A review regarding the article 'Health inequalities in cardiopulmonary resuscitation and use of automated electrical defibrillators in out-of-hospital cardiac arrest'.

Out-of-hospital cardiac arrest (OHCA) is a major cause of mortality worldwide, with a high incidence and low survival rate. Prompt cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) use are major contributors in the "chain of survival" for OHCA. the response of a community plays a key role in determining the outcomes in OHCA. The outcomes of OHCA are affected by health inequalities in bystander CPR and AED use, due to factors such as differences in sex, ethnicity, and socioeconomic status amongst others. Literature shows patients from lower socio-economic backgrounds are more likely to have risk factors for a cardiac arrest and are therefore more likely to have OHCA. Studies have also reported lower rates of bystander AED use in females compared to males. Targeting deprived areas with tailored training and access to AEDs can be beneficial in improving CPR outcomes in communities. Due to the physical nature of CPR maneuvers, age and frailty of the patient can both impact the outcome of the resuscitation. Environmental factors affecting AED use include availability, visibility, accessibility, support, extra equipment, training materials, staffing, and awareness. Education should focus on areas such as conducting BLS on both male and female patients, recognizing cardiac arrest, tailoring BLS to difference ages as well as provision for training in different languages, including sign language. Like some other countries, CPR training is now being implemented in the school curriculum.

Quality of life and healthcare utilisation improvements after atrial fibrillation ablation.

OBJECTIVE: Pulmonary vein isolation (PVI) guided by a standardised CLOSE (contiguous optimised lesions) protocol has been shown to increase clinical success after catheter ablation for paroxysmal atrial fibrillation (PAF). This study analysed healthcare utilisation and quality of life (QOL) outcomes from a large multicentre prospective study, measured association between QOL and atrial fibrillation (AF) burden and identified factors associated with lack of QOL improvement. METHODS: CLOSE-guided ablation was performed in 329 consecutive patients (age 61.4 years, 60.8% male) with drug-refractory PAF in 17 European centres. QOL was measured at baseline and 12 months post-ablation via Atrial Fibrillation Effect on QualiTy of Life Survey (AFEQT) and EuroQoL EQ-5D-5L questionnaires. All-cause and cardiovascular hospitalisations and cardioversions over 12 months pre-ablation and post-ablation were recorded. Rhythm monitoring included weekly and symptom-driven trans-telephonic monitoring, plus ECG and Holter monitoring at 3, 6 and 12 months. AF burden was defined as the percentage of postblanking tracings with an atrial tachyarrhythmia ≥30 s. Continuous measures across multiple time points were analysed using paired t-tests, and associations between various continuous measures were analysed using independent sample t-tests. Each statistical test used two-sided p values with a significance level of 0.05. RESULTS: Both QOL instruments showed significant 12-month improvements across all domains: AFEQT score increased 25.1-37.5 points and 33.3%-50.8% fewer patients reporting any problem across EuroQoL EQ-5D-5L domains. Overall, AFEQT improvement was highly associated with AF burden (p=0.009 for <10% vs ≥10% burden, p<0.001 for <20% vs ≥20% burden). Cardiovascular hospitalisations were significantly decreased after ablation (42%, p=0.001). Patients without substantial improvement in AFEQT (55/301, 18.2%) had higher AFEQT and CHA2DS2-VASc scores at baseline, and higher AF burden following PVI. CONCLUSIONS: QOL improved and healthcare utilisation decreased significantly after ablation with a standardised CLOSE protocol. QOL improvement was significantly associated with impairment at baseline and AF burden after ablation. TRIAL REGISTRATION NUMBER: NCT03062046.

Availability of automated external defibrillators in Hamilton, New Zealand.

BACKGROUND: Last year, there were 2,000 out-of-hospital cardiac arrests (OHCA) in New Zealand, 74% received CPR but only 5.1% accessed an automated external defibrillator (AED). The average survival rate of OHCA is 13%. The aim of this study was to visit all 50 AED locations shown on www.hamiltoncentral.co.nz to assess their true availability and visibility to the public in the event of an OHCA. METHOD: All premises were visited and the first staff member encountered was asked if they were aware an AED was onsite, its location, hours of availability, if restricted access applied and whether it had been used. RESULTS: Of the 50 locations, three sites no longer exist and two AEDs were listed twice. Therefore, only 45 AEDs exist. Two sites had grossly inaccurate locations. Three AEDs (7%) were continuously available. Nine AEDs were accessible after 6pm at least one day of the week. Thirteen AEDs were available on weekends; however, five required swipe card access. None of the AEDs were located outdoors. CONCLUSION: Far fewer than 50 listed AEDs are freely available to the public, especially after 6pm and on weekends. Lack of signposting and restrictions to access would lead to delayed defibrillation. This important health issue needs addressing.

