Early repolarization pattern in an ethnically diverse population: Increased risk in Hispanics.

BACKGROUND: Early repolarization (ER) pattern on ECG is associated with an increased mortality in Caucasians. This study analyzed the association between ER pattern and all-cause mortality in a population of multiple ethnicities. METHODS: A total of 20 000 individuals were randomly selected and their ECGs were analyzed for ER pattern using the 2015 consensus: end-QRS notching or slurring with a J-point (Jp) ≥0.1 mV in contiguous inferior or lateral leads. Exclusion criteria were age <18, QRS duration of ≥120 ms, and acute myocardial infarction. Kaplan-Meier survival curves were used to assess crude survival, and multivariable logistic regression models were used to determine predictors of all-cause mortality. RESULTS: A total of 17 901 patients with a mean age of 53 met inclusion criteria. Individuals were 62% female, 14% White, 37% Black, 40% Hispanic, and 9% other. Median follow-up time was 6.4 years. ER pattern was noted in 995 (5.6%) patients. Jp ≥2 mm was noted in 282 (1.6%) patients. In those with ER pattern and Jp ≥1 mm, there was no difference in mortality when compared to individuals without Jp elevation (odds ratio [OR]: 0.962, 95% confidence of interval [CI]: 0.819-1.131). Patients with Jp ≥2 mm had a significantly increased all-cause mortality (OR: 1.333, 95% CI: 1.009-1.742). This increased mortality was also significant in Hispanic patients with Jp ≥2 mm (OR: 1.584, 95% CI: 1.003-2.502). CONCLUSION: ER pattern with Jp ≥2 mm is associated with increased mortality in a multiethnic population, apparently driven by an increased risk in Hispanics.

Use of antimicrobial agent pocket irrigation for cardiovascular implantable electronic device infection prophylaxis: Results from an international survey.

PURPOSE: Survey the usage and application protocol of antimicrobial agent pocket irrigation for cardiovascular implantable electronic device (CIED) infection prophylaxis. BACKGROUND: Local antibiotic usage for CIED infection prophylaxis, in particular pocket irrigation, is a well-known strategy but with little data on its clinical effectiveness. METHODS: An anonymous voluntary online survey was sent to a total of 2,092 arrhythmia-oriented cardiologists in 51 countries (1,490 from the United States). RESULTS: There were 487 responses (response rate 23.3%: U.S. 28.2%, outside of the U.S. 11.1%). Eighty-seven percent of respondents use intraoperative antimicrobial agent pocket irrigation and/or an antimicrobial eluting pouch to reduce CIED infection. Fifty-four percent of respondents believe that it is effective to use an antimicrobial agent pocket irrigation to reduce CIED infection; 33% of respondents are uncertain; a few consider this strategy ineffective (13%) or offered no opinion. Significant differences exist in the practice patterns and beliefs between the U.S. and non-U.S. countries (P < 0.05). Ninety-eight percent of respondents report using the same pocket irrigation protocol for permanent pacemaker versus implantable cardioverter defibrillator. Bacitracin (48%), vancomycin (39%), and a cephalosporin (29%) are the most commonly chosen antibiotics. A majority of the respondents are unaware of the cost of using antimicrobial agent pocket irrigation (69%) and neither are they concerned (67%). CONCLUSION: This international survey suggests that, while there are little clinical data to support or discourage such practice, the usage of antimicrobial agent pocket irrigation for CIED infection prophylaxis is widely used in current practice.

Catheter ablation of ventricular tachycardia in nonischemic cardiomyopathy: A propensity score-matched analysis of in-hospital outcomes in the United States.

