Implantable Cardiac Devices in Patients with Brady- and Tachy-Arrhythmias: An Update of the Literature.

Implantable cardiac devices are a vital treatment option in the management of tachy/brady-arrhythmias and heart failure with conduction disease. In the recent years, these devices have become increasingly sophisticated, with high implantation success rates and longevity. However, these devices are not without risks and complications, which need to be carefully considered before implantation. In an era of rapidly evolving cardiac device therapies, this review article will provide an update on the literature and outline some of the emerging technologies that aim to maximise the efficiency of implantable devices and reduce complications. We discuss novel pacing techniques, including alternative pacing sites in anti-bradycardia and biventricular pacing, as well as the latest evidence surrounding leadless device technologies and patient selection for implantable device therapies.

External electrical and pharmacological cardioversion for atrial fibrillation, atrial flutter or atrial tachycardias: a network meta-analysis.

BACKGROUND: Atrial fibrillation (AF) is the most frequent sustained arrhythmia. Cardioversion is a rhythm control strategy to restore normal/sinus rhythm, and can be achieved through drugs (pharmacological) or a synchronised electric shock (electrical cardioversion). OBJECTIVES: To assess the efficacy and safety of pharmacological and electrical cardioversion for atrial fibrillation (AF), atrial flutter and atrial tachycardias. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, Conference Proceedings Citation Index-Science (CPCI-S) and three trials registers (ClinicalTrials.gov, WHO ICTRP and ISRCTN) on 14 February 2023. SELECTION CRITERIA: We included randomised controlled trials (RCTs) at the individual patient level. Patient populations were aged ≥ 18 years with AF of any type and duration, atrial flutter or other sustained related atrial arrhythmias, not occurring as a result of reversible causes. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methodology to collect data and performed a network meta-analysis using the standard frequentist graph-theoretical approach using the netmeta package in R. We used GRADE to assess the quality of the evidence which we presented in our summary of findings with a judgement on certainty. We calculated differences using risk ratios (RR) and 95% confidence intervals (CI) as well as ranking treatments using a P value. We assessed clinical and statistical heterogeneity and split the networks for the primary outcome and acute procedural success, due to concerns about violating the transitivity assumption. MAIN RESULTS: We included 112 RCTs (139 records), from which we pooled data from 15,968 patients. The average age ranged from 47 to 72 years and the proportion of male patients ranged from 38% to 92%. Seventy-nine trials were considered to be at high risk of bias for at least one domain, 32 had no high risk of bias domains, but had at least one domain classified as uncertain risk, and one study was considered at low risk for all domains. For paroxysmal AF (35 trials), when compared to placebo, anteroapical (AA)/anteroposterior (AP) biphasic truncated exponential waveform (BTE) cardioversion (RR: 2.42; 95% CI 1.65 to 3.56), quinidine (RR: 2.23; 95% CI 1.49 to 3.34), ibutilide (RR: 2.00; 95% CI 1.28 to 3.12), propafenone (RR: 1.98; 95% CI 1.67 to 2.34), amiodarone (RR: 1.69; 95% CI 1.42 to 2.02), sotalol (RR: 1.58; 95% CI 1.08 to 2.31) and procainamide (RR: 1.49; 95% CI 1.13 to 1.97) likely result in a large increase in maintenance of sinus rhythm until hospital discharge or end of study follow-up (certainty of evidence: moderate). The effect size was larger for AA/AP incremental and was progressively smaller for the subsequent interventions. Despite low certainty of evidence, antazoline may result in a large increase (RR: 28.60; 95% CI 1.77 to 461.30) in this outcome. Similarly, low-certainty evidence suggests a large increase in this outcome for flecainide (RR: 2.17; 95% CI 1.68 to 2.79), vernakalant (RR: 2.13; 95% CI 1.52 to 2.99), and magnesium (RR: 1.73; 95% CI 0.79 to 3.79). For persistent AF (26 trials), one network was created for electrical cardioversion and showed that, when compared to AP BTE incremental energy with patches, AP BTE maximum energy with patches (RR 1.35, 95% CI 1.17 to 1.55) likely results in a large increase, and active compression AP BTE incremental energy with patches (RR: 1.14, 95% CI 1.00 to 1.131) likely results in an increase in maintenance of sinus rhythm at hospital discharge or end of study follow-up (certainty of evidence: high). Use of AP BTE incremental with paddles (RR: 1.03, 95% CI 0.98 to 1.09; certainty of evidence: low) may lead to a slight increase, and AP MDS Incremental paddles (RR: 0.95, 95% CI 0.86 to 1.05; certainty of evidence: low) may lead to a slight decrease in efficacy. On the other hand, AP MDS incremental energy using patches (RR: 0.78, 95% CI 0.70 to 0.87), AA RBW incremental energy with patches (RR: 0.76, 95% CI 0.66 to 0.88), AP RBW incremental energy with patches (RR: 0.76, 95% CI 0.68 to 0.86), AA MDS incremental energy with patches (RR: 0.76, 95% CI 0.67 to 0.86) and AA MDS incremental energy with paddles (RR: 0.68, 95% CI 0.53 to 0.83) probably result in a decrease in this outcome when compared to AP BTE incremental energy with patches (certainty of evidence: moderate). The network for pharmacological cardioversion showed that bepridil (RR: 2.29, 95% CI 1.26 to 4.17) and quindine (RR: 1.53, (95% CI 1.01 to 2.32) probably result in a large increase in maintenance of sinus rhythm at hospital discharge or end of study follow-up when compared to amiodarone (certainty of evidence: moderate). Dofetilide (RR: 0.79, 95% CI 0.56 to 1.44), sotalol (RR: 0.89, 95% CI 0.67 to 1.18), propafenone (RR: 0.79, 95% CI 0.50 to 1.25) and pilsicainide (RR: 0.39, 95% CI 0.02 to 7.01) may result in a reduction in this outcome when compared to amiodarone, but the certainty of evidence is low. For atrial flutter (14 trials), a network could be created only for antiarrhythmic drugs. Using placebo as the common comparator, ibutilide (RR: 21.45, 95% CI 4.41 to 104.37), propafenone (RR: 7.15, 95% CI 1.27 to 40.10), dofetilide (RR: 6.43, 95% CI 1.38 to 29.91), and sotalol (RR: 6.39, 95% CI 1.03 to 39.78) probably result in a large increase in the maintenance of sinus rhythm at hospital discharge or end of study follow-up (certainty of evidence: moderate), and procainamide (RR: 4.29, 95% CI 0.63 to 29.03), flecainide (RR 3.57, 95% CI 0.24 to 52.30) and vernakalant (RR: 1.18, 95% CI 0.05 to 27.37) may result in a large increase in maintenance of sinus rhythm at hospital discharge or end of study follow-up (certainty of evidence: low). All tested electrical cardioversion strategies for atrial flutter had very high efficacy (97.9% to 100%). The rate of mortality (14 deaths) and stroke or systemic embolism (3 events) at 30 days was extremely low. Data on quality of life were scarce and of uncertain clinical significance. No information was available regarding heart failure readmissions. Data on duration of hospitalisation was scarce, of low quality, and could not be pooled. AUTHORS' CONCLUSIONS: Despite the low quality of evidence, this systematic review provides important information on electrical and pharmacological strategies to help patients and physicians deal with AF and atrial flutter. In the assessment of the patient comorbidity profile, antiarrhythmic drug onset of action and side effect profile versus the need for a physician with experience in sedation, or anaesthetics support for electrical cardioversion are key aspects when choosing the cardioversion method.

