therapies.</AbstractText>Implantable cardioverter-defibrillators reduce the risk of sudden cardiac death and prolong life in selected populations; however, many patients will receive an ICD shock, either appropriate or inappropriate. It is imperative that patients be counseled regarding this risk and adverse outcomes associated with shocks. Reduction of ICD shock should be individualized to ensure that patients receiving these devices experience the maximal benefits of therapy while minimizing the adverse consequences.</AbstractText> |
13,188 | Electrocardiographic assessment of coronary artery disease and stroke risk factors in rural and urban Tanzania: a case-control study. | Although the association between cerebrovascular and coronary artery disease (CAD) is well known in high-income countries, this association is not well documented in black Africans.</AbstractText>The aim of this study was to document electrocardiographic (ECG) evidence of CAD in stroke cases and controls and to identify other common ECG abnormalities related to known stroke risk factors in a community-based population of incident stroke cases in Tanzania, East Africa.</AbstractText>This was a case-control study. Incident stroke cases were identified by the Tanzanian Stroke Incidence Project. Age- and sex-matched controls were randomly selected from the background population. Electrocardiograms were manually analyzed using the Minnesota Coding System, looking for evidence of previous myocardial infarction (MI), atrial fibrillation (AF) or atrial flutter (AFl), and left ventricular hypertrophy (LVH).</AbstractText>In Hai, there were 93 cases and 241 controls with codable electrocardiograms, and in Dar-es-Salaam, there were 39 cases and 72 controls with codable electrocardiograms. Comparing cases and controls, there was a higher prevalence of MI and AF or AFl (but not LVH) in cases compared with controls.</AbstractText>This is the first published study of ECG assessment of CAD and other stroke risk factors in an incident population of stroke cases in sub-Saharan Africa. It suggests that concomitant CAD in black African stroke cases is more common than previously suggested.</AbstractText>Copyright © 2014 National Stroke Association. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
13,189 | Dronedarone and Captisol-enabled amiodarone in an experimental cardiac arrest. | To compare the energy required for defibrillation and postshock outcomes after the administration of dronedarone, amiodarone, and placebo in a porcine model of cardiac arrest.</AbstractText>Forty-two pigs were randomized to amiodarone, dronedarone, or control treatments. After induction of ventricular fibrillation, compressions and ventilations were performed for 3 minutes and treatment was administered over 30 seconds. If defibrillation was unsuccessful, cardiopulmonary resuscitation continued and repeated shocks were administered every 2 minutes with continual hemodynamic monitoring for a total duration of 30 minutes.</AbstractText>The cumulative energy required for defibrillation was 570 ± 422 J for dronedarone, 441 ± 365 J for amiodarone, and 347 ± 281 J for control (P = not significant). Survival at 30 minutes was 1 (7.1%) for dronedarone compared with 11 (78.6%) for control (P = 0.001). Mortality in the dronedarone group was because of refibrillation in 3 (21.4%) cases, atrioventricular block in 1 (7.1%) case, and hypotension not because of bradycardia in 9 (64.3%) cases. Two minutes after successful defibrillation, systolic aortic pressure was lower in dronedarone versus control (86.6 ± 26.9 vs. 110 ± 15.1 mm Hg; P = 0.035).</AbstractText>The administration of dronedarone resulted in a significant reduction in survival and both systolic aortic and coronary perfusion pressure compared with control.</AbstractText> |
13,190 | Early repolarization pattern: innocent finding or marker of risk? | The presence of early repolarization (ER) pattern in the 12-lead ECG, defined as elevation of the QRS-ST junction (J point) often associated with a late QRS slurring or notching (J wave), is a common finding in the general population, particularly in the inferior and precordial lateral leads. In young and healthy individuals, particularly in males, blacks and athletes, this pattern has commonly been considered to represent an innocent finding. However, experimental studies, case reports and studies on healthy subjects surviving a cardiac arrest or with primary ventricular fibrillation (VF) have suggested an association between J-point elevation and/or QRS