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Reiffel JA. Cowboys Will Always Be Cowboys - But Not Everyone Should Join The Rodeo. Am J Cardiol 2024:S0002-9149(24)00280-7. [PMID: 38649129 DOI: 10.1016/j.amjcard.2024.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 04/09/2024] [Indexed: 04/25/2024]
Affiliation(s)
- James A Reiffel
- Professor Emeritus of Medicine, Columbia University, NYC, NY.
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2
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Markman TM, Marchlinski FE, Callans DJ, Frankel DS. Programmed Ventricular Stimulation: Risk Stratification and Guiding Antiarrhythmic Therapies. JACC Clin Electrophysiol 2024:S2405-500X(24)00182-8. [PMID: 38661601 DOI: 10.1016/j.jacep.2024.02.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 02/13/2024] [Indexed: 04/26/2024]
Abstract
Electrophysiologic testing with programmed ventricular stimulation (PVS) has been utilized to induce ventricular tachycardia (VT), thereby improving risk stratification for patients with ischemic and nonischemic cardiomyopathies and determining the effectiveness of antiarrhythmic therapies, especially catheter ablation. A variety of procedural aspects can be modified during PVS in order to alter the sensitivity and specificity of the test including the addition of multiple baseline pacing cycle lengths, extrastimuli, and pacing locations. The definition of a positive result is also critically important, which has varied from exclusively sustained monomorphic VT (>30 seconds) to any ventricular arrhythmia regardless of morphology. In this review, we discuss the history of PVS and evaluate its role in sudden cardiac death risk stratification in a variety of patient populations. We propose an approach to future investigations that will capitalize on the unique ability to vary the sensitivity and specificity of this test. We then discuss the application of PVS during and following catheter ablation. The strategies that have been utilized to improve the efficacy of intraprocedural PVS are highlighted during a discussion of the limitations of this probabilistic strategy. The role of noninvasive programmed stimulation is also reviewed in predicting recurrent VT and informing management decisions including repeat ablations, modifications in antiarrhythmic drugs, and implantable cardioverter-defibrillator programming. Based on the available evidence and guidelines, we propose an approach to future investigations that will allow clinicians to optimize the use of PVS for risk stratification and assessment of therapeutic efficacy.
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Affiliation(s)
- Timothy M Markman
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Francis E Marchlinski
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David J Callans
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David S Frankel
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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3
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Naccarelli GV, Popjes ED. Aggressive treatment of atrial fibrillation in hypertrophic cardiomyopathy patients improve quality of life. J Cardiovasc Electrophysiol 2024; 35:664-666. [PMID: 38332487 DOI: 10.1111/jce.16210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 01/29/2024] [Indexed: 02/10/2024]
Affiliation(s)
- Gerald V Naccarelli
- Penn State Heart and Vascular Institute, The Milton S. Hershey Medical Center, Penn State University College of Medicine Penn State Health, Hershey, Pennsylvania, USA
| | - Eric D Popjes
- Penn State Heart and Vascular Institute, The Milton S. Hershey Medical Center, Penn State University College of Medicine Penn State Health, Hershey, Pennsylvania, USA
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Kantharia BK. Heart failure and atrial fibrillation: Is atrial fibrillation ablation in heart failure pointless or mandatory? J Cardiovasc Electrophysiol 2024; 35:530-537. [PMID: 37548071 DOI: 10.1111/jce.16021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 07/11/2023] [Indexed: 08/08/2023]
Abstract
A vast amount of now well-established clinical and epidemiological data indicates a close, interdependent, and symbiotic association between atrial fibrillation (AF) and heart failure (HF). Both AF and HF, when co-exist in a patient, have serious treatment and prognostic implications. Based on the prevailing knowledge of the topic, various societies have issued a number of guidelines regarding the management of patients with AF and HF. Overall, it is the rhythm control strategy that has shown beneficial effect over the rate control strategy with improvement in symptoms of AF and HF. While antiarrhythmic drugs (AADs) and catheter ablation (CA) may be utilized as rhythm control strategy for AF, both AADs and CA have limitations of their own. Furthermore, with the progress made in various pharmacotherapeutic agents in HF, one could question the utility of CA in HF (i.e., whether ablation is mandatory or pointless in patients who have HF). The purpose of this review is to discuss this very point, focusing on the beneficial, neutral, or detrimental outcome of CA based on the category and class of HF.
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Affiliation(s)
- Bharat K Kantharia
- Icahn School of Medicine at Mount Sinai, Cardiovascular and Heart Rhythm Consultants, New York, New York, USA
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Crawford M, Steinberg BA, Ranjan R, Konstantinidis K, Navaravong L, Bunch TJ. Mortality benefit with AF ablation: Impact of normal sinus rhythm seen in CABANA and EAST AFnet. J Cardiovasc Electrophysiol 2024; 35:538-546. [PMID: 38131368 DOI: 10.1111/jce.16160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 12/08/2023] [Accepted: 12/11/2023] [Indexed: 12/23/2023]
Abstract
Atrial fibrillation (AF) is significantly associated with morbidity and mortality and erodes the quality and quantity of life. It is standard of care to treat patients with AF and an increased risk of stroke with oral anticoagulation therapy, but the more daunting question many clinicians face is whether to pursue a "rate-only" or "rhythm" control strategy. Historical studies over the years have sought to answer this question but have found no significant difference in major clinical outcomes between the two strategies. There are opportunities based on new data to improve the natural history of the disease. The EAST AFnet trial for the first time revealed a significant morbidity and mortality advantage to rhythm control therapy when performed early in the disease process of AF and in the setting of comprehensive medical management that was maintained. The CABANA trial clearly demonstrated that catheter ablation was a more effective long-term treatment of AF in general and significantly lowers risk of AF progression compared to medical therapy. Like multiple prior trials of rhythm management strategies, when rhythm control was effective in these trials, independent of therapy assignment, there was a significantly lower risk of adverse outcomes and death. These contemporary data provide optimism that the pervasive mortality risk in patients with AF observed over the past 50 years may be improved by the timing, use, and efficacy of use of therapeutic interventions.
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Affiliation(s)
- Michael Crawford
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Benjamin A Steinberg
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Ravi Ranjan
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Klitos Konstantinidis
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Leenhapong Navaravong
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Thomas J Bunch
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
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6
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Kheshti F, Abdollahifard S, Hosseinpour A, Bazrafshan M, Attar A. Ablation versus medical therapy for patients with atrial fibrillation: An updated meta-analysis. Clin Cardiol 2024; 47:e24184. [PMID: 37937825 PMCID: PMC10826237 DOI: 10.1002/clc.24184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 10/17/2023] [Accepted: 10/26/2023] [Indexed: 11/09/2023] Open
Abstract
To investigate the effect of ablation compared to medical therapy on clinical outcomes of patients with atrial fibrillation (AF). PubMed, Scopus, Embase, and Web of Science databases were searched using ablation, medical treatment, AF, and related words. The effect of ablation and medical therapy was sought to be gathered on stroke or transitional ischemic attack, mortality, hospitalization, recurrence of AF, progression of AF, and left ventricular ejection fraction. Analyses were performed using R software. 31 studies (the results of 27 randomized controlled trials), compromising an overall 6965 patients (Ablation, n = 3643; Medical treatment, n = 3322) were reviewed in our study, revealed that catheter ablation would result in substantial benefits for patients with AF without significant difference in serious adverse events compared to medical management (Risk Ratio: 0.92, [95% Confidence Interval (CI), 0.64-1.33]). Catheter ablation in patients with AF significantly resulted in a 29% reduction in all-cause mortality (RR: 0.71, [95% CI, 0.57-0.88]), a 57% reduction in hospitalization (RR: 0.43, [95% CI, 0.27-0.67]), a 53% reduction in AF recurrence (RR: 0.47, [95% CI, 0.36-0.61]), and a dramatic reduction, 89%, in progression of paroxysmal to persistent AF (RR: 0.11, [95% CI, 0.02-0.65]); also associated with a remarkable improvement in their left ventricular ejection fraction (LVEF) (Mean Difference, MD: 6.84%, [95% CI, 3.27-10.42]) compared to medical therapy. Our study showed that ablation may be superior to medical therapy in patients with AF regarding AF recurrence, mortality, LVEF improvement, hospitalization, and AF progression outcomes.
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Affiliation(s)
- Fatemeh Kheshti
- Department of Cardiovascular Medicine, School of MedicineShiraz University of Medical SciencesShirazIran
- Students' Research CommitteeShiraz University of Medical SciencesShirazIran
| | - Saeed Abdollahifard
- Students' Research CommitteeShiraz University of Medical SciencesShirazIran
- Research Center for Neuromodulation and PainShirazIran
| | - Alireza Hosseinpour
- Department of Cardiovascular Medicine, School of MedicineShiraz University of Medical SciencesShirazIran
- Students' Research CommitteeShiraz University of Medical SciencesShirazIran
| | - Mehdi Bazrafshan
- Students' Research CommitteeShiraz University of Medical SciencesShirazIran
| | - Armin Attar
- Department of Cardiovascular Medicine, School of MedicineShiraz University of Medical SciencesShirazIran
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Trohman RG. Etiologies, Mechanisms, Management, and Outcomes of Electrical Storm. J Intensive Care Med 2024; 39:99-117. [PMID: 37731333 DOI: 10.1177/08850666231192050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
Electrical storm (ES) is characterized by three or more discrete sustained ventricular tachyarrhythmia episodes occurring within a limited time frame (generally ≤ 24 h) or an incessant ventricular tachyarrhythmia lasting > 12 h. In patients with an implantable cardioverterdefibrillator (ICD), ES is defined as three or more appropriate device therapies, separated from each other by at least 5 min, which occur within a 24-h period. ES may constitute a medical emergency, depending on the number arrhythmic episodes, their duration, the type, and the cycle length of the ventricular arrhythmias, as well as the underlying ventricular function. This narrative review was facilitated by a search of MEDLINE to identify peer-reviewed clinical trials, randomized controlled trials, meta-analyses, and other clinically relevant studies. The search was limited to English-language reports published between 1999 and 2023. ES was searched using the terms mechanisms, genetics, channelopathies, management, pharmacological therapy, sedation, neuraxial modulation, cardiac sympathetic denervation, ICDs, and structural heart disease. Google and Google scholar as well as bibliographies of identified articles were reviewed for additional references. This manuscript examines the current strategies available to treat ES and compares pharmacological and invasive treatment strategies to diminish ES recurrence, morbidity, and mortality.
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Affiliation(s)
- Richard G Trohman
- Section of Electrophysiology, Division of Cardiology, Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA
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Zhang B, Han J, Zhou D, Jiang J, Zhong J, Lu Y, Zuo C, Lu X, Xuan J, Zu A, He Y, Sun X, Chen L, Zheng L. Radiofrequency ablation using the ThermoCool SmartTouch Catheter guided by ablation index versus antiarrhythmic drugs in atrial fibrillation treatment in China: a cost-consequence analysis. J Comp Eff Res 2024; 13:e230035. [PMID: 38205729 PMCID: PMC10842291 DOI: 10.57264/cer-2023-0035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 11/27/2023] [Indexed: 01/12/2024] Open
Abstract
Aim: To evaluate the costs and consequences of two front-line atrial fibrillation (AF) treatments from Chinese healthcare system perspective: radiofrequency catheter ablation (RFCA) using ThermoCool SmartTouch Catheter guided by Ablation Index (STAI), in comparison to antiarrhythmic drugs (AADs). Patients & methods: We simulated clinical and economic consequences for AF patients initially receiving STAI or AADs using a short-term decision tree model leading to a 10-year long-term Markov model. The model projected both clinical consequences and costs associated with, among others, AF, heart failure (HF), strokes, and deaths due to AF or AF related complications. Data informing the models included combination of a local real-world study and published clinical studies. Results: STAI was advantageous versus AADs on all 4 main clinical outcomes evaluated; AF: 25.83% lower (12.84% vs 38.67%), HF: 2.22% lower (1.33% vs 3.55%), stroke or post stroke: 1.82% lower (10.00% vs 11.82%) and deaths due to AF or AF related complications: 0.64% lower (4.11% vs 4.75%). The average total cost per patient in STAI group was ¥16,682 lower (¥123,124 vs ¥139,806). The one-way sensitivity analysis indicated that the difference in total cost was most sensitive to annual AF recurrence probability in AADs-treated patients. Probabilistic sensitivity analysis indicated a 98.5% probability that RFCA treatment would result in cost savings by the end of the 10th year. Conclusion: Radiofrequency catheter ablation using SmartTouch catheter guided by Ablation Index was superior to AADs as the first-line AF treatment in Chinese setting with better clinical outcomes and at lower costs over a 10-year time horizon.