INTRODUCTION: Monomorphic ventricular tachycardia (VT) is an important cause of morbidity and mortality. Use and outcome data of catheter ablation for VT in nonischemic cardiomyopathy (NICM) are limited. METHODS AND RESULTS: We obtained data from the 2003-2014 National Inpatient Sample databases. We used propensity score matching to compare patients undergoing catheter ablation versus medical therapy of VT related to NICM, and described the temporal trends in utilization and in-hospital outcomes of catheter ablation of VT in patients with NICM in the United States. From 2003 to 2014, of 133,529 patients hospitalized with the principal diagnosis of VT in NICM, 14,651 (11.0%) underwent catheter ablation. In this period, there was an increasing trend in utilization of catheter ablation (9.3% in 2003-2004 to 12.1% in 2003-2014, adjusted OR [per year], 1.12; 95% CI, 1.08-1.16; Ptrend  < 0.001). After propensity score matching, in-hospital mortality occurred in 172 of 14,318 (1.2%) patients in the catheter ablation group, compared with 297 of 14,156 (2.1%) of patients undergoing medical therapy (47% lower; 43% relative difference [adjusted OR, 0.53; 95% CI, 0.43-0.66]). CONCLUSIONS: In patients with NICM, catheter ablation of VT is associated with lower in-hospital mortality compared with those managed medically. The utilization rates of CA for VT related to NICM have increased in the past decade. Adequately powered randomized trials will be necessary to confirm these findings.

Incidence and quantitative analysis of dissociated optic nerve fiber layer appearance: real loss of retinal nerve fiber layer?

PURPOSE: To assess the association between appearance of dissociated optic nerve fiber layer (DONFL) after internal limiting membrane (ILM) peeling and changes in the macular nerve fiber layer (NFL) area by spectral-domain optical coherence tomography (SD-OCT). METHODS: This study included 132 consecutive patients who had successfully undergone vitrectomy with ILM peeling for idiopathic epiretinal membrane or macular holes and had been followed up for ≥6 months. Two examiners evaluated macular 5-line raster horizontal SD-OCT images and categorized the patients on the basis of presence (group I) or absence (group II) of DONFL. The average macular NFL areas in both groups were measured using ImageJ at baseline and 1, 3, and 6 months after surgery. RESULTS: Among the 132 eyes of 132 patients, DONFL was noted in 42 (31.8%), 104 (78.8%), 106 (80.3%), and 106 (80.3%) eyes at 1, 3, and 6 months and at the last visit (12.8 ± 6.5 months) after surgery. These layers appeared most commonly between 1 and 3 months after ILM peeling. There was no significant difference in average macular NFL area between groups I and II (3453.4 ± 125.3 and 3513.0 ± 100.2 pixels, respectively) at 6 months after surgery (p = 0.56). CONCLUSIONS: Appearance of DONFL increased between postoperative months 1 and 3. Moreover, there was no significant difference in average NFL in terms of DONFL. Thus, appearance of DONFL might represent macular NFL rearrangement and reorganization rather than true mechanical damage to the NFL after ILM peeling.

Long-term outcomes of different ablation strategies for ventricular tachycardia in patients with structural heart disease: systematic review and meta-analysis.

Aims: To compare the long-term outcomes of standard ablation of stable ventricular tachycardia (VT) vs. substrate modification, and of complete vs. incomplete substrate modification in patients with structural heart disease (SHD) presenting with VT. Methods and results: An electronic search was performed using major databases. The main outcomes were a composite of long-term ventricular arrhythmia (VA) recurrence and all-cause mortality of standard ablation of stable VT vs. substrate modification, and long-term VA recurrence in complete vs. incomplete substrate modification. Six studies were included for the comparison of standard ablation of stable VT vs. substrate modification, with a total of 396 patients (mean age 63 ± 10 years, 87% males), and seven studies were included to assess the impact of extensive substrate modification, with a total of 391 patients (mean age 64 ± years, 90% males). More than 70% of all the patients included had ischaemic cardiomyopathy. Substrate modification was associated with decreased composite VA recurrence/all-cause mortality compared to standard ablation of stable VTs [risk ratio (RR) 0.57, 95% confidence interval (CI) 0.40-0.81]. Complete substrate modification was associated with decreased VA recurrence as compared to incomplete substrate modification (RR 0.39, 95% CI 0.27-0.58). Conclusion: In patients with SHD who had VT related mainly to ischaemic substrates, there was a significantly lower risk of the composite primary outcome of long-term VA recurrence and all-cause mortality among those undergoing substrate modification compared to standard ablation. Long-term success is improved when performing complete substrate modification.

Socioeconomic Status as a Predictor of Mortality in Patients Admitted With Atrial Fibrillation.

