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Steinberg BA. Atrial fibrillation and long-term cardiovascular outcomes: bringing the whole picture into focus. Eur Heart J 2024; 45:2130-2132. [PMID: 38848112 DOI: 10.1093/eurheartj/ehae347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/09/2024] Open
Affiliation(s)
- Benjamin A Steinberg
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, 30 North Mario Capecchi Drive, Salt Lake City, UT 84112, USA
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2
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Bisht DS. Premature atrial contraction induced cardiomyopathy: A case report. Indian Pacing Electrophysiol J 2023; 23:221-225. [PMID: 37804947 PMCID: PMC10685095 DOI: 10.1016/j.ipej.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 08/18/2023] [Accepted: 10/04/2023] [Indexed: 10/09/2023] Open
Abstract
This case report describes the successful management of a 45-year-old female patient with incessant premature atrial complexes (PACs) leading to left ventricular dysfunction. Despite initial treatment with beta-blockers, the patient's PACs persisted, prompting catheter ablation. Mapping in the left atrium identified the site of earliest atrial activation near the right superior pulmonary vein, and radiofrequency energy successfully terminated the PACs. Follow-up assessments showed the patient remained asymptomatic, with normalized left ventricular function. This case highlights the efficacy of catheter ablation in resolving PAC-induced cardiomyopathy and emphasizes the need for further research in this area.
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Echocardiographic changes and heart failure hospitalizations following rhythm control for arrhythmia-induced cardiomyopathy: results from a multicenter, retrospective study. J Interv Card Electrophysiol 2023; 66:455-462. [PMID: 36008502 DOI: 10.1007/s10840-022-01354-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 08/16/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND The incidence and prevalence of arrhythmia-induced cardiomyopathy (AIC) are unclear but likely underrecognized. LV dysfunction is common among patients with atrial fibrillation (AF), atrial flutter (AFL), and frequent premature ventricular contractions (PVC). The hallmark of AIC is the improvement of left ventricular ejection fraction (LVEF) following arrhythmia treatment. Changes in echocardiographic parameters and their effect on outcomes after rhythm control for AIC are not well understood. We aimed to study echocardiographic parameters and outcomes following rhythm control for AIC. METHODS A multicenter, retrospective study was conducted at 4 different medical centers involving patients with AIC. Clinical, echocardiographic, and outcome (mortality and heart failure hospitalizations [HFH]) parameters were extracted from the medical record. RESULTS Two hundred fifty-five patients (age 66 ± 11 years, 73% male) with AIC caused by AF (51%), atrial tachycardia/AFL (20%), and PVCs (29%) were included and followed for a median period of 6 months after successful rhythm control. Significant improvements in left ventricular (LV) ejection fraction (P < 0.0001), LV end-systolic volume (ml) (90 ± 48 to 58 ± 30; P < 0.0001), LV internal diameter end diastole (cm) (5.5 ± 0.78 to 5.3 ± 0.64; P = 0.0001) and end systole (4.7 ± 0.95 to 4.3 ± 1.02; P < 0.0001), right atrial pressure (mmHg) (11.3 ± 5.0 to 7.4 ± 3.2; P = 0.0001), and right ventricular function (n (%)) (42 (44) to 9 (11); P < 0.0001) were noted following arrhythmia treatment. No deaths occurred during follow-up. HFH occurred in 7 patients. Arrhythmia recurrence rate was 50.5%. Neither echocardiographic parameters nor recurrence of arrhythmia correlated with HFH. CONCLUSION Arrhythmia treatment significantly improved echocardiographic LV dimensions, LVEF, and RAP in this multicenter AIC cohort, underscoring the need for early recognition and aggressive rhythm control in suspected AIC patients. The event rate was too low to assess for outcome predictors.
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Hamed M, Palumbo S, Mendha T. Severe Cardiovascular Effects of Prolonged Untreated Hyperthyroidism Manifesting As Thyroid Storm. Cureus 2022; 14:e26289. [PMID: 35898385 PMCID: PMC9308973 DOI: 10.7759/cureus.26289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 06/23/2022] [Indexed: 11/17/2022] Open
Abstract
A thyroid storm is a rare but life-threatening manifestation of thyrotoxicosis. It still remains a diagnostic challenge as there are no specific laboratory investigations or universally accepted criteria for diagnosing thyroid storms. Diagnosis is mainly based on clinical findings, evidence of hyperthyroidism, and life-threatening symptoms. A thyroid storm has a high risk of mortality mostly due to multi-organ failure and heart failure. Cardiovascular manifestations are the most common presentation of hyperthyroidism; cardiac involvement also has the potential to be the most serious complication. Management of cardiovascular manifestations should be managed aggressively to prevent long-term myocardial damage. A high index of suspicion should be maintained in young adults presenting with heart failure and arrhythmia. We present a case of potentially life-threatening cardiovascular effects of thyroid storm and management in the ICU.
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Manolis AS, Manolis TA, Manolis AA, Melita H. Atrial fibrillation-induced tachycardiomyopathy and heart failure: an underappreciated and elusive condition. Heart Fail Rev 2022; 27:2119-2135. [PMID: 35318562 DOI: 10.1007/s10741-022-10221-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/02/2022] [Indexed: 11/04/2022]
Abstract
Many patients with persistent, chronic, or frequently recurring paroxysmal atrial fibrillation (AF) may develop a tachycardiomyopathy (TCM) with left ventricular (LV) dysfunction and heart failure (HF), which is reversible upon restoration and maintenance of sinus rhythm, when feasible, or via better and tighter ventricular rate (VR) control. Mechanisms involved in producing this leading cause of TCM (AF-TCM) include loss of atrial contraction, irregular heart rate, fast VR, neurohumoral activation, and structural myocardial changes. The most important of all mechanisms relates to optimal VR control, which seems to be an elusive target. Uncontrolled AF may also worsen preexisting LV dysfunction and exacerbate HF symptoms. Data, albeit less robust, also point to deleterious effects of slow VRs on LV function. Thus, a J-shaped relationship between VR and clinical outcome has been suggested, with the optimal VR control hovering at ~ 65 bpm, ranging between 60 and 80 bpm; VRs above and below this range may confer higher morbidity and mortality rates. A convergence of recent guidelines is noted towards a stricter rather than a more lenient VR control with target heart rate < 80 bpm at rest and < 110 bpm during moderate exercise which seems to prevent TCM or improve LV function and exercise capacity and relieve TCM-related symptoms and signs. Of course, restoring and maintaining sinus rhythm is always a most desirable target, when feasible, either with drugs or more likely with ablation. All these issues are herein reviewed, current guidelines are discussed and relevant data are tabulated and pictorially illustrated.
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Affiliation(s)
- Antonis S Manolis
- First Department of Cardiology, Athens University School of Medicine, Athens, Greece.
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Epicardial Adipose Tissue Thickness is Higher in Right Ventricular Outflow Tract Tachycardia. JOURNAL OF CARDIOVASCULAR EMERGENCIES 2021. [DOI: 10.2478/jce-2021-0019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
ABSTRACT
Introduction: Idiopathic ventricular arrhythmias, which occur in the absence of structural heart disease, are commonly originating from the outflow tract, and 80% of the them arise from the right ventricle. Epicardial adipose tissue (EAT), which originates from the splanchnopleuric mesoderm, has been shown to be an important source of inflammatory mediators and plays an important role in cardiac autonomic function by epicardial ganglionated plexuses. EAT may potentially contribute to the pathophysiology of idiopathic right ventricular outflow tract (RVOT) tachycardia by different mechanisms. In this study, we aimed to investigate the relationship between EAT thickness and RVOT tachycardia. Methods: This study included 55 patients (32 male, 23 female) with RVOT tachycardia and 60 control subjects (38 male, 22 female). Patients who had more than three consecutive ventricular beats over 100 bpm with specific morphological features on the electrocardiogram (ECG) were diagnosed with RVOT tachycardia. EAT thickness was measured by transthoracic echocardiography. Results: EAT thickness was significantly higher in the RVOT tachycardia group (p <0.05). Ejection fraction (EF), and the thickness of the posterior wall of the left ventricle and of the interventricular septum were significantly lower, and left ventricular end-diastolic diameter, left ventricular end-systolic diameter, and left atrial diameter were significantly higher in patients who had RVOT tachycardia compared to normal subjects (p <0.05). Conclusion: Patients who were diagnosed with RVOT tachycardia had increased EAT thickness compared to normal subjects. The underlying mechanism of the condition could be mechanical, metabolic, infiltrative, or autonomic effects of the EAT.
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Taylor ME, McDiarmid AK, Matthews IG, Kakarla J, McComb JM, Parry G, Lord SW. A retrospective evaluation of catheter ablation in atrial flutter post cardiac transplantation. Clin Transplant 2021; 35:e14429. [PMID: 34265128 DOI: 10.1111/ctr.14429] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 06/30/2021] [Accepted: 07/12/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Atrial flutter is the most common arrhythmia post cardiac transplantation. Observational studies in the non-transplant population have shown prognostic benefit with catheter ablation; however, there are no data in the heart transplant population. OBJECTIVES This study evaluated the experience of catheter ablation in atrial flutter post cardiac transplantation. METHODS A retrospective review of experience of late onset atrial flutter at the Freeman Hospital, Newcastle-upon-Tyne, UK, between 1985 and January 2020. RESULTS Sixty eight of the 722 patients who survived 6 months post cardiac transplantation developed late atrial flutter giving an incidence of 9.4%. Thirty-two patients were managed with ablation with treatment largely determined by time of flutter onset. Kaplan Meier estimates for arrhythmia free survival post first ablation for organized atrial arrhythmias was 83.3% at 1 year. Kaplan-Meier estimates for median survival post onset of atrial arrhythmias treated with ablation was 11.34 years (95% CI 8.00-14.57), compared to 5.79 years in patients managed medically (95%CI 2.26-9.32) (P = .026). CONCLUSIONS Atrial flutter is an important late complication of cardiac transplantation. Patients treated with ablation in the modern era had increased survival compared to a historical cohort.