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Affiliation(s)
- Biqi Zhang
- Department of Cardiology & Atrial Fibrillation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, 310003, China
| | - Jie Han
- Department of Cardiology & Atrial Fibrillation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, 310003, China
| | - Dongchen Zhou
- Department of Cardiology & Atrial Fibrillation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, 310003, China
| | - Jiajia Jiang
- Department of Cardiology & Atrial Fibrillation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, 310003, China
| | - Jiawei Zhong
- Department of Cardiology & Atrial Fibrillation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, 310003, China
| | - Yunlong Lu
- Department of Cardiology & Atrial Fibrillation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, 310003, China
| | - Chenyu Zuo
- Shanghai Centennial Scientific Co. Ltd., Shanghai, 200032, China
| | - Xingwei Lu
- Shanghai Centennial Scientific Co. Ltd., Shanghai, 200032, China
| | - Jianwei Xuan
- Sun Yat-sen University, Guangzhou, Guangdong, 510275, China
| | - Aohan Zu
- Department of Cardiology & Atrial Fibrillation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, 310003, China
| | - Yuxian He
- Department of Cardiology & Atrial Fibrillation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, 310003, China
| | - Xingang Sun
- Department of Cardiology & Atrial Fibrillation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, 310003, China
| | - Lu Chen
- Department of Cardiology & Atrial Fibrillation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, 310003, China
| | - Liangrong Zheng
- Department of Cardiology & Atrial Fibrillation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, 310003, China
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Sha R, Baines O, Hayes A, Tompkins K, Kalla M, Holmes AP, O'Shea C, Pavlovic D. Impact of Obesity on Atrial Fibrillation Pathogenesis and Treatment Options. J Am Heart Assoc 2024; 13:e032277. [PMID: 38156451 PMCID: PMC10863823 DOI: 10.1161/jaha.123.032277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2023]
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia. AF increases the risk of stroke, heart failure, dementia, and hospitalization. Obesity significantly increases AF risk, both directly and indirectly, through related conditions, like hypertension, diabetes, and heart failure. Obesity-driven structural and electrical remodeling contribute to AF via several reported mechanisms, including adiposity, inflammation, fibrosis, oxidative stress, ion channel alterations, and autonomic dysfunction. In particular, expanding epicardial adipose tissue during obesity has been suggested as a key driver of AF via paracrine signaling and direct infiltration. Weight loss has been shown to reverse these changes and reduce AF risk and recurrence after ablation. However, studies on how obesity affects pharmacologic or interventional AF treatments are limited. In this review, we discuss mechanisms by which obesity mediates AF and treatment outcomes, aiming to provide insight into obesity-drug interactions and guide personalized treatment for this patient subgroup.
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Affiliation(s)
- Rina Sha
- Institute of Cardiovascular Sciences, University of BirminghamBirminghamUnited Kingdom
| | - Olivia Baines
- Institute of Cardiovascular Sciences, University of BirminghamBirminghamUnited Kingdom
| | - Abbie Hayes
- Institute of Cardiovascular Sciences, University of BirminghamBirminghamUnited Kingdom
| | - Katie Tompkins
- Institute of Cardiovascular Sciences, University of BirminghamBirminghamUnited Kingdom
| | - Manish Kalla
- Institute of Cardiovascular Sciences, University of BirminghamBirminghamUnited Kingdom
| | - Andrew P. Holmes
- Institute of Cardiovascular Sciences, University of BirminghamBirminghamUnited Kingdom
| | - Christopher O'Shea
- Institute of Cardiovascular Sciences, University of BirminghamBirminghamUnited Kingdom
| | - Davor Pavlovic
- Institute of Cardiovascular Sciences, University of BirminghamBirminghamUnited Kingdom
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Beliaeva MM, Dzaurova KM, Yuricheva YA, Novikov PS, Mironov NY, Tarasovskiy GS, Zelberg MA, Sokolov SF, Golitsyn SP. Intravenous Cavutilide for Pharmacological Conversion of Paroxysmal and Persistent Atrial Fibrillation in Patients with Heart Failure. J Cardiovasc Dev Dis 2023; 10:487. [PMID: 38132655 PMCID: PMC10744291 DOI: 10.3390/jcdd10120487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 11/15/2023] [Accepted: 11/26/2023] [Indexed: 12/23/2023] Open
Abstract
This work aimed to study the efficacy and safety of the class III antiarrhythmic agent cavutilide (Niferidil, Refralon) for pharmacological cardioversion in patients with paroxysmal and persistent atrial fibrillation (AF) and heart failure (HF). METHODS AND RESULTS In this retrospective cohort study, 58 patients with stable HF (aged 69 [61;73] years, 30 males, 78% with persistent AF) and 274 patients without HF (aged 63 [57;70] years, 196 males, 56% with persistent AF) were included. The median AF duration in the group with HF was 35.5 [10.6;124] days, and that in the group without HF was 14.5 [3.6;90] days. All patients received 5-30 µg/kg cavutilide intravenously in one to four (if needed) boluses of 5-5-10-10 µg/kg at 15 min intervals. Subsequent boluses were not administered if the patient's sinus rhythm (SR) was restored or if bradycardia, QT prolongation > 500 ms or evidence of proarrhythmia was observed. Holter electrocardiogram monitoring was started before infusion and was continued for 24 h. The main criterion for an antiarrhythmic effect was sinus rhythm restoration within 24 h of the initial bolus. RESULTS Cavutilide converted AF to SR in 37.9% of patients with HF after bolus 1 (5 µg/kg), in 58.6% after bolus 2 (cumulative dose = 10 µg/kg), in 74% of cases after bolus 3 (cumulative dose = 20 µg/kg) and in 92.8% of cases after bolus 4 (cumulative dose = 30 µg/kg). Cavutilide was effective in 89% of cases with persistent AF with a median duration of 70.5 [30;159] days and in 92% of cases with paroxysmal AF with a median duration of 36 [24;102] h. In the group of patients without HF, the effectiveness of bolus 1 was 36.9%, that of the bolus 2 was 58%, that of the bolus 3 was 77% and that of the bolus 4 was 90.1%. Cavutilide restored SR in 90% of patients with persistent AF with a median duration of 82.5 [28;180] days and in 90% of cases with paroxysmal AF with a median duration of 50 [24;120] h. No statistically significant difference in the probability of SR restoration or the effectiveness of each bolus of cavutilide was found between patients with and without HF. The median time to restoration of SR in patients with HF was 23 [11;55] min, and that in patients without HF was 22 [10;45] min (p = 0.424). No cases of symptomatic/severe bradycardia were observed in either group. QT prolongation over 500 ms after cavutilide injection was registered in 19% of patients without HF and in 15.5% of those with HF (p = 0.58). Short runs of Torsade de pointes tachycardia occurred in one patient (0.4%) without HF after 10 µg cavutilide administration and were successfully treated with MgSO4. CONCLUSIONS Cavutilide demonstrated a high likelihood of AF conversion to SR in paroxysmal (92%) and persistent (89%) arrhythmia and HF. Concomitant HF and its severity do not affect the efficacy and safety of cavutilide.
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Affiliation(s)
- Maria M. Beliaeva
- Federal State Budgetary Institution, National Medical Research Centre of Cardiology Named after Academic E.I.Chazov of the Ministry of Health of the Russian Federation, Academician Chazov str., 15a, Moscow 121552, Russia
| | | | - Yulia A. Yuricheva
- Federal State Budgetary Institution, National Medical Research Centre of Cardiology Named after Academic E.I.Chazov of the Ministry of Health of the Russian Federation, Academician Chazov str., 15a, Moscow 121552, Russia
| | - Peter S. Novikov
- Federal State Budgetary Institution, National Medical Research Centre of Cardiology Named after Academic E.I.Chazov of the Ministry of Health of the Russian Federation, Academician Chazov str., 15a, Moscow 121552, Russia
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11
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Qiao M, Lei C, Tan C, Lu C, Chen Z, Zhang Q, Wang Z. Efficacy and safety of berberine for premature ventricular contractions: a meta-analysis and systematic review of randomized controlled trials. Pharm Biol 2023; 61:1474-1483. [PMID: 37855412 PMCID: PMC10588516 DOI: 10.1080/13880209.2023.2248167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 08/09/2023] [Indexed: 10/20/2023]
Abstract
CONTEXT Berberine is a potential drug that can effectively treat cardiovascular diseases, including premature ventricular contractions (PVCs). OBJECTIVE This study was conducted to assess the efficacy and safety of berberine for PVCs. METHODS The literature was searched using PubMed, Cochrane Library, Embase, China National Knowledge Infrastructure (CNKI), China Science and Technology Journal Database (VIP), Wanfang, and Chinese Biomedical Literature Database (CBM) for randomized controlled trials (RCTs) from inception to October 1, 2022. The risk of bias was assessed using the Revised Cochrane risk-of-bias tool for randomized trials, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was adopted to assess the quality of evidence. RESULTS Ten RCTs with 896 participants were included in the meta-analysis. The results showed that compared to antiarrhythmic drugs (AD), berberine (BE) combined with AD had a higher effective rate (RR = 1.26; 95% CI:1.12, 1.42; p = 0.0001) with no significant incidence of adverse reactions (RR = 0.93; 95% CI:0.33, 2.57; p = 0.88), and BE alone had no significant difference in effective rate (RR = 0.91; 95% CI:0.77, 1.07; p = 0.23), and a lower incidence of adverse reactions (RR = 0.38; 95% CI:0.15, 0.97; p = 0.04) and recurrence rate (RR = 0.40; 95% CI:0.18, 0.88; p = 0.02). CONCLUSIONS The results suggest that BE is an effective and safe adjunctive method for PVCs. In addition, BE is recommended for patients with PVCs who had severe adverse reactions after administrating AD as an alternative therapy.
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Affiliation(s)
- Meng Qiao
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, PR China
| | - Chao Lei
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, PR China
| | - Chaoren Tan
- Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Science, Beijing, PR China
| | - Cuncun Lu
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, PR China
| | - Zijia Chen
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, PR China
| | - Qiang Zhang
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, PR China
| | - Zhifei Wang
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, PR China
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Spears J, Liskov S, Camm AJ, Kowey PR. How Antiarrhythmic Drugs Are Being Used in Patients With Heart Failure: Results of a Global Survey of Cardiologists. Am J Cardiol 2023; 206:60-62. [PMID: 37683578 DOI: 10.1016/j.amjcard.2023.08.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 08/14/2023] [Indexed: 09/10/2023]
Affiliation(s)
- Jenna Spears
- Cardiology Division, Lankenau Heart Institute, Wynnewood, Pennsylvania
| | - Steven Liskov
- Cardiology Division, Lankenau Heart Institute, Wynnewood, Pennsylvania
| | - A John Camm
- Cardiology Clinical Academic Group, Molecular & Clinical Sciences Institute, St. George's University of London, London, United Kingdom
| | - Peter R Kowey
- Cardiology Division, Lankenau Heart Institute, Wynnewood, Pennsylvania; Department of Medicine, Jefferson Medical College, Philadelphia, Pennsylvania.
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Gray RA, Franz MR. Amiodarone prevents wave front-tail interactions in patients with heart failure: an in silico study. Am J Physiol Heart Circ Physiol 2023; 325:H952-H964. [PMID: 37656133 PMCID: PMC10907032 DOI: 10.1152/ajpheart.00227.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 08/25/2023] [Accepted: 08/25/2023] [Indexed: 09/02/2023]
Abstract
Amiodarone (AM) is an antiarrhythmic drug whose chronic use has proved effective in preventing ventricular arrhythmias in a variety of patient populations, including those with heart failure (HF). AM has both class III [i.e., it prolongs the action potential duration (APD) via blocking potassium channels) and class I (i.e., it affects the rapid sodium channel) properties; however, the specific mechanism(s) by which it prevents reentry formation in patients with HF remains unknown. We tested the hypothesis that AM prevents reentry induction in HF during programmed electrical stimulation (PES) via its ability to induce postrepolarization refractoriness (PRR) via its class I effects on sodium channels. Here we extend our previous human action potential model to represent the effects of both HF and AM separately by calibrating to human tissue and clinical PES data, respectively. We then combine these models (HF + AM) to test our hypothesis. Results from simulations in cells and cables suggest that AM acts to increase PRR and decrease the elevation of takeoff potential. The ability of AM to prevent reentry was studied in silico in two-dimensional sheets in which a variety of APD gradients (ΔAPD) were imposed. Reentrant activity was induced in all HF simulations but was prevented in 23 of 24 HF + AM models. Eliminating the AM-induced slowing of the recovery of inactivation of the sodium channel restored the ability to induce reentry. In conclusion, in silico testing suggests that chronic AM treatment prevents reentry induction in patients with HF during PES via its class I effect to induce PRR.NEW & NOTEWORTHY This work presents a new model of the action potential of the human, which reproduces the complex dynamics during premature stimulation in heart failure patients with and without amiodarone. A specific mechanism of the ability of amiodarone to prevent reentrant arrhythmias is presented.
