Impact of the COVID-19 pandemic on implantation of cardiac implantable electronic devices and remote monitoring activations

INTRODUCTION AND OBJECTIVES

Remote monitoring (RM) of cardiac implantable electronic devices (CIEDs) is considered more reliable, efficient, and safer than conventional in-person follow-up. However, the implementation of RM is still suboptimal. This study aimed to analyze the impact of the COVID-19 pandemic on the rates of CIED implants and RM activations in Spain.

METHODS

The COVID-19 RM Spain Registry was used to analyze the monthly number of all CIED implantations and RM activations from January 2018 to December 2021. A descriptive analysis was performed using aggregated data from the five major CIED manufacturers.

RESULTS

A total of 205 345 CIEDs were recorded. The number of implants decreased sharply (48.2%) during the pandemic lockdown (March-June 2020) but gradually increased thereafter, compensating for the previous reduction. However, pacemakers and implantable cardiac defibrillators (ICD) showed an aggregate loss of 7% and 3%, respectively, from the annual average during 2020-2021. In contrast, cardiac resynchronization therapy defibrillators (CRT-D) increased by 17%, and pacemakers (CRT-P) by 4.5% over the 2-year period. The percentage of RM activations increased from 24.5% in 2018 to 49.0% in 2021, with a sharp increase during the lockdown. The RM activation rates consistently increased during the lockdown for all devices: pacemakers (14.4% vs 37.2%; P <.001); ICD (75.6% vs 94.2%; P <.001); CRT-D/CRT-P (68.6-44.2% vs 81.6-61%; P <.001), and implantable loop recorders (50.2% vs 68.7%; P <.001).

CONCLUSIONS

The significant decline in implants during the lockdown gradually recovered, except for pacemakers and ICD. However, the COVID-19 pandemic boosted RM for all CIEDs in Spain.

Conduction system pacing and atrioventricular node ablation in heart failure: The PACE-FIB study design

AIMS

Atrial fibrillation (AF) worsens the prognosis of patients with heart failure (HF). Successful treatments are still very scarce for those with permanent AF and preserved (HFpEF) or mildly reduced (HFmrEF) ejection fraction. In this study, the long-term benefits and safety profile of heart rate regularization through left-bundle branch pacing (LBBP) and atrioventricular node ablation (AVNA) will be explored in comparison with pharmacological rate-control strategy.

METHODS AND RESULTS

The PACE-FIB trial is a multicentre, prospective, open-label, randomized (1:1) clinical study that will take place between March 2022 and February 2027. A total of 334 patients with HFpEF/HFmrEF and permanent AF will receive either LBBP followed by AVNA (intervention arm) or optimal pharmacological treatment for heart rate control according to European guideline recommendations (control arm). All patients will be followed up for a minimum of 36 months. The primary outcome measure will be the composite of all-cause mortality, HF hospitalization, and worsening HF at 36 months. Other secondary efficacy and safety outcome measures such as echocardiographic parameters, functional status, and treatment-related adverse events, among others, will be analysed too.

CONCLUSION

LBBP is a promising stimulation mode that may foster the clinical benefit of heart rate regularization through AV node ablation compared with pharmacological rate control. This is the first randomized trial specifically addressing the long-term efficacy and safety of this pace-and-ablate strategy in patients with HFpEF/HFmrEF and permanent AF.

Spanish implantable cardioverter-defibrillator registry. 19th official report of Heart Rhythm Association of the Spanish Society of Cardiology (2022)

INTRODUCTION AND OBJECTIVES

This article presents data on implantable cardioverter-defibrillator implants in Spain in 2022.

METHODS

The data were collected from implantation centers, which voluntarily completed a data collection sheet during the implantation process, either manually or through a web page.

RESULTS

In 2022, 170 hospitals participated in the registry. A total of 7693 forms were received compared with the 7970 reported by Eucomed (European Confederation of Medical Suppliers Associations), representing 96.5% of the devices. The total rate of registered implants was 162/million inhabitants (168 according to Eucomed), showing a slight increase compared with previous years. Disparities persisted among autonomous communities and Spain continued to have the lowest implantation rate among countries participating in Eucomed.

CONCLUSIONS

The data from the registry for 2022 reflect the complete recovery of activity after the impact of the COVID-19 pandemic in 2020. Despite a slight improvement, there was no significant change in our position in Europe or in the substantial differences among autonomous communities.

