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Medvedev RY, Afolabi SO, Turner DGP, Glukhov AV. Mechanisms of stretch-induced electro-anatomical remodeling and atrial arrhythmogenesis. J Mol Cell Cardiol 2024; 193:11-24. [PMID: 38797242 PMCID: PMC11260238 DOI: 10.1016/j.yjmcc.2024.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 05/15/2024] [Accepted: 05/21/2024] [Indexed: 05/29/2024]
Abstract
Atrial fibrillation (AF) is the most common cardiac rhythm disorder, often occurring in the setting of atrial distension and elevated myocardialstretch. While various mechano-electrochemical signal transduction pathways have been linked to AF development and progression, the underlying molecular mechanisms remain poorly understood, hampering AF therapies. In this review, we describe different aspects of stretch-induced electro-anatomical remodeling as seen in animal models and in patients with AF. Specifically, we focus on cellular and molecular mechanisms that are responsible for mechano-electrochemical signal transduction and the development of ectopic beats triggering AF from pulmonary veins, the most common source of paroxysmal AF. Furthermore, we describe structural changes caused by stretch occurring before and shortly after the onset of AF as well as during AF progression, contributing to longstanding forms of AF. We also propose mechanical stretch as a new dimension to the concept "AF begets AF", in addition to underlying diseases. Finally, we discuss the mechanisms of these electro-anatomical alterations in a search for potential therapeutic strategies and the development of novel antiarrhythmic drugs targeted at the components of mechano-electrochemical signal transduction not only in cardiac myocytes, but also in cardiac non-myocyte cells.
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Affiliation(s)
- Roman Y Medvedev
- Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
| | - Saheed O Afolabi
- Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA; Department of Pharmacology and Therapeutics, University of Ilorin, Ilorin, Nigeria
| | - Daniel G P Turner
- Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
| | - Alexey V Glukhov
- Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA.
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2
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O'Meara K, Stone G, Buch E, Brownstein A, Saggar R, Channick R, Sherman AE, Bender A. Atrial Arrhythmias in Patients With Pulmonary Hypertension. Chest 2024; 166:201-211. [PMID: 38453002 DOI: 10.1016/j.chest.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 03/01/2024] [Accepted: 03/04/2024] [Indexed: 03/09/2024] Open
Abstract
TOPIC IMPORTANCE Atrial arrhythmias (AA) are common in patients with pulmonary hypertension (PH) and contribute to morbidity and mortality. Given the growing PH population, understanding the pathophysiology, clinical impact, and management of AA in PH is important. REVIEW FINDINGS AA occurs in PH with a 5-year incidence of 10% to 25%. AA confers a higher morbidity and mortality, and restoration of normal sinus rhythm improves survival and functionality. AA is thought to develop because of structural alterations of the right atrium caused by changes to the right ventricle (RV) due to elevated pulmonary artery pressures. AA can subsequently worsen RV function. Current guidelines do not provide comprehensive recommendations for the management of AA in PH. Robust evidence to favor a specific treatment approach is lacking. Although the role of medical rate or rhythm control, and the use of cardioversion and ablation, can be inferred from other populations, evidence is lacking in the PH population. Much remains to be determined regarding the optimal management strategy. We present here our institutional approach and discuss areas for future research. SUMMARY This review highlights the epidemiology and pathophysiology of AA in patients with PH, describes the relationship between AA and RV dysfunction, and discusses current management practices. We outline our institutional approach and offer directions for future investigation.
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MESH Headings
- Humans
- Hypertension, Pulmonary/physiopathology
- Hypertension, Pulmonary/therapy
- Hypertension, Pulmonary/epidemiology
- Hypertension, Pulmonary/diagnosis
- Hypertension, Pulmonary/etiology
- Arrhythmias, Cardiac/physiopathology
- Arrhythmias, Cardiac/therapy
- Arrhythmias, Cardiac/epidemiology
- Arrhythmias, Cardiac/etiology
- Atrial Fibrillation/physiopathology
- Atrial Fibrillation/therapy
- Atrial Fibrillation/complications
- Atrial Fibrillation/epidemiology
- Ventricular Dysfunction, Right/physiopathology
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Affiliation(s)
- Kyle O'Meara
- Department of Pulmonary & Critical Care Medicine, Cedars Sinai Medical Center, Los Angeles, CA
| | - Gregory Stone
- UCLA Department of Internal Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Eric Buch
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Adam Brownstein
- Division of Pulmonary, Critical Care, Sleep Medicine, Clinical Immunology and Allergy, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Rajan Saggar
- Division of Pulmonary, Critical Care, Sleep Medicine, Clinical Immunology and Allergy, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Richard Channick
- Division of Pulmonary, Critical Care, Sleep Medicine, Clinical Immunology and Allergy, David Geffen School of Medicine at UCLA, Los Angeles, CA.
| | - Alexander E Sherman
- Division of Pulmonary, Critical Care, Sleep Medicine, Clinical Immunology and Allergy, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Aron Bender
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, CA
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Sefton C, Tanaka-Esposito C, Dresing T, Lee J, Chung R. Outcomes of combined left bundle branch area pacing with atrioventricular nodal ablation in patients with atrial fibrillation and pulmonary disease. Pacing Clin Electrophysiol 2024; 47:946-952. [PMID: 38641952 DOI: 10.1111/pace.14990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 03/06/2024] [Accepted: 04/09/2024] [Indexed: 04/21/2024]
Abstract
INTRODUCTION Concomitant left bundle branch area pacing (LBBAP) with atrioventricular (AV) nodal ablation is emerging as a viable management option in atrial fibrillation refractory to medical management. Its viability in patients with pulmonary disease and atrial fibrillation is unknown. METHODS AND RESULTS This is a retrospective, observational cohort study in consecutive patients who underwent concomitant LBBAP with AV nodal ablation with advanced pulmonary disease at the Cleveland Clinic Fairview Hospital between January 2019 and January 2023. Patient characteristics, comorbidities, and medication use were extracted via chart review. Rates of hospitalizations, medication use, and structural disease seen on echocardiography were compared before and after the procedure. There were 27 patients with group 3 pulmonary hypertension who underwent the procedure. In the 24 months preprocedure, there were 114 admissions for heart failure or atrial fibrillation compared to 9 admissions postprocedure (p < .001). Mean follow up was 17.3 ± 12.1 months. There were no significant complications or lead dislodgements. Echocardiographic characteristics were similar prior to and after pacemaker implantation. Use of medications for rate and rhythm control was common preprocedure, and was reduced dramatically postprocedure. CONCLUSION This small, retrospective cohort study suggests concomitant LBBAP with AV nodal ablation may be safe and efficacious for management of atrial fibrillation in patients with advanced pulmonary disease.
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Affiliation(s)
- Christopher Sefton
- Internal Medicine Residency Program, Cleveland Clinic, Cleveland, Ohio, USA
| | - Christine Tanaka-Esposito
- Section of Cardiac Electrophysiology and Pacing, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Thomas Dresing
- Section of Cardiac Electrophysiology and Pacing, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Justin Lee
- Section of Cardiac Electrophysiology and Pacing, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Roy Chung
- Section of Cardiac Electrophysiology and Pacing, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
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4
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Zhang A, Ding L, Zhang H, Mi L, Yu F, Tang M. Radiofrequency catheter ablation for pulmonary hypertension patients with atrial flutter. ESC Heart Fail 2024; 11:883-892. [PMID: 38200382 DOI: 10.1002/ehf2.14659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 11/06/2023] [Accepted: 12/18/2023] [Indexed: 01/12/2024] Open
Abstract
AIMS We aimed to evaluate the effects of radiofrequency catheter ablation (RFCA) and the factors influencing mortality after RFCA in patients with pulmonary hypertension (PH) and atrial flutter (AFL). METHODS AND RESULTS Fifty-eight consecutive PH patients with AFL who underwent an electrophysiological study and RFCA between April 2013 and August 2021 were selected for this study. In the study population, pulmonary arterial hypertension associated with congenital heart disease (PAH-CHD) was the most common type of PH (n = 34, 59%), followed by idiopathic pulmonary arterial hypertension (IPAH) (n = 19, 33%). Typical atrial flutter was the most common type of atrial flutter (n = 50, 86.2%). Sinus rhythm was restored in 53 (91.4%) patients during RFCA. After a mean follow-up of 33.8 months, AFL recurred in a total of 22 patients. Nine of them underwent repeat RFCA, and the site of the repeat ablation was not exactly the same as the first. At a median follow-up of 34.6 months after the last ablation, none of the patients who underwent repeat RFCA experienced AFL recurrence, and all of these patients survived. There were no procedure-related complications during hospitalization or follow-up. Univariate Cox regression analysis suggested that AFL recurrence after the last ablation was not associated with all-cause mortality. NT-proBNP (HR: 1.00024, 95% CI: 1.00008-1.00041, P = 0.004), pulmonary artery systolic pressure (PASP) (HR: 1.048, 95% CI: 1.020-1.076, P = 0.001), and IPAH (vs. PAH-CHD, HR 7.720, 95% CI: 1.437-41.483, P = 0.017) were independent predictors of all-cause mortality in PH patients with AFL after RFCA. Receiver operating characteristic (ROC) curve analysis revealed that the area under the curve (AUC) of PASP for predicting all-cause mortality was 0.708. There was no significant difference in the Kaplan-Meier curves for all-cause mortality between patients with AFL recurrence after the last ablation and those without recurrence (P = 0.851). Patients with higher PASP (≥110 mmHg) and IPAH showed the lower survival rate in Kaplan-Meier curves. CONCLUSION Repeat ablation was safe and feasible in patients with recurrent AFL and can maintain sinus rhythm. AFL recurrence was not associated with all-cause mortality, and patients with high PASP or IPAH were at higher risk for adverse outcomes.