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Affiliation(s)
- Richard A Gray
- Division of Biomedical Physics, Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, Maryland, United States
| | - Michael R Franz
- Cardiology Division, Veteran Affairs Medical Center, Washington, District of Columbia, United States
- Department of Pharmacology, Georgetown University Medical Center, Washington, District of Columbia, United States
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Manolis TA, Manolis AA, Apostolopoulos EJ, Melita H, Manolis AS. Depression and atrial fibrillation in a reciprocal liaison: a neuro-cardiac link. Int J Psychiatry Clin Pract 2023; 27:397-415. [PMID: 37615537 DOI: 10.1080/13651501.2023.2248214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 08/09/2023] [Indexed: 08/25/2023]
Abstract
OBJECTIVE To explore the reciprocal relationship of depression and atrial fibrillation (AF). METHODS A literature search was conducted in Pub Med, Scopus, and Google Scholar using relevant terms for depression and AF and respective therapies. RESULTS There is evidence that depression is involved in the aetiology and prognosis of AF. AF, independently of its type, incurs a risk of depression in 20-40% of patients. Also, depression significantly increases cumulative incidence of AF (from 1.92% to 4.44% at 10 years); 25% increased risk of new-onset AF is reported in patients with depression, reaching 32% in recurrent depression. Hence, emphasis is put on the importance of assessing depression in the evaluation of AF and vice versa. Persistent vs paroxysmal AF patients may suffer from more severe depression. Furthermore, depression can impact the effectiveness of AF treatments, including pharmacotherapy, anticoagulation, cardioversion and catheter ablation. CONCLUSIONS A reciprocal association of depression and AF, a neurocardiac link, has been suggested. Thus, strategies which can reduce depression may improve AF patients' course and treatment outcomes. Also, AF has a significant impact on risk of depression and quality of life. Hence, effective antiarrhythmic therapies may alleviate patients' depressive symptoms. KEY POINTSAF, independently of its type of paroxysmal, permanent or chronic, appears to have mental besides physical consequences, including depression and anxietyA reciprocal influence or bidirectional association of depression and AF, a neurocardiac link, has been suggestedAF has considerable impact on the risk of depression occurrence with 20-40% of patients with AF found to have high levels of depressionAlso, depression significantly increases 10-year cumulative incidence and risk of AF from 1.92% to 4.44% in people without depression, and the risk of new-onset AF by 25-32%Emphasis should be placed on the importance of assessing depression in the evaluation of AF and vice versaPersistent/chronic AF patients may suffer from more severe depressed mood than paroxysmal AF patients with similar symptom burdenDepression and anxiety can impact the effectiveness of certain AF treatments, including pharmacotherapy, anticoagulation treatment, cardioversion and catheter ablationThus, strategies which can reduce anxiety and depression may improve AF patients' course and treatment outcomesAlso, effective antiarrhythmic therapies to control AF may alleviate patients' depressive mood.
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Liu Z, Yang Z, Lu Y, Wang H, Zou C. Short-term and long-term effects of cryoballoon ablation versus antiarrhythmic drug therapy as first-line treatment for paroxysmal atrial fibrillation: A systematic review and meta-analysis. Clin Cardiol 2023; 46:1146-1153. [PMID: 37469293 PMCID: PMC10577536 DOI: 10.1002/clc.24092] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 06/21/2023] [Accepted: 07/06/2023] [Indexed: 07/21/2023] Open
Abstract
Cryoballoon ablation (CBA) is an effective treatment for drug-refractory atrial fibrillation (AF) patients. Whether CBA as a first-line treatment is superior in the rhythm control of AF than antiarrhythmic drugs (AAD) remains unclear. CBA is superior to AAD as initial therapy for rhythm control of paroxysmal atrial fibrillation (PAF). A comprehensive database search was performed in PubMed, Embase, Cochrane, and Web of Science from inception to March 22, 2023. Treatment efficacy was pooled using risk ratio (RR) and standardized mean difference (SMD) with a 95% confidence interval (CI). This study was registered with Prospero (CRD42023401596). Five randomized-controlled trials involving 923 patients and an observational study were included in this study. The CBA group had a significantly lower overall recurrence rate than the AAD group (CBA vs. AAD: RR = 0.59, 95% CI = 0.49-0.71, p < .05, I2 = 0). The incidence of persistent AF could be better controlled in the CBA group than in the AAD (CBA vs. AAD: RR = 0.17, 95% CI = 0.06-0.49, p < .05, I2 = 0). CBA could improve the quality of life (QoL) of patients better than AAD (CBA vs. AAD: SMD = 0.40, 95% CI = 0.14-0.67, p < .05, I2 = 68.5%). CBA can reduce hospitalization rate significantly than AAD at 36-month follow-up (CBA vs. AAD: RR = 0.29, 95% CI = 0.15-0.58, p < .05, I2 = 0%). Compared to AAD, CBA as first-line therapy could reduce the recurrence rate of atrial arrhythmia and incidence of persistent AF and improve QoL in PAF patients with lower incidences of hospitalization.
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Affiliation(s)
- Zirui Liu
- Department of CardiologyFirst Affiliated Hospital of Soochow UniversitySuzhouChina
| | - Zhengkai Yang
- Department of CardiologyFirst Affiliated Hospital of Soochow UniversitySuzhouChina
| | - Yu Lu
- Department of CardiologyFirst Affiliated Hospital of Soochow UniversitySuzhouChina
| | - Haocheng Wang
- Department of CardiologyFirst Affiliated Hospital of Soochow UniversitySuzhouChina
| | - Cao Zou
- Department of CardiologyFirst Affiliated Hospital of Soochow UniversitySuzhouChina
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16
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Kojić D, Radunović A, Bukumirić Z, Rajsic S, Sušić M, Marić M, Žugić V, Jurčević R, Tomović M. Idiopathic premature ventricular complexes treatment: Comparison of flecainide, propafenone, and sotalol. Clin Cardiol 2023; 46:1220-1226. [PMID: 37533168 PMCID: PMC10577560 DOI: 10.1002/clc.24090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 06/30/2023] [Indexed: 08/04/2023] Open
Abstract
BACKGROUND Beta-blockers (BB) or dihydropyridine calcium channel blockers (CCBs) are still the first choices in the treatment of idiopathic premature ventricular complexes (PVCs), with low-modest efficacy. Antiarrhythmic drugs (AADs) of Ic class are moderate to highly efficient but the evidence on their benefits is still limited. AIM To compare effectiveness and safety of flecainide, propafenone, and sotalol in the treatment of symptomatic idiopathic PVCs. METHODS Our single-center retrospective study analyzed 104 consecutive patients with 130 medication episodes of frequent idiopathic PVCs treated with AADs flecainide, propafenone (Ic class) or sotalol (III class). The primary outcome was complete/near complete reduction of PVCs after medication episode (PVCs burden reduction >99%), and the secondary outcome was significant PVC burden reduction (≥80%). RESULTS The complete/near complete PVCs burden reduction occurred in 31% and was significant in 43% of treated patients. A reduction of PVC burden for >99% was achieved in 56% of patients on flecainide, in 11% of patients on propafenone (p = .002), and in 21% of patients receiving sotalol (p = .031). There was no difference between propafenone and sotalol (p = .174). A reduction of PVC burden for ≥80% was achieved in 64% of patients on flecainide, in 30% of patients on propafenone (p = .009), and 33% of patients on sotalol (p = .020). There was no difference between propafenone and sotalol (p = .661). CONCLUSIONS The efficacy of AADs class Ic and III in the treatment of idiopathic PVCs was modest. Flecainide was the most effective AAD in the achievement of complete/near complete or significant PVC burden reduction, compared to propafenone and sotalol.
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Affiliation(s)
- Dejan Kojić
- Institute for Cardiovascular Diseases DedinjeBelgradeSerbia
| | - Anja Radunović
- Institute for Cardiovascular Diseases DedinjeBelgradeSerbia
| | - Zoran Bukumirić
- Institute of Medical Statistics and Informatics, Faculty of MedicineUniversity of BelgradeBelgradeSerbia
| | - Sasa Rajsic
- Department of Anesthesia and Intensive Care MedicineMedical University InnsbruckInnsbruckAustria
| | - Maša Sušić
- Institute for Cardiovascular Diseases DedinjeBelgradeSerbia
| | - Marija Marić
- Institute for Cardiovascular Diseases DedinjeBelgradeSerbia
| | - Vasko Žugić
- Institute for Cardiovascular Diseases DedinjeBelgradeSerbia
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Ken-Opurum J, Srinivas SSS, Park S, Charland S, Revel A, Preblick R. Clinical and economic outcomes associated with use of anti-arrhythmic drugs versus ablation in atrial fibrillation. J Comp Eff Res 2023; 12:e230065. [PMID: 37387403 PMCID: PMC10508306 DOI: 10.57264/cer-2023-0065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 06/12/2023] [Indexed: 07/01/2023] Open
Abstract
Aim: To evaluate the clinical and economic impact of antiarrhythmic drugs (AADs) compared with ablation both as individual treatments and as combination therapy without/with considering the order of treatment among patients with atrial fibrillation (AFib). Materials & methods: A budget impact model over a one-year time horizon was developed to assess the economic impact of AADs (amiodarone, dofetilide, dronedarone, flecainide, propafenone, sotalol, and as a group) versus ablation across three scenarios: direct comparisons of individual treatments, non-temporal combinations, and temporal combinations. The economic analysis was conducted in accordance with CHEERS guidance as per current model objectives. Results are reported as costs per patient per year (PPPY). The impact of individual parameters was evaluated using one-way sensitivity analysis (OWSA). Results: In direct comparisons, ablation had the highest annual medication/procedure cost ($29,432), followed by dofetilide ($7661), dronedarone ($6451), sotalol ($4552), propafenone ($3044), flecainide ($2563), and amiodarone ($2538). Flecainide had the highest costs for long-term clinical outcomes ($22,964), followed by dofetilide ($17,462), sotalol ($15,030), amiodarone ($12,450), dronedarone ($10,424), propafenone ($7678) and ablation ($9948). In the non-temporal scenario, total costs incurred for AADs (group) + ablation ($17,278) were lower compared with ablation alone ($39,380). In the temporal scenario, AADs (group) before ablation resulted in PPPY cost savings of ($22,858) compared with AADs (group) after ablation ($19,958). Key factors in OWSA were ablation costs, the proportion of patients having reablation, and withdrawal due to adverse events. Conclusion: Utilization of AADs as individual treatment or in combination with ablation demonstrated comparable clinical benefits along with costs savings in patients with AFib.
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18
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Marazzato J, Eikermann M, Di Biase L. Management of Atrial Arrhythmias After Lung Transplant. JACC Clin Electrophysiol 2023; 9:1824-1835. [PMID: 37648342 DOI: 10.1016/j.jacep.2023.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 12/21/2022] [Accepted: 01/18/2023] [Indexed: 09/01/2023]
Abstract
The overall survival in patients undergoing lung transplantation is poor. Although postsurgical atrial arrhythmias seem to play a major role in the morbidity and mortality of this population, data regarding the clinical and interventional management of this complication are still controversial. Through a review of the literature in the field, we observed that not only the surgical technique is clearly arrhythmogenic, but the new administration of peri-procedure beta-blockers and amiodarone for arrhythmia prevention and treatment, respectively, seems harmful in these postsurgical patients. However, low-dose beta-blockers administered after surgery seem feasible in arrhythmia prevention in specific patient subgroups, and, aside from amiodarone, alternative antiarrhythmic agents can be safely and effectively used to treat symptomatic patients on top of adequate rate control. Finally, as to complex atrial arrhythmias occurring late after lung transplant surgery, radiofrequency catheter ablation seems a feasible treatment option. In light of this evidence and considering the absence of clear recommendations in the field, we suggest a practical approach that may help the clinician in the management of this postsurgical complication. However, as most of these considerations are drawn from small-sized and retrospective studies, more evidence is needed in the future to clarify which medical and interventional strategies may best treat these postsurgical arrhythmias and thus potentially improve the outcome of these frail patients.
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Affiliation(s)
- Jacopo Marazzato
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA; Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Matthias Eikermann
- Department of Anesthesiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York, USA; Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen, Essen, Germany
| | - Luigi Di Biase
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA.
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19
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Davidson R, Medeiros M. Insights on the mechanism of flecainide in catecholaminergic polymorphic ventricular tachycardia. J Med Life 2023; 16:1294-1296. [PMID: 38024821 PMCID: PMC10652680 DOI: 10.25122/jml-2023-0191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 08/11/2023] [Indexed: 12/01/2023] Open
Abstract
Catecholaminergic polymorphic ventricular tachycardia (CPVT) is an inherited arrhythmia syndrome characterized by defective cardiac ryanodine receptor (RyR2) calcium release during times of adrenergic stimulation, resulting in bidirectional or polymorphic ventricular tachycardia. Flecainide is a class 1c anti-arrhythmic drug that has demonstrated therapeutic efficacy in treating CPVT. However, its mechanism of action remains disputed. One group proposes a direct effect of flecainide on RyR2-mediated calcium release, while another proposes an indirect effect via sodium channel blockade and modulation of intracellular calcium dynamics. In light of recent studies, this commentary aims to explore and discuss the evidence base for these potential mechanisms.
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Affiliation(s)
- Ross Davidson
- Department of Medicine, King’s College Hospital, Denmark Hill, London
| | - Maria Medeiros
- Department of Medicine, King’s College Hospital, Denmark Hill, London
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Abstract
AF is a chronic and progressive heart rhythm disorder characterised by exacerbations and remissions. Contemporary guidelines recommend antiarrhythmic drugs (AADs) as the initial therapy for the maintenance of sinus rhythm. However, these medications have modest efficacy and are associated with significant adverse effects. Several recent trials have evaluated catheter ablation as an initial therapy for AF, demonstrating that cryoballoon catheter ablation significantly improves arrhythmia outcomes (e.g. atrial tachyarrhythmia recurrence and arrhythmia burden), produces clinically meaningful improvements in patient-reported outcomes (e.g. symptoms and quality of life), and significantly decreases healthcare resource usage (e.g. hospitalisation), without increasing the risk of serious adverse events. Moreover, in contrast to antiarrhythmic drugs, catheter ablation appears to be disease-modifying, significantly reducing the progression of disease. These findings are relevant to patients, providers, and healthcare systems, helping inform the initial choice of rhythm-control therapy in patients with treatment-naïve AF.