Extraction of a fractured pacemaker lead in the left bundle branch area using a snare via a femoral approach

We present the first reported case of extraction of a ventricular lead placed in the left bundle branch area with a double-loop design snare via the femoral approach without any complication. It was a 4-month-old lead whose extraction was not possible only with a conventional stylet via an implant vein approach, so we want to show that complete procedural success is possible.

Spanish implantable cardioverter-defibrillator registry. 18th official report of the Heart Rhythm Association of the Spanish Society of Cardiology (2021)

INTRODUCTION AND OBJECTIVES

This article presents the data corresponding to implantable cardioverter-defibrillator (ICD) implantations in Spain in 2021.

METHODS

The data were drawn from implanting centers, which voluntarily completed a data collection sheet during the procedure.

RESULTS

In 2021, 7496 implant data sheets were received, compared with 7743 reported by Eucomed (European Confederation of Medical Suppliers Associations), indicating that data were collected from 96.8% of the devices implanted in Spain. Data completion ranged from 99.9% for "name of implanting hospital" to 8.9% for "implanting hospital". In 2021, 199 hospitals participated in the registry, exceeding the figures of previous years, with around 170 participating hospitals. The total rate of registered implants was 158/million inhabitants (163 according to Eucomed), making 2021 the year with the highest activity. However, the registry continues to show significant differences among the various autonomous communities and the lowest implantation rate of all the European countries participating in Eucomed.

CONCLUSIONS

The Spanish implantable cardioverter-defibrillator registry for 2021 recorded an increase in the number of ICD implantations, reflecting the recovery of hospital activity after the initial impact of the COVID-19 pandemic in 2020. Although the total number of implants has increased in Spain, figures are still much lower than the European Union average, with differences persisting among Spanish autonomous communities.

Interregional variability in the use of cardiovascular technologies (2011-2019). Correlation with economic indicators, admissions, and in-hospital mortality

INTRODUCTION AND OBJECTIVES

Equal opportunities to access technical advances with recognized clinical value should be a priority of the publicly-funded health system. We analyzed variability among all the Spanish autonomous communities in the use of cardiovascular techniques with an established indication and its relationship with economic indicators, burden of disease, and hospital mortality.

METHODS

The activity registries of various Associations of the Spanish Society of Cardiology from 2011 to 2019 were analyzed for coronary angiography, overall percutaneous coronary intervention (PCI), primary PCI, implantable cardioverter-defibrillators (ICD), cardiac resynchronization therapy, and transcatheter aortic valve replacement (TAVR). Economic indices (gross domestic product and per capita health care expenditure) were obtained from public sources and data on attendance rates and mortality from the Resources and Quality in Cardiology (RECALCAR) reports of the Spanish Society of Cardiology. We analyzed the coefficient of variation for activity and the correlation of activity with regional economic indices, attendance rates, and risk-adjusted rates of in-hospital mortality.

RESULTS

We identified wide variability in the use of technologies, especially for primary PCI (18%), ICD (22%), cardiac resynchronization therapy (36%), and TAVR (42%). A certain correlation with attendance rates was seen only for overall PCI and ICD. In general, no significant correlation was found between the use of the techniques and the economic indices of wealth and expenditure. The correlation with in-hospital mortality showed no significant results, although this was the analysis with the greatest limitations because the impact of these techniques on survival is exerted more in the mid- and long-term.

CONCLUSIONS

The results of this study, despite its inherent limitations, show marked variability between autonomous communities in the use of cardiovascular technologies, which is not explained by economic differences or by hospital attendance rates due to the corresponding diseases.

The Right Atrial Area as a New Factor to Predict Successful Pulmonary Vein Isolation: an Emergent Predictor Variable

Up to now, few factors have been identified to predict successful pulmonary vein isolation, none of which with high predictive values. The objective of our study was to compare different predictive factors of atrial fibrillation recurrence after pulmonary vein isolation,including new parameters of the right atrium (area and index volume). We retrospectively analysed data from 66 patients and included echocardiogram parameters performed within 18 months prior to the ablation procedure. We excluded patients with left ventricular dysfunction (defined as a left ventricular ejection fraction < 50%); previous diagnostic of cardiomyopathy; severe valvular heart disease; severe pulmonary hypertension; or those with poor image quality in the echocardiogram. We considered atrial fibrillation recurrence to be the presence of atrial fibrillation of 30 seconds or longer demonstrated by a standard electrocardiogram or in a 24-hour Holter electrocardiogram within a year after the ablation procedure. We found that the right atrium area (odds ratio = 1.52; 95% confidence interval 0.95–2.43, P = 0.08) and a previous pulmonary vein isolation procedure (odds ratio = 0.21; 95% confidence interval 0.04–1.01, P = 0.05) were nearly statistically significant predictors of successful atrial fibrillation ablation at one year. Although our study was limited because of a low number of patients and because it is a retrospective analysis, we found that a higher right atrial area may be related to the late recurrence of atrial fibrillation. This tendency may be useful in predicting patient outcomes.