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Affiliation(s)
- Aikai Zhang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Lei Ding
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Hongda Zhang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Lijie Mi
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Fengyuan Yu
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Min Tang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
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5
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Le Quilliec E, LeBlanc CA, Neuilly O, Xiao J, Younes R, Altuntas Y, Xiong F, Naud P, Villeneuve L, Sirois MG, Tanguay JF, Tardif JC, Hiram R. Atrial cardiomyocytes contribute to the inflammatory status associated with atrial fibrillation in right heart disease. Europace 2024; 26:euae082. [PMID: 38546222 PMCID: PMC11000822 DOI: 10.1093/europace/euae082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 03/25/2024] [Indexed: 04/09/2024] Open
Abstract
AIMS Right heart disease (RHD), characterized by right ventricular (RV) and atrial (RA) hypertrophy, and cardiomyocytes' (CM) dysfunctions have been described to be associated with the incidence of atrial fibrillation (AF). Right heart disease and AF have in common, an inflammatory status, but the mechanisms relating RHD, inflammation, and AF remain unclear. We hypothesized that right heart disease generates electrophysiological and morphological remodelling affecting the CM, leading to atrial inflammation and increased AF susceptibility. METHODS AND RESULTS Pulmonary artery banding (PAB) was surgically performed (except for sham) on male Wistar rats (225-275 g) to provoke an RHD. Twenty-one days (D21) post-surgery, all rats underwent echocardiography and electrophysiological studies (EPS). Optical mapping was performed in situ, on Langendorff-perfused hearts. The contractility of freshly isolated CM was evaluated and recorded during 1 Hz pacing in vitro. Histological analyses were performed on formalin-fixed RA to assess myocardial fibrosis, connexin-43 levels, and CM morphology. Right atrial levels of selected genes and proteins were obtained by qPCR and Western blot, respectively. Pulmonary artery banding induced severe RHD identified by RV and RA hypertrophy. Pulmonary artery banding rats were significantly more susceptible to AF than sham. Compared to sham RA CM from PAB rats were significantly elongated and hypercontractile. Right atrial CM from PAB animals showed significant augmentation of mRNA and protein levels of pro-inflammatory interleukin (IL)-6 and IL1β. Sarcoplasmic-endoplasmic reticulum Ca2+-ATPase-2a (SERCA2a) and junctophilin-2 were decreased in RA CM from PAB compared to sham rats. CONCLUSIONS Right heart disease-induced arrhythmogenicity may occur due to dysfunctional SERCA2a and inflammatory signalling generated from injured RA CM, which leads to an increased risk of AF.
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Affiliation(s)
- Ewen Le Quilliec
- Department of Medicine, Montreal Heart Institute, University of Montreal, 5000 Belanger Street, Montreal, QC HIT 1C8, Canada
| | - Charles-Alexandre LeBlanc
- Department of Medicine, Montreal Heart Institute, University of Montreal, 5000 Belanger Street, Montreal, QC HIT 1C8, Canada
| | - Orlane Neuilly
- Department of Medicine, Montreal Heart Institute, University of Montreal, 5000 Belanger Street, Montreal, QC HIT 1C8, Canada
| | - Jiening Xiao
- Department of Medicine, Montreal Heart Institute, University of Montreal, 5000 Belanger Street, Montreal, QC HIT 1C8, Canada
| | - Rim Younes
- Department of Medicine, Montreal Heart Institute, University of Montreal, 5000 Belanger Street, Montreal, QC HIT 1C8, Canada
| | - Yasemin Altuntas
- Department of Medicine, Montreal Heart Institute, University of Montreal, 5000 Belanger Street, Montreal, QC HIT 1C8, Canada
| | - Feng Xiong
- Department of Medicine, Montreal Heart Institute, University of Montreal, 5000 Belanger Street, Montreal, QC HIT 1C8, Canada
| | - Patrice Naud
- Department of Medicine, Montreal Heart Institute, University of Montreal, 5000 Belanger Street, Montreal, QC HIT 1C8, Canada
| | - Louis Villeneuve
- Department of Medicine, Montreal Heart Institute, University of Montreal, 5000 Belanger Street, Montreal, QC HIT 1C8, Canada
| | - Martin G Sirois
- Department of Medicine, Montreal Heart Institute, University of Montreal, 5000 Belanger Street, Montreal, QC HIT 1C8, Canada
| | - Jean-François Tanguay
- Department of Medicine, Montreal Heart Institute, University of Montreal, 5000 Belanger Street, Montreal, QC HIT 1C8, Canada
| | - Jean-Claude Tardif
- Department of Medicine, Montreal Heart Institute, University of Montreal, 5000 Belanger Street, Montreal, QC HIT 1C8, Canada
| | - Roddy Hiram
- Department of Medicine, Montreal Heart Institute, University of Montreal, 5000 Belanger Street, Montreal, QC HIT 1C8, Canada
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6
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Anand S, Cronin EM. Arrhythmias in Patients with Pulmonary Hypertension and Right Ventricular Failure: Importance of Rhythm Control Strategies. J Clin Med 2024; 13:1866. [PMID: 38610631 PMCID: PMC11012772 DOI: 10.3390/jcm13071866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 03/14/2024] [Accepted: 03/19/2024] [Indexed: 04/14/2024] Open
Abstract
Arrhythmias frequently complicate the course of advanced pulmonary hypertension, often leading to hemodynamic compromise, functional impairment, and mortality. Given the importance of right atrial function in this physiology, the restoration and maintenance of sinus rhythm are of critical importance. In this review, we outline the pathophysiology of arrhythmias and their impact on right heart performance; describe considerations for antiarrhythmic drug selection, anesthetic and periprocedural management; and discuss the results of catheter ablation techniques in this complex and challenging patient population.
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Affiliation(s)
| | - Edmond M. Cronin
- Section of Cardiology, Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 19140, USA;
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7
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Rubens M, Ramamoorthy V, Saxena A, Jimenez J, George S, Baker J, Ruiz J, Chaparro S. Hospital Outcomes in Patients With Pulmonary Hypertension With Atrial Fibrillation in the United States. Am J Cardiol 2024; 212:67-72. [PMID: 38040280 DOI: 10.1016/j.amjcard.2023.11.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 11/12/2023] [Accepted: 11/21/2023] [Indexed: 12/03/2023]
Abstract
In this study, using a large database, we examined the association between atrial fibrillation (AF) in hospitalized patients with pulmonary hypertension (PH) and in-hospital mortality and other adverse hospital outcomes. This study was a retrospective analysis of the United States National (Nationwide) Inpatient Sample from 2005 to 2014. All hospitalizations for patients diagnosed with primary PH and over the age of 65 years were included and then grouped based on the presence AF. The outcomes were in-hospital mortality rate, hospital length of stay, and hospitalization costs. Weighted regression analyses were performed to find the association between AF and outcomes. Of the 5,428,332 hospitalizations with PH, 2,531,075 (46.6%) had concomitant AF. The Cox proportional regression analysis showed that in patients with PE, all-cause mortality (hazard ratio 1.35, confidence interval [CI] 1.15 to 1.55) was significantly higher in patients with AF than those without AF. In addition, PH hospitalizations with AF had a longer hospital length of stay (β coefficient 1.74, 95% CI 1.58 to 1.83) and higher hospitalization cost (β coefficient 1.33, 95% CI 1.12 to 1.42). In patients aged over 65 years admitted for PH, the presence of AF was very frequent and worsened the prognosis. In conclusion, to improve patient outcomes and decrease hospital burden, it is important to consider AF during risk stratification for patients with PH to provide timely and prompt interventions. An interdisciplinary approach to treatment should be used to account for the burden of co-morbidities in this population.
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Affiliation(s)
- Muni Rubens
- Office of Clinical Research; Herbert Wertheim College of Medicine, Florida International University, Miami, Florida; Universidad Espiritu Santo, Guayaquil, Ecuador
| | | | - Anshul Saxena
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida; Center for Advanced Analytics, and
| | - Javier Jimenez
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida; Miami Cardiac and Vascular Institute, Baptist Health South Florida, Miami, Florida
| | - Shebin George
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida
| | - Jiana Baker
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida
| | - Juan Ruiz
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida
| | - Sandra Chaparro
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida; Miami Cardiac and Vascular Institute, Baptist Health South Florida, Miami, Florida.
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8
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1-e156. [PMID: 38033089 PMCID: PMC11095842 DOI: 10.1161/cir.0000000000001193] [Citation(s) in RCA: 231] [Impact Index Per Article: 231.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines liaison
| | | | | | | | | | - Paul L Hess
- ACC/AHA Joint Committee on Performance Measures liaison
| | | | | | | | | | - Kazuhiko Kido
- American College of Clinical Pharmacy representative
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9
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:109-279. [PMID: 38043043 PMCID: PMC11104284 DOI: 10.1016/j.jacc.2023.08.017] [Citation(s) in RCA: 66] [Impact Index Per Article: 66.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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10
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Ye T, Song Z, Zhou Y, Liu Z, Yu Y, Yu F, Chu Y, Shi J, Wang L, Zhang C, Liu X, Yang B, Yang J, Wang X. TRPV2 inhibitor tranilast prevents atrial fibrillation in rat models of pulmonary hypertension. Cell Calcium 2024; 117:102840. [PMID: 38160478 DOI: 10.1016/j.ceca.2023.102840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 12/19/2023] [Accepted: 12/20/2023] [Indexed: 01/03/2024]
Abstract
Atrial fibrillation (AF) is common in pulmonary hypertension (PH), whereas the mechanisms and treatments remain to be explored. TRPV2 regulates the structure and function of the cardiovascular system; however, little attention has been given to its role in AF. This study was to determine whether TRPV2 was involved in PH-induced AF and the effects of TRPV2 inhibitor tranilast on AF in rat models of PH. Monocrotaline (MCT) and SU5416/hypoxia (SuHx)-induced PH models were performed to detect atrial electrophysiological parameters. Daily tranilast (a TRPV2 inhibitor) or saline was given starting 1 day before PH establishment. PH increased the susceptibility to AF, with TRPV2 up-regulated in the right atria. Compared to PH rats, tranilast reduced AF inducibility and the prolongations of ERP and APD; mitigated cardiopulmonary remodeling and the increases in P-wave duration and P-R interval; partially reversed the down-regulation of ion channels such as Cav1.2, Nav1.5, Kv4.3, Kv4.2, Kv1.5, Kir2.1, Kir3.1, Kir3.4 as well as connexin (Cx) 40 and Cx43; improved right atrial (RA) fibrosis, enlargement, and myocardial hypertrophy; decreased the accumulation of inflammatory cells; down-regulated inflammatory indicators such as TNF-α, IL-1β, CXCL1, and CXCL2; and inhibited the activation of the PI3K-AKT-NF-κB signaling pathway. Our results reveal that TRPV2 participates in PH-induced AF, and TRPV2 inhibitor tranilast prevents PH-induced RA remodeling. TRPV2 might be a promising target for PH-induced AF.