A descriptive analysis of the epidemiology and management of paediatric traumatic out-of-hospital cardiac arrest.

AIM: Paediatric traumatic out-of-hospital cardiac arrest (OHCA) is a rare event with few survivors. We examined long-term trends in the incidence and outcomes of paediatric traumatic OHCA and explored the frequency and timing of intra-arrest interventions. METHODS: We retrospectively analysed data from the Victorian Ambulance Cardiac Arrest Registry for cases involving traumatic OHCA in patients aged ≤16 years arresting between January 2000 to December 2017. Trends were assessed using linear regression and a non-parametric test for trend. RESULTS: A total of 292 cases were attended by emergency medical services (EMS), of which 166 (56.9%) received an attempted resuscitation. The overall incidence of EMS-attended cases was 1.4 cases per 100,000 person-years, with no significant changes over time. Unadjusted outcomes also remained unchanged, with 23.5% achieving return of spontaneous circulation and 3.7% surviving to hospital discharge. The frequency of trauma-specific interventions increased between 2000-2005 and 2012-2017, including needle thoracostomy from 10.5% to 51.0% (p trend <0.001), crystalloid administration from 31.6% to 54.9% (p trend = 0.004) and blood administration from 0.0% to 6.3% (p trend = 0.01). The median time from emergency call to the delivery of interventions were: 12.9 min (IQR: 8.5, 20.0) for cardiopulmonary resuscitation, 19.7 min (IQR: 10.7, 39.6) for external haemorrhage control, 29.8 min (IQR: 22.0, 35.4) for crystalloid administration and 31.5 min (IQR: 21.0, 38.0) for needle thoracostomy. CONCLUSION: The incidence and outcomes of paediatric traumatic OHCA remained unchanged over an 18 year period. Early correction of reversible causes by reducing delays to the delivery of trauma-specific interventions may yield additional survivors.

A Survey Assessment of Perceived Importance and Methods of Maintenance of Critical Procedural Skills in Pediatric Emergency Medicine.

OBJECTIVE: The aim of this study was to delineate pediatric emergency medicine provider opinions regarding the importance of, and to ascertain existing processes by which practitioners maintain, the following critical procedural skills: oral endotracheal intubation, intraosseous line placement, pharmacologic and electrical cardioversion, tube thoracostomy, and defibrillation. METHODS: A customized survey was administered to all members of the Listserv for the American Academy of Pediatrics Section on Emergency Medicine. Perceived importance of maintaining critical pediatric procedural skills was measured using a 5-point Likert-type scale. Secondary outcomes included presence and type of mandatory training, availability of on-site backup, and perceived barriers to maintenance of skills. RESULTS: Two hundred sixty-two members (25%) responded representing 106 different institutions, 70% of freestanding children's hospitals that received graduate medical education payments in 2014, and 68% of pediatric emergency medicine fellowship programs. More than 90% of respondents felt it was either very or extremely important to maintain competency for 5 of the 6 critical procedures, but no more than 49% of respondents felt that clinical care alone provided opportunity to maintain skills. The proportion of respondents indicating no mandatory training for each critical procedural skill was as follows: oral endotracheal intubation (23%), intraosseous line placement (30%), pharmacologic cardioversion (32%), electrical cardioversion (32%), tube thoracostomy (40%), and defibrillation (32%). CONCLUSIONS: Critical procedural skills are perceived by emergency providers who care for children as extremely important to maintain. Direct care of pediatric patients likely does not provide sufficient opportunity to maintain these skills. There are widespread deficiencies relating to mandatory maintenance of critical procedural skill training.

Administrative billing codes accurately identified occurrence of electrical cardioversion and ablation/maze procedures in a prospective cohort study of atrial fibrillation patients.