slurring in the inferior and lateral ECG leads and the risk of VF. On the other hand, in recent epidemiological studies on large general population no significant association between ER patterns and cardiac mortality was found. In athletes, changes of the QRS-ST segment are frequent. We found that in a selected group of 21 young competitive athletes, without underlying heart disease, who experienced cardiac arrest, the prevalence of J wave and/or QRS slurring in the inferior and lateral (V4 to V6) leads was significantly higher in cases than in 365 control athletes. Following sport discontinuation, during the 36-month follow-up arrhythmia recurrences did not differ between subgroups with and without J wave or QRS slurring. Recently, other studies showed that among different patterns of ER rapidly ascending ST segment after the J point seems to be almost universally benign. The conflicting data regarding the prognostic role of ER patterns can be partly due to different definitions of ER used. This emphasizes the need for standardized methods of measurements of QRS end-J point-ST segment and for detailed definitions. The knowledge of the true significance in clinical setting of the various aspects of ER is still unclear and warrants prospective, long-term epidemiological studies. |
13,191 | Outcomes in Women Undergoing Electrophysiological Procedures. | The number of invasive electrophysiological procedures is steadily increasing in Western countries, as the age of the population increases and technologies advance. In recent years, gender-related differences in cardiac rhythm disorders have been increasingly appreciated, which can potentially have a great impact on the outcomes of invasive electrophysiological procedures. Among supraventricular arrhythmias, women have a higher incidence of atrioventricular nodal re-entrant tachycardia and a significantly lower incidence of atrioventricular re-entrant tachycardia compared with males, and present to ablation procedures later and after having failed more antiarrhythmic drugs. The results of catheter ablation of atrial fibrillation in women have been reported worse than in men. This finding is possibly due to a later referral of females to ablation procedures, who present older and with a higher incidence of long-standing persistent atrial fibrillation. With regard to cardiac device implantation procedures, a smaller survival benefit from prophylactic implantable cardioverter defibrillator (ICD) implantation has been shown in women, essentially due to gender-specific differences in the clinical course of patients with severe left ventricular dysfunction, with women dying predominantly from non-arrhythmic causes. On the other side, the clinical outcome of cardiac resynchronisation therapy seems to be more favourable in women, who experience a greater degree of reverse left ventricular remodelling and a striking decrease of heart failure events or mortality after biventricular pacing. This review will summarise the available evidence on gender-related differences in outcomes of invasive electrophysiological procedures. |
13,192 | Current Evidence and Recommendations for Rate Control in Atrial Fibrillation. | Atrial fibrillation (AF) is the most common cardiac arrhythmia encountered in clinical practice, which is associated with substantial risk of stroke and thromboembolism. As an arrhythmia that is particularly common in the elderly, it is an important contributor towards morbidity and mortality. Ventricular rate control has been a preferred and therapeutically convenient treatment strategy for the management of AF. Recent research in the field of rhythm control has led to the advent of newer antiarrhythmic drugs and catheter ablation techniques as newer therapeutic options. Currently available antiarrhythmic drugs still remain limited by their suboptimal efficacy and significant adverse effects. Catheter ablation as a newer modality to achieve sinus rhythm (SR) continues to evolve, but data on long-term outcomes on its efficacy and mortality outcomes are not yet available. Despite these current developments, rate control continues to be the front-line treatment strategy, especially in older and minimally symptomatic patients who might not tolerate the antiarrhythmic drug treatment. This review article discusses the current evidence and recommendations for ventricular rate control in the management of AF. We also highlight the considerations for rhythm control strategy in the management of patients of AF. |
