Third-degree burns associated with transcutaneous pacing.

A 69-year-old severely obese diabetic woman developed nausea, vomiting and diarrhoea which caused multiple metabolic alterations leading to hypotension and bradycardia due to slow atrioventricular junctional rhythm. Transcutaneous pacing (TCP) was initiated and maintained until the underlying heart rate and blood pressure normalised. TCP gel pads were kept in place prophylactically after pacing was terminated. Gel pads remained attached to the anterior thorax and back for a total of 36 hours. During this time the patient developed third-degree burns at the side of gel pad attachment. With appropriate wound care and after a long hospitalisation, the patient was discharged in stable condition. This case demonstrates that prolonged use of TCP gel pads without frequent replacement may lead to third-degree burns. It also suggest that prophylactic use of TCP gel pads should be avoided.

Dabigatran: a new anticoagulant for stroke prevention in patients with atrial fibrillation.

Ischemic stroke is arguably the most feared complication of atrial fibrillation. While warfarin has been the most effective pharmacologic treatment for stroke prevention in patients with nonvalvular atrial fibrillation, several limitations have led to its underutilization. Recently, dabigatran (Pradaxa), a new oral anticoagulant with several potential advantages over warfarin (Coumadin), became available for use in the United States for prevention of stroke and systemic embolism in patient with nonvalvular atrial fibrillation.

Pharmacologic strategies for the prevention of stroke in patients with atrial fibrillation.

OPINION STATEMENT: Stroke is a dreaded complication of atrial fibrillation. In the past, preventive therapy included aspirin and oral anticoagulation. Selected patients who are not suitable for oral anticoagulation may benefit from the addition of clopidogrel with aspirin. This combination, when compared with aspirin, offers a reduced risk of stroke at a cost of more major bleeding. We use this therapy in patients with atrial fibrillation who have unstable coronary syndromes or in patients who receive coronary artery stents who are not good candidates for "triple therapy" with aspirin, clopidogrel, and warfarin. The duration of therapy is tempered by many variables. In the case of coronary stents, we ask the interventionalist to consider a bare metal stent to shorten the duration of need for clopidogrel plus aspirin. After several months of combination therapy, we stop this therapy and begin warfarin therapy. Dabigatran is commercially available in the United States. In patients who have difficult to control International Normalized Ratio (INR) values or who do not wish to have regular coagulation monitoring, dabigatran offers a huge advantage. The benefit seems less if the INR is consistently within range. We are impressed with the superior reduction in stroke and systemic embolism with 150 mg of dabigatran twice daily compared to warfarin and also its low risk of intracranial hemorrhage. The results of clinical trials involving factor Xa agents are now being presented. How these agents fit into the marketplace remains to be seen but they will offer clinicians additional therapy for stroke prevention in atrial fibrillation.

Catheter ablation of atrial fibrillation.

Atrial fibrillation, the most common cardiac arrhythmia requiring treatment, has significant morbidity and mortality consequences. Pharmacologic therapy consisting of anticoagulants, AV nodal blocking agents and antiarrhythmics, remain the primary treatment. However, several nonpharmacologic therapies for the treatment of atrial fibrillation have been developed. In this review, we provide a detailed discussion of the most promising nonpharmacologic approach to the treatment of atrial fibrillation-catheter-based ablation.

Drug-induced QT prolongation and sudden death.

Prolongation of the QT interval can predispose to a potentially fatal polymorphic ventricular tachycardia called torsades de pointes (TdP). Although usually self-limited, TdP may degenerate into ventricular fibrillation and cause sudden death. Some medications that cause QT prolongation and possible TdP are commonly used in general practice. This paper presents a case of sudden death that is likely from drug-induced TdP. It reviews the mechanisms, risk factors, offending agents, and management of drug-induced torsades de pointes.

The effect of atrial pacing therapies on atrial tachyarrhythmia burden and frequency: results of a randomized trial in patients with bradycardia and atrial tachyarrhythmias.

OBJECTIVES: The Atrial Therapy Efficacy and Safety Trial (ATTEST) was a prospective, randomized study to evaluate preventive pacing and antitachycardia pacing (ATP) in patients with symptomatic atrial fibrillation (AF) or atrial tachycardia (AT). BACKGROUND: The effect of the combination of atrial prevention and termination algorithms on AT/AF burden and frequency in pacemaker patients is unknown. METHODS: A DDDRP pacemaker (AT500, Medtronic Inc., Minneapolis, Minnesota) with three atrial preventive pacing algorithms and two ATP algorithms was implanted in 368 patients. Patients were randomized one-month post-implant to all prevention and ATP therapies ON or OFF and followed for three months. The OFF group had DDDR pacing at a lower programmed rate of 60 ppm. The AT/AF burden and frequency were determined from daily device counters in 324 patients treated according to protocol. RESULTS: In 17,018 episodes with stored electrograms, appropriate detection was confirmed in 17,004 (99.9%). The median percentage of atrial pacing was 98% in the ON group versus 75% in the OFF group (p < 0.001). Using device-defined criteria for successful termination, ATP terminated 8,590 (54%) of 15,789 treated episodes. The median AT/AF burden during the three-month study period was 4.2 h/month ON versus 1.1 h/month OFF (p = 0.20). The median AT/AF frequency was 1.3 episodes/month ON versus 1.2 episodes/month OFF (p = 0.65). System-related, complication-free survival at four months was 90.2% (Kaplan-Meier estimate). CONCLUSIONS: This DDDRP pacemaker is safe, has accurate AT/AF detection, and provides ATP with 54% efficacy as defined by the device. The atrial prevention and termination therapies combined did not reduce AT/AF burden or frequency in this patient population.