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Affiliation(s)
- Jason G Andrade
- University of British Columbia Vancouver, Canada
- Centre for Cardiovascular Innovation Vancouver, Canada
- Montreal Heart Institute, Université de Montréal Montreal, Canada
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21
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Diemberger I, Imberti JF, Spagni S, Rapacciuolo A, Curcio A, Attena E, Amadori M, De Ponti R, D’Onofrio A, Boriani G. Drug management of atrial fibrillation in light of guidelines and current evidence: an Italian Survey on behalf of Italian Association of Arrhythmology and Cardiac Pacing. J Cardiovasc Med (Hagerstown) 2023; 24:430-440. [PMID: 37222631 PMCID: PMC10319250 DOI: 10.2459/jcm.0000000000001501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 04/10/2023] [Accepted: 04/30/2023] [Indexed: 05/25/2023]
Abstract
AIM Atrial fibrillation is a multifaceted disease requiring personalized treatment, in accordance with current ESC guidelines. Despite a wide range of literature, we still have various aspects dividing the opinion of the experts in rate control, rhythm control and thromboembolic prophylaxis. The aim of this survey was to provide a country-wide picture of current practice regarding atrial fibrillation pharmacological management according to a patient's characteristics. METHODS Data were collected using an in-person survey that was administered to members of the Italian Association of Arrhythmology and Cardiac Pacing. RESULTS We collected data from 106 physicians, working in 72 Italian hospitals from 15 of 21 regions. Our work evidenced a high inhomogeneity in atrial fibrillation management regarding rhythm control, rate control and thromboembolic prophylaxis in both acute and chronic patients. This element was more pronounced in settings in which literature shows a lack of evidence and, consequently, the indications provided by the guidelines are weak or absent. CONCLUSION This National survey evidenced a high inhomogeneity in current approaches adopted for atrial fibrillation management by a sample of Italian cardiologist experts in arrhythmia management. Further studies are needed to explore if these divergences are associated with different long-term outcomes.
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Affiliation(s)
- Igor Diemberger
- Institute of Cardiology, Department of Medical and Surgical Sciences, University of Bologna, Policlinico S.Orsola-Malpighi, Bologna
- IRCCS Policlinico di S.Orsola, U.O.C. di Cardiologia
- Pharmacologic Area of AIAC (Associazione Italiana Aritmologia e Cardiostimolazione), Rome
| | - Jacopo Francesco Imberti
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia
- Pharmacologic Area of AIAC (Associazione Italiana Aritmologia e Cardiostimolazione), Rome
| | - Stefano Spagni
- Institute of Cardiology, Department of Medical and Surgical Sciences, University of Bologna, Policlinico S.Orsola-Malpighi, Bologna
| | - Antonio Rapacciuolo
- Department of Advanced Biomedical Science, University of Naples Federico II, Corso Umberto I 40, Naples
- Pharmacologic Area of AIAC (Associazione Italiana Aritmologia e Cardiostimolazione), Rome
| | - Antonio Curcio
- Pharmacologic Area of AIAC (Associazione Italiana Aritmologia e Cardiostimolazione), Rome
- Department of Medical and Surgical Sciences, University ‘Magna Graecia’ of Catanzaro, Catanzaro
| | - Emilio Attena
- Pharmacologic Area of AIAC (Associazione Italiana Aritmologia e Cardiostimolazione), Rome
- Cardiology Unit, Roccadaspide Hospital, ASL Salerno
| | - Martina Amadori
- Institute of Cardiology, Department of Medical and Surgical Sciences, University of Bologna, Policlinico S.Orsola-Malpighi, Bologna
| | - Roberto De Ponti
- Cardiovascular Department, Circolo Hospital, Università degli Studi dell’Insubria
| | - Antonio D’Onofrio
- Departmental Unit of Electrophysiology, Evaluation and Treatment of Arrhythmias, Monaldi Hospital, Naples, Italy
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena
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Naccarelli GV. Are Class IC Antiarrhythmic Agents Safe in Atrial Fibrillation Patients With Nonobstructive Coronary Artery Disease? JACC Clin Electrophysiol 2023; 9:1181-1183. [PMID: 37495325 DOI: 10.1016/j.jacep.2023.01.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 01/31/2023] [Indexed: 07/28/2023]
Affiliation(s)
- Gerald V Naccarelli
- Penn State University College of Medicine, Penn State Health, Penn State Heart and Vascular Institute, The Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA.
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23
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Tandri H. Insanity and the Law of Diminishing Returns. JACC Clin Electrophysiol 2023; 9:822-823. [PMID: 37380315 DOI: 10.1016/j.jacep.2023.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 05/13/2023] [Indexed: 06/30/2023]
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Samuel M, Healey JS, Nault I, Sterns LD, Essebag V, Gray C, Hruczkowski T, Gardner M, Parkash R, Sapp JL. Ventricular Tachycardia and ICD Therapy Burden With Catheter Ablation Versus Escalated Antiarrhythmic Drug Therapy. JACC Clin Electrophysiol 2023; 9:808-821. [PMID: 37380314 DOI: 10.1016/j.jacep.2023.01.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 01/24/2023] [Accepted: 01/26/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND Catheter ablation improves ventricular tachycardia (VT) event-free (time to event) survival in patients with antiarrhythmic drug (AAD)-refractory VT and previous myocardial infarction (MI). The effects of ablation on recurrent VT and implantable cardioverter-defibrillator (ICD) therapy (burden) have yet to be investigated. OBJECTIVES This study sought to compare the VT and ICD therapy burden following treatment with either ablation or escalated AAD therapy among patients with VT and previous MI in the VANISH (Ventricular tachycardia AblatioN versus escalated antiarrhythmic drug therapy in ISchemic Heart disease) trial. METHODS The VANISH trial randomized patients with previous MI and VT despite initial AAD therapy to either escalated AAD treatment or catheter ablation. VT burden was defined as the total number of VT events treated with ≥1 appropriate ICD therapy. Appropriate ICD therapy burden was defined as the total number of appropriate shocks or antitachycardia pacing therapies (ATPs) delivered. The Anderson-Gill recurrent event model was used to compare burden between the treatment arms. RESULTS Of the 259 enrolled patients (median age, 69.8 years; 7.0% women), 132 patients were randomized to ablation and 129 patients were randomized to escalated AAD therapy. Over 23.4 months of follow-up, ablation-treated patients had a 40% lower shock-treated VT event burden and a 39% lower appropriate shock burden compared with patients who received escalated AAD therapy (P <0.05 for all). A reduction in VT burden, ATP-treated VT event burden, and appropriate ATP burden among ablation patients was only demonstrated in the stratum of patients with amiodarone-refractory VT (P <0.05 for all). CONCLUSIONS Among patients with AAD-refractory VT and a previous MI, catheter ablation reduced shock-treated VT event burden and appropriate shock burden compared with escalated AAD therapy. There was also lower VT burden, ATP-treated VT event burden, and appropriate ATP burden among ablation-treated patients; however, the effect was limited to patients with amiodarone-refractory VT.
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Affiliation(s)
- Michelle Samuel
- Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | | | - Isabelle Nault
- Quebec Heart and Lung Institute, Quebec City, Quebec, Canada
| | | | - Vidal Essebag
- McGill University Health Centre, Montreal, Quebec, Canada; Hôpital Sacré-Coeur de Montréal, Montreal, Quebec, Canada
| | - Christopher Gray
- Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada
| | | | - Martin Gardner
- Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada
| | - Ratika Parkash
- Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada
| | - John L Sapp
- Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada.
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Wang F, Zhou B, Sun H, Wu X. Proarrhythmia associated with antiarrhythmic drugs: a comprehensive disproportionality analysis of the FDA adverse event reporting system. Front Pharmacol 2023; 14:1170039. [PMID: 37251345 PMCID: PMC10213327 DOI: 10.3389/fphar.2023.1170039] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 05/04/2023] [Indexed: 05/31/2023] Open
Abstract
Objective: This study aimed to identify the different associations between antiarrhythmic drugs (AADs) and arrhythmias, and to determine whether pharmacokinetic drug interactions involving AADs increase the risk of AAD-related arrhythmias compared to using AADs alone. Materials and methods: The disproportionality analysis of AAD-associated cardiac arrhythmias, including AAD monotherapies and concomitant use of pharmacokinetic interacting agents involving AADs, was conducted by using reporting odds ratio (ROR) and information component (IC) as detection of potential safety signals based on FAERS data from January 2016 to June 2022. We compared the clinical features of patients reported with AAD-associated arrhythmias between fatal and non-fatal groups, and further investigated the onset time (TTO) following different AAD regimens. Results: A total of 11754 AAD-associated cardiac arrhythmias reports were identified, which was more likely to occur in the elderly (52.17%). Significant signals were detected between cardiac arrhythmia and all AAD monotherapies, with ROR ranging from 4.86 with mexiletine to 11.07 with flecainide. Regarding four specific arrhythmias in High Level Term (HLT) level, the AAD monotherapies with the highest ROR were flecainide in cardiac conduction disorders (ROR025 = 21.18), propafenone in rate and rhythm disorders (ROR025 = 10.36), dofetilide in supraventricular arrhythmias (ROR025 = 17.61), and ibutilide in ventricular arrhythmias (ROR025 = 4.91). Dofetilide/ibutilide, ibutilide, mexiletine/ibutilide and dronedarone presented no signal in the above four specific arrhythmias respectively. Compared with amiodarone monotherapy, sofosbuvir plus amiodarone detected the most significantly increased ROR in arrhythmias. Conclusion: The investigation showed the spectrum and risk of AAD-associated cardiac arrhythmias varied among different AAD therapies. The early identification and management of AAD-associated arrhythmias are of great importance in clinical practice.
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Affiliation(s)
- Feifei Wang
- Department of Pharmacy, Hefei BOE Hospital, Hefei, China
| | - Bingfeng Zhou
- Department of Cardiology, Hefei BOE Hospital, Hefei, China
| | - Hongwei Sun
- Department of Cardiology, Hefei BOE Hospital, Hefei, China
| | - Xinan Wu
- Department of Pharmacy, Hefei BOE Hospital, Hefei, China
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Oeffl N, Schober L, Faudon P, Schweintzger S, Manninger M, Köstenberger M, Sallmon H, Scherr D, Kurath-Koller S. Antiarrhythmic Drug Dosing in Children-Review of the Literature. Children (Basel) 2023; 10:children10050847. [PMID: 37238395 DOI: 10.3390/children10050847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 04/27/2023] [Accepted: 05/05/2023] [Indexed: 05/28/2023]
Abstract
Antiarrhythmic drugs represent a mainstay of pediatric arrhythmia treatment. However, official guidelines and consensus documents on this topic remain scarce. There are rather uniform recommendations for some medications (including adenosine, amiodarone, and esmolol), while there are only very broad dosage recommendations for others (such as sotalol or digoxin). To prevent potential uncertainties and even mistakes with regard to dosing, we summarized the published dosage recommendations for antiarrhythmic drugs in children. Because of the wide variations in availability, regulatory approval, and experience, we encourage centers to develop their own specific protocols for pediatric antiarrhythmic drug therapy.
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Affiliation(s)
- Nathalie Oeffl
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University of Graz, 8036 Graz, Austria
| | - Lukas Schober
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University of Graz, 8036 Graz, Austria
| | - Patrick Faudon
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University of Graz, 8036 Graz, Austria
| | - Sabrina Schweintzger
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University of Graz, 8036 Graz, Austria
| | - Martin Manninger
- Division of Cardiology, Department of Medicine, Medical University of Graz, 8036 Graz, Austria
| | - Martin Köstenberger
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University of Graz, 8036 Graz, Austria
| | - Hannes Sallmon
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University of Graz, 8036 Graz, Austria
| | - Daniel Scherr
- Division of Cardiology, Department of Medicine, Medical University of Graz, 8036 Graz, Austria
| | - Stefan Kurath-Koller
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University of Graz, 8036 Graz, Austria
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Vamos M, Zsigmond EJ, Hohnloser SH. Indications for mexiletine in the new ESC guidelines and beyond. Expert Opin Pharmacother 2023; 24:1403-1407. [PMID: 37306465 DOI: 10.1080/14656566.2023.2223964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 06/05/2023] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Mexiletine is a class IB sodium-channel blocker. Unlike class IA or IC antiarrhythmic drugs, mexiletine rather shortens than prolongs action potential duration; therefore, it is less associated with proarrhythmic effects. AREAS COVERED Recently, new European Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death were published, including a reappraisal of some established older antiarrhythmic drugs. EXPERT OPINION Mexiletine offers a first-line, genotype-specific treatment strategy for LQT3 patients as emphasized by the most recent guidelines. Besides this recommendation, current study reports suggest that in therapy-refractory ventricular tachyarrhythmias and electrical storms adjunctive mexiletine treatment may offer the possibility of stabilizing patients with or without concomitant interventional therapy such as catheter ablation.