13,193 | Body Surface Electrocardiographic Mapping for Non-invasive Identification of Arrhythmic Sources. | The authors describe a novel three-dimensional, 252-lead electrocardiography (ECG) and computed tomography (CT)-based non-invasive cardiac imaging and mapping modality. This technique images potentials, electrograms and activation sequences (isochrones) on the epicardial surface of the heart. This tool has been investigated in the normal cardiac electrophysiology and various tachyarrhythmic, conduction and anomalous depo-repolarisation disorders. The clinical application of this system includes a wide range of electrical disorders like atrial arrhythmias (premature atrial beat, atrial tachycardia, atrial fibrillation), ventricular arrhythmias (premature ventricular beat, ventricular tachycardia) and ventricular pre-excitation (Wolff-Parkinson-White syndrome). In addition, the system has been used in exploring abnormalities of the His-Purkinje conduction like the bundle branch block and intraventricular conduction disturbance and thereby useful in electrically treating the associated heart failure (cardiac resynchronisation). It has a potential role in furthering our understanding of abnormalities of ventricular action potential (depolarisation [Brugada syndrome and repolarisation], long QT and early repolarisation syndromes) and in evaluating the impact of drugs on His-Purkinje conduction and cardiac action potential. |
13,194 | Rate versus rhythm control for management of atrial fibrillation in clinical practice: results from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF) registry. | All patients with atrial fibrillation (AF) require optimization of their ventricular rate. Factors leading to use of additional rhythm control in clinical practice have not been thoroughly defined.</AbstractText>The ORBIT-AF registry enrolled patients with AF from a broad range of practice settings and collected data on rate versus rhythm control, as indicated by the treating physician. Multivariable logistic regression analysis was performed to identify factors associated with each strategy.</AbstractText>Of 10,061 patients enrolled, 6,859 (68%) were managed with rate only control versus 3,202 (32%) with rhythm control. Patients managed with rate control were significantly older and more likely to have hypertension, heart failure, prior stroke, and gastrointestinal bleeds. They also had fewer AF-related symptoms (41% with no symptoms vs 31% for rhythm control). Systemic anticoagulation was prescribed for 5,448 (79%) rate-control patients versus 2,219 (69%) rhythm-control patients (P < .0001). After multivariable adjustment, patients with higher symptom scores (severe symptoms vs. none, OR 1.62, 95% CI 1.41-1.87) and those referred to electrophysiologists (OR 1.64, 95% CI 1.45-1.85) were more likely to be managed with a rhythm control strategy.</AbstractText>In this outpatient registry of US clinical practice, the majority of patients with AF were managed with rate control alone. Patients with more symptoms and who were treated by an electrophysiologist were more likely to receive rhythm-control therapies. A significant proportion of AF patients, regardless of treatment strategy, were not treated with anticoagulation for thromboembolism prophylaxis.</AbstractText>Copyright © 2013 Mosby, Inc. All rights reserved.</CopyrightInformation> |
13,195 | Rationale and design of the SERVE-HF study: treatment of sleep-disordered breathing with predominant central sleep apnoea with adaptive servo-ventilation in patients with chronic heart failure. | Central sleep apnoea/Cheyne-Stokes respiration (CSA/CSR) is a risk factor for increased mortality and morbidity in heart failure (HF). Adaptive servo-ventilation (ASV) is a non-invasive ventilation modality for the treatment of CSA/CSR in patients with HF.</AbstractText>SERVE-HF is a multinational, multicentre, randomized, parallel trial designed to assess the effects of addition of ASV (PaceWave, AutoSet CS; ResMed) to optimal medical management compared with medical management alone (control group) in patients with symptomatic chronic HF, LVEF ≤45%, and predominant CSA. The trial is based on an event-driven group sequential design, and the final analysis will be performed when 651 events have been observed or the study is terminated at one of the two interim analyses. The aim is to randomize ∼1200 patients to be followed for a minimum of 2 years. Patients are to stay in the trial up to study termination. The first patient was randomized in February 2008 and the study is expected to end mid 2015. The primary combined endpoint is the time to first event of all-cause death, unplanned hospitalization (or unplanned prolongation of a planned hospitalization) for worsening (chronic) HF, cardiac transplantation, resuscitation of sudden cardiac arrest, or appropriate life-saving shock for ventricular fibrillation or fast ventricular tachycardia in implantable cardioverter defibrillator patients.