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McIntyre WF, Benz AP, Tojaga N, Brandes A, Lopes RD, Healey JS. Direct oral anticoagulants for stroke prevention in patients with device-detected atrial fibrillation: assessing net clinical benefit. Eur Heart J Suppl 2024; 26:iv4-iv11. [PMID: 39099575 PMCID: PMC11292410 DOI: 10.1093/eurheartjsupp/suae075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/06/2024]
Abstract
Subclinical, device-detected atrial fibrillation (AF) is frequently recorded by pacemakers and other implanted cardiac rhythm devices. Patients with device-detected AF have an elevated risk of stroke, but a lower risk of stroke than similar patients with clinical AF captured with surface electrocardiogram. Two randomized clinical trials (NOAH-AFNET 6 and ARTESiA) have tested a direct oral anticoagulant (DOAC) against aspirin or placebo. A study-level meta-analysis of the two trials found that treatment with a DOAC resulted in a 32% reduction in ischaemic stroke and a 62% increase in major bleeding; the results of the two trials were consistent. The annualized rate of stroke in the control arms was ∼1%. Several factors point towards overall net benefit from DOAC treatment for patients with device-detected AF. Strokes in ARTESiA were frequently fatal or disabling and bleeds were rarely lethal. The higher absolute rates of major bleeding compared with ischaemic stroke while on treatment with a DOAC in the two trials are consistent with the ratio of bleeds to strokes seen in the pivotal DOAC vs. warfarin trials in patients with clinical AF. Prior research has concluded that patients place a higher emphasis on stroke prevention than on bleeding. Further research is needed to identify the characteristics that will help identify patients with device-detected AF who will receive the greatest benefit from DOAC treatment.
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Affiliation(s)
- William F McIntyre
- Population Health Research Institute, McMaster University, 237 Barton St East, Hamilton, Ontario, L8L 2X2, Canada
| | - Alexander P Benz
- Population Health Research Institute, McMaster University, 237 Barton St East, Hamilton, Ontario, L8L 2X2, Canada
- Department of Cardiology, University Medical Centre Mainz, Johannes Gutenberg-University, Mainz, Germany
| | - Nedim Tojaga
- Department of Cardiology, Esbjerg and Grindsted Hospital—University Hospital of Southern Denmark, Esbjerg, Denmark
| | - Axel Brandes
- Department of Cardiology, Esbjerg and Grindsted Hospital—University Hospital of Southern Denmark, Esbjerg, Denmark
- Department of Regional Health Research, University of Southern Denmark, Esbjerg, Denmark
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Jeff S Healey
- Population Health Research Institute, McMaster University, 237 Barton St East, Hamilton, Ontario, L8L 2X2, Canada
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Astărăstoae V, Rogozea LM. Reimplantation of Implantable Cardiac Devices-An Ethical Controversy? Am J Ther 2023; Publish Ahead of Print:00045391-990000000-00156. [PMID: 37285587 DOI: 10.1097/mjt.0000000000001646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND Cardiovascular diseases are an important public health problem, the main cause of death in both men and women, with a continuous increasing prevalence and consequences upon morbidity in economic, physical, and psychological terms.The new technology have made possible the development of innovative devices, which have increased the possibility of therapeutic interventions today, extending the life of the population with cardiovascular pathology, transforming the patient care, and providing a complex, personalized therapeutic approach. FIELDS OF UNCERTAINTY The aim of the study was to evaluate from an ethical perspective the need, feasibility, and safety of reusing cardiac pacemakers to revise the legal terms and requirements.In recent years, the problem of accessibility to cardiovascular drugs has been increasingly accompanied by the accessibility to technology, interventional cardiology advancing recently, and becoming an increasingly important standard of care. DATA SOURCES A review of the specialized literature was performed in March 2023, using keywords such as implantable cardiac devices, reuse, ethics from PubMed, Scopus, Web of Science, and Google Scholar, as well as official documents issued at the international level (World Health Organization). ETHICS AND THERAPEUTIC ADVANCES An ethical analysis assesses the extent to which a medical act (PM reimplantation) is covered by the 4 universally accepted principles: nonmaleficence, beneficence, autonomy (respect for the person), and social justice, the analysis addressing to the risk-benefit ratio based on studies that analyzed the phenomenon over the past 50 years. The ethical analyzed issues start from the fact that although 80% of pacemakers, most of them working perfectly, with a battery life of more than 7 years are buried with their owners, while approximately 3 million patients die annually due to the lack of access to these devices in undeveloped and developing countries.But beyond the ethical issues, legal practice has meant that in many countries, reusing of these devices is prohibited, mostly being single-use devices. Low-income countries continue to accept this practice as the only one economically accessible to them, considering the prohibition of reusing them to be an economic rather than a medical issue. CONCLUSIONS Reusing implantable cardiac devices is of great interest because of the costs, being in certain situations, the only possibility that certain people can have access to a therapeutic method that ensures their health recovery and increases their quality of life. But this is not possible without clear procedures, without clear criteria on how sterilization should be performed, how the technique should be performed, without obtaining a truly informed consent, and especially without a proper patient's follow-up.
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Affiliation(s)
| | - Liliana M Rogozea
- Basic, Preventive and Clinical Sciences Department, Transilvania University, Brasov, Romania
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Advancing global equity in cardiac care as cardiac implantable electronic device reuse comes of age. Heart Rhythm O2 2022; 3:799-806. [PMID: 36589002 PMCID: PMC9795283 DOI: 10.1016/j.hroo.2022.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
A nation's health and economic development are inextricably and synergistically connected. Stark differences exist between wealthy and developing nations in the use of cardiac implantable electronic devices (CIEDs). Cardiovascular disease is now the leading cause of death in low- and middle-income countries (LMIC), with a significant burden from rhythm-related diseases. As science, technology, education, and regulatory frameworks have improved, CIED recycling for exportation and reuse in LMIC has become possible and primed for widespread adoption. In our manuscript, we outline the science and regulatory pathways regarding CIED reuse. We propose a pathway to advance this technology that includes creating a task force to establish standards for CIED reuse, leveraging professional organizations in areas of need to foster the professional skills for CIED reuse, collaborating with regulatory agencies to create more efficient regulatory expectations and bring the concept to scale, and establishing a global CIED reuse registry for quality assurance and future science.
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A call for large-scale CIED recycling. J Interv Card Electrophysiol 2022:10.1007/s10840-022-01389-5. [PMID: 36242678 DOI: 10.1007/s10840-022-01389-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 09/29/2022] [Indexed: 10/17/2022]
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Sinha SK, Ezeh EO, Marine JE. Post-Mortem Pacemaker Reuse: Charity for Most but not All. J Cardiovasc Electrophysiol 2022; 33:481-482. [PMID: 35040505 DOI: 10.1111/jce.15369] [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] [Received: 01/11/2022] [Accepted: 01/13/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Sunil K Sinha
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ebubechukwu O Ezeh
- Department of Medicine, Marshall University School of Medicine, Huntington, West Virginia
| | - Joseph E Marine
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Hughey AB, Muthappan P, Badin A, Baman T, Baig-Ansari N, Jawed F, Khan AB, Jiang Q, Hughey KL, Toruño RJ, Machado C, Refaat MM, Zakka P, Hotait M, Eagle KA, Crawford TC. Patients' and Family Members' Views on Pacemaker Reuse: an International Survey. J Cardiovasc Electrophysiol 2022; 33:473-480. [PMID: 35040526 DOI: 10.1111/jce.15367] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 11/12/2021] [Accepted: 12/02/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The reuse of cardiac implantable electronic devices may help increase access to these therapies in low- and middle-income countries (LMICs). No published data exist regarding the views of patients and family members in LMICs regarding this practice. METHODS AND RESULTS A paper questionnaire eliciting attitudes regarding pacemaker reuse was administered to ambulatory adult patients and patients' family members at outpatient clinics at Centro Nacional Cardiologia in Managua, Nicaragua, Indus Hospital in Karachi, Pakistan, Hospital Carlos Andrade Marín and Hospital Eugenio Espejo in Quito, Ecuador, and American University of Beirut Medical Center in Beirut, Lebanon. There were 945 responses (Nicaragua - 100; Pakistan - 493; Ecuador - 252; Lebanon - 100). A majority of respondents agreed or strongly agreed that they would be willing to accept a reused pacemaker if risks were similar to a new device (707, 75%), if there were a higher risk of device failure compared to a new device (584, 70%), or if there were a higher risk of infection compared to a new device (458, 56%). A large majority would be willing to donate their own pacemaker at the time of their death (884, 96%) or the device of a family member (805, 93%). Respondents who were unable to afford a new device were more likely to be willing to accept a reused device (79% vs. 63%, P<0.001). CONCLUSIONS Patients and their family members support the concept of pacemaker reuse for patients who cannot afford new devices. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Andrew B Hughey
- Michigan Heart, Saint Joseph Mercy Health System, Ypsilanti, MI, USA
| | - Palaniappan Muthappan
- Wright State University Boonshoft School of Medicine, Internal Medicine, Dayton, OH, USA
| | - Auroa Badin
- University of Texas Health Science Center at San Antonio, Internal Medicine, San Antonio, Texas, USA
| | | | - Naila Baig-Ansari
- The Indus Hospital, Indus Hospital Research Center, Karachi, Pakistan
| | | | - Abdul B Khan
- Indus Hospital, Indus Hospital Research Center, Karachi, Pakistan
| | - Qingmei Jiang
- University of Michigan, Michigan Medicine, Internal Medicine, Ann Arbor, MI, USA
| | - Katherine L Hughey
- University of Michigan, Michigan Medicine, Family Medicine Ann Arbor, MI, USA
| | | | - Christian Machado
- Providence Hospital and Medical Center, Cardiology/Electrophysiology, Southfield, Michigan, USA.,Wayne State University, Internal Medicine, Detroit, Michigan, USA
| | - Marwan M Refaat
- Department of Internal Medicine, Cardiovascular Medicine Division, American University of Beirut Medical Center, Lebanon
| | - Patrick Zakka
- Emory University School of Medicine, Internal Medicine, Atlanta, Georgia, USA
| | - Mostafa Hotait
- Department of Internal Medicine, Cardiovascular Medicine Division, American University of Beirut Medical Center, Lebanon
| | - Kim A Eagle
- University of Michigan, Michigan Medicine, Internal Medicine, Ann Arbor, MI, USA
| | - Thomas C Crawford
- University of Michigan, Michigan Medicine, Internal Medicine, Ann Arbor, MI, USA
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Akinyele B, Marine JE, Love C, Crawford TC, Chrispin J, Vlay SC, Spragg DD, Eagle KA, Berger RD, Calkins H, Tomaselli GF, Sinha SK. Unregulated online sales of cardiac implantable electronic devices in the United States: A six-month assessment. Heart Rhythm O2 2020; 1:235-238. [PMID: 34113877 PMCID: PMC8183896 DOI: 10.1016/j.hroo.2020.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Background An estimated 1 million patients require cardiac implantable electronic devices (CIEDs) but go without annually. This disparity exists in low-to-middle-income nations largely owing to the cost of CIED hardware. Humanitarian reuse of CIEDs has been shown to be safe and feasible. However, recent publications have raised concern that promotion of CIED reuse may foster a CIED “black market,” to the dismay of manufacturers, regulators, and clinicians alike. Objective To determine if unregulated CIED sales for potential human use is a real issue by investigating unregulated public online CIED sale listings in the United States of America. Methods An observational study was undertaken over 6 months using multiple internet search engines from May 1 to November 1, 2019. We cataloged usable CIEDs (still in packaging, manufactured <7 years) and pricing. Manufacturers were contacted to determine status of sellers and unregulated CIEDs using model/serial numbers. Results In total, 58 CIEDs—47 implantable cardioverter-defibrillators and 11 permanent pacemakers—from 4 manufacturers were listed for sale on 3 websites. During the study period, 8 of 11 pacemakers and 37 of 47 implantable cardioverter-defibrillators were sold (price range: $100–$1500 [US dollars]). No new listings were seen in the last 3 months of observation, possibly owing to concomitant industry investigation. Conclusion There does exist a public online market for unregulated CIED sales in the United States. This specific market seems to be small and unlikely to significantly expand with active monitoring by manufacturers and regulators.
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Affiliation(s)
- Bolanle Akinyele
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joseph E Marine
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Charles Love
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Thomas C Crawford
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan
| | - Jonathan Chrispin
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Stephen C Vlay
- Division of Cardiovascular Disease, Stony Brook University, Stony Brook, New York
| | - David D Spragg
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kim A Eagle
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan
| | - Ronald D Berger
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Hugh Calkins
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Gordon F Tomaselli
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - Sunil K Sinha
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Lemery R. The great pandemic of 2020: A defining moment for Heart Rhythm Societies and their members. J Cardiovasc Electrophysiol 2020; 31:1577-1578. [DOI: 10.1111/jce.14570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 04/20/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Robert Lemery
- AZ Heart Rhythm Center and St‐Joseph Hospital Dignity Health Phoenix Arizona
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