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Affiliation(s)
- Mark E Taylor
- Department of Cardiology, Freeman Hospital, Newcastle-upon-Tyne, UK
| | - Adam K McDiarmid
- Department of Cardiology, Freeman Hospital, Newcastle-upon-Tyne, UK
| | - Iain G Matthews
- Department of Cardiology, Northumbria Healthcare, Wansbeck Hospital, Woodhorn Lane, Ashington, UK
| | - Jayant Kakarla
- Department of Cardiology, Freeman Hospital, Newcastle-upon-Tyne, UK
| | - Janet M McComb
- Department of Cardiology, Freeman Hospital, Newcastle-upon-Tyne, UK
| | - Gareth Parry
- Institute of Transplantation, Freeman Hospital, Newcastle-upon-Tyne, UK
| | - Stephen W Lord
- Department of Cardiology, Freeman Hospital, Newcastle-upon-Tyne, UK
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Yoshida Y, Yamane T, Nakahara S, Kobori A, Sohara H, Aonuma K, Satake S. Efficacy and Safety of SATAKE HotBalloon ® Catheter for Treatment of Paroxysmal Atrial Fibrillation - A Post-Marketing Surveillance Study. Circ J 2021; 85:1314-1320. [PMID: 33883380 DOI: 10.1253/circj.cj-20-0883] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND SATAKE HotBalloon®catheter (HBC) is a radiofrequency balloon catheter for the treatment of atrial fibrillation (AF), and was approved for use in Japan to treat drug-resistant paroxysmal AF in 2015. Post-marketing surveillance study was conducted by Toray Industries, Inc. to evaluate the efficacy and safety of HBC treatment in patients with paroxysmal AF in a real-world setting. This study is the first nation-wide survey of HBC treatment for paroxysmal AF in clinical practice in Japan.Methods and Results:This was a single-arm, multicenter observational study with an observation period of 48 weeks after ablation. Pulmonary vein isolation and AF non-recurrence rates were evaluated and adverse events (AEs) were observed at 46 sites in Japan. An AF event was defined as recurrence of AF or re-ablation from 12 to 48 weeks after ablation. The success rate of pulmonary vein isolation was 99.0% (486/491) for patients with AF. The cumulative AF non-recurrence rate was 94.1% at 24 weeks and 87.8% at 48 weeks. AEs were found to occur 21.5% (114/530), and ablation-related AEs were found to occur 2.6% (14/530) during the study period, with the most common being pericardial effusion (0.8%, 4/530). CONCLUSIONS This study demonstrates the efficacy and safety of HBC ablation in Japanese patients with recurrent symptomatic paroxysmal AF refractory to antiarrhythmic therapy.
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Galvão RDC, Pucci JPV, Vieira OG. Atypical location of Coumel Tachycardia in Adult: Case Report. JOURNAL OF CARDIAC ARRHYTHMIAS 2020. [DOI: 10.24207/jca.v33i3.3398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Coumel Tachycardia or Incessant Junctional Reentrant (IJRT) generally affects the infant-juvenile population and is characterized by tachycardia due to atrioventricular reentry (AV) mediated by an exclusive, slow, decremental retrograde conduction pathway mostly located in the posterosseptal region of the tricuspid ring. Case report: The present study reported the case of an adult, 49 years old, with IJRT of atypical location. The patient reported feeling palpitations for 5 years with worsening in the last 6 months. After one of his seizures, an electrocardiogram (ECG) documented tachycardia due to AV reentry with a long RP ‘interval. Subjected to an electrophysiological study, an accessory pathway of exclusive retrograde conduction with decreasing characteristics was observed, located in the right mid-septal region. There was easy induction of IJRT, remaining sustained throughout the study. A radiofrequency ablation was performed in the mid-septal D region with interruption of tachycardia, with no more atrioventricular retrograde conduction, the procedure ended without complications. Discussion: Interestingly, the case described differs both in terms of the age range of the most frequent involvement of the IJRT (children and young people), as well as the most common location of the accessory pathway (posterior and postero-septal region of the tricuspid ring). Ablation proved to be effective in this case and is the treatment of choice for IJRT despite the anomalous location of the accessory pathway (Middle-septal D: described in bibliographic reviews in only 7% of IJRT cases) and a potentially dangerous region due to proximity to the trunk of the His beam.
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Silva KAS, Emter CA. Large Animal Models of Heart Failure: A Translational Bridge to Clinical Success. JACC Basic Transl Sci 2020; 5:840-856. [PMID: 32875172 PMCID: PMC7452204 DOI: 10.1016/j.jacbts.2020.04.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 04/10/2020] [Indexed: 12/12/2022]
Abstract
Preclinical large animal models play a critical and expanding role in translating basic science findings to the development and clinical approval of novel cardiovascular therapeutics. This state-of-the-art review outlines existing methodologies and physiological phenotypes of several HF models developed in large animals. A comprehensive list of porcine, ovine, and canine models of disease are presented, and the translational importance of these studies to clinical success is highlighted through a brief overview of recent devices approved by the FDA alongside associated clinical trials and preclinical animal reports. Increasing the use of large animal models of HF holds significant potential for identifying new mechanisms underlying this disease and providing valuable information regarding the safety and efficacy of new therapies, thus, improving physiological and economical translation of animal research to the successful treatment of human HF.
Preclinical large animal models of heart failure (HF) play a critical and expanding role in translating basic science findings to the development and clinical approval of novel therapeutics and devices. The complex combination of cardiovascular events and risk factors leading to HF has proved challenging for the development of new treatments for these patients. This state-of-the-art review presents historical and recent studies in porcine, ovine, and canine models of HF and outlines existing methodologies and physiological phenotypes. The translational importance of large animal studies to clinical success is also highlighted with an overview of recent devices approved by the Food and Drug Administration, together with preclinical HF animal studies used to aid both development and safety and/or efficacy testing. Increasing the use of large animal models of HF holds significant potential for identifying the novel mechanisms underlying the clinical condition and to improving physiological and economical translation of animal research to successfully treat human HF.
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Key Words
- AF, atrial fibrillation
- ECM, extracellular matrix
- EDP, end-diastolic pressure
- EF, ejection fraction
- FDA, Food and Drug Administration
- HF, heart failure
- HFpEF
- HFpEF, heart failure with preserved ejection fraction
- HFrEF
- HFrEF, heart failure with reduced ejection fraction
- I/R, ischemia/reperfusion
- IABP, intra-aortic balloon pump
- LAD, left anterior descending
- LCx, left circumflex
- LV, left ventricular
- MI, myocardial infarction
- PCI, percutaneous coronary intervention
- RV, right ventricular
- heart failure
- large animal model
- preclinical
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Affiliation(s)
| | - Craig A Emter
- Department of Biomedical Sciences, University of Missouri-Columbia, Columbia, Missouri
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Liuba I, Schaller RD, Frankel DS. Premature atrial complex-induced cardiomyopathy: Case report and literature review. HeartRhythm Case Rep 2020; 6:191-193. [PMID: 32322494 PMCID: PMC7156972 DOI: 10.1016/j.hrcr.2019.12.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Ioan Liuba
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert D Schaller
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David S Frankel
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Gunasekaran S, Lee DC, Knight BP, Fan L, Collins JD, Chow K, Carr JC, Passman R, Kim D. Left Ventricular Extracellular Volume Expansion Is Not Associated with Atrial Fibrillation or Atrial Fibrillation-mediated Left Ventricular Systolic Dysfunction. Radiol Cardiothorac Imaging 2020; 2:e190096. [PMID: 32420547 PMCID: PMC7208181 DOI: 10.1148/ryct.2020190096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 09/26/2019] [Accepted: 10/08/2019] [Indexed: 05/02/2023]
Abstract
PURPOSE To determine whether left ventricular (LV) extracellular volume (ECV) expansion is associated with atrial fibrillation (AF) or AF-mediated LV systolic dysfunction (LVSD) while minimizing the influence of biologic and imaging methodologic confounders. MATERIALS AND METHODS This study examined the prevalence of LV ECV expansion in 137 patients with AF (mean age, 62 years ± 11 [standard deviation]; 92 male patients and 45 female patients; 83 paroxysmal and 54 persistent) who underwent preablation cardiovascular MRI. Biologic confounders were minimized by measuring the ECV fraction and excluding patients with severe LV hypertrophy, defined as wall thickness greater than 1.5 cm. Imaging confounders were minimized by using an arrhythmia-insensitive-rapid (AIR) cardiac T1 mapping pulse sequence. Other cardiac functional parameters, including LV ejection fraction (LVEF) and left atrial end-diastolic volume indexed to body surface area, were assessed using cine cardiovascular MRI. A substudy was conducted in 32 patients with no AF (mean age, 54 years ± 16) in sinus rhythm to establish control values and convert these values between the AIR sequence and literature-based modified Look-Locker inversion recovery (MOLLI) values. RESULTS The mean ECV was not significantly different (P > .05) between patients with AF with a normal LVEF (24.5% ± 2.8; n = 107), patients with AF with LVSD (24.5% ± 2.5; n = 30), and patients with no AF (24.4% ± 3.8; n = 32), but there was a significant interaction between ECV and CHA2DS2-VASc score (P = .045). Compared with the literature data obtained from healthy control patients scanned using MOLLI, 99.3% of patients with AF had ECV below the fibrosis cutoff point (32.8% when converted from MOLLI T1 mapping to AIR T1 mapping), including a subset of patients with AF (n = 28) with low CHA2DS2-VASc score (0/1 for men/women). CONCLUSION Study results suggest that an LV ECV expansion is not associated with AF or AF-mediated LVSD. Supplemental material is available for this article. © RSNA, 2020See also the commentary by Stillman in this issue.