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Affiliation(s)
- Tianxin Ye
- Department of Cardiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Zhuonan Song
- Department of Cardiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Yunping Zhou
- Department of Cardiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Zhangchi Liu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, China; Cardiovascular Research Institute, Wuhan University, Wuhan 430060, China; Hubei Key Laboratory of Cardiology, Wuhan 430060, China
| | - Yi Yu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, China; Cardiovascular Research Institute, Wuhan University, Wuhan 430060, China; Hubei Key Laboratory of Cardiology, Wuhan 430060, China
| | - Fangcong Yu
- Department of Cardiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Yanan Chu
- Department of Cardiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Jiaran Shi
- Department of Cardiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Longbo Wang
- Department of Cardiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Cui Zhang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, China; Cardiovascular Research Institute, Wuhan University, Wuhan 430060, China; Hubei Key Laboratory of Cardiology, Wuhan 430060, China
| | - Xin Liu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, China; Cardiovascular Research Institute, Wuhan University, Wuhan 430060, China; Hubei Key Laboratory of Cardiology, Wuhan 430060, China
| | - Bo Yang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, China; Cardiovascular Research Institute, Wuhan University, Wuhan 430060, China; Hubei Key Laboratory of Cardiology, Wuhan 430060, China
| | - Jinxiu Yang
- Department of Cardiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China.
| | - Xingxiang Wang
- Department of Cardiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China.
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11
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Seitler S, Dimopoulos K, Ernst S, Price LC. Medical Emergencies in Pulmonary Hypertension. Semin Respir Crit Care Med 2023; 44:777-796. [PMID: 37595615 DOI: 10.1055/s-0043-1770120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/20/2023]
Abstract
The management of acute medical emergencies in patients with pulmonary hypertension (PH) can be challenging. Patients with preexisting PH can rapidly deteriorate due to right ventricular decompensation when faced with acute physiological challenges that would usually be considered low-risk scenarios. This review considers the assessment and management of acute medical emergencies in patients with PH, encompassing both pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH), acknowledging these comprise the more severe groups of PH. Management protocols are described in a systems-based approach. Respiratory emergencies include pulmonary embolism, airways disease, and pneumonia; cardiac emergencies including arrhythmia and chest pain with acute myocardial infarction are discussed, alongside PH-specific emergencies such as pulmonary artery dissection and extrinsic coronary artery compression by a dilated proximal pulmonary artery. Other emergencies including sepsis, severe gastroenteritis with dehydration, syncope, and liver failure are also considered. We propose management recommendations for medical emergencies based on available evidence, international guidelines, and expert consensus. We aim to provide advice to the specialist alongside the generalist, and emergency doctors, nurses, and acute physicians in nonspecialist centers. A multidisciplinary team approach is essential in the management of patients with PH, and communication with local and specialist PH centers is paramount. Close hemodynamic monitoring during medical emergencies in patients with preexisting PH is vital, with early referral to critical care recommended given the frequent deterioration and high mortality in this setting.
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Affiliation(s)
- Samuel Seitler
- National Pulmonary Hypertension Service, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Konstantinos Dimopoulos
- National Pulmonary Hypertension Service, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Adult Congenital Heart Disease Service, Royal Brompton Hospital, London, United Kingdom
| | - Sabine Ernst
- Adult Congenital Heart Disease Service, Royal Brompton Hospital, London, United Kingdom
| | - Laura C Price
- National Pulmonary Hypertension Service, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
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12
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Teixeira-Fonseca JL, Joviano-Santos JV, da Silva Alcântara F, de Lima Conceição MR, Leal-Silva P, Roman-Campos D. Evaluation of right atrium structure and function in a rat model of monocrotaline-induced pulmonary hypertension: Exploring the possible antiarrhythmic properties of amiodarone. Clin Exp Pharmacol Physiol 2023; 50:893-902. [PMID: 37610053 DOI: 10.1111/1440-1681.13813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 06/02/2023] [Accepted: 07/25/2023] [Indexed: 08/24/2023]
Abstract
Atrial arrhythmias (AA) are common in pulmonary hypertension (PH) and are closely associated with poor clinical outcomes. One of the most studied models to investigate PH is the rat model of monocrotaline (MCT) induced PH (MCT-PH). To date, little is known about right atrium (RA) function in the MCT-PH model and the propensity of RA to develop arrhythmias. Therefore, the aim of the study was to evaluate the function of the RA of control (CTRL) and MCT treated rats, and the ability of amiodarone, a classical antiarrhythmic, to prevent the occurrence of AA in the RA in MCT-PH rats. RA function was studied in MCT-PH rats 20 days after a single subcutaneous injection of MCT 50 mg/kg. The histological results indicated the presence of RA and right ventricular hypertrophy. Surface electrocardiogram demonstrated increased P wave duration, PR wave duration and QT interval in MCT rats. RA from MCT rats were more susceptible to develop ex vivo burst pacing arrhythmias when compared to CTRL. Intriguingly, amiodarone in clinical relevant concentration was not able to prevent the occurrence arrhythmias in RA from MCT-PH animals. Hence, we conclude that the rat model of MCT-PH impairs RA structure and function, and acute exposure of RA to amiodarone in clinical relevant concentration is not able to attenuate the onset of arrhythmias in the ex vivo RA preparation.
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Affiliation(s)
- Jorge Lucas Teixeira-Fonseca
- Laboratory of Cardiobiology, Department of Biophysics, Paulista School of Medicine, Federal University of Sao Paulo, São Paulo, Brazil
| | | | - Fabiana da Silva Alcântara
- Laboratory of Cardiobiology, Department of Biophysics, Paulista School of Medicine, Federal University of Sao Paulo, São Paulo, Brazil
| | - Michael Ramon de Lima Conceição
- Laboratory of Cardiobiology, Department of Biophysics, Paulista School of Medicine, Federal University of Sao Paulo, São Paulo, Brazil
| | - Polyana Leal-Silva
- Laboratory of Cardiobiology, Department of Biophysics, Paulista School of Medicine, Federal University of Sao Paulo, São Paulo, Brazil
| | - Danilo Roman-Campos
- Laboratory of Cardiobiology, Department of Biophysics, Paulista School of Medicine, Federal University of Sao Paulo, São Paulo, Brazil
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13
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Morales-Lara AC, Elkhatib W, Oluleye O, Alhusain R, Saad A, Salwa N, Siddiqui H, Wieczorek MA, Ray J, Parikh P, Burger C, Shapiro B, Kusumoto F, Pillai D, Adedinsewo D. Impact of Pulmonary Hypertension Hemodynamic Phenotype on Incident Atrial Fibrillation. Cardiology 2023; 148:353-362. [PMID: 37276844 DOI: 10.1159/000531402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 05/25/2023] [Indexed: 06/07/2023]
Abstract
INTRODUCTION Atrial fibrillation/flutter (AF) is common among patients with pulmonary hypertension (PH) and is associated with poor clinical outcomes. AF has been shown to occur more commonly among patients with postcapillary PH, although AF also occurs among patients with precapillary PH. The goal of this study was to evaluate the independent impact of PH hemodynamic phenotype on incident AF among patients with PH. METHODS We retrospectively identified 262 consecutive patients, without a prior diagnosis of atrial arrhythmias, seen at the PH clinic at Mayo Clinic, Florida, between 1997 and 2017, who had right heart catheterization and echocardiography performed, with follow-up for outcomes through 2021. Kaplan-Meier analysis and Cox-proportional hazards regression modeling were used to evaluate the independent effect of PH hemodynamic phenotype on incident AF. RESULTS Our study population was classified into two broad PH hemodynamic groups: precapillary (64.9%) and postcapillary (35.1%). The median age was 59.5 years (Q1: 48.4, Q3: 68.4), and 72% were female. In crude models, postcapillary PH was significantly associated with incident AF (HR 2.17, 95% CI: 1.26-3.74, p = 0.005). This association was lost following multivariable adjustment, whereas left atrial volume index remained independently associated with incident AF (aHR 1.30, 95% CI: 1.09-1.54, p = 0.003). CONCLUSION We found PH hemodynamic phenotype was not significantly associated with incident AF in our patient sample; however, echocardiographic evidence of left atrial remodeling appeared to have a greater impact on AF development. Larger studies are needed to validate these findings and identify potential modifiable risk factors for AF in this population.
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Affiliation(s)
| | - Wiaam Elkhatib
- Department of Internal Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | | | - Rashid Alhusain
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Amjad Saad
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Najiyah Salwa
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Habeeba Siddiqui
- Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, Florida, USA
| | - Mikolaj A Wieczorek
- Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, Florida, USA
| | - Jordan Ray
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Pragnesh Parikh
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Charles Burger
- Department of Pulmonary Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Brian Shapiro
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Fred Kusumoto
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Dilip Pillai
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Demilade Adedinsewo
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida, USA
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14
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Havranek S, Fingrova Z, Skala T, Reichenbach A, Dusik M, Jansa P, Ambroz D, Dytrych V, Klimes D, Hutyra M, Kautzner J, Linhart A, Wichterle D. Catheter ablation of atrial fibrillation and atrial tachycardia in patients with pulmonary hypertension: a randomized study. Europace 2023:7161651. [PMID: 37178136 DOI: 10.1093/europace/euad131] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 04/14/2023] [Indexed: 05/15/2023] Open
Abstract
AIMS Atrial fibrillation (AF), typical atrial flutter (AFL), and other atrial tachycardias (ATs) are common in patients with pulmonary hypertension. Frequently, several supraventricular arrhythmias are successively observed in individual patients. We investigated the hypothesis of whether more extensive radiofrequency catheter ablation of the bi-atrial arrhythmogenic substrate instead of clinical arrhythmia ablation alone results in superior clinical outcomes in patients with pulmonary arterial hypertension (PH) and supraventricular arrhythmias. METHODS AND RESULTS Patients with combined post- and pre-capillary or isolated pre-capillary PH and supraventricular arrhythmia indicated to catheter ablation were enrolled in three centres and randomized 1:1 into two parallel treatment arms. Patients underwent either clinical arrhythmia ablation only (Limited ablation group) or clinical arrhythmia plus substrate-based ablation (Extended ablation group). The primary endpoint was arrhythmia recurrence >30 s without antiarrhythmic drugs after the 3-month blanking period. A total of 77 patients (mean age 67 ± 10 years; 41 males) were enrolled. The presumable clinical arrhythmia was AF in 38 and AT in 36 patients, including typical AFL in 23 patients. During the median follow-up period of 13 (interquartile range: 12; 19) months, the primary endpoint occurred in 15 patients (42%) vs. 17 patients (45%) in the Extended vs. Limited ablation group (hazard ratio: 0.97, 95% confidence interval: 0.49-2.0). There was no excess of procedural complications and clinical follow-up events including an all-cause death in the Extended ablation group. CONCLUSION Extensive ablation, compared with a limited approach, was not beneficial in terms of arrhythmia recurrence in patients with AF/AT and PH. CLINICAL TRIALS REGISTRATION ClinicalTrials.gov; NCT04053361.
