[Idiopathic premature ventricular complexes originating from the ventricular outflow tract: evaluation, prognosis and management]

Idiopathic premature ventricular complexes originating from the ventricular outflow tract: evaluation, prognosis and management The prognosis of ventricular premature complexes (VPC) in the absence of heart disease is considered benign. VPC usually originate from the right or, less commonly, left ventricular outflow tract. QRS complexes therefore usually assume a left bundle branch block and inferior axis morphology. These VPC, particularly if very frequent (> 20,000 per day), may adversely affect left ventricular function and their suppression can restore normal function. Moreover, there is a clinical overlap with arrhythmogenic right ventricular dysplasia and this diagnosis should be considered when facing a left bundle branch block shaped VPC. However, the prognosis of outflow tract VPC is good for appropriately selected patients with normal left ventricular function, absence of syncope or ventricular tachycardia, and no evidence of cardiac disease.

Substitution of (R,S)-methadone by (R)-methadone: Impact on QTc interval

BACKGROUND

Methadone is administered as a chiral mixture of (R,S)-methadone. The opioid effect is mainly mediated by (R)-methadone, whereas (S)-methadone blocks the human ether-à-go-go-related gene (hERG) voltage-gated potassium channel more potently, which can cause drug-induced long QT syndrome, leading to potentially lethal ventricular tachyarrhythmias.

METHODS

To investigate whether substitution of (R,S)-methadone by (R)-methadone could reduce the corrected QT (QTc) interval, (R,S)-methadone was replaced by (R)-methadone (half-dose) in 39 opioid-dependent patients receiving maintenance treatment for 14 days. (R)-methadone was then replaced by the initial dose of (R,S)-methadone for 14 days (n = 29). Trough (R)-methadone and (S)-methadone plasma levels and electrocardiogram measurements were taken.

RESULTS

The Fridericia-corrected QT (QTcF) interval decreased when (R,S)-methadone was replaced by a half-dose of (R)-methadone; the median (interquartile range [IQR]) values were 423 (398-440) milliseconds (ms) and 412 (395-431) ms (P = .06) at days 0 and 14, respectively. Using a univariate mixed-effect linear model, the QTcF value decreased by a mean of -3.9 ms (95% confidence interval [CI], -7.7 to -0.2) per week (P = .04). The QTcF value increased when (R)-methadone was replaced by the initial dose of (R,S)-methadone for 14 days; median (IQR) values were 424 (398-436) ms and 424 (412-443) ms (P = .01) at days 14 and 28, respectively. The univariate model showed that the QTcF value increased by a mean of 4.7 ms (95% CI, 1.3-8.1) per week (P = .006).

CONCLUSIONS

Substitution of (R,S)-methadone by (R)-methadone reduces the QTc interval value. A safer cardiac profile of (R)-methadone is in agreement with previous in vitro and pharmacogenetic studies. If the present results are confirmed by larger studies, (R)-methadone should be prescribed instead of (R,S)-methadone to reduce the risk of cardiac toxic effects and sudden death.

Stepwise evaluation of syncope: A prospective population-based controlled study

BACKGROUND

Evaluation of syncope remains often unstructured. The aim of the study was to assess the effectiveness of a standardized protocol designed to improve the diagnosis of syncope.

METHODS

Consecutive patients with syncope presenting to the emergency departments of two primary and tertiary care hospitals over a period of 18 months underwent a two-phase evaluation including: 1) noninvasive assessment (phase I); and 2) specialized tests (phase II), if syncope remained unexplained after phase I. During phase II, the evaluation strategy was alternately left to physicians in charge of patients (control), or guided by a standardized protocol relying on cardiac status and frequency of events (intervention). The primary outcomes were the diagnostic yield of each phase, and the impact of the intervention (phase II) measured by multivariable analysis.

RESULTS

Among 1725 patients with syncope, 1579 (92%) entered phase I which permitted to establish a diagnosis in 1061 (67%) of them, including mainly reflex causes and orthostatic hypotension. Five-hundred-eighteen patients (33%) were considered as having unexplained syncope and 363 (70%) entered phase II. A cause for syncope was found in 67 (38%) of 174 patients during intervention periods, compared to 18 (9%) of 189 during control (p<0.001). Compared to control periods, intervention permitted diagnosing more cardiac (8%, vs 3%, p=0.04) and reflex syncope (25% vs 6%, p<0.001), and increased the odds of identifying a cause for syncope by a factor of 4.5 (95% CI: 2.6-8.7, p<0.001). Overall, adding the diagnostic yield obtained during phase I and phase II (intervention periods) permitted establishing the cause of syncope in 76% of patients.