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Ro WB, Kang MH, Park HM. Serial evaluation of cardiac biomarker NT-proBNP with speckle tracking echocardiography in a 6-year-old Golden Retriever dog with subaortic stenosis and dilated cardiomyopathy. Vet Q 2020; 40:77-82. [PMID: 32036775 PMCID: PMC7054909 DOI: 10.1080/01652176.2020.1727992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Woong-Bin Ro
- Department of Veterinary Internal Medicine, College of Veterinary Medicine, Konkuk University, Seoul, Republic of Korea
| | - Min-Hee Kang
- Department of Veterinary Internal Medicine, College of Veterinary Medicine, Konkuk University, Seoul, Republic of Korea
| | - Hee-Myung Park
- Department of Veterinary Internal Medicine, College of Veterinary Medicine, Konkuk University, Seoul, Republic of Korea
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Strict Versus Lenient Versus Poor Rate Control Among Patients With Atrial Fibrillation and Heart Failure (from the Get With The Guidelines - Heart Failure Program). Am J Cardiol 2020; 125:894-900. [PMID: 31980141 DOI: 10.1016/j.amjcard.2019.12.025] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 12/11/2019] [Accepted: 12/13/2019] [Indexed: 11/21/2022]
Abstract
Randomized data suggest lenient rate control (resting heart rate <110 beats/min) is noninferior to strict rate control (resting heart rate <80 beats/min) in patients with atrial fibrillation (AF). However, the optimal rate control strategy in patients with AF and heart failure (HF) remains unknown. Accordingly, we performed an observational analysis using data from the Get With The Guidelines-HF Program linked with Medicare data from July 1, 2011, to September 30, 2014. Of 13,981 patients with AF and HF, 9,100 (65.0%) had strict rate control, 4,617 (33.0%) had lenient rate control, and 264 (1.9%) had poor rate control by resting heart rate on the day of discharge. After multivariable adjustment, compared with strict rate control, lenient rate control was associated with higher adjusted risks of death (hazard ratio [HR] 1.21, 95% confidence interval [CI] 1.11 to 1.33, p <0.001), all-cause readmission (HR 1.09, 95% CI 1.03 to 1.15, p <0.002), death or all-cause readmission (HR 1.11, 95% CI 1.05 to 1.18, p <0.001), but not cardiovascular readmission (HR1.08, 95% CI 1.00 to 1.16, p = 0.051) at 90 days. Associations were comparable in patients with poor rate control and with heart rate modeled as a continuous variable. The presence or absence of reduced ejection fraction did not impact the magnitude of most observed associations. In conclusion, in patients with HF and AF, 2 of 3 patients had a heart rate that met strict-control goals at discharge. Heart rates >80 beats/min were associated with adverse outcomes irrespective of left ventricular ejection fraction.
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Gunasekaran S, Lee DC, Knight BP, Collins JD, Fan L, Trivedi A, Ragin AB, Carr JC, Passman RS, Kim D. Left ventricular extracellular volume expansion does not predict recurrence of atrial fibrillation following catheter ablation. Pacing Clin Electrophysiol 2020; 43:159-166. [PMID: 31797387 PMCID: PMC7024017 DOI: 10.1111/pace.13853] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 10/17/2019] [Accepted: 10/28/2019] [Indexed: 01/25/2023]
Abstract
INTRODUCTION A recent study reported that diffuse left ventricular (LV) fibrosis is a predictor of atrial fibrillation (AF) recurrence following catheter ablation, by measuring postcontrast cardiac T1 (an error prone metric as per the 2017 Society for Cardiovascular Magnetic Resonance consensus statement) using an inversion-recovery pulse sequence (an error prone method in arrhythmia) in AF ablation candidates. The purpose of this study was to verify the prior study, by measuring extracellular volume (ECV) fraction (an accurate metric) using a saturation-recovery pulse sequence (accurate method in arrhythmia). METHODS AND RESULTS This study examined 100 AF patients (mean age = 62 ± 11 years, 69 males and 31 females, 67 paroxysmal [pAF] and 33 persistent [peAF]) who underwent a preablation cardiovascular magnetic resonance (CMR) exam. LV ECV and left atrial (LA) and LV functional parameters were quantified using standard analysis methods. During an average follow-up period of 457 ± 261 days with 4 ± 3 rhythm checks per patient, 72 patients maintained sinus rhythm. Between those who maintained sinus rhythm (n = 72) and those who reverted to AF (n = 28), the only clinical characteristic that was significantly different was age (60 ± 12 years vs 66 ± 9 years); for CMR metrics, neither mean LV ECV (25.1 ± 3.3% vs 24.7 ± 3.7%), native LV T1 (1093.8 ± 73.5 ms vs 1070.2 ± 115.9 ms), left ventricular ejection fraction (54.1 ± 11.2% vs 55.7 ± 7.1%), nor LA end diastolic volume/body surface area (42.4 ± 14.8 mL/m2 vs 43.4 ± 19.6 mL/m2 ) were significantly different (P ≥ .23). According to Cox regression tests, none of the clinical and imaging variables predict AF recurrence. CONCLUSION Neither LV ECV nor other CMR metrics predict recurrence of AF following catheter ablation.
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Affiliation(s)
- Suvai Gunasekaran
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
- Department of Biomedical Engineering, Northwestern University, Evanston, IL, United States
| | - Daniel C. Lee
- Division of Cardiology, Department of Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Bradley P. Knight
- Division of Cardiology, Department of Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Jeremy D. Collins
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
- Department of Radiology, Mayo Clinic, Rochester, MN, United States
| | - Lexiaozi Fan
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
- Department of Biomedical Engineering, Northwestern University, Evanston, IL, United States
| | - Amar Trivedi
- Division of Cardiology, Department of Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Ann B. Ragin
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - James C. Carr
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Rod S. Passman
- Division of Cardiology, Department of Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Daniel Kim
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
- Department of Biomedical Engineering, Northwestern University, Evanston, IL, United States
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Steinberg BA, Piccini JP. Tackling Patient-Reported Outcomes in Atrial Fibrillation and Heart Failure: Identifying Disease-Specific Symptoms? Cardiol Clin 2019; 37:139-146. [PMID: 30926015 DOI: 10.1016/j.ccl.2019.01.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Atrial fibrillation (AF) and heart failure (HF) both significantly affect morbidity and mortality and also account for high symptom burden and impaired health-related quality of life (hrQoL). Several well-designed and broadly implemented patient-reported outcome instruments are available for both AF and HF and can easily measure hrQoL in each disease process. A better understanding of the diverse phenotypes of AF and HF, as well as the heterogeneous treatment effects of disease-specific interventions, is necessary to further disentangle the complex relationship between symptoms of AF and HF.
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Affiliation(s)
- Benjamin A Steinberg
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, 30 North 1900 East, Room 4A100, Salt Lake City, UT 84132, USA.
| | - Jonathan P Piccini
- Duke University Medical Center, Durham, NC, USA; Duke Center for Atrial Fibrillation, Duke University Medical Center, Duke Clinical Research Institute, DUMC #3115, Durham, NC 27705, USA
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17
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Lee A, Walters TE, Gerstenfeld EP, Haqqani HM. Frequent Ventricular Ectopy: Implications and Outcomes. Heart Lung Circ 2019; 28:178-190. [DOI: 10.1016/j.hlc.2018.09.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 09/19/2018] [Accepted: 09/20/2018] [Indexed: 11/29/2022]
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18
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Lambert CT, Kanj M, Menon V. Wobbly and Weak. Circ Heart Fail 2018; 11:e004981. [PMID: 30354564 DOI: 10.1161/circheartfailure.118.004981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Mohammed Kanj
- Heart and Vascular Institute, Cleveland Clinic Foundation, OH
| | - Venu Menon
- Heart and Vascular Institute, Cleveland Clinic Foundation, OH
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19
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Improvement in ejection fraction after cryoballoon pulmonary vein isolation for atrial fibrillation in individuals with systolic dysfunction. J Interv Card Electrophysiol 2018; 54:225-229. [PMID: 30328546 DOI: 10.1007/s10840-018-0475-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 10/11/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Cryoballoon pulmonary vein isolation (PVI) is commonly used for rhythm control of atrial fibrillation (AF). Data are limited examining the outcomes of cryoballoon PVI in patients with systolic dysfunction. We evaluate the impact of cryoballoon PVI in patients with systolic dysfunction. METHODS We evaluated a single-center prospective registry of patients undergoing cryoballoon PVI between 8/2011 and 6/2016. Patients with systolic dysfunction (EF < 55%) between the time of AF diagnosis and their cryoballoon PVI procedure were assessed for AF recurrence at 6 months and 1 year post-procedure, with a 3-month blanking period. RESULTS Final analysis included 66 patients with systolic dysfunction undergoing cryoballoon PVI. An AF diagnosis for ≥ 1 year prior to PVI was present in 62.1% (n = 41), and 53.0% (n = 35) had systolic dysfunction for ≥ 1 year pre-procedure. The proportion of AF-free patients at 1 year was 51.5%. Of patients with echocardiograms performed at 1 year (n = 43), a greater proportion of individuals without AF recurrence had an improvement in EF of ≥ 10% than in those with AF recurrence (54.2% vs. 25.0%, p = 0.039). Of the patients who had systolic dysfunction at the time of the ablation (EF < 55%), there was a significant increase in EF post-procedure (36.5% pre-procedure vs. 48.3% post-procedure, mean change 11.8%, p < 0.001). CONCLUSION In patients with systolic dysfunction, cryoballoon PVI provides an acceptable AF recurrence-free rate at 1 year. AF recurrence-free individuals were more likely to have improvement in EF. Further evaluation is needed to determine the potential role of early cryoballoon PVI in patients with a new diagnosis of systolic dysfunction and AF.