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Affiliation(s)
- Mate Vamos
- Cardiac Electrophysiology Division, Department of Internal Medicine, University of Szeged, Szeged, Hungary
| | - Elod-Janos Zsigmond
- Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary
- Department of Cardiology, Medical Centre, Hungarian Defence Forces, Budapest, Hungary
| | - Stefan H Hohnloser
- Department of Cardiology, J. W. Goethe University, Frankfurt Am Main, Germany
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Li X, Li M, Shao Y, Gu W, Ni B, Gu J, Chen M. Thoracoscopic ablation delays progression from paroxysmal to persistent atrial fibrillation. J Thorac Cardiovasc Surg 2023; 165:1387-94. [PMID: 33992460 DOI: 10.1016/j.jtcvs.2021.03.114] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 02/21/2021] [Accepted: 03/01/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The study objective was to determine whether mini-invasive transthoracoscopic atrial fibrillation ablation can delay the progression of atrial fibrillation from paroxysmal to persistent. METHODS Patients aged 18 to 80 years with paroxysmal nonvalvular atrial fibrillation and a history of stroke or systemic thromboembolism were consecutively enrolled from September 2014 to June 2019. In the treatment group, patients underwent transthoracoscopic atrial fibrillation ablation plus left atrial appendage excision (atrial fibrillation ablation plus left atrial appendage excision group). Patients unwilling to receive surgical intervention were treated with antiarrhythmic drugs and oral anticoagulants and recruited as a control group (atrial fibrillation plus antiarrhythmic drugs group). The primary end point was the progression of atrial fibrillation from paroxysmal to persistent. RESULTS This study included 49 patients in the atrial fibrillation plus antiarrhythmic drugs group (29 men) and 77 patients in the atrial fibrillation ablation plus left atrial appendage excision group (48 men). In the atrial fibrillation ablation plus left atrial appendage excision group, after a median follow-up of 951 days (interquartile range, 529-1366 days), 8 patients (10.4%) progressed to persistent atrial fibrillation. In the atrial fibrillation plus antiarrhythmic drugs group, after a median follow-up of 835 days (interquartile range, 548-1214 days), 14 patients (28.6%) progressed to persistent atrial fibrillation. The atrial fibrillation ablation plus left atrial appendage excision group had a significantly lower incidence of atrial fibrillation progression than the atrial fibrillation plus antiarrhythmic drugs group during follow-up (3.9 vs 12.3 per 100 person-years, log-rank 8.6, P = .003). CONCLUSIONS Patients with paroxysmal nonvalvular atrial fibrillation who chose to undergo transthoracoscopic atrial fibrillation ablation had a lower incidence of progression to persistent atrial fibrillation than patients who chose conservative therapy. This strategy might be especially suitable for patients with paroxysmal nonvalvular atrial fibrillation at high risk of stroke and high risk of bleeding.
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Liu AY, Charron J, Fugaro D, Spoolstra S, Kaplan R, Lohrmann G, Gao X, Gay H, Passman R, Kim S, Lin AC, Chicos A, Arora R, Patil K, Pfenniger A, Knight BP, Verma N. Implementation of an intravenous sotalol initiation protocol: Implications for feasibility, safety, and length of stay. J Cardiovasc Electrophysiol 2023; 34:502-506. [PMID: 36640424 PMCID: PMC10699543 DOI: 10.1111/jce.15819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 12/02/2022] [Accepted: 01/09/2023] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Oral sotalol initiation requires a multiple-day, inpatient admission to monitor for QT prolongation during loading. A 1-day intravenous (IV) sotalol loading protocol was approved by the United States Food and Drug Administration in March 2020, but limited data on clinical use and administration currently exists. This study describes implementation of an IV sotalol protocol within an integrated health system, provides initial efficacy and safety outcomes, and examines length of stay (LOS) compared with oral sotalol initiation. METHODS IV sotalol was administered according to a prespecified initiation protocol to adult patients with refractory atrial or ventricular arrhythmias. Baseline characteristics, safety and feasibility outcomes, and LOS were compared with patients receiving oral sotalol over a similar time period. RESULTS From January 2021 to June 2022, a total of 29 patients (average age 66.0 ± 8.6 years, 27.6% women) underwent IV sotalol load and 20 patients (average age 60.4 ± 13.9 years, 65.0% women) underwent oral sotalol load. The load was successfully completed in 22/29 (75.9%) patients receiving IV sotalol and 20/20 (100%) of patients receiving oral sotalol, although 7/20 of the oral sotalol patients (35.0%) required dose reduction. Adverse events interrupting IV sotalol infusion included bradycardia (seven patients, 24.1%) and QT prolongation (three patients, 10.3%). No patients receiving IV or oral sotalol developed sustained ventricular arrhythmias before discharge. LOS for patients completing IV load was 2.6 days shorter (mean 1.0 vs. 3.6, p < .001) compared with LOS with oral load. CONCLUSION IV sotalol loading has a safety profile that is similar to oral sotalol. It significantly shortens hospital LOS, potentially leading to large cost savings.
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Affiliation(s)
- Albert Y. Liu
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
| | - Jessica Charron
- Division of Cardiology, Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Dana Fugaro
- Division of Cardiology, Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Scott Spoolstra
- Division of Cardiology, Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Rachel Kaplan
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Graham Lohrmann
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
| | - Xu Gao
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
| | - Hawkins Gay
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
| | - Rod Passman
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
| | - Susan Kim
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
| | - Albert C. Lin
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
| | - Alexandru Chicos
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
| | - Rishi Arora
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
| | - Kaustubha Patil
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
| | - Anna Pfenniger
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
| | - Bradley P. Knight
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
| | - Nishant Verma
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
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Guarracini F, Bonvicini E, Zanon S, Martin M, Casagranda G, Mochen M, Coser A, Quintarelli S, Branzoli S, Mazzone P, Bonmassari R, Marini M. Emergency Management of Electrical Storm: A Practical Overview. Medicina (Kaunas) 2023; 59:medicina59020405. [PMID: 36837606 PMCID: PMC9963509 DOI: 10.3390/medicina59020405] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 02/08/2023] [Accepted: 02/17/2023] [Indexed: 02/22/2023]
Abstract
Electrical storm is a medical emergency characterized by ventricular arrythmia recurrence that can lead to hemodynamic instability. The incidence of this clinical condition is rising, mainly in implantable cardioverter defibrillator patients, and its prognosis is often poor. Early acknowledgment, management and treatment have a key role in reducing mortality in the acute phase and improving the quality of life of these patients. In an emergency setting, several measures can be employed. Anti-arrhythmic drugs, based on the underlying disease, are often the first step to control the arrhythmic burden; besides that, new therapeutic strategies have been developed with high efficacy, such as deep sedation, early catheter ablation, neuraxial modulation and mechanical hemodynamic support. The aim of this review is to provide practical indications for the management of electrical storm in acute settings.
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Affiliation(s)
- Fabrizio Guarracini
- Department of Cardiology, S. Chiara Hospital, 38122 Trento, Italy
- Correspondence: ; Tel.: +39-(0)461-903121; Fax: +39-(0)461-903122
| | - Eleonora Bonvicini
- Department of Cardiology, S. Chiara Hospital, 38122 Trento, Italy
- Department of Cardiology, University of Verona, 37126 Verona, Italy
| | - Sofia Zanon
- Department of Cardiology, University of Verona, 37126 Verona, Italy
| | - Marta Martin
- Department of Cardiology, S. Chiara Hospital, 38122 Trento, Italy
| | | | - Marianna Mochen
- Department of Radiology, Santa Chiara Hospital, 38122 Trento, Italy
| | - Alessio Coser
- Department of Cardiology, S. Chiara Hospital, 38122 Trento, Italy
| | | | - Stefano Branzoli
- Cardiac Surgery Unit, Santa Chiara Hospital, 38122 Trento, Italy
- Department of Cardiac Surgery, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, 1090 Brussels, Belgium
| | - Patrizio Mazzone
- Cardiothoracovascular Department, Electrophysiology Unit, Niguarda Hospital, 20162 Milan, Italy
| | | | - Massimiliano Marini
- Department of Cardiology, S. Chiara Hospital, 38122 Trento, Italy
- Heart Rhythm Management Centre, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, 1090 Brussel, Belgium
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Naccarelli GV, Kowey PR. Should we limit antiarrhythmic drug choice in patients with left ventricular hypertrophy? J Cardiovasc Electrophysiol 2023; 34:453-454. [PMID: 36335634 DOI: 10.1111/jce.15732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 10/31/2022] [Indexed: 11/08/2022]
Affiliation(s)
- Gerald V Naccarelli
- The Milton S. Hershey Medical Center, Penn State Heart and Vascular Institute, Penn State University College of Medicine, Hershey, Pennsylvania, USA
| | - Peter R Kowey
- Lankenau Heart Institute, Wynnewood, Pennsylvania, USA.,Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Kim W, Kim M, Kim YT, Park W, Kim JB, Kim C, Joung B. Cost-effectiveness of rhythm control strategy: Ablation versus antiarrhythmic drugs for treating atrial fibrillation in Korea based on real-world data. Front Cardiovasc Med 2023; 10:1062578. [PMID: 36760559 PMCID: PMC9902500 DOI: 10.3389/fcvm.2023.1062578] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 01/09/2023] [Indexed: 01/26/2023] Open
Abstract
Background Ablation-based treatment has emerged as an alternative rhythm control strategy for symptomatic atrial fibrillation (AF). Recent studies have demonstrated the cost-effectiveness of ablation compared with medical therapy in various circumstances. We assessed the economic comparison between ablation and medical therapy based on a nationwide real-world population. Methods and findings For 192,345 patients with new-onset AF (age ≥ 18 years) identified between August 2015 and July 2018 from the Korean Health Insurance Review and Assessment Service (HIRA) database, medical resource use data were collected to compare AF patients that underwent ablation (N = 2,131) and those administered antiarrhythmic drugs (N = 8,048). Subsequently, a Markov chain Monte Carlo model was built. The patients had at least one risk factor for stroke, and the base-case used a 20-year time horizon, discounting at 4.5% annually. Transition probabilities and costs were estimated using the present data, and utilities were derived from literature review. The costs were converted to US $ (2019). Sensitivity analyses were performed using probabilistic and deterministic methods. The net costs and quality-adjusted life years (QALY) for antiarrhythmic drugs and ablation treatments were $37,421 and 8.8 QALYs and $39,820 and 9.3 QALYs, respectively. Compared with antiarrhythmic drugs, incremental cost-effectiveness ratio of ablation was $4,739/QALY, which is lower than the willingness-to-pay (WTP) threshold of $32,000/QALY. Conclusion In symptomatic AF patients with a stroke risk under the age of 75 years, ablation-based rhythm control is potentially a more economically attractive option compared with antiarrhythmic drug-based rhythm control in Korea.
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Affiliation(s)
- Woojin Kim
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Min Kim
- Division of Cardiology, Department of Internal Medicine, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Yun Tae Kim
- Department of Public Health, Yonsei University Graduate School, Seoul, Republic of Korea
| | - Woongbi Park
- Department of Public Health, Yonsei University Graduate School, Seoul, Republic of Korea
| | - Jin-bae Kim
- Division of Cardiology, Department of Internal Medicine, Kyung Hee University Hospital, Seoul, Republic of Korea,*Correspondence: Jin-bae Kim,
| | - Changsoo Kim
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea,Institute of Human Complexity and Systems Science, Yonsei University, Incheon, Republic of Korea,Changsoo Kim,
| | - Boyoung Joung
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea,Boyoung Joung,
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Karedath J, Valle Villatoro AL, Faisal S, Kathuria Anand I, Anirudh Chunchu V, Umer M, Ala S, Amin A. The Effectiveness of Catheter Ablation in the Management of Ventricular Tachycardia in Comparison With Antiarrhythmic Drugs in Patients With Structural Heart Disease: A Meta-Analysis. Cureus 2023; 15:e33608. [PMID: 36788893 PMCID: PMC9910821 DOI: 10.7759/cureus.33608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2023] [Indexed: 01/11/2023] Open
Abstract
The aim of this meta-analysis is to compare the safety and efficacy of catheter ablation versus antiarrhythmic drugs (AADs) in the management of ventricular tachycardia (VT) in patients with structural heart diseases. Two independent investigators searched electronic databases including PubMed, Cochrane, and Excerpta Medica database (EMBASE) using keyword combinations (Medical Subject Headings (MeSH) terms and free terms) such as "catheter ablation," "ventricular tachycardia," "escalation," and "antiarrhythmic drugs" from inception to November 30, 2022. The primary efficacy outcomes included recurrence of VT at follow-up, all-cause mortality, and cardiovascular mortality. The secondary efficacy outcomes assessed in the current meta-analysis included implantable cardioverter-defibrillator (ICD) shock and hospitalization due to cardiac reasons. Safety outcomes included treatment-related adverse events and serious adverse events. A total of three studies were included in this meta-analysis. There was no significant difference in the risk of recurrence of VT (RR: 0.94, 95% CI: 0.72-1.24, p-value: 0.67), all-cause mortality (RR: 0.99, 95% CI: 0.67, 1.46, p-value: 0.98), cardiovascular mortality (risk ratio (RR): 0.90, 95% confidence interval (CI): 0.56-1.45, p-value: 0.67), incidence of ICD shocks (RR: 0.99, 95% CI: 0.76-1.29, p-value: 0.93, I-square: 0%), and hospitalization due to cardiac reasons in follow-up (RR: 0.77, 95% CI: 0.55-1.07, p-value: 0.12) between the catheter ablation group and the antiarrhythmic drug group. However, the risk of treatment-related adverse events was lower in the ablation group compared to the antiarrhythmic medicine (AAM) group (RR: 0.44, 95% CI: 0.29-0.67, p-value: 0.0001). In this meta-analysis of three randomized controlled trials (RCTs) among patients with structural heart disease who had ventricular tachycardia, the incidence of the recurrence of VT, all-cause mortality, cardiovascular mortality, and ICD shock was not significantly different between patients who received catheter ablation and antiarrhythmic drugs. However, regarding safety, catheter ablation is a safe procedure with a low risk of treatment-related events compared to antiarrhythmic drugs.