CONCLUSION

Application of a standardized diagnostic protocol in patients with syncope improved the likelihood of identifying a cause for this symptom. Future trials should assess the efficacy of diagnosis-specific therapy.

[Past, present and future of percutaneous catheter ablation technologies for cardiac arrhythmias]

Drug therapy treatment of cardiac arrhythmias has been disappointing, while percutaneous catheter ablation, efficient and at low risk, has become the first line therapy of the majority of rhythm disturbances, in only two decades. The ultimate challenge, which is atrial fibrillation ablation, is on the way to be successfully solved. This is mainly due to: innovative ablational energy sources; 3D virtual electro-anatomical reconstructions of heart cavities, to map and understand complex arrhythmias' circuits; revolutionary magnetic navigation systems that permit the target positioning of the catheters in the most inaccessible places, even though the operator works at a command board placed away from the patient.

Stereoselective Block of hERG Channel by (S)-Methadone and QT Interval Prolongation in CYP2B6 Slow Metabolizers

Methadone inhibits the cardiac potassium channel hERG and can cause a prolonged QT interval. Methadone is chiral but its therapeutic activity is mainly due to (R)-methadone. Whole-cell patch-clamp experiments using cells expressing hERG showed that (S)-methadone blocked the hERG current 3.5-fold more potently than (R)-methadone (IC50s (half-maximal inhibitory concentrations) at 37 degrees C: 2 and 7 microM). As CYP2B6 slow metabolizer (SM) status results in a reduced ability to metabolize (S)-methadone, electrocardiograms, CYP2B6 genotypes, and (R)- and (S)-methadone plasma concentrations were obtained for 179 patients receiving (R,S)-methadone. The mean heart-rate-corrected QT (QTc) was higher in CYP2B6 SMs (*6/*6 genotype; 439+/-25 ms; n=11) than in extensive metabolizers (non *6/*6; 421+/-25 ms; n=168; P=0.017). CYP2B6 SM status was associated with an increased risk of prolonged QTc (odds ratio=4.5, 95% confidence interval=1.2-17.7; P=0.03). This study reports the first genetic factor implicated in methadone metabolism that may increase the risk of cardiac arrhythmias and sudden death. This risk could be reduced by the administration of (R)-methadone.

Brugada syndrome and fever: genetic and molecular characterization of patients carrying SCN5A mutations

OBJECTIVE

Brugada syndrome (BrS) is characterized by ventricular tachyarrhythmias leading to sudden cardiac death and is caused, in part, by mutations in the SCN5A gene encoding the sodium channel Na(v)1.5. Fever can trigger or exacerbate the clinical manifestations of BrS. The aim of this work was to characterize the genetic and molecular determinants of fever-dependent BrS.

METHODS

Four male patients with typical BrS ST-segment elevation in V1-V3 or ventricular arrhythmias during fever were screened for mutations in the SCN5A gene. Wild-type (WT) and mutant Na(v)1.5 channels were expressed in HEK293 cells. The sodium currents (I(Na)) were analysed using the whole-cell patch clamp technique at various temperatures. Protein expression of WT and mutant channels was studied by Western blot experiments.

RESULTS

Two mutations in SCN5A, L325R and R535X, were identified. Expression of the two mutant Na(v)1.5 channels in HEK293 cells revealed in each case a severe loss-of-function. Upon the increase of temperature up to 42 degrees C, we observed a pronounced acceleration of Na(v)1.5 activation and fast inactivation kinetics. Cardiac action potential modelling experiments suggest that in patients with reduced I(Na), fever could prematurely shorten the action potential by virtue of its effect on WT channels. Further experiments revealed that L325R channels are likely misfolded, since their function could be partially rescued by mexiletine or curcumin. In co-expression experiments, L325R channels interfered with the proper function of WT channels, suggesting that a dominant negative phenomenon may underlie BrS triggered by fever.

CONCLUSIONS

The genetic background of BrS patients sensitive to fever is heterogeneous. Our experimental data suggest that the clinical manifestations of fever-exacerbated BrS may not be mutation specific.

[What do we actually know about out-of-hospital cardiac arrest?]