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20
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Abstract
This article summarizes the initial experience with permanent His bundle pacing, the lessons learned, and the concepts that have been developed in the subsequent decade of experience with His bundle pacing. This article also addresses the advancements in technology, which have allowed His bundle pacing to be more widely adopted and used in various clinical situations.
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Affiliation(s)
- Pramod Deshmukh
- Cardiac and Vascular Center, Arrhythmia Center, Robert Packer Hospital, 1 Guthrie Square, Sayre, PA 18840, USA.
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21
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Sustained atrial fibrillation increases the risk of anticoagulation-related bleeding in heart failure. Clin Res Cardiol 2018; 107:1170-1179. [PMID: 29948286 DOI: 10.1007/s00392-018-1293-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 06/05/2018] [Indexed: 10/14/2022]
Abstract
BACKGROUND Oral anticoagulation therapy in individuals with atrial fibrillation (AF) reduces the risk of thromboembolic events at cost of an increased bleeding risk. Whether anticoagulation-related outcomes differ between patients with paroxysmal and sustained AF receiving anticoagulation is controversially discussed. METHODS In the present analysis of the prospective multi-center cohort study thrombEVAL, the incidence of anticoagulation-related adverse events was analyzed according to the AF phenotype. Information on outcome was centrally recorded over 3 years, validated via medical records and adjudicated by an independent review panel. Study monitoring was provided by an independent institution. RESULTS Overall, the sample comprised 1089 AF individuals, of whom n = 398 had paroxysmal AF and n = 691 experienced sustained AF. In Cox regression analysis with adjustment for potential confounders, sustained AF indicated an independently elevated risk of clinically relevant bleeding compared to paroxysmal AF [hazard ratio (HR) 1.40 (1.02; 1.93); P = 0.038]. For clinically relevant bleeding, a significant interaction of the pattern of AF type with concomitant heart failure (HF) was detected: HRHF 2.45 (1.51, 3.98) vs. HRno HF 0.85 (0.55, 1.34); Pinteraction = 0.003. In HF patients, sustained AF indicated also an elevated risk of major bleeding [HR 2.25 (1.26, 4.20); P = 0.006]. A simplified HAS-BLED score incorporating only information on age (> 65 years), bleeding history, and HF with sustained AF demonstrated better discriminative performance for clinically relevant bleeding than the original version: AUCHAS-BLED: 0.583 vs. AUCsimplifiedHAS-BLED: 0.642 (P = 0.004). CONCLUSIONS In HF patients receiving oral anticoagulation, sustained AF indicates a substantially elevated risk of bleeding. CLINICAL TRIAL REGISTRATION https://clinicaltrials.gov , identifier: NCT01809015.
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22
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Modeling of Amiodarone Effect on Heart Rate Control in Critically Ill Patients with Atrial Tachyarrhythmias. Clin Pharmacokinet 2017; 55:991-1002. [PMID: 26946135 DOI: 10.1007/s40262-016-0372-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
AIMS Amiodarone is the gold-standard medication to control heart rate in critically ill patients with atrial tachyarrhythmias (ATs); however, effective doses and covariates influencing its efficacy remain unknown. We therefore performed pharmacodynamic modeling of heart rate reduction induced by amiodarone in these patients. METHODS AND RESULTS This observational study included 80 consecutive severely ill patients receiving amiodarone to treat ATs. A total of 1348 time-heart rate observations with 361 amiodarone dose administrations were analyzed during a period of up to 6 days after hospital treatment initiation using a nonlinear mixed-effect model. Pretreatment with amiodarone before intensive care administration, paroxysmal versus persistent AT, catecholamine infusion, and fluid and magnesium loading were among the covariates assessed in the model. In case of paroxysmal AT in a patient not pretreated with amiodarone, a 300 mg intravenous loading dose combined with an 800 mg oral dose on the first day, followed by 800 mg/day orally for 4 days was effective in achieving a heart rate between 80 and 115 bpm within the first day, and to maintain it during the next 4 days. Corresponding doses were twice as high in patients with persistent AT. Use of intravenous magnesium (p < 0.02) and fluid loading (p < 0.02) was associated with an earlier and greater heart rate decrease, while use of dobutamine had an opposite influence (p < 0.05). CONCLUSIONS In critically ill patients with AT, the dose of amiodarone required to control heart rate is influenced by the type of AT and by other easily measurable conditions which may allow better individualization of amiodarone dosing.
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23
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Usefulness of the WCD in patients with suspected tachymyopathy. Clin Res Cardiol 2017; 107:70-75. [PMID: 28993851 DOI: 10.1007/s00392-017-1159-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Accepted: 08/31/2017] [Indexed: 10/18/2022]
Abstract
AIMS The wearable cardioverter defibrillator (WCD) is used for temporary protection of patients deemed to be at high risk for sudden death. There is limited experience regarding the clinical development of patients with tachymyopathy. We aimed to evaluate the clinical development of tachymyopathy patients protected with a WCD in a single-center non-randomized patient cohort. METHODS AND RESULTS We fitted 130 consecutive patients deemed to be at high risk for ventricular tachyarrhythmias with the WCD. Of these, 20 patients (15%) presenting with newly diagnosed heart failure in the setting of rapidly conducted atrial fibrillation/flutter were suspected to suffer from tachymyopathy. The control group consisted of the remaining 110 patients with other indications for WCD therapy. LVEF increased by more than 10% in 13/20 (65%) tachymyopathy patients compared to 40/110 (36%) patients in the control population (p = 0.01). Similarly, BNP levels decreased in 15/20 (75%) tachymyopathy patients compared to 41/110 (37%) in the control group (p = 0.05). ICD implantation rates were lower in the tachymyopathy group (3/20) compared to the control population (40/110; p = 0.04). On further follow-up (mean 12 ± 8 months), patients with suspected tachymyopathy had no sustained ventricular arrhythmias. Compared to 5/110 patients in the control group, no tachymyopathy patient died. CONCLUSION Most of the patients with suspected tachymyopathy have a favorable clinical outcome. The WCD is useful for temporary protection while LV function recovers.
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Gupta A, Talwar K. Tachycardiomyopathy: A case report and review of literature. INTERNATIONAL JOURNAL OF THE CARDIOVASCULAR ACADEMY 2017. [DOI: 10.1016/j.ijcac.2017.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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25
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Affiliation(s)
- Claire A Martin
- Department of Cardiology, Barts Health NHS Trust, London, UK
| | - Pier D Lambiase
- Department of Cardiology, Barts Health NHS Trust, London, UK
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26
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Wu F, Heimbach T, Hatsis P, Tang HM, Dugyala R, Yue Q, Wang T, He H. Integrated TK-TD modeling for drug-induced concurrent tachycardia and QT changes in beagle dogs. J Pharmacokinet Pharmacodyn 2017. [PMID: 28643108 DOI: 10.1007/s10928-017-9532-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Drug-induced cardiotoxicity, including tachycardia and QT prolongation, remains a major safety concern that needs to be identified and its risk mitigated in early stages of drug development. In the present study, an integrated toxicokinetic-toxicodynamic (TK-TD) modeling approach within a nonlinear mixed-effect modeling framework is applied to investigate concurrent abnormal heart rate and QT changes in three beagle dogs, using a Novartis internal compound (NVS001) as the case example. By accounting for saturable drug absorption, circadian rhythms, drug-effect tolerance, and nonlinear rate-dependency of QT interval, the dynamic TK-TD model captures the experimentally observed drug effects on heart rate and QT interval across a wide dosing range of NVS001 in beagle dogs. Further analyses reveal that the NVS001-induced QT prolongation observed in the low-dose groups is potentially caused by direct drug inhibition on the hERG channel, while the apparent QT shortening in the high-dose groups may be due to strong rate-dependency of QT at high heart rates. This study also suggests that the TK-TD model can be used to identify direct drug effects on the non-rate-dependent QT component by dissociating QT changes from tachycardia and deriving a new QT correction method. The integrated TK-TD model presented here may serve as a novel quantitative framework for evaluating drug-induced concurrent changes in heart rate and QT to potentially facilitate preclinical and clinical safety studies.
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Affiliation(s)
- Fan Wu
- Department of PK Sciences, Novartis Institutes for BioMedical Research, 1 Health Plaza, East Hanover, NJ, USA.
| | - Tycho Heimbach
- Department of PK Sciences, Novartis Institutes for BioMedical Research, 1 Health Plaza, East Hanover, NJ, USA
| | - Panos Hatsis
- Department of PK Sciences, Novartis Institutes for BioMedical Research, 1 Health Plaza, East Hanover, NJ, USA
| | - Hai-Ming Tang
- Department of Preclinical Safety, Novartis Institutes for BioMedical Research, 1 Health Plaza, East Hanover, NJ, USA
| | - Raviprakash Dugyala
- Department of Preclinical Safety, Novartis Institutes for BioMedical Research, 1 Health Plaza, East Hanover, NJ, USA
| | - Qin Yue
- Department of PK Sciences, Novartis Institutes for BioMedical Research, 5300 Chiron Way, Emeryville, CA, USA
| | - Tao Wang
- Department of Preclinical Safety, Novartis Institutes for BioMedical Research, 5300 Chiron Way, Emeryville, CA, USA
| | - Handan He
- Department of PK Sciences, Novartis Institutes for BioMedical Research, 1 Health Plaza, East Hanover, NJ, USA
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27
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Sharma E, Arunachalam K, Di M, Chu A, Maan A. PVCs, PVC-Induced Cardiomyopathy, and the Role of Catheter Ablation. Crit Pathw Cardiol 2017; 16:76-80. [PMID: 28509708 DOI: 10.1097/hpc.0000000000000106] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Premature ventricular contractions (PVCs) are common arrhythmias noticed in the clinical setting because of premature depolarization of the ventricular myocytes. Although often thought to be reflective of underlying disease rather than intrinsically harmful, PVCs have recently been linked with worse outcomes in patients without significant cardiac disease. Long-term exposure to a high PVC burden can lead to the development of PVC-induced cardiomyopathy. The pathogenesis of this condition is poorly understood at the current time. Many studies have suggested that catheter ablation of these PVCs may result in reversal of the PVC-induced cardiomyopathy. This article will go over the natural history of PVCs and PVC-induced cardiomyopathy, as well as review the current literature on the role of catheter ablation in treating PVC-induced cardiomyopathy.