Spanish Implantable Cardioverter-defibrillator Registry. 17th Official Report of the Heart Rhythm Association of the Spanish Society of Cardiology (2020)

INTRODUCTION AND OBJECTIVES

We present the data corresponding to implantable cardioverter-defibrillator (ICD) implants in Spain in 2020.

METHODS

The data in this registry were drawn from implantation centers, which voluntarily completed a data collection sheet.

RESULTS

In 2020, 7056 implant sheets were received compared with 7106 reported by Eucomed (European Confederation of Medical Suppliers Associations), indicating that data were collected from 99% of the devices implanted in Spain. Completion of the implant sheet ranged from 99.8% for the field "name of the implanting hospital" to 2.6% for the variable "referral hospital". A total of 173 hospitals performed ICD implants and participated in the registry, which is a similar figure to that in 2019 (n=172). The total rate of registered implants was 149/million inhabitants (150 according to Eucomed), revealing a slight reduction in implants in Spain in 2020 as a result of the impact of the COVID-19 pandemic. This reduction was uneven among the autonomous communities.

CONCLUSIONS

The Spanish Implantable Cardioverter Defibrillator Registry for 2020 shows an improvement in the rate of implants reported and a reduction in the number of ICD implants, which likely reflects the decrease in hospital activity not related to the treatment of COVID-19 infection. Similar to previous years, the total number of implants in Spain is still much lower than the average for the European Union, with an increase in the differences between Spanish autonomous communities.

Safety and efficacy of dronedarone from clinical trials to real-world evidence: implications for its use in atrial fibrillation

Efficacy and safety of dronedarone was shown in the ATHENA trial for paroxysmal or persistent atrial fibrillation (AF) patients. Further trials revealed safety concerns in patients with heart failure and permanent AF. This review summarizes insights from recent real-world studies and meta-analyses, including reports on efficacy, with focus on liver safety, mortality risk in patients with paroxysmal/persistent AF, and interactions of dronedarone with direct oral anticoagulants. Reports of rapidly progressing liver failure in dronedarone-prescribed patients in 2011 led to regulatory cautions about potential liver toxicity. Recent real-world evidence suggests dronedarone liver safety profile is similar to other antiarrhythmics and liver toxicity could be equally common with many Class III antiarrhythmics. Dronedarone safety concerns (increased mortality in patients with permanent AF) were raised based on randomized controlled trials (RCT) (ANDROMEDA and PALLAS), but comedication with digoxin may have increased the mortality rates in PALLAS, considering the dronedarone-digoxin pharmacokinetic (PK) interaction. Real-world data on apixaban-dronedarone interactions and edoxaban RCT observations suggest no significant safety risks for these drug combinations. Median trough plasma concentrations of dabigatran 110 mg during concomitant use with dronedarone are at acceptable levels, while PK data on the rivaroxaban-dronedarone interaction are unavailable. In RCTs and real-world studies, dronedarone significantly reduces AF burden and cardiovascular hospitalizations, and demonstrates a low risk for proarrhythmia in patients with paroxysmal or persistent AF. The concerns on liver safety must be balanced against the significant reduction in hospitalizations in patients with non-permanent AF and low risk for proarrhythmias following dronedarone treatment.

Safety and efficiency of a common and simplified protocol for pacemaker and defibrillator surveillance based on remote monitoring only: a long-term randomized trial (RM-ALONE)

Aims

This trial aimed to evaluate the safety and efficiency of a common and simplified protocol for the surveillance of cardiac implantable electronic devices based on remote monitoring (RM) in patients with pacemakers (PMs) and implantable cardiac defibrillators (ICDs) for at least 24 months.