</AbstractText>The SERVE-HF study is a randomized study that will provide important data on the effect of treatment with ASV on morbidity and mortality, as well as the cost-effectiveness of this therapy, in patients with chronic HF and predominantly CSA/CSR.</AbstractText>ISRCTN19572887.</AbstractText> |
13,196 | Unique cardiac Purkinje fiber transient outward current β-subunit composition: a potential molecular link to idiopathic ventricular fibrillation. | A chromosomal haplotype producing cardiac overexpression of dipeptidyl peptidase-like protein-6 (DPP6) causes familial idiopathic ventricular fibrillation. The molecular basis of transient outward current (I(to)) in Purkinje fibers (PFs) is poorly understood. We hypothesized that DPP6 contributes to PF I(to) and that its overexpression might specifically alter PF I(to) properties and repolarization.</AbstractText>To assess the potential role of DPP6 in PF I(to).</AbstractText>Clinical data in 5 idiopathic ventricular fibrillation patients suggested arrhythmia origin in the PF-conducting system. PF and ventricular muscle I(to) had similar density, but PF I(to) differed from ventricular muscle in having tetraethylammonium sensitivity and slower recovery. DPP6 overexpression significantly increased, whereas DPP6 knockdown reduced, I(to) density and tetraethylammonium sensitivity in canine PF but not in ventricular muscle cells. The K(+)-channel interacting β-subunit K(+)-channel interacting protein type-2, essential for normal expression of I(to) in ventricular muscle, was weakly expressed in human PFs, whereas DPP6 and frequenin (neuronal calcium sensor-1) were enriched. Heterologous expression of Kv4.3 in Chinese hamster ovary cells produced small I(to); I(to) amplitude was greatly enhanced by coexpression with K(+)-channel interacting protein type-2 or DPP6. Coexpression of DPP6 with Kv4.3 and K(+)-channel interacting protein type-2 failed to alter I(to) compared with Kv4.3/K(+)-channel interacting protein type-2 alone, but DPP6 expression with Kv4.3 and neuronal calcium sensor-1 (to mimic PF I(to) composition) greatly enhanced I(to) compared with Kv4.3/neuronal calcium sensor-1 and recapitulated characteristic PF kinetic/pharmacological properties. A mathematical model of cardiac PF action potentials showed that I(to) enhancement can greatly accelerate PF repolarization.</AbstractText>These results point to a previously unknown central role of DPP6 in PF I(to), with DPP6 gain of function selectively enhancing PF current, and suggest that a DPP6-mediated PF early-repolarization syndrome might be a novel molecular paradigm for some forms of idiopathic ventricular fibrillation.</AbstractText> |
13,197 | Surgical treatment of aortoesophageal fistula induced by a foreign body in the esophagus: 40 years of experience at a single hospital. | Aortoesophageal fistula (AEF) is a rare but usually fatal complication of a foreign body in the esophagus. Little effective therapy exists to cure an AEF induced by esophageal foreign body. This report describes the authors' 40 years of experience treating patients with AEF caused by a foreign body and compares different treatments of patients and their clinical outcomes.</AbstractText>The treatments of five patients with AEF caused by esophageal foreign body impaction were recorded at Wuhan General Hospital of Guangzhou Command from 1970 to 2011. One of these five patients was managed with nonsurgical measures, whereas three were treated by surgery with cardiopulmonary bypass, and one was treated by surgery with endovascular stent-graft repair.</AbstractText>All five AEF cases were confirmed by computed tomography, esophagogastroscopy, surgical findings, or two or both. The nonsurgically treated patient died of fatal hemorrhage. Another patient died during the postoperative period because of ventricular fibrillation (he had a history of coronary heart disease before the operation), and still another patient died of fatal hemorrhage during the surgery. The remaining two patients were completely cured by surgery: the one via traditional open thoracotomy with cardiopulmonary bypass and the other by surgery with endovascular stent-graft repair.</AbstractText>The authors' experience indicates that early diagnosis and an aggressive surgical treatment without delay is the only form of effective therapy for AEF. Endovascular stent-graft repair may be a safe and feasible method for treating patients with AEF that has potential as an improved treatment option for AEF.</AbstractText> |