Lower socioeconomic status (SES) is associated with a higher risk of cardiovascular disease. However, the association between SES and mortality in patients with atrial fibrillation (AF) is not clear. We examined whether SES predicts all-cause mortality in patients hospitalized with AF. This is a retrospective study of patients aged >18 years, admitted with a primary diagnosis of AF to Montefiore Medical Center between 2000 and 2010. Multivariable logistic regression models were used to determine predictors of survival adjusted for age, gender, heart failure, diabetes mellitus, chronic kidney disease, previous myocardial infraction, chronic obstructive pulmonary disease, hypertension, peripheral vascular disease, and SES. SES was determined using the New York City Department of Health Standardized Score (a log composite score of household income, value of housing units, net rental income, household occupations, and educational level). The cohort was divided into quartiles based on SES score, with Q4 the highest and Q1 the lowest SES score. There were 4,503 patients identified with a mean follow up of 4.5 years in the following SES quartiles: Q1 (n = 1,132), Q2 (n = 1,119), Q3 (n = 1,126), and Q4 (n = 1,126). The unadjusted mortality varied across quartiles (Q1 to Q4), 54%, 58%, 56%, and 59%, respectively (p = 0.004). After controlling for other variables in the multivariable analysis, patients with the lowest SES (Q1) had a significantly higher mortality than patients in the quartile with the highest (Q4) SES (odds ratio 1.3, CI 1.1 to 1.5). In conclusion, patients admitted to the hospital with AF have varying mortality based on their SES. After controlling for co-morbidities, patients with AF and lower SES scores had higher mortality. Further research studies are warranted to study this risk of increased mortality in AF population.

Prevalence of right atrial non-pulmonary vein triggers in atrial fibrillation patients treated with thyroid hormone replacement therapy.

BACKGROUND: Thyroid hormone (TH) is known to enhance arrhythmogenicity, and high-normal thyroid function is related with an increased recurrence of atrial fibrillation (AF) after catheter ablation. However, the impact of thyroid hormone replacement (THR) on AF ablation is not well known. METHODS: This study evaluated 1163 consecutive paroxysmal AF patients [160 (14%) on THR and 1003 (86%) without THR] undergoing their first catheter ablation. A total of 146 patients on THR and 146 controls were generated by propensity matching, based on calculated risk factor scores, using a logistic model (age, sex, body mass index, and left atrium size). The presence of non-pulmonary vein (PV) triggers was disclosed by a high-dose isoproterenol challenge (up to 30 µg/min) after PV isolation. RESULTS: Clinical characteristics were not different between the groups. When compared to the control, non-PV triggers were significantly greater in the THR patients [112 (77%) vs. 47 (32%), P < 0.001], and most frequently originated from the right atrium (95 vs. 56%, P < 0.001). Other sources of non-PV triggers were the interatrial septum (25 vs. 11%, P = 0.002), coronary sinus (70 vs. 52%, P = 0.01), left atrial appendage (47 vs. 34%, P = 0.03), crista terminalis/superior vena cava (11 vs. 8%, P = 0.43), and mitral valve annulus (7 vs. 5%, P = 0.45) (THR vs. control), respectively. After mean follow-up of 14.7 ± 5.2 months, success rate was lower in patients on THR therapy [94 (64.4%)] compared to patients not receiving THR therapy [110 (75.3%), log-rank test value = 0.04]. CONCLUSIONS: Right atrial non-PV triggers were more prevalent in AF patients treated with THR. Elimination of non-PV triggers provided better arrhythmia-free survival in the non-THR group.

Clinical Impact of Heparin Kinetics During Catheter Ablation of Atrial Fibrillation: Meta-Analysis and Meta-Regression.