Methods and results

The RM-ALONE is a multicentre prospective trial that randomly assigned 445 patients in two groups, both followed by RM: the home monitoring-only (HMo) based on RM + remote interrogations (RIs) every 6 months and the HM + IO that adds in-office evaluations every 6 months to RM. Four hundred and forty-five patients were enrolled in the study, 294 PMs and 151 ICDs recipients. In the HMo group, 20% of patients experienced ≥1 major adverse cardiac event (MACE) vs. 19.5% in HM + IO group (P = 0.006 for non-inferiority). The proportion of patients with a PM/ICD who experienced ≥1 MACE was 15.2/29.3% in HMo group and 16.1/26.3% in HM + IO group (hazard ratio 0.95/1.15, 95% confidence interval 0.53–1.70/0.62–2.10). There were 789 in-office evaluations (136 in the HMo and 653 in the HM + IO; P < 0.001). There was a 79.2% reduction of in-office evaluations with no significant differences in unscheduled visits between groups: 122 (54.5%) in HMo and 101 (45.3%) in HM + IO; P = 0.15. The time a physician/nurse spent per patient/follow-up was significantly reduced in the HMo group: 4/5 min (0–30)/(1–30) vs. 10/10 min (0–40)/(1–40) in HM + IO (P < 0.0001).

Conclusion

The RM-ALONE protocol common for ICD and PM surveillance, consisting of RM + RI every 6 months has proven safe and efficient in reducing hospital visits and staff workload.

Trends and Bibliometric Impact of Research Grants of the Spanish Society of Cardiology/Spanish Heart Foundation (2007-2012)

INTRODUCTION AND OBJECTIVES

The Spanish Society of Cardiology/Spanish Heart Foundation (SEC/FEC) annually awards grants for cardiovascular research projects. Our objective was to analyze the trend in these investments and their resulting scientific production from 2007 to 2012.

METHODS

A search of the publications funded by the SEC/FEC was carried out, according to the following inclusion criteria: publication in a journal indexed in MEDLINE or EMBASE, publication date after the grant, authorship by the principal investigator of the grant, and acknowledgment of SEC/FEC funding. The impact factor and subsequent citations of the articles were analyzed (Web of Science).

RESULTS

A total of 235 grants were awarded (39/y) with an allocation of €3 854 300 (€642 383/y), 37% of them to women. In all, 122 publications resulted from 88 research projects (37%) funded by the SEC/FEC. Up to October 2017, these publications had received 2258 citations in subsequent studies in the Web of Science, with a mean of 18.5 and a median of 8 citations/study.

CONCLUSIONS

Despite the economic crisis, the mean number and size of the grants awarded by the SEC/FEC increased in the period analyzed. Grants were awarded on an equal opportunity basis to men and women. The bibliometric impact of the funded projects is acceptable, although efforts should be made to improve it.

Spanish Implantable Cardioverter-defibrillator Registry. 14th Official Report of the Spanish Society of Cardiology Electrophysiology and Arrhythmias Section (2017)

INTRODUCTION AND OBJECTIVES

The Spanish Automatic Defibrillator Registry has provided activity data since 2002.

METHODS

The data in this registry are submitted by implantation centers that voluntarily complete a data collection sheet.

RESULTS

During 2017, a total of 6273 implant sheets were received, compared with 6429 reported by Eucomed (European Confederation of Medical Suppliers Associations). Therefore, the registry contains data on 97.6% of the devices implanted in Spain. Compliance ranged from 99.7% for the field "name of the implanting hospital" to 46.1% for the variable "New York Heart Association functional class". A total of 181 hospitals reported data to the registry, representing an increase compared with the number of participating hospitals in 2016 (177) and in previous years (169 in 2015, 162 in 2014, 154 in 2013, and 153 in 2012).

CONCLUSIONS

The number of implants per million inhabitants in Spain increased for several years but decreased in 2017. As in previous years, the total number of implants in Spain is still much lower than the European Union average, and the gap continues to widen. There are still substantial differences between autonomous communities.

Implantable cardioverter-defibrillator in hypertrophic cardiomyopathy

Sudden cardiac death (SCD) is the most devastating complication in hypertrophic cardiomyopathy (HCM). The implantable cardioverter–defibrillator (ICD) has proven to be effective in SCD prevention in several clinical scenarios. In HCM population, it has demonstrated to successfully abort life-threatening ventricular arrhythmias despite the extreme morphology characteristic of HCM, often with massive degrees of left ventricular hypertrophy and/or LV outflow tract obstruction. Studies showed a high rate of appropriate intervention in secondary prevention and in primary prevention of patients considered at high risk. This appropriate intervention rate is even more significant considering the young and otherwise healthy patients that compose HCM population. Since SCD incidence in HCM is relatively low, optimal identification of patients at high risk is crucial. Classical strategy of risk stratification based on clinical risk factors has several limitations and has proven to overestimate risk. A new risk prediction model that provides individual 5-year estimated risk appears to be superior to traditional models based on bivariate risk factors. Perioperative complications seem to be similar to those related to the implant of other cardiac devices, while long-term complications have been traditionally in the spotlight. HCM patients are considered more vulnerable to ICD-related complications and inappropriate ICD therapy because of their young age at implant and increased prevalence of atrial fibrillation, but long-term follow-up data on ICD-related complications in general practice is limited. The subcutaneous implantable cardioverter defibrillator seems to be a safe and effective alternative in HCM, although long-term data are scarce.