BACKGROUND: Administrative billing codes for electrical cardioversion and ablation/maze procedures may be useful for atrial fibrillation (AF) research if the codes are accurate relative to medical record documentation. HYPOTHESIS: Administrative billing codes accurately identify occurrence of electrical cardioversion and ablation/maze procedures in AF patients. METHODS: We studied adults ages 30 to 84 who experienced new-onset AF between October 2001 and December 2004 in Group Health Cooperative (acquired by Kaiser Permanente in 2017), an integrated healthcare system in Washington state and northern Idaho. Using medical record review as the gold standard, we calculated sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for 3 administrative billing codes for electrical cardioversion and 3 codes for AF ablation/maze procedures. RESULTS: Of 1953 study participants, during a mean (SD) of 1.5 (0.7) years of follow-up after AF onset, 470 (24%) experienced electrical cardioversion and 44 (2%) experienced ablation/maze procedures, according to medical record review. For electrical cardioversion, individual codes had 7.7% to 76.4% sensitivity, >99% specificity, 83.7% to 96.5% PPV, and 77.3% to 93.0% NPV. Considering any of 3 codes (code 1 or code 2 or code 3) improved sensitivity to 84.9%. For ablation/maze, individual codes had 18.2% to 47.7% sensitivity, >99% specificity, 66.7% to 95.5% PPV, and >98% NPV. Considering any of 3 codes improved sensitivity to 84.1%. CONCLUSIONS: Administrative billing data accurately identified electrical cardioversion and ablation/maze procedures and can be used instead of medical record review. Our findings apply to healthcare settings with available administrative billing databases.

Burden of arrhythmias in peripartum cardiomyopathy: Analysis of 9841 hospitalizations.

BACKGROUND: Peripartum cardiomyopathy (PPCM) is associated with significant morbidity and mortality. Arrhythmogenic causes of death have been implicated in a significant number of patients. However, there is a dearth of systematic studies evaluating the burden of arrhythmias in PPCM. METHODS: We used the Healthcare Utilization Project, Nationwide Inpatient Sample database (2007-2012) and identified 9841 hospitalizations for women aged ≥18years with a primary diagnosis of PPCM. Frequency of arrhythmias, utilization of electrophysiologic procedures, length of stay, hospitalization costs and outcomes associated with arrhythmias were determined. RESULTS: Mean age was 30.05±6.69years. Arrhythmias were present in 18.7% of hospitalized PPCM cohort. Ventricular tachycardia was the most common arrhythmia and was noted in 4.2%. Approximately 2.2% of cases experienced cardiac arrest. Electrical cardioversion was performed in 0.3%, Catheter ablation in 1.9%, PPM implantation in 3.4% and ICD in 6.8% of hospitalizations for PPCM with arrhythmias. In-hospital mortality was 3-times more frequent in arrhythmia cohort (2.1% vs. 0.7%). Hospitalization costs were significantly higher in PPCM with arrhythmias. Elixhauser comorbidity score (adjusted OR:1.10; 95%CI:1.02-1.18; p=0.016), in-hospital mortality (adjusted OR:2.35; 95%CI:1.38-4.02; p=0.002), cardiogenic shock (adjusted OR:2.61; 95%CI:1.44-4.72; p=0.002), utilization of balloon pump (adjusted OR:13.4; 95%CI: 2.55-70.53; p<0.001), Swan-Ganz catheterization (adjusted OR:3.12; 95%CI:1.21-8.06; p=0.019), and coronary angiography (adjusted OR:1.79; 95%CI:1.19-2.70; p=0.005) were significantly associated with arrhythmias in PPCM. CONCLUSIONS: Arrhythmias were present in 18.7% of PPCM related hospitalizations. Morbidity, in-hospital mortality, length of inpatient stay, hospitalization costs and cardiac procedure utilization were significantly higher in the arrhythmia cohort.

Impaired Mental Health-Related Quality of Life in Patients with Idiopathic Ventricular Fibrillation.

BACKGROUND: Idiopathic ventricular fibrillation (iVF) is diagnosed in cardiac arrest survivors without an identifiable cause. Data regarding the health-related quality of life (HRQoL) in iVF patients are lacking. The purpose of this study was to investigate the HRQoL of iVF patients and to compare it to patients with an implantable cardioverter defibrillator (ICD) diagnosed with an underlying disease and healthy subjects. METHODS: In 61 iVF patients with an ICD (iVF-ICD) and 59 ICD patients with a diagnosis (diagnosis-ICD), HRQoL was assessed using the 12-item Short-Form Health Survey (SF-12), the EuroQoL-5 dimensions (EQ-5D), the 9-item Patient Health Questionnaire, and the ICD Patient Concerns (ICDC) Questionnaire. In addition, 860 healthy subjects completed the SF-12. RESULTS: IVF-ICD showed similar SF-12 physical summary scores compared with diagnosis-ICD patients (50.8 [interquartile range (IQR) = 42.1-53.9] vs 54.1 [IQR = 46.5-58.3]; P = 0.080) and healthy subjects (51.8 [IQR = 45.9-54.1]; P = 0.691). The mental summary score was impaired in iVF-ICD patients compared with diagnosis-ICD patients (45.9 [IQR = 40.7-49.4] vs 54.6 [IQR = 46.0-57.9]; P < 0.001) and healthy subjects (47.7 [IQR = 43.0-50.4]; P = 0.027). Scores on all five EQ-5D domains were similar between iVF-ICD patients and diagnosis-ICD patients, as well as symptoms of severe depression (19% vs 12%; P = 0.101). ICD concerns were similar between iVF-ICD and diagnosis-ICD patients (ICDC-scores 2 vs 2; P = 0.494). CONCLUSIONS: Data suggest that there is a reduced mental HRQoL in patients with iVF compared to other cardiac arrest survivors. Screening and treatment of psychological distress should therefore be considered in iVF patients.