INTRODUCTION: Appropriate activated clotting time (ACT) during catheter ablation of atrial fibrillation (CA-AF) is essential to minimize periprocedural complications. METHODS AND RESULTS: An electronic search was performed using major databases. Outcomes were thromboembolic (TE) and bleeding complications according to ACT levels (seconds). Heparin dose (U/kg) and time (minutes) to achieve the target ACT was compared among patients receiving vitamin K antagonist (VKA) versus non-VKA oral anticoagulants (NOAC). Nineteen studies involving 7,150 patients were identified. Patients with ACT > 300 had less TE (OR, 0.51; 95% CI 0.35-0.74) and bleeding (OR, 0.70; 95% CI 0.60-0.83) compared to ACT < 300, when using any type of oral anticoagulation. The use of VKA was associated with reduced heparin requirements (mean dose: 157 U/kg vs. 209 U/kg, P < 0.03; SDM -0.86 [95% CI -1.39 to -0.33]), and with lower time to achieve the target ACT (mean time: 24 minutes vs. 49 minutes, P < 0.03; SDM -11.02 [95% CI -13.29 to -8.75]) compared to NOACs. No significant publication bias was found. CONCLUSIONS: Performing CA-AF with a target ACT > 300 decreases the risk of TE without increasing the risk of bleeding. Patients receiving VKAs required less heparin and reached the target ACT faster compared to NOACs.

Ultrasound stratification of the FDG-avid thyroid nodule.

AIM: To determine whether the malignancy risk in an 2-[(18)F]-fluoro-2-deoxy-d-glucose (FDG)-avid thyroid nodule can be stratified according to the presence or absence of suspicious ultrasound features and thereby identify which nodules require further cytological assessment. MATERIALS AND METHODS: A retrospective review of FDG-positron-emission tomography (PET) combined with computed tomography (CT) studies with FDG-avid thyroid nodules (defined as FDG uptake greater than blood pool) that were further assessed with ultrasound and fine-needle aspiration cytology or surgery was performed. FDG-avid thyroid nodules were classified as having either suspicious ultrasound features (marked hypo-echogenicity, irregular margins, microcalcifications, marked hypervascularity, or nodules that were taller than they were wide) or no suspicious ultrasound features and these findings were correlated with the subsequent cytological results. RESULTS: Forty-eight FDG-avid thyroid nodules were assessed. On cytological assessment five nodules were malignant (10.4%), nine were indeterminate (18.75%), and 34 were benign (70.8%). On ultrasound, 24 (50%) had no suspicious features and 24 (50%) had one or more suspicious features. Of the nodules with no suspicious features, 22 (91.6%) were benign, two (8.3%) were indeterminate, and none were malignant. Of the nodules with suspicious features, five (20.8%) were malignant, seven (29.1%) were indeterminate, and 12 (50%) were benign. The absence of suspicious ultrasound features demonstrated a strong association with benign cytology (p=0.009). Out of the suspicious sonographic features, marked hypoechoic appearance (p=0.02), irregular margins (p=0.009), and taller than wide morphology (p=0.04) were statistically most significantly associated with malignancy. CONCLUSION: The rate of malignancy in FDG-avid thyroid nodules is low in the absence of specific suspicious ultrasound features. The SUV values are non-discriminatory to differentiate between benign and malignant cytology. This suggests that ultrasound can be used to further stratify an FDG-avid thyroid nodule and invasive procedures to investigate the FDG-avid thyroid nodule may not be necessary in the absence of suspicious ultrasound features.

Referral Patterns for Primary Prophylaxis Implantable Cardioverter Defibrillator Therapy for an Urban US Population.

Implantable cardioverter defibrillators (ICDs) have been demonstrated to improve survival for both primary and secondary prevention of sudden cardiac arrest. However, studies suggest that ICD therapy is underused in appropriate candidates. Sex and racial disparities in ICD use have been suggested. We sought to characterize the referral patterns of high-risk patients for the primary prophylaxis of sudden cardiac arrest at a tertiary academic medical center serving a diverse population in an urban US setting. Electronic hospital databases were retrospective reviewed for patients meeting criteria for prophylactic ICD implantation. We evaluated the association of gender, age, race, and primary language with the referral and subsequent implantation of an ICD. We identified 1,055 patients satisfying prophylactic ICD criteria: 600 men, mean age 62.6 years, 27.6% black, 19.3% white, 23.3% Hispanic, and 49.8% primary language of English. Of the 673 patients (63.7%) referred for ICD evaluation, 345 underwent implantation, 125 declined, and 203 had significant co-morbidities that precluded implantation. Gender, race, and primary language were not associated with referral for ICD or with decision to proceed with implantation. Patients of increased age were less likely to be referred for ICD and were more likely to refuse implantation. ICD therapy was not considered in 146 patients eligible for prophylactic implantation. In conclusion, referral rates for ICD consideration were higher at our institution than in previous reports. Nonetheless, 14% of appropriate patients were not considered. This argues for the importance of increased education for patients and referring physicians.