Criteria for the Management of Technological Assets in Cardiovascular Imaging

Adequate, updated and functional technology is essential in cardiology. In Spain, the economic scenario has strongly impacted technology renewal programs and obsolescence is a growing problem. The current report attempts to describe the current situation and the conditions that must concur to update, replace or adopt new technologies in the field of cardiology.

Treatment of atrial fibrillation in patients with enhanced sympathetic tone by pulmonary vein isolation or pulmonary vein isolation and renal artery denervation: clinical background and study design : The ASAF trial: ablation of sympathetic atrial fibrillation

BACKGROUND

Hypertension is an important, modifiable risk factor for the development of atrial fibrillation (AF). Even after pulmonary vein isolation (PVI), 20-40% experience recurrent AF. Animal studies have shown that renal denervation (RDN) reduces AF inducibility. One clinical study with important limitations suggested that RDN additional to PVI could reduce recurrent AF.

OBJECTIVE

The goal of this multicenter randomized controlled study is to investigate whether RDN added to PVI reduces AF recurrence.

METHODS

The main end point is the time until first AF recurrence according to EHRA guidelines after a blanking period of 3 months. Assuming a 12-month accrual period and 12 months of follow-up, a power of 0.80, a two-sided alpha of 0.05 and an expected drop-out of 10% per group, 69 patients per group are required. We plan to randomize a total of 138 hypertensive patients with AF and signs of sympathetic overdrive in a 1:1 fashion. Patients should use at least two antihypertensive drugs. Sympathetic overdrive includes obesity, exercise-induced excessive blood pressure (BP) increase, significant white coat hypertension, hospital admission or fever induced AF, tachycardia induced AF and diabetes mellitus. The interventional group will undergo PVI + RDN and the control group will undergo PVI.

RESULTS

Patients will have follow-up for 1 year, and continuous loop monitoring is advocated.

CONCLUSION

This randomized, controlled study will elucidate if RDN on top of PVI reduces AF recurrence.

[Bayes' syndrome in cardiac surgery: prevalence of interatrial block in patients younger than 65 years undergoing cardiac surgery and association with postoperative atrial fibrillation]

OBJECTIVE

Interatrial block (IAB) is a well-known entity that is associated with an increased risk of atrial fibrillation (AF). This association is called Bayes' syndrome. The aim of our study was to define the prevalence of IAB among patients younger than 65 years undergoing cardiac surgery and determine whether there is an association between the presence of interatrial conduction delay and postoperative atrial fibrillation (POAF).

METHOD

A total of 207 patients were enrolled. Partial IAB was defined as P-wave>120ms. Advanced IAB was defined as P-wave>120ms+biphasic morphology in the inferior leads. Ocurrence of POAF was assessed and a comparative analysis was conducted between patients that did and did not develop AF.

RESULTS

IAB prevalence was 78.3% (partial 66.2%, advanced 12.1%). POAF occurred in 28.5% of all patients, and was more frequent among patients with advanced IAB (44%) compared to 27.7% and 24.4% of POAF among patients with partial IAB and without IAB, respectively. Patients who developed POAF were significantly older, had significantly higher NTproBNP, higher prevalence of atrial enlargement and thyroid disease. After multivariate analysis, advanced IAB was found to be independently associated with POAF.

CONCLUSIONS

IAB is a frequent finding among patients undergoing cardiac surgery. According to our results, advanced IAB is independently associated with POAF in younger patients (<65 years) undergoing cardiac surgery.

Clinical profile and incidence of ventricular arrhythmia in patients undergoing defibrillator generator replacement in Spain

INTRODUCTION AND OBJECTIVES

Implantable cardioverter-defibrillators reduce mortality in some patients with heart disease. Battery replacement is a frequent occurrence in clinical practice and is required in up to 30% of implants. The benefit/risk ratio of defibrillators varies over time and should be reevaluated at the time of replacement. The aim of this study was to determine the clinical characteristics and incidence of defibrillator therapies in patients who underwent generator replacement.