ST-Segment Elevation Myocardial Infarction (STEMI) Management in the Era of COVID-19: A Systematic and Critical Review of Published Guidance Reports.

Background: Coronavirus disease 2019 (COVID-19) had a major impact on healthcare systems worldwide. During the early phase of the pandemic many elective procedures were postponed. At the same time, the safe and effective management of medical emergencies such as ST-segment elevation myocardial infarction (STEMI) has been a challenge. Methods: A systematic literature search was conducted aiming to identify published guidance reports by national or international societies regarding the management of patients suffering STEMI in the era of COVID-19. Results: Among 1681 articles initially retrieved, six fulfilled the inclusion criteria and were included in the systematic review. Two reports were international consensus documents, while four reports were national guidance statements from Asian countries (Taiwan, India, Iran, and China). Most documents were drafted during the early phase of the pandemic. According to the international consensus documents, percutaneous coronary intervention (PCI) should be regarded as the reperfusion method of choice. On the other hand, in three out of four national consensus statements (Taiwan, Iran and China) fibrinolysis was considered as the reperfusion method of choice for STEMI in suspected/confirmed patients with COVID-19, unless contraindicated or in the presence of high cardiovascular risk clinical features. Authors of all documents underlined the need for early COVID-19 testing in patients with STEMI to better determine the next therapeutical steps. Conclusions: National and international consensus statements for STEMI management in the era of COVID-19 have been published mainly during the early peak phase of the pandemic. Authors recognise that these recommendations are mainly based on expert opinions and observational data. As global immunization rates increase and methods for rapid COVID-19 detection are widely available, the implementation of traditional evidence-based practices used before the pandemic is becoming more feasible.

The Role of Risk Factor Modification in Atrial Fibrillation: Outcomes in Catheter Ablation.

The management of atrial fibrillation has evolved significantly over the last ten years with advancements in medical and catheter ablation approaches, but these have limited success when used in isolation. Trends in the management of lifestyle modifications have surfaced, as it is now better understood that modifiable risk factors contribute significantly to the development and propagation of atrial fibrillation, as well as failure of treatment. International guidelines have integrated the role of lifestyle modification in the management of atrial fibrillation and specifically in the persistent form of atrial fibrillation; these guidelines must be addressed prior to considering catheter ablation. Effective risk factor modification is critical in increasing the likelihood of an arrhythmia-free survival following catheter ablation.

Blood groups and Rhesus status as potential predictors of outcomes in patients with cardiac resynchronisation therapy.