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Affiliation(s)
- Jithin Karedath
- Internal Medicine, James Cook University Hospital, Middlesbrough, GBR
| | | | - Sana Faisal
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- Internal Medicine, Jinnah Sindh Medical University, Karachi, PAK
| | | | | | - Muhammad Umer
- Internal Medicine, Dow University of Health Sciences, Civil Hospital Karachi, Karachi, PAK
| | - Samprith Ala
- Medicine, Avalon University School of Medicine, Willemstad, CUW
| | - Adil Amin
- Cardiology, Pakistan Navy Station (PNS) Shifa, Karachi, PAK
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Almorad A, O'Neill L, Wielandts JY, Gillis K, De Becker B, Nakatani Y, De Asmundis C, Iacopino S, Pambrun T, Marc LM, Jaïs P, Haïssaguerre M, Duytschaever M, Chierchia JB, Derval N, Knecht S. Long-term clinical outcome of atrial fibrillation ablation in patients with history of mitral valve surgery. Front Cardiovasc Med 2022; 9:928974. [PMID: 36620626 PMCID: PMC9811118 DOI: 10.3389/fcvm.2022.928974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 11/25/2022] [Indexed: 12/24/2022] Open
Abstract
Aims Atrial fibrillation (AF) occurs frequently after mitral valve (MV) surgery. This study aims to evaluate the efficacy and long-term clinical outcomes after the first AF ablation in patients with prior MV surgery. Methods Sixty consecutive patients with a history of MV surgery without MAZE referred to three European centers for a first AF ablation between 2007 and 2017 (group 1) were retrospectively enrolled. They were matched (propensity score match) with 60 patients referred for AF ablation without prior MV surgery (group 2). Results After the index ablation, 19 patients (31.7%) from group 1 and 24 (40%) from group 2 had no recurrence of atrial arrhythmias (ATa) (p = 0.3). After 62 (48-84) months of follow-up and 2 (2-2) procedures, 90.0% of group 1 and 95.0% of group 2 patients were in sinus rhythm (p = 0.49). In group 1, 19 (31.7%) patients had mitral stenosis, and 41 (68.3%) had mitral regurgitation. Twenty-seven (45.0%) patients underwent mechanical valve replacement and 33 (55.0%) MV annuloplasty. At the final follow-up, 28 (46.7%) and 33 (55.0%) patients were off antiarrhythmic drugs (p = 0.46). ATa recurrence was seen more commonly in patients with prior MV surgery (54 vs. 22%, respectively, p < 0.05). No major complication occurred. Conclusion Long-term freedom of atrial arrhythmias after atrial fibrillation catheter ablation is achievable and safe in patients with a history of mitral valve surgery. In AF patients without a history of mitral valve surgery, repeated procedures are needed to maintain sinus rhythm.
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Affiliation(s)
- Alexandre Almorad
- Department of Cardiology, AZ Sint Jan Hospital Bruges, Bruges, Belgium,Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, Brussels, Belgium,*Correspondence: Alexandre Almorad ✉
| | - Louisa O'Neill
- Department of Cardiology, AZ Sint Jan Hospital Bruges, Bruges, Belgium
| | | | - Kris Gillis
- Department of Cardiology, AZ Sint Jan Hospital Bruges, Bruges, Belgium
| | | | - Yosuke Nakatani
- Department of Cardiac Pacing and Electrophysiology, Hospital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Avenue de Magellan, Pessac, France
| | - Carlo De Asmundis
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, Brussels, Belgium
| | - Saverio Iacopino
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, Brussels, Belgium
| | - Thomas Pambrun
- Department of Cardiac Pacing and Electrophysiology, Hospital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Avenue de Magellan, Pessac, France
| | - La Meir Marc
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, Brussels, Belgium
| | - Pierre Jaïs
- Department of Cardiac Pacing and Electrophysiology, Hospital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Avenue de Magellan, Pessac, France
| | - Michel Haïssaguerre
- Department of Cardiac Pacing and Electrophysiology, Hospital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Avenue de Magellan, Pessac, France
| | | | - Jean-Baptista Chierchia
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, Brussels, Belgium
| | - Nicolas Derval
- Department of Cardiac Pacing and Electrophysiology, Hospital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Avenue de Magellan, Pessac, France
| | - Sébastien Knecht
- Department of Cardiology, AZ Sint Jan Hospital Bruges, Bruges, Belgium,Sébastien Knecht ✉
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Hwang I, Jin Z, Park JW, Kwon OS, Lim B, Hong M, Kim M, Yu HT, Kim TH, Uhm JS, Joung B, Lee MH, Pak HN. Corrigendum: Computational modeling for antiarrhythmic drugs for atrial fibrillation according to genotype. Front Physiol 2022; 13:991997. [PMID: 36531166 PMCID: PMC9757488 DOI: 10.3389/fphys.2022.991997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 11/21/2022] [Indexed: 12/03/2022] Open
Abstract
[This corrects the article DOI: 10.3389/fphys.2021.650449.].
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36
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Gillis AM, Dobrev D. Targeting the RyR2 to Prevent Atrial Fibrillation. Circ Arrhythm Electrophysiol 2022; 15:e011514. [PMID: 36178743 PMCID: PMC9592734 DOI: 10.1161/circep.122.011514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Anne M. Gillis
- Department of Cardiac Sciences, University of Calgary and Libin Cardiovascular Institute, Calgary, Alberta, Canada
| | - Dobromir Dobrev
- Institute of Pharmacology, West German Heart and Vascular Center, University Duisburg-Essen, Essen, Germany
- Department of Pharmacology and Therapeutics, McGill University, Montreal, Canada
- Department of Molecular Physiology & Biophysics, Baylor College of Medicine, Houston, TX
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Teppo K, Jaakkola J, Biancari F, Halminen O, Linna M, Haukka J, Putaala J, Mustonen P, Kinnunen J, Luojus A, Itäinen-Strömberg S, Hartikainen J, Aro AL, Airaksinen KEJ, Lehto M. Rural-Urban differences in Use of Rhythm Control Therapies in Patients with Incident Atrial Fibrillation: A Finnish Nationwide Cohort Study. Int J Environ Res Public Health 2022; 19:11191. [PMID: 36141456 PMCID: PMC9517432 DOI: 10.3390/ijerph191811191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 08/30/2022] [Accepted: 09/03/2022] [Indexed: 06/16/2023]
Abstract
Background: Rural-urban disparities have been reported in the access, utilization, and quality of healthcare. We aimed to assess whether use of antiarrhythmic therapies (AATs) in patients with atrial fibrillation (AF) differs between those with rural and urban residence. Methods: The registry-based FinACAF cohort covers all patients with AF from all levels of care in Finland. Patients were divided into rural and urban categories and into urbanization degree tertiles based on their municipality of residence at the time of AF diagnosis. The primary outcome was the use of any AAT, including cardioversion, catheter ablation, and fulfilled antiarrhythmic drug (AAD) prescription. Results: We identified 177,529 patients (49.9% female, mean age 73.0 (SD13.0) years) with incident AF during 2010-2018. Except for AADs, the differences in AAT use were nonsignificant when patients were stratified according to the rural-urban classification system (urban vs. rural adjusted incidence rate ratios (aIRRs) with 95% CIs for any AAT 1.01 (0.99-1.03), AADs 1.11 (1.07-1.15), cardioversion 1.01 (0.98-1.03), catheter ablation 1.05 (0.98-1.12)). However, slightly higher use of all rhythm control modalities was observed in the highest urbanization degree tertile when compared to the lowest tertile (aIRRs with 95% Cis for any AAT 1.06 (1.03-1.08), AADs 1.18 (1.14-1.23), cardioversion 1.05 (1.02-1.08), catheter ablation 1.10 (1.02-1.19)). Conclusions: This nationwide retrospective cohort study observed that urban residence is associated with higher use of AADs in patients with incident AF. Otherwise, the observed disparities were only marginal, suggesting that in the use of rhythm control therapies, no large rural-urban inequity exists in Finland.
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Affiliation(s)
- Konsta Teppo
- Faculty of Medicine, University of Turku, 20500 Turku, Finland
| | - Jussi Jaakkola
- Faculty of Medicine, University of Turku, 20500 Turku, Finland
- Heart Unit, Satakunta Central Hospital, 28500 Pori, Finland
| | - Fausto Biancari
- Heart and Lung Center, Helsinki University Hospital, University of Helsinki, 00014 Helsinki, Finland
| | - Olli Halminen
- Department of Industrial Engineering and Management, Aalto University, 02150 Espoo, Finland
| | - Miika Linna
- Department of Industrial Engineering and Management, Aalto University, 02150 Espoo, Finland
- University of Eastern Finland, 70211 Kuopio, Finland
| | - Jari Haukka
- University of Helsinki, 00014 Helsinki, Finland
| | - Jukka Putaala
- Neurology, Helsinki University Hospital, University of Helsinki, 00014 Helsinki, Finland
| | - Pirjo Mustonen
- Heart Center, Turku University Hospital, 20014 Turku, Finland
| | - Janne Kinnunen
- Neurology, Helsinki University Hospital, University of Helsinki, 00014 Helsinki, Finland
| | - Alex Luojus
- Heart and Lung Center, Helsinki University Hospital, University of Helsinki, 00014 Helsinki, Finland
- University of Helsinki, 00014 Helsinki, Finland
| | - Saga Itäinen-Strömberg
- Heart and Lung Center, Helsinki University Hospital, University of Helsinki, 00014 Helsinki, Finland
- University of Helsinki, 00014 Helsinki, Finland
| | - Juha Hartikainen
- University of Eastern Finland, 70211 Kuopio, Finland
- Heart Center, Kuopio University Hospital, 70210 Kuopio, Finland
| | - Aapo L. Aro
- Heart and Lung Center, Helsinki University Hospital, University of Helsinki, 00014 Helsinki, Finland
- University of Helsinki, 00014 Helsinki, Finland
| | - K. E. Juhani Airaksinen
- Faculty of Medicine, University of Turku, 20500 Turku, Finland
- Heart Center, Turku University Hospital, 20014 Turku, Finland
| | - Mika Lehto
- Heart and Lung Center, Helsinki University Hospital, University of Helsinki, 00014 Helsinki, Finland
- University of Helsinki, 00014 Helsinki, Finland
- Department of Internal Medicine, Lohja Hospital, Lohja, Finland
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38
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Strasburger JF, Eckstein G, Butler M, Noffke P, Wacker-Gussmann A. Fetal Arrhythmia Diagnosis and Pharmacologic Management. J Clin Pharmacol 2022; 62 Suppl 1:S53-S66. [PMID: 36106782 PMCID: PMC9543141 DOI: 10.1002/jcph.2129] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 07/25/2022] [Indexed: 11/24/2022]
Abstract
One of the most successful achievements of fetal intervention is the pharmacologic management of fetal arrhythmias. This management usually takes place during the second or third trimester. While most arrhythmias in the fetus are benign, both tachy‐ and bradyarrhythmias can lead to fetal hydrops or cardiac dysfunction and require treatment under certain conditions. This review will highlight precise diagnosis by fetal echocardiography and magnetocardiography, the 2 primary means of diagnosing fetuses with arrhythmia. Additionally, transient or hidden arrhythmias such as bundle branch block, QT prolongation, and torsades de pointes, which can lead to cardiomyopathy and sudden unexplained death in the fetus, may also need pharmacologic treatment. The review will address the types of drug therapies; current knowledge of drug usage, efficacy, and precautions; and the transition to neonatal treatments when indicated. Finally, we will highlight new assessments, including the role of the nurse in the care of fetal arrhythmias. The prognosis for the human fetus with arrhythmias continues to improve as we expand our ability to provide intensive care unit–like monitoring, to better understand drug treatments, to optimize subsequent pregnancy monitoring, to effectively predict timing for delivery, and to follow up these conditions into the neonatal period and into childhood. Coordinated initiatives that facilitate clinical fetal research are needed to address gaps in knowledge and to facilitate fetal drug and device development.
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Affiliation(s)
- Janette F Strasburger
- Division of Cardiology, Departments of Pediatrics and Biomedical Engineering, Children's Wisconsin, Herma Heart Institute, and Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Gretchen Eckstein
- Division of Cardiology, Departments of Pediatrics and Biomedical Engineering, Children's Wisconsin, Herma Heart Institute, and Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Mary Butler
- College of Nursing, University of Wisconsin-Oshkosh, Oshkosh, Wisconsin, USA
| | - Patrick Noffke
- Division of Cardiology, Departments of Pediatrics and Biomedical Engineering, Children's Wisconsin, Herma Heart Institute, and Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Annette Wacker-Gussmann
- German Heart Center, Department of Congenital Heart Disease and Pediatric Cardiology Munich, Munchen, Bavaria, Germany
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Furutani K, Kawano R, Ichiwara M, Adachi R, Clancy CE, Sack JT, Kita S. Pore opening, not voltage sensor movement, underpins the voltage-dependence of facilitation by a hERG blocker. Mol Pharmacol 2022; 102:MOLPHARM-AR-2022-000569. [PMID: 36041862 PMCID: PMC9595204 DOI: 10.1124/molpharm.122.000569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 07/19/2022] [Accepted: 08/04/2022] [Indexed: 11/07/2022] Open
Abstract
A drug that blocks the cardiac myocyte voltage-gated K+ channels encoded by the human Ether-à-go-go-Related Gene (hERG) carries a potential risk of long QT syndrome and life-threatening cardiac arrhythmia, including Torsade de Points Interestingly, certain hERG blockers can also facilitate hERG activation to increase hERG currents, which may reduce proarrhythmic potential. However, the molecular mechanism involved in the facilitation effect of hERG blockers remains unclear. The hallmark feature of the facilitation effect by hERG blockers is that a depolarizing preconditioning pulse shifts voltage-dependence of hERG activation to more negative voltages. Here we utilize a D540K hERG mutant to study the mechanism of the facilitation effect. D540K hERG is activated by not only depolarization but also hyperpolarization. This unusual gating property enables tests of the mechanism by which voltage induces facilitation of hERG by blockers. With D540K hERG, we find that nifekalant, a hERG blocker and Class III antiarrhythmic agent, blocks and facilitates not only current activation by depolarization but also current activation by hyperpolarization, suggesting a shared gating process upon depolarization and hyperpolarization. Moreover, in response to hyperpolarizing conditioning pulses, nifekalant facilitates D540K hERG currents but not wild-type currents. Our results indicate that induction of facilitation is coupled to pore opening, not voltage per se We propose that gated access to the hERG central cavity underlies the voltage-dependence of induction of facilitation. This study identifies hERG channel pore gate opening as the conformational change facilitated by nifekalant, a clinically important antiarrhythmic agent. Significance Statement Nifekalant is a clinically important antiarrhythmic agent and a hERG blocker which can also facilitate voltage-dependent activation of hERG channels after a preconditioning pulse. Here we show that the mechanism of action of the preconditioning pulse is to open a conductance gate to enable drug access to a facilitation site. Moreover, we find that facilitation increases hERG currents by altering pore dynamics, rather than acting through voltage sensors.