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Affiliation(s)
- Stepan Havranek
- 2nd Department of Medicine-Department of Cardiovascular Medicine of the 1st Faculty of Medicine and General University Hospital in Prague, U Nemocnice 2, 12800 Prague, Czech Republic
| | - Zdenka Fingrova
- 2nd Department of Medicine-Department of Cardiovascular Medicine of the 1st Faculty of Medicine and General University Hospital in Prague, U Nemocnice 2, 12800 Prague, Czech Republic
| | - Tomas Skala
- First Department of Internal Medicine-Cardiology, Olomouc University Hospital, Olomouc, Czech Republic
| | - Adrian Reichenbach
- Cardiology Department, Institute of Clinical and Experimental Medicine, Prague, Czech Republic
| | - Milan Dusik
- 2nd Department of Medicine-Department of Cardiovascular Medicine of the 1st Faculty of Medicine and General University Hospital in Prague, U Nemocnice 2, 12800 Prague, Czech Republic
| | - Pavel Jansa
- 2nd Department of Medicine-Department of Cardiovascular Medicine of the 1st Faculty of Medicine and General University Hospital in Prague, U Nemocnice 2, 12800 Prague, Czech Republic
| | - David Ambroz
- 2nd Department of Medicine-Department of Cardiovascular Medicine of the 1st Faculty of Medicine and General University Hospital in Prague, U Nemocnice 2, 12800 Prague, Czech Republic
| | - Vladimir Dytrych
- 2nd Department of Medicine-Department of Cardiovascular Medicine of the 1st Faculty of Medicine and General University Hospital in Prague, U Nemocnice 2, 12800 Prague, Czech Republic
| | - Dalibor Klimes
- First Department of Internal Medicine-Cardiology, Olomouc University Hospital, Olomouc, Czech Republic
| | - Martin Hutyra
- First Department of Internal Medicine-Cardiology, Olomouc University Hospital, Olomouc, Czech Republic
| | - Josef Kautzner
- Cardiology Department, Institute of Clinical and Experimental Medicine, Prague, Czech Republic
| | - Ales Linhart
- 2nd Department of Medicine-Department of Cardiovascular Medicine of the 1st Faculty of Medicine and General University Hospital in Prague, U Nemocnice 2, 12800 Prague, Czech Republic
| | - Dan Wichterle
- 2nd Department of Medicine-Department of Cardiovascular Medicine of the 1st Faculty of Medicine and General University Hospital in Prague, U Nemocnice 2, 12800 Prague, Czech Republic
- Cardiology Department, Institute of Clinical and Experimental Medicine, Prague, Czech Republic
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15
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Teixeira-Fonseca JL, de Lima Conceição MR, Leal-Silva P, Roman-Campos D. Ranolazine exerts atrial antiarrhythmic effects in a rat model of monocrotaline-induced pulmonary hypertension. Basic Clin Pharmacol Toxicol 2023; 132:359-368. [PMID: 36799082 DOI: 10.1111/bcpt.13845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 02/10/2023] [Accepted: 02/13/2023] [Indexed: 02/18/2023]
Abstract
Atrial arrhythmias are a hallmark of heart diseases. The antiarrhythmic drug ranolazine with multichannel blocker properties is a promising agent to treat atrial arrhythmias. We therefore used the rat model of monocrotaline-induced pulmonary-hypertension to assess whether ranolazine can reduce the incidence of ex vivo atrial arrhythmias in isolated right atrium. Four-week-old Wistar rats were injected with 50 mg/kg of monocrotaline, and isolated right atrium function was studied 14 days later. The heart developed right atrium and right ventricular hypertrophy, and the ECG showed an increased P wave duration and QT interval, which are markers of the disease. Moreover, monocrotaline injection caused enhanced chronotropism and faster kinetics of contraction and relaxation in isolated right atrium. Additionally, in a concentration-dependent manner, ranolazine showed chronotropic and ionotropic effects upon isolated right atrium, with higher potency in the control when compared with experimental model. Using a burst pacing protocol, the isolated right atrium from the monocrotaline-treated animals was more susceptible to develop arrhythmias, and ranolazine was able to attenuate the phenotype. Thus, we concluded that the rat model of monocrotaline-induced pulmonary-hypertension develops right atrium remodelling, which increased the susceptibility to present ex vivo atrial arrhythmias, and the antiarrhythmic drug ranolazine ameliorated the phenotype.
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Affiliation(s)
- Jorge Lucas Teixeira-Fonseca
- Laboratory of Cardiobiology, Department of Biophysics, Paulista School of Medicine, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Michael Ramon de Lima Conceição
- Laboratory of Cardiobiology, Department of Biophysics, Paulista School of Medicine, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Polyana Leal-Silva
- Laboratory of Cardiobiology, Department of Biophysics, Paulista School of Medicine, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Danilo Roman-Campos
- Laboratory of Cardiobiology, Department of Biophysics, Paulista School of Medicine, Federal University of Sao Paulo, Sao Paulo, Brazil
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16
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Sammut MA, Condliffe R, Elliot C, Hameed A, Lewis R, Kiely DG, Kyriacou A, Middleton JT, Raithatha A, Rothman A, Thompson AAR, Turner R, Charalampopoulos A. Atrial flutter and fibrillation in patients with pulmonary arterial hypertension or chronic thromboembolic pulmonary hypertension in the ASPIRE registry: Comparison of rate versus rhythm control approaches. Int J Cardiol 2023; 371:363-370. [PMID: 36130620 DOI: 10.1016/j.ijcard.2022.09.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 09/06/2022] [Accepted: 09/13/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND The development of atrial flutter and fibrillation (AFL/AF) in patients with pre-capillary pulmonary hypertension has been associated with an increased risk of morbidity and mortality. Rate and rhythm control strategies have not been directly compared. METHODS Eighty-four patients with pulmonary arterial hypertension (PAH) or chronic thromboembolic pulmonary hypertension (CTEPH) with new-onset AFL/AF were identified in the ASPIRE registry. First, baseline characteristics and rates of sinus rhythm (SR) restoration of 3 arrhythmia management strategies (rate control, medical rhythm control and DC cardioversion, DCCV) in an early (2009-13) and later (2014-19) cohort were compared. Longer-term outcomes in patients who achieved SR versus those who did not were then explored. RESULTS Sixty (71%) patients had AFL and 24 (29%) AF. Eighteen (22%) patients underwent rate control, 22 (26%) medical rhythm control and 44 (52%) DCCV. SR was restored in 33% treated by rate control, 59% medical rhythm control and 95% DCCV (p < 0.001). Restoration of SR was associated with greater improvement in functional class (FC) and Incremental Shuttle Walk Distance (p both <0.05). It also independently predicted superior survival (3-year survival 62% vs 23% in those remaining in AFL/AF, p < 0.0001). In addition, FC III/IV independently predicted higher mortality (HR 2.86, p = 0.007). Right atrial area independently predicted AFL/AF recurrence (OR 1.08, p = 0.01). DCCV was generally well tolerated with no immediate major complications. CONCLUSIONS Restoration of SR is associated with superior functional improvement and survival in PAH/CTEPH compared with rate control. DCCV is generally safe and is more effective than medical therapy at achieving SR.
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Affiliation(s)
| | - Robin Condliffe
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK; Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Charlie Elliot
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK; Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Abdul Hameed
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK; Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Robert Lewis
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK; Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Andreas Kyriacou
- Department of Cardiology, Northern General Hospital, Sheffield, UK
| | - Jennifer T Middleton
- Department of Cardiology, Northern General Hospital, Sheffield, UK; Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK; Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Ajay Raithatha
- Department of Critical Care, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Alex Rothman
- Department of Cardiology, Northern General Hospital, Sheffield, UK; Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK; Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - A A Roger Thompson
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK; Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Richard Turner
- Department of Respiratory Medicine, Imperial College Healthcare Trust, London, UK
| | - Athanasios Charalampopoulos
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK; Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK.
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17
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Jackson I, Etuk A, Jackson N. Arrhythmia prevalence, predictors, and impact on hospital-associated outcomes among patients with diffuse large B-cell lymphoma. Am J Med Sci 2023; 365:56-62. [PMID: 36030898 DOI: 10.1016/j.amjms.2022.08.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 06/23/2022] [Accepted: 08/19/2022] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Diffuse large B-cell lymphoma (DLBCL) patients have been reported to have cardiac manifestations, however, arrhythmias have not been characterized in this population. We examined the predictors of arrhythmias and assessed the impact of arrhythmias on inpatient outcomes among DLBCL patients. METHODS Retrospective cohort analysis was performed using the National Inpatient Sample data collected between 2016 and 2018. Multivariable logistic and linear regression models were used to examine the predictors of arrhythmias and inpatient outcomes among DLBCL patients. RESULTS 11% of DLBCL patients had a diagnosis of arrhythmias. Patients aged 70 years or older had 2.6 times higher odds (95% CI: 2.37-2.78) of having arrhythmias compared to patients younger than 70 years. Females were 23% (AOR: 0.77; 95% CI: 0.71-0.83) less likely to have a diagnosis of arrhythmias relative to their male counterparts. Compared to non-Hispanic whites, patients who were non-Hispanic blacks (AOR: 0.69; 95% CI: 0.60-0.81), Hispanics (AOR: 0.60; 95% CI: 0.52-0.69) or in the non-Hispanic other category (AOR: 0.80; 95% CI: 0.70-0.91) were significantly less likely to be diagnosed with arrhythmias. Other factors that predicted arrhythmias were patient disposition and comorbidity index. Additionally, arrhythmias were associated with higher inpatient mortality, length of stay and hospital costs. CONCLUSIONS Older male patients were more likely to be diagnosed with arrhythmias while non-Hispanic blacks and Hispanics were less likely to have arrhythmias. These findings highlight the need for surveillance to enable early detection of arrhythmias in this population.