METHODS

This multicenter retrospective study involved patients from the UMBRELLA national registry who underwent replacement due to defibrillator battery depletion. The incidence of ventricular arrhythmias was determined via remote monitoring. Risk factors for sustained ventricular arrhythmia after replacement were analyzed.

RESULTS

A total of 354 patients were included (mean age [standard deviation], 61.8 [14.5] years; men, 80%; secondary prevention, 42%; ventricular arrhythmias in the explanted generator, 62%). After a 25-month follow-up, 70 patients (20%) received appropriate therapies and 8 (2.3%) received inappropriate discharges. Male sex, structural heart disease, heart failure, and the absence of resynchronization were independent predictors of ventricular arrhythmia occurrence.

CONCLUSIONS

One-fifth of patients had appropriate defibrillator therapies in the first 2 years after generator replacement. Determination of the factors associated with arrhythmia occurrence after replacement may be useful to optimize implantable cardioverter-defibrillator treatment.

Spanish Implantable Cardioverter-defibrillator Registry. Tenth Official Report of the Spanish Society of Cardiology Electrophysiology and Arrhythmias Section (2013)

INTRODUCTION AND OBJECTIVES

To present the findings of the Spanish Implantable Cardioverter-defibrillator Registry for 2013 compiled by the Electrophysiology and Arrhythmias Section of the Spanish Society of Cardiology.

METHODS

Prospective data were voluntarily recorded on a data collection form and sent to the Spanish Society of Cardiology by each implantation team.

RESULTS

Overall, 4772 device implantations were reported, representing 85% of the estimated total number of implantations. The reported implantation rate was 102 per million population and the estimated total implantation rate was 120 per million. The proportion of first implantations was 68.8%. Data were received from 154 hospitals (4 fewer than in 2012). Most implantable cardioverter-defibrillator recipients were men (83.3%). The mean age was 62.5 (13.4) years. Most patients had severe or moderate-to-severe ventricular dysfunction and were in New York Heart Association functional class II. The most frequent underlying cardiac condition was ischemic heart disease, followed by dilated cardiomyopathy. Indications for primary prevention accounted for 53.0% of first implantations, consolidating the decrease first observed in 2012. Overall, 79.8% of devices were implanted by cardiac electrophysiologists.

CONCLUSIONS

The 2013 Spanish Implantable Cardioverter-defibrillator Registry includes information on 85% of the devices implanted in Spain. The total number of implantations increased compared with the previous 2 years. The percentage of implantations for primary prevention indications decreased compared with the previous year.

El cambio de paradigma en la prevención de ictus en la fibrilación auricular. Retos y oportunidades emergentes para el médico de familia

La fibrilación auricular (FA), cuya frecuencia sigue aumentando en la población de nuestro entorno, es la arritmia sostenida más prevalente, llegando a afectar hasta al 10% de los pacientes de edad avanzada. Esta enfermedad duplica la mortalidad por cualquier causa y aumenta hasta en 5–6 veces el riesgo de ictus, que tiene la característica de ser especialmente grave. Los pilares fundamentales del tratamiento de la FA son la reversión a ritmo sinusal o el control de la frecuencia de respuesta ventricular y la prevención de los fenómenos tromboembólicos. Para este último objetivo los tratamientos que se han mostrado más efectivos son los anticoagulantes orales. Desde hace décadas, y hasta hace apenas unos pocos años, los únicos fármacos orales disponibles para este fin han sido los fármacos antivitamina K, representados en nuestro medio principalmente por el acenocumarol y, en menor grado, por la warfarina. Estos fármacos han demostrado reducir el desarrollo de ictus y la mortalidad comparados con placebo y con los antiagregantes, por lo cual han sido y siguen siendo el tratamiento estándar y el comparador para cualquier fármaco antitrombótico en los pacientes con FA. La variabilidad en su respuesta terapéutica, sus interacciones y su estrecha ventana terapéutica, que conlleva la necesidad de monitorizar frecuentemente la respuesta, han originado la búsqueda de nuevos fármacos que, al menos manteniendo sus ventajas, logren evitar alguno de sus inconvenientes. Actualmente disponemos de una serie de nuevos fármacos que cumplen estas premisas, si bien tienen el inconveniente de un mayor coste directo. La llegada de estos nuevos anticoagulantes orales (NACO) hace necesario conocerlos adecuadamente, alcanzar un consenso en cuanto a sus indicaciones de uso y realizar cambios en la gestión clínica de estos pacientes en los casos en los que se utilicen.