Healthcare Utilization and Expenditures Associated With Appropriate and Inappropriate Implantable Defibrillator Shocks.

BACKGROUND: In patients with implantable cardioverter-defibrillators, healthcare utilization (HCU) and expenditures related to shocks have not been quantified. METHODS AND RESULTS: We performed a retrospective cohort study of patients with implantable cardioverter-defibrillators identified from commercial and Medicare supplemental claims databases linked to adjudicated shock events from remote monitoring data. A shock event was defined as ≥1 spontaneous shocks delivered by an implanted device. Shock-related HCU was ascertained from inpatient and outpatient claims within 7 days following a shock event. Shock events were adjudicated and classified as inappropriate or appropriate, and HCU and expenditures, stratified by shock type, were quantified. Of 10 266 linked patients, 963 (9.4%) patients (61.3±13.6 years; 81% male) had 1885 shock events (56% appropriate, 38% inappropriate, and 6% indeterminate). Of these events, 867 (46%) had shock-related HCU (14% inpatient and 32% outpatient). After shocks, inpatient cardiovascular procedures were common, including echocardiography (59%), electrophysiology study or ablation (34%), stress testing (16%), and lead revision (11%). Cardiac catheterization was common (71% and 51%), but percutaneous coronary intervention was low (6.5% and 5.0%) after appropriate and inappropriate shocks. Expenditures related to appropriate and inappropriate shocks were not significantly different. CONCLUSIONS: After implantable cardioverter-defibrillator shock, related HCU was common, with 1 in 3 shock events followed by outpatient HCU and 1 in 7 followed by hospitalization. Use of invasive cardiovascular procedures was substantial, even after inappropriate shocks, which comprised 38% of all shocks. Implantable cardioverter-defibrillator shocks seem to trigger a cascade of health care. Strategies to reduce shocks could result in cost savings.

Differences Between Access to Follow-Up Care and Inappropriate Shocks Based on Insurance Status of Implantable Cardioverter Defibrillator Recipients.

Differences in implantable cardioverter defibrillator (ICD) utilization based on insurance status have been described, but little is known about postimplant follow-up patterns associated with insurance status and outcomes. We collected demographic, clinical, and device data from 119 consecutive patients presenting with ICD shocks. Insurance status was classified as uninsured/Medicaid (uninsured) or private/Health Maintenance Organization /Medicare (insured). Shock frequencies were analyzed before and after a uniform follow-up pattern was implemented regardless of insurance profile. Uninsured patients were more likely to present with an inappropriate shock (63% vs 40%, p = 0.01), and they were more likely to present with atrial fibrillation (AF) as the shock trigger (37% vs 19%, p = 0.04). Uninsured patients had a longer interval between previous physician contact and index ICD shock (147 ± 167 vs 83 ± 124 days, p = 0.04). Patients were followed for a mean of 521 ± 458 days after being enrolled in a uniform follow-up protocol, and there were no differences in the rate of recurrent shocks based on insurance status. In conclusion, among patients presenting with an ICD shock, underinsured/uninsured patients had significantly longer intervals since previous physician contact and were more likely to present with inappropriate shocks and AF, compared to those with private/Medicare coverage. After the index shock, both groups were followed uniformly, and the differences in rates of inappropriate shocks were mitigated. This observation confirms the importance of regular postimplant follow-up as part of the overall ICD management standard.

The Impact of First Procedure Success Rate on the Economics of Atrial Fibrillation Ablation.

OBJECTIVES: The purpose of this study was to compare health care costs associated with repeat ablation of atrial fibrillation (AF) with health care costs associated with a successful first procedure. BACKGROUND: Catheter ablation has become established as a rhythm control strategy for symptomatic paroxysmal and persistent AF. The economic impact of ablation is not completely understood, and it may be affected by repeat procedures performed for recurrent AF. METHODS: The source of data was the MarketScan (Truven Health, Ann Arbor, