Internal Versus External Electrical Cardioversion of Atrial Arrhythmia in Patients With Implantable Cardioverter-Defibrillator: A Randomized Clinical Trial

Evaluation of troponin I serum levels in patients with arrhythmias with and without coronary artery disease

BACKGROUND

Elevated levels of cardiac enzymes in the blood are an indicator of ongoing cardiac ischemia. Persistent tachycardia may lead to myocardial ischemia due to oxygen supply-demand mismatch.

OBJECTIVES

We sought to evaluate the probability of underlying coronary artery disease (CAD) in patients with symptomatic supraventricular (SVT) or ventricular tachyarrhythmias (VT) based on cardiac enzyme level fluctuation.

MATERIALS AND METHODS

Troponin I (TNI) levels were measured twice and coronary angiography was also performed in patients without a history of cardiovascular disease and symptomatic SVT or VT.

RESULTS

Of the 114 (group A: CAD (n = 40), group B: no CAD (n = 74)) patients eligible for the study, 34 patients in group A and 64 patients in group B had SVT, while 6 patients in group A and 10 patients in group B had VT. All patients with underlying CAD developed a significantly elevated TNI level compared to baseline, irrespective of arrhythmia type (2.02 ± 7.98 ng/ml vs. 5.64 ± 13.38, p = 0.031). In patients without CAD, TNI level was not significantly elevated compared to the baseline level, irrespective of arrhythmia type (0.34 ± 1.38 ng/ml vs. 0.48 ± 1.48 ng/ml, p = 0.158). Most patients with normal TNI levels (46 of 47 patients; 98 %) had SVT. CAD was present in 13 of 47 patients (27 %) with tachycardia, despite normal TNI levels.

CONCLUSIONS

Elevated TNI levels are not helpful to discriminate between SVT and VT. An increase in TNI level in repeated blood sampling can help identify patients with higher probability of underlying CAD. Patients with VT demonstrated higher increases in TNI levels, compared to patients with SVT.

Comparative Effectiveness of Direct Current Cardioversion in Patients With Atrial Fibrillation and Obesity With Body Mass Index ≥50 kg/m2

Atrial fibrillation is one of the most frequently encountered arrhythmia, with obesity being an independent risk factor. There are sparse data on the success rates of direct current cardioversion (DCCV) in patients with severe obesity. We compared the effectiveness of DCCV in patients with a body mass index (BMI) >50 kg/m2 with those with a BMI <30 kg/m2. A retrospective chart review of 111 patients was performed between January 1, 2011 and January 1, 2022. The study cohort was stratified into 2 groups: BMI ≥50 kg/m2 and BMI <30 kg/m2. The primary outcome was successful achievement of normal sinus rhythm after DCCV. The secondary outcomes included number of attempted shocks, number of successful shocks on first attempts, and energy of successful shock. The primary outcome occurred in 94.6% of patients with a BMI <30 kg/m2 group compared with 81.8% in the patients with a BMI ≥50 kg/m2 (p = 0.042). Patients in the higher BMI cohort had a higher median energy during a successful shock than the lower BMI cohort (250 J [200 to 360 J] vs 200 J [150 to 200 J], p <0.001). There was no difference in the number of shocks used between the 2 groups or in the success of the first shock delivered between BMI ≥50 kg/m2 and BMI <30 kg/m2 (75% vs 58.2%, p = 0.093). In conclusion, patients with a BMI ≥50 kg/m2 had lower rates of successful DCCV than patients with a BMI <30 kg/m2; therefore, clinicians must be aware of the alternative strategies to improve DCCV success and the possibility of DCCV failure in patients with higher BMIs.

Long-term risk of cardiovascular implantable electronic device reinterventions following external cardioversion of atrial fibrillation and flutter: A nationwide cohort study

BACKGROUND

External cardioversion (ECV) is an essential part of rhythm control of atrial fibrillation and flutter in patients with and without cardiovascular implantable electronic devices (CIEDs). Long-term follow-up data on ECV-related CIED dysfunctions are limited.

OBJECTIVE

The purpose of this study was to investigate the risk of CIED reintervention following ECV in a nationwide cohort.

METHODS

We identified CIED implants and surgical reinterventions from 2005 to 2021 in the Danish Pacemaker and ICD Register. We included CIED patients undergoing ECV from 2010 to 2019 from the Danish National Patient Registry. For each ECV-exposed generator, 5 matched generators without ECV were identified, and for each ECV-exposed lead, 3 matched leads were identified. The primary endpoints were generator replacement and lead reintervention.