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Affiliation(s)
- Inimfon Jackson
- Department of Medicine, Einstein Medical Center, Philadelphia, PA, USA.
| | - Aniekeme Etuk
- Department of Internal Medicine, Thomas Hospital Infirmary Health, Fairhope, AL, USA
| | - Nsikak Jackson
- Department of Management, Policy and Community Health, University of Texas School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, USA
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18
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Bandorski D, Heibel S, Höltgen R, Bogossian H, Ghofrani HA, Zarse M, Gall H. Incidence and prognostic significance of malignant arrhythmias during (repetitive) Holter electrocardiograms in patients with pulmonary hypertension. Front Cardiovasc Med 2023; 10:1084051. [PMID: 37139131 PMCID: PMC10150006 DOI: 10.3389/fcvm.2023.1084051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 03/20/2023] [Indexed: 05/05/2023] Open
Abstract
Background In patients with pulmonary hypertension (PH), increased pulmonary vascular resistance (PVR) may lead to increased right ventricular afterload and cardiac remodelling, potentially providing the substrate for ventricular arrhythmias. Studies dealing with long term monitoring of patients with PH are rare. The present study evaluated the incidence and the types of arrhythmias retrospectively recorded by Holter ECG in patients with newly detected PH during a long-term Holter ECG follow-up. Moreover, their impact on patient survival was evaluated. Patients and methods Medical records were screened for demographic data, aetiology of PH, incidence of coronary heart disease, level of brain natriuretic peptide (BNP), results from Holter ECG monitoring, 6-minute walk test distance, echocardiographic data and hemodynamic data derived from right heart catheterization. Two subgroups were analyzed: 1. patients (n = 65) with PH (group 1 + 4) and derivation of at least 1 Holter ECG within 12 months from initial detection of PH and 2. patients (all PH etiologies, n = 59) with 3 follow-up Holter ECGs. The frequency and complexity of premature ventricular contractions (PVC) was classified into "lower" and "higher" (=non sustained ventricular tachycardia, nsVT) burden. Results Holter ECG revealed sinus rhythm (SR) in most of the patients (n = 60). Incidence of atrial fibrillation (AFib) was low (n = 4). Patients with premature atrial contractions (PAC) tend to have a shorter period of survival (p = 0.098), PVC were not correlated with significant survival differences. During follow-up PAC and PVC were common in all PH groups. Holter ECG revealed non sustained ventricular tachycardia in 19/59 patients [(32.2%); n = 6 during first Holter-ECG, n = 13 during second/third Holter-ECG]. In all patients suffering from nsVT during follow-up previous Holter ECG revealed multiform/repetitive PVC. PVC burden was not linked to differences in systolic pulmonary arterial pressure, right atrial pressure, brain natriuretic peptide and results of six-minute walk test. Conclusion Patients with PAC tend to have a shortened survival. None of the evaluated parameters (BNP, TAPSE, sPAP) was correlated with the development of arrhythmias. Patients with multiform/repetitive PVC seem to be at risk for ventricular arrhythmias.
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Affiliation(s)
- Dirk Bandorski
- Faculty of Medicine, Semmelweis University, Budapest, Hungary
- Correspondence: Dirk Bandorski
| | - Sebastian Heibel
- Medical Clinic III, Sana Klinikum Offenbach, Offenbach am Main, Germany
| | - Reinhard Höltgen
- Klinikum Westmünsterland, St. Agnes-Hospital Bocholt-Rhede, Bocholt, Germany
| | | | - Hossein Ardeschir Ghofrani
- The German Center for Lung Research (DZL), University of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Markus Zarse
- Cardiology Department, School of Medicine, Witten/Herdecke University, Witten, Germany
| | - Henning Gall
- The German Center for Lung Research (DZL), University of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
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19
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Garry JD, Kolaitis NA, Kronmal R, Thenappan T, Hemnes A, Grinnan D, Bull T, Chakinala MM, Horn E, Simon MA, De Marco T. Anticoagulation in pulmonary arterial hypertension - association with mortality, healthcare utilization, and quality of life: The Pulmonary Hypertension Association Registry (PHAR). J Heart Lung Transplant 2022; 41:1808-1818. [PMID: 36150996 PMCID: PMC10329839 DOI: 10.1016/j.healun.2022.08.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 07/29/2022] [Accepted: 08/22/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Routine long-term anticoagulation in pulmonary arterial hypertension (PAH) is controversial. To date, anticoagulation has been found to be beneficial or neutral in idiopathic disease (IPAH) and neutral-to-harmful in connective tissue disease (CTD-PAH). We sought to examine the association between anticoagulation and mortality, healthcare utilization, and quality of life (QoL) in PAH. METHODS The PHAR is a prospective registry of PAH patients referred to 58 pulmonary hypertension care centers in the United States. We compared patients who received anticoagulation during enrollment (questionnaire documented) to those who did not. Cox proportional hazard models were used for mortality, Poisson multivariate regression models for healthcare utilization, and generalized estimating equations for QOL RESULTS: Of 1175 patients included, 316 patients were treated with anticoagulation. IPAH/hereditary PAH (HPAH) comprised 46% of the cohort and CTD-PAH comprised 33%. After adjustment for demographics, clinical characteristics, site and disease severity, anticoagulation was not associated with mortality in the overall population (HR, 1.00; 95% CI, 0.72-1.36), IPAH/HPAH (HR, 1.19; 95% CI, 0.74-1.94), or CTD-PAH (HR 0.87; 95% CI, 0.53-1.42). Anticoagulation was associated with an increased rate of emergency department visits (IRR: 1.41), hospitalizations (IRR: 1.30), and hospital days (IRR 1.33). QOL measured by emPHasis-10 score was worse in patients receiving anticoagulation (mean difference 1.74; 95% CI 0.40-3.09). CONCLUSIONS Anticoagulation is not associated with higher mortality, but is associated with increased healthcare utilization in the PHAR. PAH-specific QoL may be worse in patients receiving anticoagulation. The risks and benefits surrounding routine prescription of anticoagulation for PAH should be carefully considered.
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Affiliation(s)
- Jonah D Garry
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.
| | | | - Richard Kronmal
- Department of Biostatistics, University of Washington, Seattle, Washington
| | | | - Anna Hemnes
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Daniel Grinnan
- Department of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Todd Bull
- Department of Medicine, University of Colorado, Aurora, Colorado
| | - Murali M Chakinala
- Department of Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Evelyn Horn
- Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Marc A Simon
- Department of Medicine, University of California, San Francisco, California
| | - Teresa De Marco
- Department of Medicine, University of California, San Francisco, California
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20
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The Oracle of the Auricle? Chest 2022; 162:509-510. [DOI: 10.1016/j.chest.2022.05.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 05/25/2022] [Indexed: 11/20/2022] Open
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21
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Xue L, Yang YC, Zhao Q, Zhao ZH, Zeng QX, Yang T, Luo Q, Liu BY, Ma XP, Liu ZH, Xiong CM. The spectrum and prevalence of arrhythmia in different clinical pulmonary hypertension groups in Chinese population. Clin Cardiol 2022; 45:495-502. [PMID: 35253244 DOI: 10.1002/clc.23803] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 02/17/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Arrhythmia is not uncommon among pulmonary hypertension (PH) population, and may be associated with disease severity. HYPOTHESIS To investigate different spectrums and prevalence of arrhythmias in different clinical PH groups in Chinese population. METHODS Patients diagnosed with PH between April 15, 2019, and August 2, 2021, were enrolled prospectively. The prevalence of different types of arrhythmias in PH patients were calculated. Logistic regression analyses were conducted to determine independent predictors for arrhythmia. RESULTS One thousand patients were enrolled. The prevalence of any arrhythmia, sinus node dysfunction, sinus tachycardia, atrial fibrillation, atrial flutter, other types of atrial tachycardia, atrioventricular block, and ventricular tachycardia is 44.4%, 12.2%, 15.2%, 8.1%, 4.1%, 10.2%, 7.1%, and 2.5%. Logistic regression analyses revealed that older age and larger right ventricle (odds ratio: 1.111 and 1.095, p < .05) were independently related with higher probability of supraventricular arrhythmia; Complicating with coronary artery disease, larger right ventricle, and increased left ventricular end-diastolic diameter (odds ratio: 19.540, 1.106, and 1.085, p < .05) were independently correlated with sinus node dysfunction/atrioventricular block in patients with pulmonary arterial hypertension. CONCLUSIONS Nearly half of PH patients experienced at least one type of arrhythmia. The most common seen arrhythmias were supraventricular arrhythmia, sinus tachycardia, and sinus node dysfunction. Older age and larger right ventricle were independently related with higher probability of supraventricular arrhythmia; Complicating with coronary artery disease, larger right ventricle and increased left ventricular end-diastolic diameter were independently correlated with higher probability of sinus node dysfunction/atrioventricular block in patients with pulmonary arterial hypertension.
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Affiliation(s)
- Lin Xue
- Department of Cardiology, Center for Diagnosis and Management of Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yi-Cheng Yang
- Department of Cardiology, Center for Diagnosis and Management of Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qing Zhao
- Department of Cardiology, Center for Diagnosis and Management of Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhi-Hui Zhao
- Department of Cardiology, Center for Diagnosis and Management of Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qi-Xian Zeng
- Department of Cardiology, Center for Diagnosis and Management of Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tao Yang
- Department of Cardiology, Center for Diagnosis and Management of Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qin Luo
- Department of Cardiology, Center for Diagnosis and Management of Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bing-Yang Liu
- Department of Cardiology, Center for Diagnosis and Management of Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiu-Ping Ma
- Department of Cardiology, Center for Diagnosis and Management of Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhi-Hong Liu
- Department of Cardiology, Center for Diagnosis and Management of Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chang-Ming Xiong
- Department of Cardiology, Center for Diagnosis and Management of Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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22
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Dusik M, Fingrova Z, Ambroz D, Jansa P, Linhart A, Havranek S. The Role of Pulmonary Artery Wedge Pressure on the Incidence of Atrial Fibrillation and Atrial Tachycardias in Patients With Isolated Pre-capillary Pulmonary Hypertens. Physiol Res 2021; 70:841-849. [PMID: 34717065 DOI: 10.33549/physiolres.934706] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Atrial fibrillation and atrial tachycardias (AF/AT) have been reported as a common condition in patients with pulmonary hypertension (PH). As yet, limited data exists about the significance of the borderline post-capillary pressure component on the occurrence of AF / AT in patients with isolated pre-capillary PH. We retrospectively studied the prevalence of AF / AT in 333 patients (mean age 61 ± 15 years, 44% males) with pre-capillary idiopathic / familiar pulmonary arterial hypertension, and inoperable chronic thromboembolic pulmonary hypertension. The prevalence of AF / AT was analyzed in different categories of pulmonary artery wedge pressure (PAWP). In the study population overall, the mean PAWP was 10.5 ± 3 mmHg, median of 11 mmHg, range 2-15 mmHg. AF / AT was diagnosed in 79 patients (24%). The proportion of AF / AT among patients with PAWP below the median (?11 mmHg) was lower than in subjects with PAWP between 12 and 15 mmHg, 30 (16%) vs. 46 (35%), p = 0.0001. Compared to the patients with PAWP?11 mmHg, subjects with PAWP between 12 and 15 mmHg were older (65 ± 13 years vs. 58 ± 16), with more prevalent arterial hyperte\nsion [100 (70%) vs. 106 (55%)] and diabetes mellitus [50 (35%) vs. 48 (25%)], showed larger size of the left atrium (42 ± 7 vs. 40 ± 6 mm), and higher values of right atrium pressure (12 ± 5 vs. 8 ± 5 mm Hg), p < 0.05 in all comparisons. The prevalence of AF / AT in the group studied increased with the growing post-capillary component.