Each year at least 300,000 people in the United States and 8000 to 10,000 people in Switzerland suffer from out-of-hospital cardiac arrest, mostly due to ventricular fibrillation. Early defibrillation provides definitive treatment for most of cardiac arrest victims. Semi-automatic external defibrillators are easy to handle devices allowing to deliver an early electric shock and can be successfully used by lay people following minimal training. Newer strategies of defibrillation designed to respond faster to out-of-hospital cardiac arrest, including public access defibrillation, as well as improvement of each link of the chain of survival appears as the best strategy for the management of out-of-hospital cardiac arrest.

Molecular and clinical determinants of drug-induced long QT syndrome: an iatrogenic channelopathy

More than 70 drugs present on the Swiss market can cause drug-induced long QT syndrome (LQTS), which is associated with torsades de pointes (TdP) arrhythmias, potentially leading to sudden cardiac death. Basic and clinical investigations performed during the last decade have helped a better understanding of the mechanisms and risk factors of this serious public health problem. In their vast majority, QT interval prolonging drugs block the human ERG (hERG) channel involved in the repolarisation phase of the cardiac action potential, and thus lengthen the QT interval. Beside the well-known QT interval prolonging action of class IA, IC and III anti-arrhythmic drugs, many antibiotics, neurotropic, antifungal, and antimalarial drugs are also able to cause drug-induced LQTS. Reviewing the literature indicates that the risk of QT interval prolongation and TdP is increased in females, in patients with organic heart diseases and hypokalaemia. Furthermore in a few cases, genetic factors have also been reported. However thus far, no genetic test is available to detect at-risk patients, and in consequence, drug prescribers are still relying only on the clinical history and findings to perform an evaluation of the risk. Treatment of drug-induced LQTS and TdP includes identifying and withdrawing the culprit drug(s), infusing magnesium and, in resistant cases acceleration of the heart rate. In this review article we provide a list of QT interval prolonging drugs adapted to the pharmaceuticals found on the Swiss market that can be used as a check-list for drug prescribers and at-risk patients.

Molecular and clinical determinants of drug-induced long QT syndrome: an iatrogenic channelopathy

More than 70 drugs present on the Swiss market can cause drug-induced long QT syndrome (LQTS), which is associated with torsades de pointes (TdP) arrhythmias, potentially leading to sudden cardiac death. Basic and clinical investigations performed during the last decade have helped a better understanding of the mechanisms and risk factors of this serious public health problem. In their vast majority, QT interval prolonging drugs block the human ERG (hERG) channel involved in the repolarisation phase of the cardiac action potential, and thus lengthen the QT interval. Beside the well-known QT interval prolonging action of class IA, IC and III anti-arrhythmic drugs, many antibiotics, neurotropic, antifungal, and antimalarial drugs are also able to cause drug-induced LQTS. Reviewing the literature indicates that the risk of QT interval prolongation and TdP is increased in females, in patients with organic heart diseases and hypokalaemia. Furthermore in a few cases, genetic factors have also been reported. However thus far, no genetic test is available to detect at-risk patients, and in consequence, drug prescribers are still relying only on the clinical history and findings to perform an evaluation of the risk. Treatment of drug-induced LQTS and TdP includes identifying and withdrawing the culprit drug(s), infusing magnesium and, in resistant cases acceleration of the heart rate. In this review article we provide a list of QT interval prolonging drugs adapted to the pharmaceuticals found on the Swiss market that can be used as a check-list for drug prescribers and at-risk patients.

Guidelines for the clinical management of atrial fibrillation: a practical perspective

PURPOSE

Since the management of atrial fibrillation may be difficult in the individual patient, our purpose was to develop simple clinical recommendations to help the general internist manage this common clinical problem.

DATA SOURCES

Systematic review of the literature with evaluation of data-related evidence and framing of graded recommendations.

DATA SYNTHESIS

Atrial fibrillation affects some 1% of the population in Western countries and is linked to a significant increase in morbidity and mortality. The management of atrial fibrillation requires individualised evaluation of the risks and benefits of therapeutic modalities, relying whenever possible on simple and validated tools. The two main points requiring a decision in clinical management are 1) whether or not to implement thromboembolic prevention therapy, and 2) whether preference should be given to a "rate control" or "rhythm control" strategy. Thromboembolic prophylaxis should be prescribed after individualised risk assessment: for patients at risk, oral anticoagulation with warfarin decreases the rate of embolic complications by 60% and aspirin by 20%, at the expense of an increased incidence of haemorrhagic complications. "Rate control" and "rhythm control" strategies are probably equivalent, and the choice should also be made on an individualised basis. To assist the physician in making his choices for the care of an atrial fibrillation patient we propose specific tables and algorithms, with graded recommendations.