En el presente artículo revisaremos las indicaciones y forma de uso de las diferentes opciones (clásicas y nuevas) de tratamiento antitrombótico en pacientes con FA, la situación de los pacientes anticoagulados en nuestro entorno, las características de los NACO, sus recomendaciones de uso y los retos a los que se ven sometidos los/as médicos de familia en relación con estos cambios.

SmartDelay determined AV optimization: a comparison of AV delay methods used in cardiac resynchronization therapy (SMART-AV): rationale and design

BACKGROUND

The clinical benefit of cardiac resynchronization therapy (CRT) for patients with moderate-to-severely symptomatic heart failure, left ventricular systolic dysfunction, and ventricular conduction delay is established. However, some patients do not demonstrate clinical improvement following CRT. It is unclear whether systematic optimization of the programmed atrioventricular (AV) delay improves the rate of clinical response.

METHODS

SMART-AV is a randomized, multicenter, double-blinded, three-armed trial that will investigate the effects of optimizing AV delay timing in heart failure patients receiving CRT + defibrillator (CRT-D) therapy. A minimum of 950 patients will be randomized in a 1:1:1 ratio using randomly permuted blocks within each center programmed to either DDD or DDDR with a lower rate of 60. The study will include echocardiographic measurements of volumes and function [e.g., left ventricular end-systolic volume (LVESV)], biochemical measurements of plasma biomarker profiles, and functional measurements (e.g., 6-minute hall walk) in CRT-D patients who are enrolled and randomized to fixed AV delay (i.e., 120 ms), AV delay determined by electrogram-based SmartDelay, or an AV delay determined by echocardiography (i.e., mitral inflow). Patients will be evaluated prior to initiation of CRT, 3 and 6 months post-implant. The primary endpoint is the relative change in LVESV at 6 months between the groups. Patient enrollment commenced in May 2008 and the study is registered at clinicaltrials.gov.

CONCLUSION

SMART-AV is a randomized, clinical trial designed to evaluate three different methods of AV delay optimization to determine whether systematic AV optimization is beneficial for patients receiving CRT for 6 months post-implant.

Temas de actualidad 2005: electrofisiología y arritmias

Cardiac electrophysiology laboratories deal with a wide range of pathological conditions, diagnostic techniques, and treatments. Since a huge quantity of material has been published in recent months, this article will be limited to discussion of the most significant developments in the prognostic evaluation of arrhythmias, hereditary disease, syncope, atrial fibrillation, implantable cardioverter-defibrillators, cardiac resynchronization therapy, and catheter ablation. Even within these areas, discussion will be restricted to specific concrete topics and to a limited number of publications that were judged to have important implications for clinical practice. Our principal aim was to provide clinical cardiologists with an overview of the latest developments in cardiac electrophysiology.

[Antitachycardia pacing efficacy significantly improves with cardiac resynchronization therapy]

INTRODUCTION AND OBJECTIVES

The effect of cardiac resynchronization therapy on antitachycardia pacing still has to be determined.

PATIENTS AND METHOD

A total of 490 heart failure patients with an indication for an implantable cardioverter-defibrillator participated in the VENTAK CHF/CONTAK CD study, a single-blind, randomized, placebo-controlled study. We compared antitachycardia pacing efficacy in patients with or without cardiac resynchronization therapy. Due to the device design, antitachycardia pacing was always given simultaneously via both left and right leads (i.e., biventricular antitachycardia pacing). Patients were randomized at the time of implantation, with the pacing mode being programmed accordingly one month later.

RESULTS

During follow-up, 32 patients received antitachycardia pacing: 15 with cardiac resynchronization therapy and 17 without. In the 15 patients receiving resynchronization, 221 episodes of tachycardia were treated by antitachycardia pacing. The sinus rhythm conversion rate was 90.5%. In patients not receiving resynchronization, there were 139 episodes of tachycardia and the sinus rhythm conversion rate was 69.1%. The sinus rhythm conversion rate in the cardiac resynchronization therapy group was significantly higher than that in the control group (P<.0001). Moreover, antitachycardia pacing efficacy improved with time in the whole study population.

CONCLUSIONS

The efficacy of biventricular antitachycardia pacing in heart failure patients is significantly better in those with cardiac resynchronization therapy than in those without.