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Affiliation(s)
- M Dusik
- 2nd Department of Medicine, Department of Cardiovascular Medicine, General University Hospital in Prague, 1st Faculty of Medicine, Charles University in Prague, Prague, Czech Republic.
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Zaky A, Zafar I, Masjoan-Juncos JX, Husain M, Mariappan N, Morgan CJ, Hamid T, Frölich MA, Ahmad S, Ahmad A. Echocardiographic, Biochemical, and Electrocardiographic Correlates Associated With Progressive Pulmonary Arterial Hypertension. Front Cardiovasc Med 2021; 8:705666. [PMID: 34355033 PMCID: PMC8329095 DOI: 10.3389/fcvm.2021.705666] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 06/09/2021] [Indexed: 12/15/2022] Open
Abstract
Background: Pulmonary arterial hypertension (PAH) is a progressive proliferative vasculopathy associated with mechanical and electrical changes, culminating in increased vascular resistance, right ventricular (RV) failure, and death. With a main focus on invasive tools, there has been an underutilization of echocardiography, electrocardiography, and biomarkers to non-invasively assess the changes in myocardial and pulmonary vascular structure and function during the course of PAH. Methods: A SU5416-hypoxia rat model was used for inducing PAH. Biventricular functions were measured using transthoracic two-dimensional (2D) echocardiography/Doppler (echo/Doppler) at disease onset (0 week), during progression (3 weeks), and establishment (5 weeks). Similarly, electrocardiography was performed at 0, 3, and 5 weeks. Invasive hemodynamic measurements and markers of cardiac injury in plasma were assessed at 0, 3, and 5 weeks. Results: Increased RV systolic pressure (RVSP) and rate of isovolumic pressure rise and decline were observed at 0, 3, and 5 weeks in PAH animals. EKG showed a steady increase in QT-interval with progression of PAH, whereas P-wave height and RS width were increased only during the initial stages of PAH progression. Echocardiographic markers of PAH progression and severity were also identified. Three echocardiographic patterns were observed: a steady pattern (0-5 weeks) in which echo parameter changed progressively with severity [inferior vena cava (IVC) expiratory diameter and pulmonary artery acceleration time (PAAT)], an early pattern (0-3 weeks) where there is an early change in parameters [RV fractional area change (RV-FAC), transmitral flow, left ventricle (LV) output, estimated mean PA pressure, RV performance index, and LV systolic eccentricity index], and a late pattern (3-5 weeks) in which there is only a late rise at advanced stages of PAH (LV diastolic eccentricity index). RVSP correlated with PAAT, PAAT/PA ejection times, IVC diameters, RV-FAC, tricuspid systolic excursion, LV systolic eccentricity and output, and transmitral flow. Plasma myosin light chain (Myl-3) and cardiac troponin I (cTnI) increased progressively across the three time points. Cardiac troponin T (cTnT) and fatty acid-binding protein-3 (FABP-3) were significantly elevated only at the 5-week time point. Conclusion: Distinct electrocardiographic and echocardiographic patterns along with plasma biomarkers were identified as useful non-invasive tools for monitoring PAH progression.
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Affiliation(s)
- Ahmed Zaky
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Iram Zafar
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Juan Xavier Masjoan-Juncos
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Maroof Husain
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Nithya Mariappan
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Charity J. Morgan
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Tariq Hamid
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Michael A. Frölich
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Shama Ahmad
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Aftab Ahmad
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
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24
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Stam K, Clauss S, Taverne YJHJ, Merkus D. Chronic Thromboembolic Pulmonary Hypertension - What Have We Learned From Large Animal Models. Front Cardiovasc Med 2021; 8:574360. [PMID: 33937352 PMCID: PMC8085273 DOI: 10.3389/fcvm.2021.574360] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 03/08/2021] [Indexed: 12/21/2022] Open
Abstract
Chronic thrombo-embolic pulmonary hypertension (CTEPH) develops in a subset of patients after acute pulmonary embolism. In CTEPH, pulmonary vascular resistance, which is initially elevated due to the obstructions in the larger pulmonary arteries, is further increased by pulmonary microvascular remodeling. The increased afterload of the right ventricle (RV) leads to RV dilation and hypertrophy. This RV remodeling predisposes to arrhythmogenesis and RV failure. Yet, mechanisms involved in pulmonary microvascular remodeling, processes underlying the RV structural and functional adaptability in CTEPH as well as determinants of the susceptibility to arrhythmias such as atrial fibrillation in the context of CTEPH remain incompletely understood. Several large animal models with critical clinical features of human CTEPH and subsequent RV remodeling have relatively recently been developed in swine, sheep, and dogs. In this review we will discuss the current knowledge on the processes underlying development and progression of CTEPH, and on how animal models can help enlarge understanding of these processes.
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Affiliation(s)
- Kelly Stam
- Department of Cardiology, Erasmus University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Sebastian Clauss
- Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University Munich, Munich, Germany.,Institute of Surgical Research at the Walter-Brendel-Centre of Experimental Medicine, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Munich, Munich Heart Alliance, Munich, Germany
| | - Yannick J H J Taverne
- Department of Cardiothoracic Surgery, Erasmus University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Daphne Merkus
- Department of Cardiology, Erasmus University Medical Center Rotterdam, Rotterdam, Netherlands.,Institute of Surgical Research at the Walter-Brendel-Centre of Experimental Medicine, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Munich, Munich Heart Alliance, Munich, Germany
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25
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Andersen MØ, Diederichsen SZ, Svendsen JH, Carlsen J. Assessment of cardiac arrhythmias using long-term continuous monitoring in patients with pulmonary hypertension. Int J Cardiol 2021; 334:110-115. [PMID: 33819493 DOI: 10.1016/j.ijcard.2021.03.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 02/17/2021] [Accepted: 03/19/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Cardiac arrhythmias are considered a prominent phenomenon in patients with pulmonary hypertension (PH). Older studies reported that 8% to 35% of patients with PH had supraventricular tachycardia (SVT), associated with adverse outcomes. Still, these arrhythmias have only been investigated via short-term monitoring or limited electrocardiogram recordings. METHODS Patients without previous arrhythmias diagnosed with PH at a tertiary facility received an insertable cardiac monitor as part of a prospective cohort study. Baseline assessments included World Health Organization functional class, six-minute walk test, echocardiography, and cardiac magnetic resonance imaging. RESULTS Thirty-four patients with PH were included. Twenty-four patients had pulmonary arterial hypertension (PAH) and 10 had chronic thromboembolic PH (CTEPH). During 46 patient-years of continuous monitoring (median: 594 (range: 334-654) days per patient), 70 arrhythmia episodes were recorded in 13 patients (38%), with a median of two (range: 1-3) episodes and an arrhythmic burden median of 1.6 (range: 0.1-228) minutes per patient. SVTs were the most common arrhythmias, with 16% of episodes being atrial fibrillation and 84% being other types of SVTs. Additionally, three patients experienced bradycardias, including one resulting in syncope and subsequent pacemaker implantation. None of the patients had sustained ventricular arrhythmias. CONCLUSIONS Arrhythmias were seen in 38% of contemporary patients with PH during long-term continuous monitoring; however, the vast majority of episodes were short and self-limiting. Modern therapy may alleviate the development of arrhythmias in stable patients with PH. This study is the first study to deploy long-term continuous monitoring in patients with PH.
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Affiliation(s)
- Mads Ørbæk Andersen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, 9- Blegdamsvej, Copenhagen, Denmark
| | - Søren Zöga Diederichsen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, 9- Blegdamsvej, Copenhagen, Denmark
| | - Jesper Hastrup Svendsen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, 9- Blegdamsvej, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, Copenhagen 2200, Denmark
| | - Jørn Carlsen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, 9- Blegdamsvej, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, Copenhagen 2200, Denmark.
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26
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Zou S, Cen Z, Jia R, Lu S, Hao Y, Cui K. Electrophysiological study and radiofrequency ablation of hemodynamically-instable ventricular arrhythmias in a patient with pulmonary hypertension: A case report. Medicine (Baltimore) 2021; 100:e24896. [PMID: 33663121 PMCID: PMC7909233 DOI: 10.1097/md.0000000000024896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 02/04/2021] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Hemodynamically-instable ventricular arrhythmias (VAs) are rare in patients with pulmonary hypertension (PH). To the best of our knowledge, only 1 case has been reported so far. Moreover, the pathogenesis of this kind of arrhythmia remains obscured and its treatment is challenging. Here we report another case and presented the substrate for VAs initiation and therapeutic effect of radiofrequency ablation. PATIENT CONCERNS This is a 57-year-old man who presented paroxysmal palpitation associated with presyncope at rest. Surface electrocardiogram (ECG) revealed frequent ventricular premature contractions and non-sustained ventricular tachycardia when symptoms occurred. He also had a history of severe PH which was secondary to atrial septal defect and partial anomalous pulmonary venous drainage and suffered from obvious dyspnea when climbing stairs World Health Organization Class III (WHO Class III). DIAGNOSIS Hemodynamically-instable VAs associated with severe PH. INTERVENTION Echocardiography revealed enlargement of right ventricle (right ventricle [RV]: 43 mm). Electrophysiological examination showed the origin of VAs is next to a small low-voltage zone of RV. Radiofrequency delivery at the origin successfully terminated VAs without occurrence of complication. OUTCOME The patient was free from arrhythmias and got an improvement of exercise tolerance, just with mild dyspnea when climbing stairs World Health Organization Class II (WHO class II), during six-month follow up. LESSONS This case suggests the low-voltage zone of remodeled RV, which may be secondary to increased pulmonary artery pressure, serves as the substrate for VAs initiation in patient with PH. Radiofrequency ablation can successfully terminate VAs and the termination of VAs can significantly improve the patient's impaired exercise tolerance.