13,198 | Impact of pre-procedural beta blockade on inpatient mortality in patients undergoing primary percutaneous coronary intervention for ST elevation myocardial infarction. | Early use of β blockers (BBs) in acute myocardial infarction remains controversial, with some studies demonstrating benefit and others harm. The aim of this study was to assess the association between pre-percutaneous coronary intervention (PCI) BB use and in-hospital outcomes in patients who underwent primary PCI for ST-segment elevation myocardial infarction between 2007 and 2009 at institutions participating in the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC-2). Inverse propensity score weighting was used to account for the nonrandomized use of pre-PCI BBs. The cohort comprised 7,667 patients, with 4,769 (62%) receiving pre-PCI BBs. These patients were older, with higher rates of diabetes mellitus, hypertension, and previous myocardial infarction, PCI, or coronary artery bypass grafting. In adjusted models, pre-PCI BB use was associated with lower rates of intraprocedural ventricular tachycardia or ventricular fibrillation (odds ratio [OR] 0.58, p <0.01) and lower in-hospital mortality (OR 0.65, p = 0.022), with increases in rates of emergent coronary artery bypass grafting (OR 1.56, p <0.01) and repeat PCI (OR 1.93, p <0.01). There were no significant increases in rates of cardiogenic shock and congestive heart failure. In conclusion, pre-PCI BB use in this population was associated with decreased arrhythmia and mortality, without increasing rates of cardiogenic shock and heart failure but with higher rates of repeat PCI and emergent coronary artery bypass grafting, suggesting that there may yet remain a role for early BB use in pre-PCI patients with ST-segment elevation myocardial infarctions. |
13,199 | Ambulatory hypertensive patients treated by cardiologists in France. | While general practitioners treat most hypertensive patients in France, hypertension is the most frequent pathology treated by cardiologists, raising questions about the differing profiles of such patients. Poor control of hypertension is commonly reported, and yet has not improved over time. Better understanding of the determinants of control, at both patient and physician levels, is necessary to implement improvements in practice.</AbstractText>To describe the hypertensive population treated by independent cardiologists in France and to assess the prevalence and determinants of not-at-goal blood pressure (BP), at patient and physician levels.</AbstractText>The COLHYGE study was an observational cross-sectional epidemiological study. Consecutive patients (n=5798) were selected by 371 independent cardiologists in France. Data concerning patients and physicians were assessed.</AbstractText>Our study population had an elevated cardiovascular risk, high prevalence of patients in secondary cardiovascular prevention (27.5%) and a high proportion of diabetic patients (22.8%). Only 20.8% of the population presented controlled BP. At the patient level, the following variables were negatively and independently associated with BP control: age; body mass index; heart rate; recently diagnosed hypertension; left ventricular hypertrophy; patient belief that they are taking too many pills; prescription of calcium channel blockers, lipid-lowering agents and antiplatelet agents. Presence of atrial fibrillation and the prescription of renin-angiotensin system blockers and fixed combinations correlated positively with BP control. At the physician level, working in big cities and having an exclusive independent practice were associated with good BP control. There was high heterogeneity among physicians in terms of BP control, independent of the patient and physician characteristics assessed.</AbstractText>The COLHYGE study has confirmed a high cardiovascular risk and poor BP control among hypertensive patients treated by cardiologists in France. Strategies aiming to control BP should focus on both patient and physician characteristics.</AbstractText>Copyright © 2012 Elsevier Masson SAS. All rights reserved.</CopyrightInformation> |
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