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Affiliation(s)
- Esseim Sharma
- From The Warren Alpert Medical School of Brown University, Providence, RI
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28
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29
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Rosa GM, Meliota G, Brunelli C, Ferrero S. Pharmacokinetic drug evaluation of bucindolol for the treatment of atrial fibrillation in heart failure patients. Expert Opin Drug Metab Toxicol 2017; 13:473-481. [DOI: 10.1080/17425255.2017.1291631] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Gian Marco Rosa
- Department of Internal Medicine, Cardiology, IRCCS AOU San Martino – IST, University of Genoa, Genova, Italy
| | - Giovanni Meliota
- Department of Internal Medicine, Cardiology, IRCCS AOU San Martino – IST, University of Genoa, Genova, Italy
| | - Claudio Brunelli
- Department of Internal Medicine, Cardiology, IRCCS AOU San Martino – IST, University of Genoa, Genova, Italy
| | - Simone Ferrero
- Department of Obstetrics and Gynaecology, IRCCS AOU San Martino – IST, University of Genoa, Genova, Italy
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30
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Nazeri A, Elayda MA, Segura AM, Stainback RF, Nathan J, Lee VV, Bove C, Sampaio L, Grace B, Massumi A, Razavi M. Comparative Efficacy of Nebivolol and Metoprolol to Prevent Tachycardia-Induced Cardiomyopathy in a Porcine Model. Tex Heart Inst J 2017; 43:477-481. [PMID: 28100964 DOI: 10.14503/thij-15-5495] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Chronic tachycardia is a well-known cause of nonischemic cardiomyopathy. We hypothesized that nebivolol, a β-blocker with nitric oxide activity, would be superior to a pure β-blocker in preventing tachycardia-induced cardiomyopathy in a porcine model. Fifteen healthy Yucatan pigs were randomly assigned to receive nebivolol, metoprolol, or placebo once a day. All pigs underwent dual-chamber pacemaker implantation. The medication was started the day after the pacemaker implantation. On day 7 after implantation, each pacemaker was set at atrioventricular pace (rate, 170 beats/min), and the pigs were observed for another 7 weeks. Transthoracic echocardiograms, serum catecholamine levels, and blood chemistry data were obtained at baseline and at the end of the study. At the end of week 8, the pigs were euthanized, and complete histopathologic studies were performed. All the pigs developed left ventricular cardiomyopathy but remained hemodynamically stable and survived to the end of the study. The mean left ventricular ejection fraction decreased from baseline by 34%, 20%, and 20% in the nebivolol, metoprolol, and placebo groups, respectively. These changes did not differ significantly among the 3 groups (P =0.51). Histopathologic analysis revealed mild left ventricular perivascular fibrosis with cardiomyocyte hypertrophy in 14 of the 15 pigs. Both nebivolol and metoprolol failed to prevent cardiomyopathy in our animal model of persistent tachycardia and a high catecholamine state.
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31
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Affiliation(s)
- Hassan A Mohamed
- Department of Medicine, Division of Cardiology, Regina General Hospital, Regina, SK, Canada
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32
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Chiang CE, Wu TJ, Ueng KC, Chao TF, Chang KC, Wang CC, Lin YJ, Yin WH, Kuo JY, Lin WS, Tsai CT, Liu YB, Lee KT, Lin LJ, Lin LY, Wang KL, Chen YJ, Chen MC, Cheng CC, Wen MS, Chen WJ, Chen JH, Lai WT, Chiou CW, Lin JL, Yeh SJ, Chen SA. 2016 Guidelines of the Taiwan Heart Rhythm Society and the Taiwan Society of Cardiology for the management of atrial fibrillation. J Formos Med Assoc 2016; 115:893-952. [PMID: 27890386 DOI: 10.1016/j.jfma.2016.10.005] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 08/24/2016] [Accepted: 10/10/2016] [Indexed: 12/21/2022] Open
Abstract
Atrial fibrillation (AF) is the most common sustained arrhythmia. Both the incidence and prevalence of AF are increasing, and the burden of AF is becoming huge. Many innovative advances have emerged in the past decade for the diagnosis and management of AF, including a new scoring system for the prediction of stroke and bleeding events, the introduction of non-vitamin K antagonist oral anticoagulants and their special benefits in Asians, new rhythm- and rate-control concepts, optimal endpoints of rate control, upstream therapy, life-style modification to prevent AF recurrence, and new ablation techniques. The Taiwan Heart Rhythm Society and the Taiwan Society of Cardiology aimed to update the information and have appointed a jointed writing committee for new AF guidelines. The writing committee members comprehensively reviewed and summarized the literature, and completed the 2016 Guidelines of the Taiwan Heart Rhythm Society and the Taiwan Society of Cardiology for the Management of Atrial Fibrillation. This guideline presents the details of the updated recommendations, along with their background and rationale, focusing on data unique for Asians. The guidelines are not mandatory, and members of the writing committee fully realize that treatment of AF should be individualized. The physician's decision remains most important in AF management.
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Affiliation(s)
- Chern-En Chiang
- General Clinical Research Center, Division of Cardiology, Taipei Veterans General Hospital and National Yang-Ming University, Taipei, Taiwan.
| | - Tsu-Juey Wu
- Cardiovascular Center, Department of Internal Medicine, Taichung Veterans General Hospital and National Yang-Ming University, Taipei, Taiwan
| | - Kwo-Chang Ueng
- Department of Internal Medicine, School of Medicine, Chung-Shan Medical University (Hospital), Taichung, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Kuan-Cheng Chang
- Division of Cardiology, Department of Medicine, China Medical University Hospital, Taichung, Taiwan; Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan
| | - Chun-Chieh Wang
- Department of Internal Medicine, Section of Cardiology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yenn-Jiang Lin
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Wei-Hsian Yin
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan; Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Jen-Yuan Kuo
- Division of Cardiology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan; Department of Medicine, Mackay Medical College, Taipei, Taiwan
| | - Wei-Shiang Lin
- Division of Cardiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan
| | - Chia-Ti Tsai
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
| | - Yen-Bin Liu
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan; Division of Cardiology, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Kun-Tai Lee
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Department of Internal Medicine, Faculty of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Li-Jen Lin
- Department of Internal Medicine, National Cheng Kung University College of Medicine and Hospital, Tainan, Taiwan
| | - Lian-Yu Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
| | - Kang-Ling Wang
- General Clinical Research Center, Division of Cardiology, Taipei Veterans General Hospital and National Yang-Ming University, Taipei, Taiwan
| | - Yi-Jen Chen
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Division of Cardiovascular Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Mien-Cheng Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | | | - Ming-Shien Wen
- Department of Internal Medicine, Section of Cardiology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Wen-Jone Chen
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan; Division of Cardiology, Poh-Ai Hospital, Yilan, Taiwan
| | - Jyh-Hong Chen
- Department of Internal Medicine, National Cheng Kung University College of Medicine and Hospital, Tainan, Taiwan; College of Medicine, China Medical University, Taichung, Taiwan
| | - Wen-Ter Lai
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Department of Internal Medicine, Faculty of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chuen-Wang Chiou
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Jiunn-Lee Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
| | - San-Jou Yeh
- Department of Internal Medicine, Section of Cardiology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan.
| | - Shih-Ann Chen
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan.
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Deshmukh A, Deshmukh P. His bundle pacing: Initial experience and lessons learned. J Electrocardiol 2016; 49:658-63. [PMID: 27591359 DOI: 10.1016/j.jelectrocard.2016.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Indexed: 10/21/2022]
Abstract
Direct His bundle pacing provides the most physiologic means of artificial pacing of the ventricles with a preserved His-Purkinje system and may play a role in patients with a diseased intrinsic conduction system. We describe our initial motivations and experience with permanent direct His bundle pacing and important lessons learned since that time.
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Affiliation(s)
- Amrish Deshmukh
- Department of Medicine, University of Chicago, 5841 S. Maryland Avenue, MC 6092, Chicago, IL.
| | - Pramod Deshmukh
- Arrhythmia Center, Robert Packer Hospital, 1 Guthrie Square, Sayre, PA.
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Garcia B, Clementy N, Benhenda N, Pierre B, Babuty D, Olshansky B, Fauchier L. Mortality After Atrioventricular Nodal Radiofrequency Catheter Ablation With Permanent Ventricular Pacing in Atrial Fibrillation. Circ Arrhythm Electrophysiol 2016; 9:CIRCEP.116.003993. [DOI: 10.1161/circep.116.003993] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 05/27/2016] [Indexed: 11/16/2022]
Abstract
Background—
Atrioventricular nodal radiofrequency ablation (AVNA) with permanent ventricular pacing can be used to control rate in patients with atrial fibrillation (AF). However, long-term outcomes after AVNA are uncertain, especially in light of irreversible pacemaker dependence.