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Affiliation(s)
- Song Zou
- Department of Cardiology, West China Hospital
| | - Zhifu Cen
- Department of Cardiology, West China Hospital
| | - Ruikun Jia
- Department of Cardiology, West China Hospital
| | - Sijie Lu
- Department of Cardiology, West China Hospital
| | - Yan Hao
- State Key Laboratory of Biotherapy, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Kaijun Cui
- Department of Cardiology, West China Hospital
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27
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Fingrova Z, Ambroz D, Jansa P, Kuchar J, Lindner J, Kunstyr J, Aschermann M, Linhart A, Havranek S. The prevalence and clinical outcome of supraventricular tachycardia in different etiologies of pulmonary hypertension. PLoS One 2021; 16:e0245752. [PMID: 33471824 PMCID: PMC7817034 DOI: 10.1371/journal.pone.0245752] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 01/06/2021] [Indexed: 11/24/2022] Open
Abstract
Purpose Patients with pulmonary hypertension (PH) frequently suffer from supraventricular tachycardias (SVT). The main purpose of our study was to identify the cumulative incidence of SVT in patients with different etiologies of PH. The secondary objective was to analyse the clinical impact of SVT. Methods We retrospectively studied the prevalence of SVT and the clinical outcome in 755 patients (41% males; 60 ± 15 years; mean follow-up 3.8 ± 2.8 years) with PH of different etiologies. The prevalence of SVT was analysed separately in isolated pre-capillary PH (Ipc-PH) and in patients with combined post- and pre-capillary PH (Cpc-PH). Results The prevalence of SVT in the Ipc-PH group (n = 641) was 25% (n = 162). The most prevalent arrhythmias were atrial fibrillation followed by a typical atrial flutter (17% and 4.4% of all Icp-PH patients). An excessive prevalence of SVT was found in patients with pulmonary arterial hypertension associated with congenital heart disease (35%, p = 0.01). Out of the overall study population, Cpc-PH was present in 114 (15%) patients. Patients with Cpc-PH manifested a higher prevalence of SVT than subjects with Ipc-PH (58; 51% vs. 162; 25%; p <0.0001) and were more likely to have persistent or permanent atrial fibrillation (38; 29% vs. 61; 10%; p <0.0001). Parameters significantly associated with mortality in a multivariate analysis included age, male gender, functional exercise capacity and right atrial diameter (p < 0.05). Neither diagnosis of SVT nor type of arrhythmia predicted mortality. Conclusions The study detected a significant prevalence of SVT in the population of PH of different origins. Different spectrum and prevalence of arrhythmia might be expected in different etiologies of PH. Patients with an elevated post-capillary pressure showed a higher arrhythmia prevalence, predominantly due to an excessive number of atrial fibrillations. The diagnosis of SVT was not associated with mortality.
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Affiliation(s)
- Zdenka Fingrova
- 1Faculty of Medicine, 2 Department of Medicine-Department of Cardiovascular Medicine, General University Hospital, Charles University, Prague, Czech Republic
| | - David Ambroz
- 1Faculty of Medicine, 2 Department of Medicine-Department of Cardiovascular Medicine, General University Hospital, Charles University, Prague, Czech Republic
| | - Pavel Jansa
- 1Faculty of Medicine, 2 Department of Medicine-Department of Cardiovascular Medicine, General University Hospital, Charles University, Prague, Czech Republic
| | - Jan Kuchar
- 1Faculty of Medicine, 2 Department of Medicine-Department of Cardiovascular Medicine, General University Hospital, Charles University, Prague, Czech Republic
- Regional Hospital in Tabor, Tabor, Czech Republic
| | - Jaroslav Lindner
- 1 Faculty of Medicine, 2 Department of Surgery–Department of Cardiovascular Surgery, General University Hospital, Charles University, Prague, Czech Republic
| | - Jan Kunstyr
- 1 Faculty of Medicine, Department of Anaesthesiology, Resuscitation and Intensive Medicine, General University Hospital, Charles University, Prague, Czech Republic
| | - Michael Aschermann
- 1Faculty of Medicine, 2 Department of Medicine-Department of Cardiovascular Medicine, General University Hospital, Charles University, Prague, Czech Republic
| | - Ales Linhart
- 1Faculty of Medicine, 2 Department of Medicine-Department of Cardiovascular Medicine, General University Hospital, Charles University, Prague, Czech Republic
| | - Stepan Havranek
- 1Faculty of Medicine, 2 Department of Medicine-Department of Cardiovascular Medicine, General University Hospital, Charles University, Prague, Czech Republic
- * E-mail:
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28
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Hjalmarsson C, Butler O, Hesselstrand R, Holl K, Jansson K, Klok R, Rådegran G, Söderberg S, Kjellström B. Poor outcome of patients with pulmonary arterial hypertension with insufficient response to phosphodiesterase‐5 inhibitors alone or in combination with other specific therapy: a registry‐based study. Pulm Circ 2020; 10:2045894020958557. [PMID: 33062261 PMCID: PMC7534092 DOI: 10.1177/2045894020958557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 08/24/2020] [Indexed: 11/18/2022] Open
Abstract
Phosphodiesterase-5 inhibitors are commonly used in pulmonary arterial hypertension but, as suggested by the RESPITE study, phosphodiesterase-5 inhibitor therapy (mono-/combination) does not always have a satisfactory treatment effect. This study aimed to investigate the clinical course of pulmonary arterial hypertension patients not at treatment goal after at least 90 days of treatment with phosphodiesterase-5 inhibitors, alone or in combination with other pulmonary arterial hypertension therapies. The study included 106 incident patients from the Swedish Pulmonary Arterial Hypertension Registry, treated with phosphodiesterase-5 inhibitors for ≥90 days, who were not at a pre-specified treatment goal, i.e. in World Health Organisation functional class III, with 6-min walking distance 165–440 m, and N-terminal prohormone of brain natriuretic peptide >300 ng/L. Changes in World Health Organisation functional class, 6-min walking distance, N-terminal prohormone of brain natriuretic peptide, and risk group between index and follow-up were assessed. Of patients with complete follow-up data, (n = 53) 77% were on combination therapy and risk assessment yielded 98% at intermediate risk at index. At follow-up, 11 patients transitioned from World Health Organisation functional class III to World Health Organisation functional class II, the median (Q1; Q3) change in 6-min walking distance was 6 (−30; 42) meters and in N-terminal prohormone of brain natriuretic peptide 47 (−410; 603) ng/L, while 89% remained at an intermediate risk. Of those without complete follow-up data, 11 patients died and 2 underwent lung transplantation. In conclusion, pulmonary arterial hypertension patients treated with phosphodiesterase-5 inhibitors, as single or combination therapy and not achieving the pre-specified treatment goals after ≥90 days have an unfavourable clinical course.
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Affiliation(s)
- Clara Hjalmarsson
- Department of Molecular and Clinical MedicineSahlgrenska AcademyGothenburg UniversityDepartment of CardiologySahlgrenska University HospitalGothenburgSweden
| | | | - Roger Hesselstrand
- Department of Clinical Sciences Lund, RheumatologyLund UniversitySkåne University HospitalLundSweden
| | | | - Kjell Jansson
- Department of Cardiology and Department of Clinical PhysiologyInstitution of Medicine and Health SciencesLinköping UniversityLinköpingSweden
| | | | - Göran Rådegran
- Department of Clinical Sciences Lund, CardiologyThe Section for Heart Failure and Valvular DiseaseLund UniversitySkåne University HospitalLundSweden
| | - Stefan Söderberg
- Department of Public Health and Clinical Medicine, and Heart CentreUmeå UniversityUmeåSweden
| | - Barbro Kjellström
- Department of Clinical Sciences Lund, Clinical PhysiologyLund UniversitySkåne University HospitalLundSweden
- Cardiology UnitDepartment of MedicineKarolinska InstituteStockholmSweden
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29
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Bandorski D, Bogossian H, Ghofrani A, Schmitt J, Höltgen R. [Tachycardia and pulmonary arterial hypertension]. Herzschrittmacherther Elektrophysiol 2020; 31:33-38. [PMID: 32048010 DOI: 10.1007/s00399-020-00668-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 01/13/2020] [Indexed: 11/28/2022]
Abstract
Pulmonary hypertension is newly defined as an elevation of the mean pulmonary arterial pressure >20 mmHg and a pulmonary vascular resistance ≥3 Wood units. Arrhythmias are an increasing problem in patients with pulmonary hypertension. Pathophysiological aspects leading to supraventricular arrhythmias are atrial fibrosis caused by increased right atrial pressure and dilation. An increased sympathetic tone leads to prolongation of action potential and delayed polarisations causing arrhythmias. Therapy of arrhythmias includes drugs (preferred amiodarone) and electrophysiological therapy like electric cardioversion and ablation, which is safe in patients with pulmonary hypertension.