Cardiac resynchronisation therapy (CRT) improves prognosis in patients with heart failure (HF) however the role of ABO blood groups and Rhesus factor are poorly understood. We hypothesise that blood groups may influence clinical and survival outcomes in HF patients undergoing CRT. A total of 499 patients with HF who fulfilled the criteria for CRT implantation were included. Primary outcome of all-cause mortality and/or heart transplant/left ventricular assist device was assessed over a median follow-up of 4.6 years (IQR 2.3-7.5). Online repositories were searched to provide biological context to the identified associations. Patients were divided into blood (O, A, B, and AB) and Rhesus factor (Rh-positive and Rh-negative) groups. Mean patient age was 66.4 ± 12.8 years with a left ventricular ejection fraction of 29 ± 11%. There were no baseline differences in age, gender, and cardioprotective medication. In a Cox proportional hazard multivariate model, only Rh-negative blood group was associated with a significant survival benefit (HR 0.68 [0.47-0.98], p = 0.040). No association was observed for the ABO blood group (HR 0.97 [0.76-1.23], p = 0.778). No significant interaction was observed with prevention, disease aetiology, and presence of defibrillator. Rhesus-related genes were associated with erythrocyte and platelet function, and cholesterol and glycated haemoglobin levels. Four drugs under development targeting RHD were identified (Rozrolimupab, Roledumab, Atorolimumab, and Morolimumab). Rhesus blood type was associated with better survival in HF patients with CRT. Further research into Rhesus-associated pathways and related drugs, namely whether there is a cardiac signal, is required.

Ateroesclerosis coronaria en pacientes hipertensos: el papel de la variabilidad genética del fibrinógeno / Coronary artery atherosclerosis in hypertensive patients: the role of fibrinogen genetic variability

Introducción y objetivos: Se examina si los polimorfismos rs180070 y rs2070011 del gen del fibrinógeno podrían afectar al riesgo de enfermedad coronaria de los pacientes hipertensos al modificar el proceso inflamatorio y la coagulación. Métodos: Se practicó una angiografía coronaria a causa de síntomas de angina estable a 744 participantes, de los que 332 tenían hipertensión. Resultados: La presencia del alelo A (rs180070) se asoció a cifras de fibrinógeno significativamente elevadas en los pacientes hipertensos (p = 0,05). En el análisis multivariable, la homocigosis para A (rs180070) (β = 0,257 ± 18,6; p < 0,001), pero no la presencia de hipertensión (β = 0,05 ± 11,9; p = 0,29), fue un factor independiente predictivo de la concentración de fibrinógeno. En los pacientes hipertensos, la concentración de fibrinógeno > 443 mg/dl (odds ratio = 3,50; intervalo de confianza del 95%, 1,14-10,90; p = 0,029), pero no la homocigosis para A (odds ratio = 3,00; intervalo de confianza del 95%, 0,78-11,90; p = 0,110), fueron un factor independiente predictivo de enfermedad coronaria. Además, los valores de interleucina 6 fueron más altos en los individuos homocigotos para el polimorfismo rs180070 que en todos los demás genotipos (p = 0,046). De hecho, este genotipo fue el único factor independiente predictivo de la concentración de interleucina 6 en el análisis ajustado (β = 0,151 ± 0,642; p = 0,032). También se asoció a cifras de dímero D superiores en la hipertensión en comparación con los portadores del alelo G (p = 0,048). Conclusiones: La presencia de homocigosis para A (rs180070) se asocia a un aumento de las concentraciones de mediadores inflamatorios y mayor incidencia de enfermedad coronaria angiográfica. Tiene importancia que el fibrinógeno es un factor independiente predictivo de la presencia angiográfica de enfermedad coronaria en los pacientes hipertensos (AU)

Introduction and objectives: We examined whether the rs180070 and rs2070011 polymorphisms of the fibrinogen gene could affect the risk of coronary artery disease in hypertensive patients by modifying the inflammatory process and coagulation. Methods: A total of 744 participants underwent coronary angiography due to symptoms of stable angina, while hypertension was present in 332 patients. Results: The presence of the A allele (rs180070) was associated with significantly high levels of fibrinogen in hypertensive patients (P = .05). On multivariate analysis, A homozygosity (rs180070) (β = 0.257 ± 18.6; P < .001), but not hypertension status (β = 0.05 ± 11.9; P = .29) was an independent predictor of fibrinogen levels. In hypertensive patients, higher fibrinogen levels > 443 mg/dL (odds ratio = 3.50; 95% confidence interval, 1.14-10.90; P = .029), but not A homozygosity (odds ratio = 3.00; 95% confidence interval, 0.78-11.90; P = .110) were independent predictors of the presence of coronary artery disease. Moreover, interleukin-6 levels were higher in A homozygotes for the rs180070 polymorphism compared with all other genotypes (P = .046). Indeed, this genotype was the only adjusted independent predictor of interleukin-6 levels (β = 0.151 ± 0.642; P = .032). It was also associated with higher D-dimer levels in hypertension compared with G allele carriers (P = .048). Conclusions: The presence of A homozygosity (rs180070) is associated with increased levels of inflammatory mediators and a higher incidence of angiographic coronary artery disease. Importantly, fibrinogen is an independent predictor of the angiographic presence of coronary artery disease in hypertensive patients (AU)