CONCLUSIONS

On the evidence of data from the literature we propose simple algorithms and tables for the clinical management of atrial fibrillation in the individual patient.

Guidelines for the clinical management of atrial fibrillation: a practical perspective

PURPOSE

Since the management of atrial fibrillation may be difficult in the individual patient, our purpose was to develop simple clinical recommendations to help the general internist manage this common clinical problem.

DATA SOURCES

Systematic review of the literature with evaluation of data-related evidence and framing of graded recommendations.

DATA SYNTHESIS

Atrial fibrillation affects some 1% of the population in Western countries and is linked to a significant increase in morbidity and mortality. The management of atrial fibrillation requires individualised evaluation of the risks and benefits of therapeutic modalities, relying whenever possible on simple and validated tools. The two main points requiring a decision in clinical management are 1) whether or not to implement thromboembolic prevention therapy, and 2) whether preference should be given to a "rate control" or "rhythm control" strategy. Thromboembolic prophylaxis should be prescribed after individualised risk assessment: for patients at risk, oral anticoagulation with warfarin decreases the rate of embolic complications by 60% and aspirin by 20%, at the expense of an increased incidence of haemorrhagic complications. "Rate control" and "rhythm control" strategies are probably equivalent, and the choice should also be made on an individualised basis. To assist the physician in making his choices for the care of an atrial fibrillation patient we propose specific tables and algorithms, with graded recommendations.

CONCLUSIONS

On the evidence of data from the literature we propose simple algorithms and tables for the clinical management of atrial fibrillation in the individual patient.

Development of a cytogenetic map for the Chinese raccoon dog (Nyctereutes procyonoides procyonoides) and the arctic fox (Alopex lagopus) genomes, using canine-derived microsatellite probes

New chromosomal assignments of canine-derived cosmid clones containing microsatellites to the Chinese raccoon dog and arctic fox genomes are presented in the study. The localizations are in agreement with data obtained from comparative chromosome painting experiments between the dog and arctic fox genomes. However, paracentric inversions have been detected by comparing the loci order in canid karyotypes. The number of physically mapped loci increased to thirty-five both in the Chinese raccoon dog and in the arctic fox. Furthermore, the present status of the cytogenetic map of the Chinese raccoon dog and arctic fox is presented in this study.

Differentiation of the Italian wolf and the domestic dog based on microsatellite analysis

The Italian wolf is in the process of regaining the Alpine region which comes into conflict with the extensive sheep keeping practiced in Switzerland during the summer. As in Switzerland, the wolf is a protected species, the government reimburses losses caused by wolves. Therefore we wanted to know whether the Italian wolf could be distinguished from the domestic dog by microsatellite analysis if DNA samples of the predators could be secured. The evaluation of combined genotypes for the microsatellites CanBern6, CPH4, CPH7, CPH9, CPH12, CPH22 and ZuBeCa1 made it possible to identify an individual as either a domestic dog or an Italian wolf. The assignment of an individual to either one of the two populations is based on the logarithm of the likelihood ratio of an individual being an Italian wolf rather than a domestic dog, given a specific combined genotype. The distribution of the Italian wolf combined genotypes (n=42) is clearly distinct from the distribution of the domestic dog combined genotypes (n=90). The likelihood ratio for the "worst" Italian wolf combined genotype was 2.3 E+5 and for the "worst" domestic dog combined genotype was 3.8 E-5.

Canine-derived cosmid probes containing microsatellites can be used in physical mapping of Arctic fox (Alopex lagopus) and Chinese raccoon dog (Nyctereutes procyonoides procyonoides) genomes

Rapid development of the canine marker genome map facilitates genome mapping of other Canidae species. In this study we present chromosomal localization of 18 canine-derived cosmid probes containing microsatellites in the arctic fox (Alopex lagopus) and Chinese raccoon dog (Nyctereutes procyonoides procyonoides) genomes by the use of fluorescence in situ hybridization (FISH). The chromosome localizations in the arctic fox are in general agreement with data obtained from comparative genome maps of the dog and the fox. However, our studies showed that the order of the loci on some chromosomes was changed during karyotype evolution. Therefore, we suggest that small intrachromosomal rearrangements took place.