Airmed-cardio: a GSM and Internet services-based system for out-of-hospital follow-up of cardiac patients

A platform built around three information entities (patient, health-care_agent, and central_station) was designed to enable patients with chronic heart disease (in stable condition; emergency situations were excluded deliberately) to complete specifically defined protocols for out-of-hospital follow-up and monitoring. The patients belonged to one of four specific risk groups: arterial hypertension, malignant arrhythmias, heart failure, and postinfarction rehabilitation. They were provided with portable recording equipment and a cellular phone that supported data transmission [electrocardiogram (ECG)] and wireless application protocol (WAP) (remaining parameters and ad hoc questionnaires). The central station was an automatized platform, with no human operator. The information received was organized chronologically in patient folders. The health-care_agents had continuous and secure access to the patient folders, through tools based on the world wide web and WAP, and to short messages sent by their patients. A pilot project was conducted with 89 patients (mean length of participation: 50.1 days). A total of 2168 ECGs (mean duration transmission = 2 min/30 s; network errors < 0.1%) and 4011 short messages (none lost, in 95% of cases 30 s < delay < 1 min) were transmitted; 6083 WAP sessions (mean duration = 3 min 11 s; network failures < 0.1%) were The functionality of the platform was also evaluated, analyzing the subjective component of usability, showing the evolution of patient acceptance over time.

Paroxysmal atrial fibrillation prevention by pacing in patients with pacemaker indication

AIMS

The prevent-atrial fibrillation (AF) registry analyses the clinical relevance and usefulness of the four preventive pacing algorithms, available in a family of cardiac stimulators, to prevent atrial fibrillation.

METHODS AND RESULTS

This study is a prospective, non-randomized, multicentre registry. Patients are eligible for the registry if they have sick sinus syndrome (SSS) with or without pre-existing atrial fibrillation. The preventive pacing algorithms were programmed for each patient on an individual basis using the diagnostic features of the devices. In the period from April 2000 to April 2001 a total of 68 patients (33 male, 35 female) has been included in the registry in 14 hospitals in Spain. Mean age was 72+/-12 years and the pacemaker indication was SSS in 15 patients (22%) and SSS with paroxysmal AF in 53 patients (78%). The median AF burden for the total group (n=32) was significantly reduced from 3.9 to 1.3% (67%, P=0.034, Wilcoxon signed rank test). The decrease in AF burden was accompanied by a non-significant decrease in the median number of episodes per day from 1.47 to 0.64 (a decrease of 56%). The average atrial pacing % was increased from 72 to 78%.

CONCLUSIONS

The prevent-AF registry demonstrated the usefulness of four preventive pacing algorithms in daily clinical practice. During the registry a significant reduction in AF burden and all other endpoints was observed. Dedicated diagnostics were key to adapting the optimal pacing therapy during follow-up.

Comparison of defibrillation thresholds using monodirectional electrical vector versus bidirectional electrical vector

BACKGROUND

Currently, two main lead configurations are used for implantable cardioverter-defibrillators (ICD). One generates a monodirectional electrical vector by using the can surface as an active part (hot can) together with a right ventricular defibrillation coil. The other one (TRIAD) produces a bidirectional electrical vector by adding a proximal defibrillation electrode on the same lead. The purpose of this prospective study was to determine whether there is a difference between these configurations in terms of the acute defibrillation threshold (DFT). The secondary objective was to evaluate the possible sequential effect of successive arrhythmia induction and defibrillation shocks on the final DFT value.

METHODS

In 44 patients (37 males, 7 females, mean age 59.18 +/- 12.05 years; mean ejection fraction 35.21 +/- 11.69%), a Hot Can Ventak family ICD (Guidant, St. Paul, MN, USA) was implanted in a left pectoral pocket. During the implant procedure, step-down to failure DFT testing was performed twice in each patient using the two different above-mentioned configurations: the bidirectional and the monodirectional. The first configuration to be tested was determined by a 1:1 randomization by center.

RESULTS

The step-down DFT protocol was followed in 35 patients. The average DFT was 8.6 +/- 4.0 J for TRIAD and 10.4 +/- 4.3 J for the monodirectional (p = 0.009) lead configuration; this represents a 16.3% decrease in the DFT using a bidirectional configuration. Furthermore, no relationship between the final DFT and the number of ventricular fibrillation inductions and shocks received was observed, confirming the secondary objective.

CONCLUSIONS

Compared to the monodirectional electrical vector, the bidirectional electrical vector is clearly more beneficial for the patient.