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Affiliation(s)
- D Bandorski
- Medizinische Fakultät, Semmelweis Universität, Campus Hamburg, Lohmühlenstraße 5/Haus P, 20099, Hamburg, Deutschland. .,Intensivmedizin und internistische Diagnostik, Neurologische Klinik Bad Salzhausen, Am Hasensprung 6, 63667, Nidda, Deutschland.
| | - H Bogossian
- Abteilung für Kardiologie, Elektrophysiologie und Angiologie, Märkische Kliniken GmbH, Klinikum Lüdenscheid, Paulmannshöher Str. 14, 58515, Lüdenscheid, Deutschland.,Universität Witten/Herdecke, Witten, Deutschland
| | - A Ghofrani
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Gießen, Klinikstraße 33, 35392, Gießen, Deutschland
| | - J Schmitt
- Medizinische Klinik 1, Innere Medizin/Kardiologie, Universitätsklinikum Gießen, Klinikstraße 33, 35392, Gießen, Deutschland
| | - R Höltgen
- St. Agnes-Hospital Bocholt Rhede, Medizinische Klinik, Kardiologie/Elektrophysiologie, Klinikum Westmünsterland, Barloer Weg 125, 46397, Bocholt, Deutschland
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Bandorski D, Höltgen R, Ghofrani A, Johnson V, Schmitt J. [Arrhythmias in patients with pulmonary hypertension and chronic lung disease]. Herzschrittmacherther Elektrophysiol 2019; 30:234-239. [PMID: 31440896 DOI: 10.1007/s00399-019-00637-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 07/19/2019] [Indexed: 10/26/2022]
Abstract
Pulmonary arterial hypertension (PAH) occurs in 1% of the global population and can be divided in different disease groups. Pathophysiological aspects leading to supraventricular arrhythmias in these patients are due to increased pulmonary and right atrial pressure, increased activity of the sympathetic nervous system leading to right atrial electrical remodeling and ischemia in the right atrium. In the clinical setting these patients present with atrial flutter, atrial fibrillation or with ectopic atrial tachycardia. Regarding ventricular tachycardia there is a lack of data. Occurrence of arrhythmia in these patients leads to a deterioration of PAH, so rhythm control should be the aim. This can be achieved by right atrial ablation, especially in patients presenting with atrial flutter; electric cardioversion or antiarrhythmic drug therapy are without definite guideline recommendations since there are too few clinical trials. Ablation with a transseptal approach in the left atrium is considered rather dangerous and should be avoided. Regarding arrhythmias in patients with chronic lung disease, few data are available. For patients with chronic obstructive pulmonary disease (COPD), there are good data available. These patients often suffer from coronary heart disease, atrial fibrillation, and ventricular tachycardia. Beta-blockers play an important role in COPD patients, even during exacerbation. Interventional therapies are safe but the arrhythmogenic foci often located outside of the pulmonary veins (in the right atrium).
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Affiliation(s)
- Dirk Bandorski
- Medizinische Fakultät, Semmelweis Universität, Campus Hamburg, Lohmühlenstraße 5/Haus P, 20099, Hamburg, Deutschland. .,Intensivmedizin und internistische Diagnostik, Asklepios Neurologische Klinik Bad Salzhausen, Am Hasensprung 6, 63667, Nidda, Deutschland.
| | - Reinhard Höltgen
- Medizinische Klinik, Kardiologie/Elektrophysiologie, Klinikum Westmünsterland, St. Agnes-Hospital Bocholt Rhede, Barloer Weg 125, 46397, Bocholt, Deutschland
| | - Ardeschir Ghofrani
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Gießen, Klinikstraße 33, 35392, Gießen, Deutschland
| | - Viktoria Johnson
- Medizinische Klinik 1, Innere Medizin/Kardiologie, Universitätsklinikum Gießen, Klinikstraße 33, 35392, Gießen, Deutschland
| | - Jörn Schmitt
- Medizinische Klinik 1, Innere Medizin/Kardiologie, Universitätsklinikum Gießen, Klinikstraße 33, 35392, Gießen, Deutschland
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Middleton JT, Maulik A, Lewis R, Kiely DG, Toshner M, Charalampopoulos A, Kyriacou A, Rothman A. Arrhythmic Burden and Outcomes in Pulmonary Arterial Hypertension. Front Med (Lausanne) 2019; 6:169. [PMID: 31396515 PMCID: PMC6664000 DOI: 10.3389/fmed.2019.00169] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 07/08/2019] [Indexed: 12/17/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a devastating, life-limiting disease driven by small vessel vascular remodeling leading to a rise in pulmonary vascular resistance (PVR). Patients present with a range of symptoms including shortness of breath, exercise intolerance, palpitations or syncope. Symptoms may be related to vascular disease progression or arrhythmia secondary to the adaptation of the right heart to pressure overload. Arrhythmic burden is high in patients with left heart disease and guideline-based treatment of arrhythmias improves quality of life and prognosis. In PAH the incidence and prevalence of arrhythmias is less well-defined and there are no PAH-specific guidelines for arrhythmia management. We undertook a literature search identifying 13 relevant papers; detection of arrhythmias was acquired from 12-lead electrocardiogram (ECG) or Holter monitors. In all forms of pulmonary hypertension (PH) the prevalence of supraventricular arrhythmias (SVA) was 26-31%, ventricular arrhythmias (VA) 24% and a 5-year incidence of SVA ~13.2-25.1%. Prevalence and incidence of arrhythmias in PAH is less clear due to limited study numbers and the heterogenous nature of the patient population studied. For arrhythmia treatment, only single-arm studies of therapeutic strategies were reported using antiarrhythmic drugs (AAD), direct current cardioversion (DCCV) and ablation. Periods between ECG or Holter have not been investigated, highlighting the possibility that significant arrhythmias may be undetected. Advances in monitoring allow long-term surveillance via implanted/non-invasive monitors. Use of such technologies may provide an accurate estimate of incidence and prevalence of arrhythmias in patients with PAH, further defining relationships to adverse outcomes, and therapeutic options.
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Affiliation(s)
- Jennifer T. Middleton
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
- Department of Infection, Immunity and Cardiovascular Disease, Medical School, University of Sheffield, Sheffield, United Kingdom
- Department of Cardiology, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Angshuman Maulik
- Department of Infection, Immunity and Cardiovascular Disease, Medical School, University of Sheffield, Sheffield, United Kingdom
- Department of Cardiology, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Robert Lewis
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
- Department of Infection, Immunity and Cardiovascular Disease, Medical School, University of Sheffield, Sheffield, United Kingdom
| | - David G. Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Mark Toshner
- Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
- Royal Papworth Hospital NHS Foundation Trust, Cambridgeshire, United Kingdom
| | - Athanasios Charalampopoulos
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Andreas Kyriacou
- Department of Cardiology, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Alexander Rothman
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
- Department of Infection, Immunity and Cardiovascular Disease, Medical School, University of Sheffield, Sheffield, United Kingdom
- Department of Cardiology, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
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Linz D, Dobrev D. Outcome of atrial fibrillation ablation in pulmonary hypertension: Is pulmonary hypertension a modifiable risk factor? IJC HEART & VASCULATURE 2019; 23:100360. [PMID: 31016225 PMCID: PMC6465768 DOI: 10.1016/j.ijcha.2019.100360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 03/31/2019] [Accepted: 04/04/2019] [Indexed: 11/24/2022]
Affiliation(s)
- Dominik Linz
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute (SAHMRI), University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Dobromir Dobrev
- Institute of Pharmacology, West German Heart and Vascular Center, University Duisburg-Essen, Essen, Germany
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Desai R, Patel U, Singh S, Bhuva R, Fong HK, Nunna P, Zalavadia D, Dave H, Savani S, Doshi R. The burden and impact of arrhythmia in chronic obstructive pulmonary disease: Insights from the National Inpatient Sample. Int J Cardiol 2019; 281:49-55. [PMID: 30711267 DOI: 10.1016/j.ijcard.2019.01.074] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Revised: 12/22/2018] [Accepted: 01/18/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND We aimed to analyze the burden and predictors of arrhythmias and in-hospital mortality in chronic obstructive pulmonary disease (COPD)-related hospitalizations using the nationwide cohort. METHODS We queried the National Inpatient Sample (NIS) (2010-2014) databases to identify adult COPD hospitalizations with arrhythmia. Categorical and continuous variables were compared using Chi-square and Student's t-test/ANOVA. Predictors of any arrhythmia including AF and in-hospital mortality were evaluated by multivariable analyses. RESULTS Out of 21,596,342 COPD hospitalizations, 6,480,799 (30%) revealed co-existent arrhythmias including 4,767,401 AF-arrhythmias (22.1%) and 1,713,398 non AF-arrhythmias (7.9%). The AF or non-AF arrhythmia cohort consisted mostly of older (mean age~ 75.8 & 69.1 vs. 67.5 years) white male (53.3% & 51.9% vs. 46.9%) patients compared to those without arrhythmias (p < 0.001). The all-cause mortality (5.7% & 5.2 vs. 2.9%), mean length of stay (LOS) (6.4 & 6.5 vs. 5.3 days), and hospital charges ($52,699.49 & $58,102.39 vs. $41,208.02) were higher with AF and non AF-arrhythmia compared to the non-arrhythmia group (p < 0.001). Comorbidities such as cardiomyopathy (OR 2.11), cardiogenic shock (OR 1.88), valvular diseases (OR 1.60), congestive heart failure (OR 1.48) and pulmonary circulation disorders (OR 1.25) predicted in-hospital arrhythmias. Invasive mechanical ventilation (OR 6.41), cardiogenic shock (OR 5.95), cerebrovascular disease (OR 3.95), septicemia (OR 2.30) and acute myocardial infarction (OR 2.24) predicted higher mortality (p < 0.001) in the COPD-arrhythmia cohort. CONCLUSIONS About 30% of COPD hospitalizations revealed co-existent arrhythmias (AF 22.1%). All-cause mortality, LOS and hospital charges were significantly higher with arrhythmias. We observed racial and sex-based disparities for arrhythmias and related mortality.
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Affiliation(s)
- Rupak Desai
- Department of Cardiology, Atlanta VA Medical Center, Decatur, GA, USA.
| | - Upenkumar Patel
- Department of Internal Medicine, Nassau University Medical Center, East Meadow, NY, USA
| | - Sandeep Singh
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Rushikkumar Bhuva
- Department of Internal Medicine, Canton Medical Education Foundation, Canton, OH, USA
| | - Hee Kong Fong
- Department of Internal Medicine, University of Missouri-Columbia, Columbia, MO, USA
| | - Pratyusha Nunna
- Clinical Observer, Carle Foundation Hospital, Urbana, IL, USA
| | - Dipen Zalavadia
- Department of Internal Medicine, The Wright Center for Graduate Medical Education, Scranton, PA, USA
| | - Hitanshu Dave
- Department of Internal Medicine, Jersey Shore University Medical Center, Neptune, NJ, USA
| | - Sejal Savani
- Public Health, New York University, New York, NY, USA
| | - Rajkumar Doshi
- Department of Internal Medicine, University of Nevada School of Medicine, Reno, NV, USA
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