RESULTS

We compared 2582 ECV-exposed patients with 12,910 matched patients with a pacemaker (47%), implantable cardioverter-defibrillator (ICD) (29%), cardiac resynchronization therapy-pacemaker (6%), or cardiac resynchronization therapy-defibrillator (18%). During 2 years of follow-up, 210 ECV-exposed generators (8.1%) vs 670 matched generators (5.2%) underwent replacements, and 247 ECV-exposed leads (5.6%) vs 306 matched leads (2.3%) underwent reintervention. Unadjusted hazard ratios were 1.61 (95% confidence interval [CI] 1.37-1.91; P <.001) for generator replacement and 2.39 (95% CI 2.01-2.85; P <.001) for lead reintervention. One-year relative risks were 1.73 (95% CI 1.41-2.12; P <.001) for generator replacement and 2.85 (95% CI 2.32-3.51; P <.001) for lead reintervention, and 2-year relative risks were 1.39 (95% CI 1.19-1.63; P <.001) and 2.18 (95% CI 1.84-2.57; P <.001), respectively.

CONCLUSION

ECV in patients with a CIED is associated with a higher risk of generator replacement and lead reintervention. The risks of reinterventions were more pronounced within the first year after cardioversion.

ANMCO-SIMEU consensus document: appropriate management of atrial fibrillation in the emergency department

Atrial fibrillation (AF) accounts for 2% of the total presentations to the emergency department (ED) and represents the most frequent arrhythmic cause for hospitalization. It steadily increases the risk of thromboembolic events and is often associated with several comorbidities that negatively affect patient's quality of life and prognosis. AF has a considerable impact on healthcare resources, making the promotion of an adequate and coordinated management of this arrhythmia necessary in order to avoid clinical complications and to implement the adoption of appropriate technological and pharmacological treatment options. AF management varies across regions and hospitals and there is also heterogeneity in the use of anticoagulation and electric cardioversion, with limited use of direct oral anticoagulants. The ED represents the first access point for early management of patients with AF. The appropriate management of this arrhythmia in the acute setting has a great impact on improving patient's quality of life and outcomes as well as on rationalization of the financial resources related to the clinical course of AF. Therefore, physicians should provide a well-structured clinical and diagnostic pathway for patients with AF who are admitted to the ED. This should be based on a tight and propositional collaboration among several specialists, i.e. the ED physician, cardiologist, internal medicine physician, anesthesiologist. The aim of this ANMCO-SIMEU consensus document is to provide shared recommendations for promoting an integrated, accurate, and up-to-date management of patients with AF admitted to the ED or Cardiology Department, in order to make it homogeneous across the national territory.

External Cardioversion-Defibrillation with Pushing Down on the Chest Wall to Increase the Success Rate in Obese Patients

Case series

Patients: Female, 17-year-old • Male, 63-year-old • Male, 65-year-old

Final Diagnosis: Atrial fibrillation

Symptoms: Palpitations

Medication: —

Clinical Procedure: Cardioversion

Specialty: Cardiology • Pediatrics and Neonatology

External versus internal cardioversion for atrial fibrillation: a meta-analysis of randomized controlled trials

BACKGROUND

Patients with atrial fibrillation (AF) often require rhythm control strategy for amelioration of symptoms. It is unclear if there is any difference between external cardioversion (ECV) and internal cardioversion (ICV) for successful conversion of AF to normal sinus rhythm.

METHODS

We performed a meta-analysis of published randomized controlled trials (RCTs) evaluating success of cardioversion using ECV versus ICV.

RESULTS

In the pooled analysis of 5 RCTS, there was no difference in success of cardioversion using ECV versus ICV (OR 1.69, 95% CI 0.24-11.83, p = 0.6). In the subgroup analysis, there was no difference between ECV and direct electrode ICV (OR 0.41, 95% CI 0.09-1.83, p = 0.24). However, ECV was significantly better compared with ICV using ICD (OR 11.97, 95% CI 1.87-76.73, p = 0.009).

CONCLUSIONS

There was no difference between ECV versus ICV in effectiveness for termination of AF. Larger well-designed randomized controlled trials are needed to confirm our findings.