Prognostic value of automatically detected early repolarization.

Early repolarization associated with sudden cardiac death is based on the presence of >1-mm J-point elevations in inferior and/or lateral leads with horizontal and/or downsloping ST segments. Automated electrocardiographic readings of early repolarization (AER) obtained in clinical practice, in contrast, are defined by ST-segment elevation in addition to J-point elevation. Nonetheless, such automated readings may cause alarm. We therefore assessed the prevalence and prognostic significance of AER in 211,920 patients aged 18 to 75 years. The study was performed at a tertiary medical center serving a racially diverse urban population with a large proportion of Hispanics (43%). The first recorded electrocardiogram of each individual from 2000 to 2012 was included. Patients with ventricular paced rhythm or acute coronary syndrome at the time of acquisition were excluded from the analysis. All automated electrocardiographic interpretations were reviewed for accuracy by a board-certified cardiologist. The primary end point was death during a median follow-up of 8.0 ± 2.6 years. AER was present in 3,450 subjects (1.6%). The prevalence varied significantly with race (African-Americans 2.2%, Hispanics 1.5%, and non-Hispanic whites 0.9%, p <0.01) and gender (male 2.4% vs female 0.6%, p <0.001). In a Cox proportional hazards model controlling for age, smoking status, heart rate, QTc, systolic blood pressure, low-density lipoprotein cholesterol, body mass index, and coronary artery disease, there was no significant difference in mortality regardless of race or gender (relative risk 0.98, 95% confidence interval 0.89 to 1.07). This was true even if J waves were present. In conclusion, AER was not associated with an increased risk of death, regardless of race or gender, and should not trigger additional diagnostic testing.

Characteristics of spontaneous idiopathic epiretinal membrane separation in spectral domain optical coherence tomography.

PURPOSE: To investigate the prevalence, characteristics, and visual acuity of spontaneous idiopathic epiretinal membrane (ERM) separations using spectral domain optical coherence tomography. METHODS: In a series of 1,248 consecutive eyes with idiopathic ERM, Group I with preexisting posterior vitreous detachment included 1,091 eyes (87.4%) and Group II without preexisting posterior vitreous detachment included 157 eyes (12.6%). Groups IA and IIA included self-resolution cases of ERM from Groups I and II, respectively. RESULTS: The ERM self-separation occurred in 37 eyes (3.0%) for 32.6 ± 11.7 months, with 16 eyes (1.5%) in Group IA and 21 eyes (13.4%) in Group IIA. The mean best-corrected visual acuity (logMAR) improved in Groups IA and IIA by 0.1 (P = 0.013) and 0.06 (P = 0.078), respectively. From tomographic analyses, dominant undulation and retinal nerve fiber layer defects were more frequent in Group IA than Group IIA (P < 0.001 and P = 0.024, respectively). However, the completeness of ERM separation, inner segment/outer segment junction defects, and ERM recurrence were more frequent in Group IIA than Group IA (P = 0.039, P = 0.023 and P = 0.041, respectively). Multivariate analysis for factors related to visual improvement revealed only inner segment/outer segment junction defects as significantly associated (P = 0.025). CONCLUSION: Different mechanisms underlying the self-resolution of idiopathic ERM lead to distinct tomographic characteristics and may affect the postseparation visual function.

Characteristics of ventricular tachycardia arising from the inflow region of the right ventricle.

INTRODUCTION: Ventricular tachycardia (VT) arising from the right ventricular inflow (RVI) region is uncommon. There is minimal literature on the clinical and electrocardiographic characteristics of RVI VT. METHODS: A retrospective analysis of patients with RVI VT who underwent electrophysiology study between 2006 and 2011 was performed. Patients with structural heart disease (including arrhythmogenic right ventricular dysplasia) were excluded. RESULTS: Seventy patients underwent an electrophysiology study for VT arising from the right ventricle during the study period. Nine patients (13%) met the inclusion criteria for RVI VT and were the subject of this analysis. The median age was 46 years (range, 14-71), and VT cycle length was 295 milliseconds (range, 279-400 milliseconds). All VTs had an left bundle-branch block morphology. An inferiorly directed QRS axis was noted in 7 (78%) of 9 patients and a left superior axis in 2 (22%) of 9 patients. A QS or rS pattern was noted in all patients in aVR and V(1). A transition from S to R wave occurred in V(3) to V(5) in all patients, with 78% of the patients transitioning in V(4) or V(5). Ablation was attempted in 8 (89%) of 9 patients and was successful in 6 (67%) of 9 patients. Ablation was limited in all unsuccessful patients due to the proximity to the His and risk of complete heart block. CONCLUSIONS: Electrocardiographic findings of a left bundle-branch block with a normal QRS axis, QS or rS patterns in aVR and V(1), and late S to R transition (V(4)/V(5)) are commonly found in RVI VT. Because of the proximity to the His, ablation of RVI VT may be more challenging than that of right ventricular outflow tract VT.

Optimal reconstructed section thickness for the detection of liver lesions with multidetector CT.

AIM: To evaluate the impact of different reconstructed section thicknesses on liver lesion detection using multidetector computed tomography (CT). METHODS: Fifty-three patients were examined using a 16-section CT machine with axial reconstructions provided at 2.5, 5, 7.5, and 10mm section thicknesses. Images of different reconstructed section thicknesses from different patients were presented in random order to three independent, blinded radiologists for review at multiple sessions. All images were then reviewed by three radiologists in a common session. Consensus was reached following review of the previous interpretation results and results of follow-up imaging regarding the number of true liver lesions (n=101) for comparison. RESULTS: Mean detection rates were as follows: 93/101 lesions detected with the 2.5mm section thickness, 98/101 lesions detected at the 5mm section thickness, 78/101 lesions detected at the 7.5mm section thickness, and 54/101 lesions detected at the 10mm section thickness. Lesions missed at the 2.5mm section thickness were due to masking by image noise. There was particular difficulty detecting subcapsular lesions and lesions adjacent to fissures or the gall bladder at the 7.5mm and 10mm section thicknesses. CONCLUSION: The optimal reconstructed section thickness for lesion detection in the liver was 5mm.

Spontaneous tonsillar haemorrhage due to von Willebrand's disease.

OBJECTIVE: We report a case of spontaneous tonsillar haemorrhage due to underlying von Willebrand's disease, without symptoms or signs of infection. METHOD: Case report and literature review of reported causes of spontaneous tonsillar haemorrhage. CASE REPORT: Spontaneous tonsillar haemorrhage is uncommon. Acute bacterial tonsillitis, peri-tonsillar abscess, infectious mononucleosis and idiopathic causes have been reported. Two cases of tonsillitis with underlying bleeding disorders have been reported. We present the first reported case of spontaneous tonsillar haemorrhage secondary to von Willebrand's disease, without evidence of tonsillitis. CONCLUSION: Spontaneous tonsillar haemorrhage is usually related to infection of the tonsils or peri-tonsillar space. An underlying bleeding disorder should be suspected if no evidence of infection is found.

The psychological impact of implantable cardioverter-defibrillator recalls and the durable positive effects of counseling.

BACKGROUND: It is known that patients with lifesaving devices such as implantable cardioverter-defibrillators (ICDs) may be alarmed and worried by recalls or alerts related to their ICDs. OBJECTIVES: This study aimed to determine whether counseling has any short- or long-term benefits, and to look for characteristics that identify those most worried and those most in need of counseling. METHODS: Among 100 patients with recall or alert ICDs, 14 were pacer dependent; 50 had ICDs for 1 degrees prevention and 22 were women. Patients completed a survey indicating how worried they were on learning of the recall or alert (0-10 scale). After counseling and advice in accordance with manufacturer guidelines, patients were asked to indicate their level of worry, and were again asked after 6 months. RESULTS: For all patients, the "worry level" at the initial interview was 5.0+/-3.7, falling to 2.2+/-3.0 after counseling (P < 0.001) and 1.4+/-2.3 after 6 months (P < 0.001 vs both earlier levels). There were no significant differences between those implanted for 1 degrees versus 2 degrees prevention or for pacer dependency. Women were initially more worried than men, but not for the long term. The 49 patients whose ICDs could be managed by reprogramming or software fix had significant reduction in worry after counseling and at 6 months compared to others. The 18 patients recommended for operative intervention remained more concerned after counseling (3.5+/-3.3 vs 1.9+/-2.9, P = 0.043). CONCLUSIONS: Patients' concerns resulting from ICD recalls or alerts can be reduced by appropriate counseling. Those patients whose ICDs could be reprogrammed to safer parameters had the most reduction in worry levels.

Rate responsive pacemakers: a rapid assessment protocol.

BACKGROUND: Rate responsive (RR) pacemakers are commonly implanted with nominal conservative factory-set responsiveness, which is usually accepted because established exercise protocols are time-consuming. We aimed for efficient assessment of RR pacemaker settings. METHODS: We tested exercise heart rates in controls and paced patients using a brief exercise test that approximates real-life levels of exertion. The test used a nonmotorized treadmill: 30 seconds walking at patient-determined speed followed by 15 seconds brisk exertion. Subjects totaled 110: 26 with RR pacemakers; 22 with non-RR pacers; 27 "sick" nonpaced control patients; and 35 healthy controls. Heart rate (HR) was measured prior to exercise, after 30 seconds of casual walk, after 15 seconds of brisk walk, and 1 minute into recovery. Testing required <5 minutes from set-up to recovery. RESULTS: The 26 RR pacer patients had a mean HR at rest = 74 +/- 10 beats per minute (bpm), walk = 87 +/- 14, and brisk = 94 +/- 18 (increase 27%). Non-RR pacer patients (n = 22): rest = 73 +/- 12 bpm, walk = 88 +/- 14, and brisk = 94 +/- 17 (increase 24.3%, P = 0.60 vs RR patients). "Sick" controls (n = 27): rest = 78 +/- 14 bpm, walk = 102 +/- 17, and brisk = 117 +/- 18 (increase 51.9%, P< 0.001 vs RR pts). For the healthy controls, HRs were at rest 83+/11 bpm, walk = 104 +/- 12, and brisk = 117 +/- 13 (P< 0.001 compared to both paced groups; P = NS vs sick controls). CONCLUSIONS: Nominal RR settings may be suboptimal for many patients. The nonmotorized treadmill test allows quick and inexpensive assessment of RR programming, with the potential for efficient RR optimization.

Intravenous sedation for cardiac procedures can be administered safely and cost-effectively by non-anesthesia personnel.

AIMS: Primary: to determine the safety and efficacy of intravenous sedation for cardiac procedures administered by non-anesthesia personnel. Secondary: to assess cost effectiveness of such sedation. METHODS: Anesthesiologists trained non-anesthesia personnel, and established our sedation protocol, which was then used in 9,558 patients who had cardiac procedures with sedation by non-anesthesia personnel, recorded on a computerized database. Most sedation used was midazolam (MID) and morphine (MOR). Complications and problems were derived from the database and quality assurance committee records. Doses were based on desired level of sedation and procedure duration; highest dose used: MID 78 mg, MOR 84 mg. RESULTS: Data included catheterization (n = 3,819) and transesophageal echo procedures (n = 260); and overall electrophysiology (n = 5,479) and selected subsets. There were complications or problems in only 9 patients (0.1%), a strong safety statement. There were 3 deaths in electrophysiology related procedures, 2 deaths in catheterization related procedures, all in very sick patients and not definitely related to sedation; 4 others developed clinical instability (hives, hypotension and heart failure-all with no sequellae), 2 of which needed reversal medications. Three patients (<0.03%) proved difficult to sedate, and their procedures were completed with help from the anesthesia department; by protocol this was not a complication. A total of $5,365,691 was saved during the last decade on cardiac procedures performed with conscious sedation. CONCLUSION: Non-anesthesia personnel can administer intravenous sedation for cardiac procedures in cardiac settings, with safety and cost-effectiveness demonstrated over many years. Anesthesia services are still appropriate for selected cases.