Methods and Results—
We examined 9122 consecutive patients with AF. The outcomes in 453 patients with AVNA (26% of whom underwent an implantable cardiac defibrillator implant and 37% underwent cardiac resynchronization therapy implant) were compared with AF patients without AVNA after propensity score 1:1 matching. During follow-up in the propensity-matched cohort (2.41±3.23 years, median 1.23, quartiles 0.33–3.12), 100 patients died (yearly rate of death 6.6%). Mode of death was available in 86% of patients, which was cardiovascular in 67% of the patients (related to heart failure in 38%, sudden death in 5%, and other cardiovascular reason in 24%) and noncardiovascular in 33%. AVNA in patients with AF was associated with a lower risk of mortality (odds ratio 0.47, 95% confidence interval, 0.29–0.77;
P
=0.003), a lower risk of cardiovascular mortality (odds ratio =0.41, 95% confidence interval 0.23–0.73;
P
=0.003), and nonsignificant lower risk of stroke and thromboembolic events (odds ratio =0.61, 95% confidence interval 0.36–1.06;
P
=0.08).
Conclusions—
In sick AF patients with multiple comorbidities, AVNA with permanent ventricular pacing for rate control seems safe during follow-up and may be associated with lower mortality.
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Affiliation(s)
- Bruno Garcia
- From the Service de Cardiologie, Pôle Cœur Thorax Vasculaire, Centre Hospitalier Universitaire Trousseau et Faculté de Médecine, Université François Rabelais, Tours, France (B.G., N.C., N.B., B.P., D.B., L.F.); and Division of Cardiology, Cardiac Electrophysiology, Mercy Hospital-North Iowa, Mason City, IA (B.O.)
| | - Nicolas Clementy
- From the Service de Cardiologie, Pôle Cœur Thorax Vasculaire, Centre Hospitalier Universitaire Trousseau et Faculté de Médecine, Université François Rabelais, Tours, France (B.G., N.C., N.B., B.P., D.B., L.F.); and Division of Cardiology, Cardiac Electrophysiology, Mercy Hospital-North Iowa, Mason City, IA (B.O.)
| | - Nazih Benhenda
- From the Service de Cardiologie, Pôle Cœur Thorax Vasculaire, Centre Hospitalier Universitaire Trousseau et Faculté de Médecine, Université François Rabelais, Tours, France (B.G., N.C., N.B., B.P., D.B., L.F.); and Division of Cardiology, Cardiac Electrophysiology, Mercy Hospital-North Iowa, Mason City, IA (B.O.)
| | - Bertrand Pierre
- From the Service de Cardiologie, Pôle Cœur Thorax Vasculaire, Centre Hospitalier Universitaire Trousseau et Faculté de Médecine, Université François Rabelais, Tours, France (B.G., N.C., N.B., B.P., D.B., L.F.); and Division of Cardiology, Cardiac Electrophysiology, Mercy Hospital-North Iowa, Mason City, IA (B.O.)
| | - Dominique Babuty
- From the Service de Cardiologie, Pôle Cœur Thorax Vasculaire, Centre Hospitalier Universitaire Trousseau et Faculté de Médecine, Université François Rabelais, Tours, France (B.G., N.C., N.B., B.P., D.B., L.F.); and Division of Cardiology, Cardiac Electrophysiology, Mercy Hospital-North Iowa, Mason City, IA (B.O.)
| | - Brian Olshansky
- From the Service de Cardiologie, Pôle Cœur Thorax Vasculaire, Centre Hospitalier Universitaire Trousseau et Faculté de Médecine, Université François Rabelais, Tours, France (B.G., N.C., N.B., B.P., D.B., L.F.); and Division of Cardiology, Cardiac Electrophysiology, Mercy Hospital-North Iowa, Mason City, IA (B.O.)
| | - Laurent Fauchier
- From the Service de Cardiologie, Pôle Cœur Thorax Vasculaire, Centre Hospitalier Universitaire Trousseau et Faculté de Médecine, Université François Rabelais, Tours, France (B.G., N.C., N.B., B.P., D.B., L.F.); and Division of Cardiology, Cardiac Electrophysiology, Mercy Hospital-North Iowa, Mason City, IA (B.O.)
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35
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Heusch G, Kleinbongard P. Ivabradine: Cardioprotection By and Beyond Heart Rate Reduction. Drugs 2016; 76:733-40. [DOI: 10.1007/s40265-016-0567-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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36
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Abstract
Long-standing tachycardia is a well-recognised cause of heart failure and left ventricular dysfunction, and has led to the nomenclature, tachycardia-induced cardiomyopathy (TIC). TIC is generally a reversible cardiomyopathy if the causative tachycardia can be treated effectively, either with medications, surgery or catheter ablation. The diagnosis is usually made after demonstrating recovery of left ventricular function with normalisation of heart rate in the absence of other identifiable aetiologies. One hundred years after the first reported case of TIC, our understanding of the pathophysiology of TIC in humans remains limited despite extensive work in animal models of TIC. In this review we will discuss the proposed mechanisms of TIC, the causative tachyarrhythmias and their treatment, outcomes for patients diagnosed with TIC, and future directions for research and clinical care.
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Affiliation(s)
- Ethan R Ellis
- Clinical Fellow, Harvard Medical School, Beth Israel Deaconess Medical Center
| | - Mark E Josephson
- Herman C. Dana Professor of Medicine, Harvard Medical School, Chief of the Cardiovascular Division, Beth Israel Deaconess Medical Center and Director, Harvard-Thorndike Electrophysiology Institute and Arrhythmia Service, Beth Israel Deaconess Medical Center, Boston, US
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Brembilla-Perrot B, Ferreira JP, Manenti V, Sellal JM, Olivier A, Villemin T, Beurrier D, De Chillou C, Louis P, Brembilla A, Juillière Y, Girerd N. Predictors and prognostic significance of tachycardiomyopathy: insights from a cohort of 1269 patients undergoing atrial flutter ablation. Eur J Heart Fail 2016; 18:394-401. [DOI: 10.1002/ejhf.482] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 11/14/2015] [Accepted: 12/05/2015] [Indexed: 11/11/2022] Open
Affiliation(s)
| | - João Pedro Ferreira
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433; Université de Lorraine; CHRU de Nancy and F-CRIN INI-CRCT Nancy France
- Department of Physiology and Cardiothoracic Surgery, Cardiovascular Research and Development Unit, Faculty of Medicine; University of Porto; Porto Portugal
| | - Vladimir Manenti
- Department of Cardiology Nancy University Hospital; Rue du Morvan 54511 Vandoeuvre-les-Nancy France
| | - Jean Marc Sellal
- Department of Cardiology Nancy University Hospital; Rue du Morvan 54511 Vandoeuvre-les-Nancy France
| | - Arnaud Olivier
- Department of Cardiology Nancy University Hospital; Rue du Morvan 54511 Vandoeuvre-les-Nancy France
| | - Thibaut Villemin
- Department of Cardiology Nancy University Hospital; Rue du Morvan 54511 Vandoeuvre-les-Nancy France
| | - Daniel Beurrier
- Department of Cardiology Nancy University Hospital; Rue du Morvan 54511 Vandoeuvre-les-Nancy France
| | - Christian De Chillou
- Department of Cardiology Nancy University Hospital; Rue du Morvan 54511 Vandoeuvre-les-Nancy France
| | - Pierre Louis
- Department of Cardiology Nancy University Hospital; Rue du Morvan 54511 Vandoeuvre-les-Nancy France
| | | | - Yves Juillière
- Department of Cardiology Nancy University Hospital; Rue du Morvan 54511 Vandoeuvre-les-Nancy France
| | - Nicolas Girerd
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433; Université de Lorraine; CHRU de Nancy and F-CRIN INI-CRCT Nancy France
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38
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Basuray A, Fang JC. Management of Patients With Recovered Systolic Function. Prog Cardiovasc Dis 2016; 58:434-43. [PMID: 26796969 DOI: 10.1016/j.pcad.2016.01.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Accepted: 01/10/2016] [Indexed: 11/25/2022]
Abstract
Advancements in the treatment of heart failure (HF) with systolic dysfunction have given rise to a new population of patients with improved ejection fraction (EF). The management of this distinct population is not well described due to a lack of consensus on the definition of myocardial recovery, a scarcity of data on the natural history of these patients, and the absence of focused clinical trials. Moreover, an improvement in EF may have different prognostic and management implications depending on the underlying etiology of cardiomyopathy. This can be challenging for the clinician who is approached by a patient inquiring about a reduction of medical therapy after apparent EF recovery. This review explores management strategies for HF patients with recovered EF in a disease-specific format.