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Affiliation(s)
| | - Ryotaro Kawano
- Department of Pharmacology, Tokushima Bunri University, Japan
| | - Minami Ichiwara
- Department of Pharmacology, Tokushima Bunri University, Japan
| | - Ryo Adachi
- Department of Pharmacology, Tokushima Bunri University, Japan
| | | | - Jon T Sack
- UC Davis School of Medicine, United States
| | - Satomi Kita
- Department of Pharmacology, Tokushima Bunri University, Japan
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40
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Airaksinen KEJ. How to Optimize Cardioversion of Atrial Fibrillation. J Clin Med 2022; 11. [PMID: 35743443 DOI: 10.3390/jcm11123372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 05/22/2022] [Accepted: 06/10/2022] [Indexed: 12/07/2022] Open
Abstract
Cardioversion (CV) is an essential component of rhythm control strategy in the treatment of atrial fibrillation (AF). Timing of CV is an important manageable factor in optimizing the safety and efficacy of CV. Based on observational studies, the success rate of CV seems to be best (≈95%) at 12−48 h after the onset of arrhythmic symptoms compared with a lower success rate of ≈85% in later elective CV. Early AF recurrences are also less common after acute CV compared with later elective CV. CV causes a temporary increase in the risk of thromboembolic complications. Effective anticoagulation reduces this risk, especially during the first 2 weeks after successful CV. However, even during therapeutic anticoagulation, each elective CV increases the risk of stroke 4-fold (0.4% vs. 0.1%) during the first month after the procedure, compared with acute (<48 h) CV or avoiding CV. Spontaneous CVs are common during the early hours of AF. The short wait-and-see approach, up to 24−48 h, is a reasonable option for otherwise healthy but mildly symptomatic patients who are using therapeutic anticoagulation, since they are most likely to have spontaneous rhythm conversion and have no need for active CV. The probability of early treatment failure and antiarrhythmic treatment options should be evaluated before proceeding to CV to avoid the risks of futile CVs.
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Dickow J, Kirchhof P, Van Houten HK, Sangaralingham LR, Dinshaw LHW, Friedman PA, Packer DL, Noseworthy PA, Yao X. Generalizability of the EAST-AFNET 4 Trial: Assessing Outcomes of Early Rhythm-Control Therapy in Patients With Atrial Fibrillation. J Am Heart Assoc 2022; 11:e024214. [PMID: 35621202 PMCID: PMC9238730 DOI: 10.1161/jaha.121.024214] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Background EAST‐AFNET 4 (Early Treatment of Atrial Fibrillation for Stroke Prevention Trial) demonstrated clinical benefit of early rhythm‐control therapy (ERC) in patients with new‐onset atrial fibrillation (AF) and concomitant cardiovascular conditions compared with current guideline‐based practice. This study aimed to evaluate the generalizability of EAST‐AFNET 4 in routine practice. Methods and Results Using a US administrative database, we identified 109 739 patients with newly diagnosed AF during the enrollment period of EAST‐AFNET 4. Patients were classified as either receiving ERC, using AF ablation or antiarrhythmic drug therapy, within the first year after AF diagnosis (n=27 106) or not receiving ERC (control group, n=82 633). After propensity score overlap weighting, Cox proportional hazards regression was used to compare groups for the primary composite outcome of all‐cause mortality, stroke, or hospitalization with the diagnoses heart failure or myocardial infarction. Most patients (79 948 of 109 739; 72.9%) met the inclusion criteria for EAST‐AFNET 4. ERC was associated with a reduced risk for the primary composite outcome (hazard ratio [HR], 0.85; 95% CI, 0.75–0.97 [P=0.02]) with largely consistent results between eligible (HR, 0.89; 95% CI, 0.76–1.04 [P=0.14]) or ineligible (HR, 0.77; 95% CI, 0.60–0.98 [P=0.04]) patients for EAST‐AFNET 4 trial inclusion. ERC was associated with lower risk of stroke in the overall cohort and in trial‐eligible patients. Conclusions This analysis replicates the clinical benefit of ERC seen in EAST‐AFNET 4. The results support adoption of ERC as part of the management of recently diagnosed AF in the United States.
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Affiliation(s)
- Jannis Dickow
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN.,Department of Cardiology University Heart and Vascular Center HamburgUniversity Hospital Hamburg Eppendorf Hamburg Germany.,DZHK (German Center for Cardiovascular Research)Partner Site Hamburg/Kiel/Lübeck Berlin Germany
| | - Paulus Kirchhof
- Department of Cardiology University Heart and Vascular Center HamburgUniversity Hospital Hamburg Eppendorf Hamburg Germany.,DZHK (German Center for Cardiovascular Research)Partner Site Hamburg/Kiel/Lübeck Berlin Germany.,Institute of Cardiovascular SciencesUniversity of Birmingham Birmingham United Kingdom
| | - Holly K Van Houten
- OptumLabs Eden Prairie MN.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Mayo Clinic Rochester MN
| | - Lindsey R Sangaralingham
- OptumLabs Eden Prairie MN.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Mayo Clinic Rochester MN
| | - Leon H W Dinshaw
- Department of Cardiology University Heart and Vascular Center HamburgUniversity Hospital Hamburg Eppendorf Hamburg Germany
| | - Paul A Friedman
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| | | | - Peter A Noseworthy
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Mayo Clinic Rochester MN
| | - Xiaoxi Yao
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Mayo Clinic Rochester MN
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Camm AJ, Naccarelli GV, Mittal S, Crijns HJGM, Hohnloser SH, Ma CS, Natale A, Turakhia MP, Kirchhof P. The Increasing Role of Rhythm Control in Patients With Atrial Fibrillation: JACC State-of-the-Art Review. J Am Coll Cardiol 2022; 79:1932-1948. [PMID: 35550691 DOI: 10.1016/j.jacc.2022.03.337] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 03/01/2022] [Accepted: 03/04/2022] [Indexed: 12/16/2022]
Abstract
The considerable mortality and morbidity associated with atrial fibrillation (AF) pose a substantial burden on patients and health care services. Although the management of AF historically focused on decreasing AF recurrence, it evolved over time in favor of rate control. Recently, more emphasis has been placed on reducing adverse cardiovascular outcomes using rhythm control, generally by using safe and effective rhythm-control therapies (typically antiarrhythmic drugs and/or AF ablation). Evidence increasingly supports early rhythm control in patients with AF that has not become long-standing, but current clinical practice and guidelines do not yet fully reflect this change. Early rhythm control may effectively reduce irreversible atrial remodeling and prevent AF-related deaths, heart failure, and strokes in high-risk patients. It has the potential to halt progression and potentially save patients from years of symptomatic AF; therefore, it should be offered more widely.
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Affiliation(s)
- A John Camm
- Cardiovascular Clinical Academic Group, St George's University of London, London, United Kingdom.
| | - Gerald V Naccarelli
- Penn State Heart and Vascular Institute, Penn State University, Hershey, Pennsylvania, USA
| | - Suneet Mittal
- Snyder Center for Comprehensive Atrial Fibrillation and Department of Cardiology, Valley Health System, Ridgewood, New Jersey, USA
| | - Harry J G M Crijns
- Department of Cardiology, Maastricht University Medical Centre (MUMC) and Cardiovascular Research Institute (CARIM), Maastricht, the Netherlands
| | | | - Chang-Sheng Ma
- National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St David's Medical Center, Austin, Texas, USA
| | - Mintu P Turakhia
- Center for Digital Health and Department of Medicine, Stanford University, Stanford, California, USA
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Berlin, Germany; Atrial Fibrillation Network (AFNET), Münster, Germany; Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
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43
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Tang JKK, Deyell MW. Reply to "Pro-arrhythmia with antiarrhythmic drugs in patients with idiopathic ventricular arrhythmia: A common problem with vague definitions and complex interactions". J Cardiovasc Electrophysiol 2022; 33:1637-1638. [PMID: 35445496 DOI: 10.1111/jce.15508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 04/13/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Jacky K K Tang
- Division of Cardiology, Heart Rhythm Services, University of British Columbia, Vancouver, Canada
| | - Marc W Deyell
- Division of Cardiology, Heart Rhythm Services, University of British Columbia, Vancouver, Canada.,Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, Canada
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Arenal Á, Ávila P, Jiménez-Candil J, Tercedor L, Calvo D, Arribas F, Fernández-Portales J, Merino JL, Hernández-Madrid A, Fernández-Avilés FJ, Berruezo A. Substrate Ablation vs Antiarrhythmic Drug Therapy for Symptomatic Ventricular Tachycardia. J Am Coll Cardiol 2022; 79:1441-1453. [PMID: 35422240 DOI: 10.1016/j.jacc.2022.01.050] [Citation(s) in RCA: 63] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 01/20/2022] [Accepted: 01/24/2022] [Indexed: 01/30/2023]
Abstract
BACKGROUND In patients with ischemic cardiomyopathy and an implantable cardioverter-defibrillator (ICD), catheter ablation and antiarrhythmic drugs (AADs) reduce ICD shocks, but the most effective approach remains uncertain. OBJECTIVES This trial compares the efficacy and safety of catheter ablation vs AAD as first-line therapy in ICD patients with symptomatic ventricular tachycardias (VTs). METHODS The SURVIVE-VT (Substrate Ablation vs Antiarrhythmic Drug Therapy for Symptomatic Ventricular Tachycardia) is a prospective, multicenter, randomized trial including patients with ischemic cardiomyopathy and appropriated ICD shock. Patients were 1:1 randomized to complete endocardial substrate-based catheter ablation or antiarrhythmic therapy (amiodarone + beta-blockers, amiodarone alone, or sotalol ± beta-blockers). The primary outcome was a composite of cardiovascular death, appropriate ICD shock, unplanned hospitalization for worsening heart failure, or severe treatment-related complications. RESULTS In this trial, 144 patients (median age, 70 years; 96% male) were randomized to catheter ablation (71 patients) or AAD (73 patients). After 24 months, the primary outcome occurred in 28.2% of patients in the ablation group and 46.6% of those in the AAD group (hazard ratio [HR]: 0.52; 95% CI: 0.30-0.90; P = 0.021). This difference was driven by a significant reduction in severe treatment-related complications (9.9% vs 28.8%, HR: 0.30; 95% CI: 0.13-0.71; P = 0.006). Eight patients were hospitalized for heart failure in the ablation group and 13 in the AAD group (HR: 0.56; 95% CI: 0.23-1.35; P = 0.198). There was no difference in cardiac mortality (HR: 0.93; 95% CI: 0.19-4.61; P = 0.929). CONCLUSIONS In ICD patients with ischemic cardiomyopathy and symptomatic VT, catheter ablation reduced the composite endpoint of cardiovascular death, appropriate ICD shock, hospitalization due to heart failure, or severe treatment-related complications compared to AAD. (Substrate Ablation vs Antiarrhythmic Drug Therapy for Symptomatic Ventricular Tachycardia [SURVIVE-VT]: NCT03734562).
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Affiliation(s)
- Ángel Arenal
- Cardiology Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Facultad de Medicina, Universidad Complutense, Madrid, Spain; Center for Biomedical Research in Cardiovascular Disease Network (CIBERCV).
| | - Pablo Ávila
- Cardiology Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Facultad de Medicina, Universidad Complutense, Madrid, Spain; Center for Biomedical Research in Cardiovascular Disease Network (CIBERCV)
| | - Javier Jiménez-Candil
- Center for Biomedical Research in Cardiovascular Disease Network (CIBERCV); Arrhythmia Unit, Cardiology Department, IBSAL-Hospital Universitario, Universidad de Salamanca, Salamanca, Spain
| | - Luis Tercedor
- Arrhythmia Unit, Cardiology Department, Hospital General Virgen de las Nieves, Granada, Spain
| | - David Calvo
- Arrhythmia Unit, Cardiology Department, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | | | | | - José Luis Merino
- Hospital Universitario La Paz, IdiPAZ, Universidad Autónoma, Madrid, Spain
| | | | - Francisco J Fernández-Avilés
- Cardiology Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Facultad de Medicina, Universidad Complutense, Madrid, Spain; Center for Biomedical Research in Cardiovascular Disease Network (CIBERCV)
| | - Antonio Berruezo
- Arrhythmia Unit, Cardiology Department, Hospital Clinic and Teknon Medical Center, Barcelona, Spain
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Vaduganathan M, Piccini JP, Camm AJ, Crijns HJGM, Anker SD, Butler J, Stewart J, Braceras R, Albuquerque APA, Wieloch M, Hohnloser SH. Dronedarone for the Treatment of Atrial Fibrillation with Concomitant Heart Failure with Preserved and Mildly Reduced Ejection Fraction: Post-Hoc Analysis of the ATHENA Trial. Eur J Heart Fail 2022; 24:1094-1101. [PMID: 35293087 PMCID: PMC9543163 DOI: 10.1002/ejhf.2487] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 02/15/2022] [Accepted: 03/11/2022] [Indexed: 11/08/2022] Open
Abstract
AIMS Limited therapeutic options are available for the management of atrial fibrillation/flutter (AF/AFL) with concomitant heart failure with preserved and mildly reduced ejection fraction. (HFpEF and HFmrEF). Dronedarone reduces the risk of cardiovascular events in patients with AF, but sparse data are available examining its role in patients with AF complicated by HFpEF and HFmrEF. METHODS AND RESULTS ATHENA was an international, multicenter trial that randomized 4,628 patients with paroxysmal or persistent AF/AFL and cardiovascular risk factors to dronedarone 400 mg twice daily versus placebo. We evaluated patients with 1) symptomatic HFpEF and HFmrEF (defined as LVEF>40%, evidence of structural heart disease, and New York Heart Association class II/III or diuretic use), 2) HF with reduced ejection fraction (HFrEF) or left ventricular dysfunction (LVEF≤40%), and 3) those without HF. We assessed effects of dronedarone vs placebo on death or cardiovascular hospitalization (primary endpoint), other key efficacy endpoints, and safety. Overall, 534 (12%) had HFpEF or HFmrEF, 422 (9%) had HFrEF or LV dysfunction, and 3,672 (79%) did not have HF. Patients with HFpEF and HFmrEF had a mean age of 73±9 years, 37% were women, and had a mean LVEF of 57±9%. Over 21±5 months mean follow-up, dronedarone consistently reduced risk of death or cardiovascular hospitalization (hazard ratio 0.76; 95% confidence interval 0.69-0.84) without heterogeneity based on HF status (Pinteraction >0.10). This risk reduction in the primary endpoint was consistent across the range of LVEF (as a continuous function) in HF without heterogeneity (Pinteraction =0.71). Rates of death, cardiovascular hospitalization, and HF hospitalization each directionally favored dronedarone vs. placebo in HFpEF and HFmrEF, but these treatment effects were not statistically significant. CONCLUSIONS Dronedarone is associated with reduced cardiovascular events in patients with paroxysmal or persistent AF/AFL and HF across the spectrum of LVEF, including among those with HFpEF and HFmrEF. These data support a rationale for a future dedicated and powered clinical trial to affirm the net clinical benefit of dronedarone in this population.
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Affiliation(s)
- Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Jonathan P Piccini
- Duke University Medical Center and the Duke Clinical Research Institute, Durham, NC, USA
| | - A John Camm
- Cardiology Clinical Academic Group Molecular & Clinical Sciences Institute, St George's University of London, London, UK
| | | | - Stefan D Anker
- Department of Cardiology (CVK); and Berlin Institute of Health Center for Regenerative Therapies (BCRT); German Centre for Cardiovascular Research (DZHK) partner site Berlin; Charité Universitätsmedizin Berlin, Germany
| | - Javed Butler
- Department of Medicine, University of Mississippi, Jackson, MS, USA
| | | | | | | | - Mattias Wieloch
- Sanofi, Paris, France.,Department of Coagulation Disorders, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Stefan H Hohnloser
- Division of Clinical Electrophysiology, Department of Cardiology, J. W. Goethe University, Frankfurt, Germany
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Murray K, Wahid M, Alagiakrishnan K, Senaratne J. Clinical electrophysiology of the aging heart. Expert Rev Cardiovasc Ther 2022; 20:123-139. [PMID: 35282746 DOI: 10.1080/14779072.2022.2045196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Advancements in medical and consumer-grade technologies have made it easier than ever to monitor a patient's heart rhythm and to diagnose arrhythmias. Octogenarians with symptomatic arrhythmias have unique management challenges due to their frailty, complex drug interactions, cognitive impairment, and competing comorbidities. The management decisions are further complicated by the lack of randomized evidence to guide treatment. AREAS COVERED A comprehensive literature review was undertaken to outline various tachyarrhythmias and bradyarrhythmias and their management, the role of cardiac implantable electronic devices, cardiac ablations, and specific geriatric arrhythmia considerations as recommended in international guidelines. EXPERT OPINION Atrial fibrillation (AF) is arguably the most important arrhythmia in the elderly and is associated with significant morbidity and mortality. Early diagnosis of AF, potentially with smart devices (wearables), has the potential to reduce the incidence of stroke, systemic emboli, and the risk of dementia. Bradyarrhythmias have a high incidence in the elderly as well, often requiring implantation of a permanent pacemaker. Leadless pacemakers implanted directly into the right ventricle are great options for gaining traction in elderly patients.
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Affiliation(s)
- Kyle Murray
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Muizz Wahid
- Department of Internal Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Kanna Alagiakrishnan
- Division of Geriatric Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Janek Senaratne
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
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Roman S, Patel K, Hana D, Guice KC, Patel J, Stadnick C, Basta A, Khouzam RN. Rate versus rhythm control for atrial fibrillation: from AFFIRM to EAST-AFNET 4 - a paradigm shift. Future Cardiol 2022; 18:354-353. [PMID: 35255732 DOI: 10.2217/fca-2021-0034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The clinical choice between rate or rhythm control therapies has been debated over the years. In 2002, the AFFIRM trial demonstrated that the rhythm-control strategy had no survival advantage over the rate-control strategy. Eighteen years later, EAST-AFNET 4 showed that the rhythm-control approach is better than rate control in reducing adverse cardiovascular outcomes in patients with a recent diagnosis of atrial fibrillation (AF). During the time between AFFIRM and EAST-AFNET 4, rhythm control understanding, specifically ablation, improved, while rate-control strategies remained the same possibly leading to the change in results seen in EAST-AFNET 4. This review seeks to evaluate the rate- and rhythm-control strategies, focusing on the important clinical trials in the past two decades. These trials have shown great advancement in AF management; however, the search for the best approach to controlling AF and minimizing the burden of symptoms is still a work in progress and needs further research.
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Affiliation(s)
- Sherif Roman
- Department of Medicine, St Joseph's University Medical Center, NJ 07503, USA
| | - Kevin Patel
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - David Hana
- Department of Medicine, Loyola University Medical Center/Trinity - Mercy Hospital, IL 60616, USA
| | - Kenneth C Guice
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Jay Patel
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Christopher Stadnick
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Amir Basta
- Department of Medicine, Ain Shams University, Cairo, 1181, Egypt
| | - Rami N Khouzam
- Department of Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, TN 38163, USA
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Borowicz-Reutt KK. Effects of Antiarrhythmic Drugs on Antiepileptic Drug Action-A Critical Review of Experimental Findings. Int J Mol Sci 2022; 23:ijms23052891. [PMID: 35270033 PMCID: PMC8911389 DOI: 10.3390/ijms23052891] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 02/28/2022] [Accepted: 03/04/2022] [Indexed: 01/27/2023] Open
Abstract
Severe cardiac arrhythmias developing in the course of seizures increase the risk of SUDEP (sudden unexpected death in epilepsy). Hence, epilepsy patients with pre-existing arrhythmias should receive appropriate pharmacotherapy. Concomitant treatment with antiarrhythmic and antiseizure medications creates, however, the possibility of drug–drug interactions. This is due, among other reasons, to a similar mechanism of action. Both groups of drugs inhibit the conduction of electrical impulses in excitable tissues. The aim of this review was the analysis of such interactions in animal seizure models, including the maximal electroshock (MES) test in mice, a widely accepted screening test for antiepileptic drugs.
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Affiliation(s)
- Kinga K Borowicz-Reutt
- Independent Unit of Experimental Neuropathophysiology, Department of Toxicology, Medical University of Lublin, 20-090 Lublin, Poland
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Volgman AS, Nair G, Lyubarova R, Merchant FM, Mason P, Curtis AB, Wenger NK, Aggarwal NT, Kirkpatrick JN, Benjamin EJ. Management of Atrial Fibrillation in Patients 75 Years and Older: JACC State-of-the-Art Review. J Am Coll Cardiol 2022; 79:166-179. [PMID: 35027110 DOI: 10.1016/j.jacc.2021.10.037] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 10/18/2021] [Indexed: 12/11/2022]
Abstract
The prevalence of atrial fibrillation (AF) is increasing as the population ages. AF treatment-related complications also increase markedly in older adults (defined as ≥75 years of age for this review). The older AF population has a high risk of stroke, bleeding, and death. Syncope and fall-related injuries are the most common reasons for nonprescription of oral anticoagulation (OAC), and are more common in older adults when OACs are used with antiarrhythmic drugs. Digoxin may be useful for rate control, but associations with increased mortality limit its use. Beyond rate and rhythm control considerations, stroke prophylaxis is critical to AF management, and the benefits of direct OACs, compared with warfarin, extend to older adults. Invasive procedures such as AF catheter ablation, pacemaker implantation/atrioventricular junction ablation, and left atrial appendage occlusion may be useful in appropriately selected cases. However, older adults have generally been under-represented in clinical trials.
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Affiliation(s)
| | - Gatha Nair
- Division of Cardiology, Rush University Medical Center, Chicago, Illinois, USA
| | - Radmila Lyubarova
- Division of Cardiology, Albany Medical Center, Albany, New York, USA
| | - Faisal M Merchant
- Department of Medicine, Section of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Pamela Mason
- Department of Cardiology, University of Virginia, Charlottesville, Virginia, USA
| | - Anne B Curtis
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Nanette K Wenger
- Department of Medicine, Section of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Neelum T Aggarwal
- Departments of Neurological Sciences, Rush Alzheimer's Disease Center, Rush University Medical Center, Chicago, Illinois, USA
| | | | - Emelia J Benjamin
- Boston Medical Center, and Boston University School of Medicine and School of Public Health, Boston, Massachusetts, USA
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Thind M, Zareba W, Atar D, Crijns HJGM, Zhu J, Pak H, Reiffel J, Ludwigs U, Wieloch M, Stewart J, Kowey P. Efficacy and safety of dronedarone versus placebo in patients with atrial fibrillation stratified according to renal function: Post hoc analyses of the EURIDIS-ADONIS trials. Clin Cardiol 2022; 45:101-109. [PMID: 35019175 PMCID: PMC8799050 DOI: 10.1002/clc.23765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 12/01/2021] [Accepted: 12/13/2021] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND The use of antiarrhythmic drugs (AADs) in patients with chronic kidney disease (CKD) is complex because impaired renal clearance can cause increased drug levels, and risk of intolerance or adverse events. Due to the propensity for CKD to occur alongside atrial fibrillation/atrial flutter (AF/AFL), it is essential that AAD safety and efficacy are assessed for patients with CKD. HYPOTHESIS Dronedarone, an approved AAD, may present a suitable therapeutic option for patients with AF/AFL and concomitant CKD. METHODS EURIDIS-ADONIS (EURIDIS, NCT00259428; ADONIS, NCT00259376) were identically designed, multicenter, double-blind, parallel-group trials investigating AF/AFL control with dronedarone 400 mg twice daily versus placebo (randomized 2:1). In this post hoc analysis, the primary endpoint was time to first AF/AFL. Patients were stratified according to renal function using the CKD-Epidemiology Collaboration equation and divided into estimated glomerular filtration rate (eGFR) subgroups of 30-44, 45-59, 60-89, and ≥90 ml/min. Time-to-events between treatment groups were compared using log-rank testing and Cox regression. RESULTS At baseline, most (86%) patients demonstrated a mild or mild-to-moderate eGFR decrease. Median time to first AF/AFL recurrence was significantly longer with dronedarone versus placebo for all eGFR subgroups except the 30 to 44 ml/min group, where the trend was similar but statistical power may have been limited by the small population. eGFR stratification had no significant effect on serious adverse events, deaths, or treatment discontinuations. CONCLUSIONS This analysis suggests that dronedarone could be an effective therapeutic option for AF with an acceptable safety profile in patients with impaired renal function.
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Affiliation(s)
- Munveer Thind
- Division of CardiologyLankenau Heart InstituteWynnewoodPennsylvaniaUSA
| | - Wojciech Zareba
- Division of CardiologyUniversity of Rochester Medical CenterRochesterNew YorkUSA
| | - Dan Atar
- Department of CardiologyOslo University Hospital UllevalOsloNorway
- Institute of Clinical MedicineUniversity of OsloNorway
| | - Harry J. G. M. Crijns
- Department of CardiologyMaastricht University Medical Centre (MUMC)MaastrichtThe Netherlands
| | - Jun Zhu
- Fuwai HospitalCAMS & PUMCBeijingChina
| | - Hui‐Nam Pak
- Yonsei University College of MedicineYonsei University Health SystemSeoulRepublic of Korea
| | - James Reiffel
- Division of CardiologyColumbia University Medical CenterNew YorkNew YorkUSA
| | | | - Mattias Wieloch
- SanofiParisFrance
- Department of Clinical Sciences MalmöLund UniversityMalmöSweden
| | | | - Peter Kowey
- Division of CardiologyLankenau Heart InstituteWynnewoodPennsylvaniaUSA
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