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Okada A, Nakajima I, Morita Y, Inoue YY, Kamakura T, Wada M, Ishibashi K, Miyamoto K, Okamura H, Nagase S, Noda T, Aiba T, Kamakura S, Anzai T, Noguchi T, Yasuda S, Kusano K. Diagnostic Value of Right Ventricular Dysfunction in Tachycardia-Induced Cardiomyopathy Using Cardiac Magnetic Resonance Imaging. Circ J 2016; 80:2141-8. [DOI: 10.1253/circj.cj-16-0532] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Atsushi Okada
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
- Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Ikutaro Nakajima
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Yoshiaki Morita
- Department of Radiology, National Cerebral and Cardiovascular Center
| | - Yuko Y. Inoue
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Tsukasa Kamakura
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Mitsuru Wada
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Kohei Ishibashi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Koji Miyamoto
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Hideo Okamura
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Satoshi Nagase
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Takashi Noda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Takeshi Aiba
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Shiro Kamakura
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Toshihisa Anzai
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
- Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
- Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
- Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
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Steinberg BA, Kim S, Thomas L, Fonarow GC, Gersh BJ, Holmqvist F, Hylek E, Kowey PR, Mahaffey KW, Naccarelli G, Reiffel JA, Chang P, Peterson ED, Piccini JP. Increased Heart Rate Is Associated With Higher Mortality in Patients With Atrial Fibrillation (AF): Results From the Outcomes Registry for Better Informed Treatment of AF (ORBIT-AF). J Am Heart Assoc 2015; 4:e002031. [PMID: 26370445 PMCID: PMC4599492 DOI: 10.1161/jaha.115.002031] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 07/27/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Most patients with atrial fibrillation (AF) require rate control; however, the optimal target heart rate remains under debate. We aimed to assess rate control and subsequent outcomes among patients with permanent AF. METHODS AND RESULTS We studied 2812 US outpatients with permanent AF in the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation. Resting heart rate was measured longitudinally and used as a time-dependent covariate in multivariable Cox models of all-cause and cause-specific mortality during a median follow-up of 24 months. At baseline, 7.4% (n=207) had resting heart rate <60 beats per minute (bpm), 62% (n=1755) 60 to 79 bpm, 29% (n=817) 80 to 109 bpm, and 1.2% (n=33) ≥110 bpm. Groups did not differ by age, previous cerebrovascular disease, heart failure status, CHA2DS2-VASc scores, renal function, or left ventricular function. There were significant differences in race (P=0.001), sinus node dysfunction (P=0.004), and treatment with calcium-channel blockers (P=0.006) and anticoagulation (P=0.009). In analyses of continuous heart rates, lower heart rate ≤65 bpm was associated with higher all-cause mortality (adjusted hazard ratio [HR], 1.15 per 5-bpm decrease; 95% CI, 1.01 to 1.32; P=0.04). Similarly, increasing heart rate >65 bpm was associated with higher all-cause mortality (adjusted HR, 1.10 per 5-bpm increase; 95% CI, 1.05 to 1.15; P<0.0001). This relationship was consistent across endpoints and in a broader sensitivity analysis of permanent and nonpermanent AF patients. CONCLUSIONS Among patients with permanent AF, there is a J-shaped relationship between heart rate and mortality. These data support current guideline recommendations, and clinical trials are warranted to determine optimal rate control. CLINICAL TRIAL REGISTRATION URL: http://clinicaltrials.gov/. Unique identifier: NCT01165710.
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Affiliation(s)
- Benjamin A Steinberg
- Duke University Medical CenterDurham, NC
- Duke Clinical Research InstituteDurham, NC
| | | | | | | | | | | | | | - Peter R Kowey
- Lankenau Institute for Medical ResearchWynnewood, PA
| | | | | | - James A Reiffel
- Columbia University College of Physicians and SurgeonsNew York, NY
| | - Paul Chang
- Janssen Pharmaceuticals, Inc.Raritan, NJ
| | - Eric D Peterson
- Duke University Medical CenterDurham, NC
- Duke Clinical Research InstituteDurham, NC
| | - Jonathan P Piccini
- Duke University Medical CenterDurham, NC
- Duke Clinical Research InstituteDurham, NC
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Posselt BN, Cox AT, D'Arcy J, Rooms M, Saba M. Atrial and ventricular tachyarrhythmias in military personnel. J ROY ARMY MED CORPS 2015; 161:244-52. [PMID: 26246345 DOI: 10.1136/jramc-2015-000494] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 06/30/2015] [Indexed: 01/08/2023]
Abstract
Although rare, sudden cardiac death does occur in British military personnel. In the majority of cases, the cause is considered to be a malignant ventricular tachyarrhythmia, which can be precipitated by a number of underlying pathologies. Conversely, a tachyarrhythmia may have a more benign and treatable cause, yet the initial clinical symptoms may be similar, making differentiation difficult. This is an overview of the mechanisms underlying the initiation and propagation of arrhythmias and the various pathological conditions that predispose to arrhythmia genesis, classified according to which parts of the heart are involved: atrial tachyarrhythmias, atrial and ventricular, as well as those affecting the ventricles alone. It encompasses atrial tachycardia, atrial flutter, supraventricular tachycardias and ventricular tachycardias, including the more commonly encountered inherited primary electrical diseases, also known as the channelopathies. The clinical features, investigation and management strategies are outlined. The occupational impact-in serving military personnel and potential recruits-is described, with explanations relating to the different conditions and their specific implication on continued military service.
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Affiliation(s)
- Bonnie N Posselt
- Defence Medical Services, Royal Centre for Defence Medicine, Birmingham, UK
| | - A T Cox
- Defence Medical Services, Royal Centre for Defence Medicine, Birmingham, UK Department of Cardiology, St George's, University of London, London, UK
| | - J D'Arcy
- Defence Medical Services, Royal Centre for Defence Medicine, Birmingham, UK Department of Cardiology, RCDM (Oxford), John Radcliffe Hospital, Oxford, UK
| | - M Rooms
- Regional Occupational Health Team (North), Catterick Garrison, North Yorkshire, UK
| | - M Saba
- Regional Occupational Health Team (North), Catterick Garrison, North Yorkshire, UK
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42
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Atrial Fibrillation or Flutter During Pregnancy in Patients With Structural Heart Disease. JACC Clin Electrophysiol 2015; 1:284-292. [DOI: 10.1016/j.jacep.2015.04.013] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 03/11/2015] [Accepted: 04/09/2015] [Indexed: 11/17/2022]
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Huo Y, Kassab GS. Remodeling of left circumflex coronary arterial tree in pacing-induced heart failure. J Appl Physiol (1985) 2015; 119:404-11. [PMID: 26159756 DOI: 10.1152/japplphysiol.00262.2015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 07/06/2015] [Indexed: 11/22/2022] Open
Abstract
Congestive heart failure (CHF) is a very serious heart disease that manifests an imbalance between left ventricle supply and demand. Although the mechanical demand of the failing heart has been well characterized, the systematic remodeling of the entire coronary arterial tree that constitutes the supply of the myocardium is lacking. We hypothesize that the well-known increase in ventricle wall stress during CHF causes coronary vascular rarefaction to increase the vascular flow resistance, which in turn compromises the perfusion of the heart. Morphometric (diameters, length, and numbers) data of the swine left circumflex (LCx) arterial tree were measured in both CHF (n = 6) and control (n = 6) groups, from which a computer reconstruction of the entire LCx tree was implemented down to the capillary level to enable a hemodynamic analysis of coronary circulation. The vascular flow resistance was increased by ∼75% due to a significant decrease of vessel numbers (∼45%) and diameters in the first capillary segments (∼10%) of the LCx arterial tree after 3-4 wk of pacing. The structural remodeling significantly changed the wall shear stress in vessel segments of the entire LCx arterial tree of CHF animals. This study enhances our knowledge of coronary arterial tree remodeling in heart failure, which provides a deeper understanding of the deterioration of supply-demand relation in left ventricle.
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Affiliation(s)
- Yunlong Huo
- Department of Mechanics and Engineering Science, College of Engineering, Peking University, Beijing, China; State Key Laboratory for Turbulence and Complex Systems, College of Engineering, Peking University, Beijing, China; College of Medicine, Hebei University, Baoding, China; and
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44
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Abstract
Atrial fibrillation (AF) and heart failure (HF) are two epidemics of the century that have a close and complex relationship. The mechanisms underlying this association remain an area of ongoing intense research. In this review, we will describe the relationship between these two public health concerns, the mechanisms that fuel the development and perpetuation of both, and the evolving concepts that may revolutionize our approach to this dual epidemic.
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Affiliation(s)
- Christina Luong
- Division of Cardiology, University of British Columbia, 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada
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45
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Steinberg BA, Schulte PJ, Hofmann P, Ersbøll M, Alexander JH, Broderick-Forsgren K, Anstrom KJ, Granger CB, Piccini JP, Velazquez EJ, Shah BR. Outcomes after nonemergent electrical cardioversion for atrial arrhythmias. Am J Cardiol 2015; 115:1407-14. [PMID: 25784514 DOI: 10.1016/j.amjcard.2015.02.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 02/06/2015] [Accepted: 02/06/2015] [Indexed: 10/24/2022]
Abstract
Electrical cardioversion (ECV) is recommended for rhythm control in patients with atrial arrhythmia; yet, ECV use and outcomes in contemporary practice are unknown. We reviewed all nonemergent ECVs for atrial arrhythmias at a tertiary care center (2010 to 2013), stratifying patients by transesophageal echocardiography (TEE) use before ECV and comparing demographics, history, vitals, and laboratory studies. Outcomes included postprocedural success and complications and repeat cardioversion, rehospitalization, and death within 30 days. Overall, 1,017 patients underwent ECV, 760 (75%) for atrial fibrillation and 240 (24%) for atrial flutter; 633 underwent TEE before ECV and 384 did not. TEE recipients were more likely to be inpatients (74% vs 44%, p <0.001), have higher mean CHADS2 scores (2.6 vs 2.4, p = 0.03), and lower mean international normalized ratios (1.2 vs 2.1, p <0.001). Overall, 89 patients (8.8%) did not achieve sinus rhythm and 14 experienced procedural complications (1.4%). Within 30 days, 80 patients (7.9%) underwent repeat ECV, 113 (11%) were rehospitalized, and 14 (1.4%) died. Although ECV success was more common in patients who underwent TEE before ECV (77% vs 68%, p = 0.01), there were no differences in 30-day death or rehospitalization rates (11.1% vs 13.0%, p = 0.37). In multivariate analyses, higher pre-ECV heart rate was associated with increased rehospitalization or death (adjusted hazard ratio 1.15/10 beats/min, 95% confidence interval 1.07 to 1.24, p <0.001), whereas TEE use was associated with lower rates (adjusted hazard ratio 0.58, 95% confidence interval 0.39 to 0.86, p = 0.007). In conclusion, failures, complications, and rehospitalization after nonemergent ECV are common and associated more with patient condition than procedural characteristics. TEE use was associated with better clinical outcomes.
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Arrigo M, Bettex D, Rudiger A. [Treatment of atrial fibrillation in intensive care units and emergency departments]. Med Klin Intensivmed Notfmed 2015; 110:614-20. [PMID: 25876744 DOI: 10.1007/s00063-015-0006-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Revised: 12/08/2014] [Accepted: 12/18/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Atrial fibrillation is the most common arrhythmia in patients hospitalized in intensive care units and emergency departments and is associated with an increased morbidity and mortality. In critically ill patients, atrial fibrillation can cause hemodynamic instability and cardiogenic shock. The mechanisms and the management of atrial fibrillation are significantly different in critically ill patients compared to outpatients. DIAGNOSIS AND TREATMENT The initial management includes the evaluation of the hemodynamic consequences of new-onset atrial fibrillation and the optimization of reversible causes. In patients with hemodynamic instability the rapid restoration of an adequate perfusion pressure is the initial goal. Often, a rapid conversion in sinus rhythm is required to achieve hemodynamic stabilization. Electrical cardioversion, if possible performed after pretreatment with an antiarrhythmic drug to increase the success rate, frequently plays a central role in the conversion to sinus rhythm of hemodynamically unstable patients. Stable patients are initially treated with a short-acting intravenous β-blocker to achieve heart rate control. A conversion to sinus rhythm may be achieved pharmacologically with vernakalant, an atrial-specific multichannel blocker. EVALUATION All patients with atrial fibrillation lasting more than 48 h should be evaluated for anticoagulation in order to reduce cardio-embolic complications. After recovering from the acute illness, atrial fibrillation persists only in a minority of patients.
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Affiliation(s)
- M Arrigo
- Klinik für Kardiologie, Universitäres Herzzentrum, Universitätsspital Zürich, Raemistrasse 100, 8091, Zürich, Schweiz.,Herzchirurgische Intensivstation, Institut für Anästhesiologie, Universitätsspital Zürich, Raemistrasse 100, 8091, Zürich, Schweiz
| | - D Bettex
- Herzchirurgische Intensivstation, Institut für Anästhesiologie, Universitätsspital Zürich, Raemistrasse 100, 8091, Zürich, Schweiz
| | - A Rudiger
- Herzchirurgische Intensivstation, Institut für Anästhesiologie, Universitätsspital Zürich, Raemistrasse 100, 8091, Zürich, Schweiz.
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Abstract
Atrial fibrillation (AF) is the most common sustained clinical arrhythmia and is associated with significant morbidity, mostly secondary to heart failure and stroke, and an estimated two-fold increase in premature death. Efforts to increase our understanding of AF and its complications have focused on unravelling the mechanisms of electrical and structural remodelling of the atrial myocardium. Yet, it is increasingly recognized that AF is more than an atrial disease, being associated with systemic inflammation, endothelial dysfunction, and adverse effects on the structure and function of the left ventricular myocardium that may be prognostically important. Here, we review the molecular and in vivo evidence that underpins current knowledge regarding the effects of human or experimental AF on the ventricular myocardium. Potential mechanisms are explored including diffuse ventricular fibrosis, focal myocardial scarring, and impaired myocardial perfusion and perfusion reserve. The complex relationship between AF, systemic inflammation, as well as endothelial/microvascular dysfunction and the effects of AF on ventricular calcium handling and oxidative stress are also addressed. Finally, consideration is given to the clinical implications of these observations and concepts, with particular reference to rate vs. rhythm control.
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Affiliation(s)
- Rohan S Wijesurendra
- Division of Cardiovascular Medicine, BHF Centre of Research Excellence, University of Oxford, John Radcliffe Hospital, Level 6 West Wing, Oxford OX3 9DU, UK
| | - Barbara Casadei
- Division of Cardiovascular Medicine, BHF Centre of Research Excellence, University of Oxford, John Radcliffe Hospital, Level 6 West Wing, Oxford OX3 9DU, UK
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48
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Lobo TJ, Pachon CT, Pachon JC, Pachon EI, Pachon MZ, Pachon JC, Santillana TG, Zerpa JC, Albornoz RN, Jatene AD. Atrial fibrillation ablation in systolic dysfunction: clinical and echocardiographic outcomes. Arq Bras Cardiol 2014; 104:45-52. [PMID: 25387404 PMCID: PMC4387610 DOI: 10.5935/abc.20140167] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 07/31/2014] [Indexed: 11/20/2022] Open
Abstract
Background Heart failure and atrial fibrillation (AF) often coexist in a deleterious
cycle. Objective To evaluate the clinical and echocardiographic outcomes of patients with
ventricular systolic dysfunction and AF treated with radiofrequency (RF)
ablation. Methods Patients with ventricular systolic dysfunction [ejection fraction (EF) <50%]
and AF refractory to drug therapy underwent stepwise RF ablation in the same
session with pulmonary vein isolation, ablation of AF nests and of residual atrial
tachycardia, named "background tachycardia". Clinical (NYHA functional class) and
echocardiographic (EF, left atrial diameter) data were compared (McNemar test and
t test) before and after ablation. Results 31 patients (6 women, 25 men), aged 37 to 77 years (mean, 59.8±10.6), underwent RF
ablation. The etiology was mainly idiopathic (19 p, 61%). During a mean follow-up
of 20.3±17 months, 24 patients (77%) were in sinus rhythm, 11 (35%) being on
amiodarone. Eight patients (26%) underwent more than one procedure (6 underwent 2
procedures, and 2 underwent 3 procedures). Significant NYHA functional class
improvement was observed (pre-ablation: 2.23±0.56; postablation: 1.13±0.35;
p<0.0001). The echocardiographic outcome also showed significant ventricular
function improvement (EF pre: 44.68%±6.02%, post: 59%±13.2%, p=0.0005) and a
significant left atrial diameter reduction (pre: 46.61±7.3 mm; post: 43.59±6.6 mm;
p=0.026). No major complications occurred. Conclusion Our findings suggest that AF ablation in patients with ventricular systolic
dysfunction is a safe and highly effective procedure. Arrhythmia control has a
great impact on ventricular function recovery and functional class
improvement.
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Affiliation(s)
- Tasso Julio Lobo
- Serviço de Arritmias - Eletrofisiologia e Marca-passo, Hospital do Coração de São Paulo Hcor, São Paulo, SP, Brazil
| | - Carlos Thiene Pachon
- Serviço de Arritmias - Eletrofisiologia e Marca-passo, Hospital do Coração de São Paulo Hcor, São Paulo, SP, Brazil
| | - Jose Carlos Pachon
- Serviço de Arritmias - Eletrofisiologia e Marca-passo, Hospital do Coração de São Paulo Hcor, São Paulo, SP, Brazil
| | - Enrique Indalecio Pachon
- Serviço de Arritmias - Eletrofisiologia e Marca-passo, Hospital do Coração de São Paulo Hcor, São Paulo, SP, Brazil
| | - Maria Zelia Pachon
- Serviço de Arritmias - Eletrofisiologia e Marca-passo, Hospital do Coração de São Paulo Hcor, São Paulo, SP, Brazil
| | - Juan Carlos Pachon
- Serviço de Arritmias - Eletrofisiologia e Marca-passo, Hospital do Coração de São Paulo Hcor, São Paulo, SP, Brazil
| | - Tomas Guillermo Santillana
- Serviço de Arritmias - Eletrofisiologia e Marca-passo, Hospital do Coração de São Paulo Hcor, São Paulo, SP, Brazil
| | - Juan Carlos Zerpa
- Serviço de Arritmias - Eletrofisiologia e Marca-passo, Hospital do Coração de São Paulo Hcor, São Paulo, SP, Brazil
| | - Remy Nelson Albornoz
- Serviço de Arritmias - Eletrofisiologia e Marca-passo, Hospital do Coração de São Paulo Hcor, São Paulo, SP, Brazil
| | - Adib Domingos Jatene
- Serviço de Arritmias - Eletrofisiologia e Marca-passo, Hospital do Coração de São Paulo Hcor, São Paulo, SP, Brazil
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49
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Aleong RG, Sauer WH, Davis G, Bristow MR. New-onset atrial fibrillation predicts heart failure progression. Am J Med 2014; 127:963-71. [PMID: 24931393 DOI: 10.1016/j.amjmed.2014.06.006] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 06/02/2014] [Accepted: 06/02/2014] [Indexed: 01/24/2023]
Abstract
BACKGROUND Atrial fibrillation and heart failure with reduced left ventricular ejection fraction have interrelated pathophysiologies. New-onset atrial fibrillation in heart failure patients has been associated with increased mortality, but has not been definitively related to clinical heart failure progression. METHODS To test the hypothesis that new-onset atrial fibrillation is related to clinical heart failure progression, in 2392 patients without atrial fibrillation at randomization in the Beta-blocker Evaluation of Survival Trial we measured clinical endpoints in patients who did (Group 1, n = 190) or did not (Group 2, n = 2202) develop new-onset atrial fibrillation. Results were also compared with the 303 patients who entered the trial in atrial fibrillation (Baseline/chronic group), and in Group 1/2 patients we conducted a multivariate analysis of covariates potentially related to time to first heart failure hospitalization. RESULTS Compared with Group 2, Group 1 patients post atrial fibrillation onset had a ∼2-fold increase in mortality (P < .0001) and a ∼4.5-fold increase in all-cause or heart failure hospitalization days/patient (hospitalization burden, both P < .0001). In Group 1, both types of hospitalization burden were 2.9-fold greater than in the Baseline/chronic group (P < .001), and hospitalization burden increased ∼6-fold (P < .0001) compared with the pre-event period. On multivariate analysis, new-onset atrial fibrillation was a highly significant (P < .00001) predictor of heart failure hospitalization. CONCLUSIONS In addition to being a discrete electrophysiologic event, in heart failure patients, new-onset atrial fibrillation is a predictor of and trigger for clinical heart failure progression.
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Affiliation(s)
- Ryan G Aleong
- Division of Cardiology, University of Colorado, Aurora.
| | | | | | - Michael R Bristow
- Division of Cardiology, University of Colorado, Aurora; ARCA biopharma, Inc., Westminster, Colo
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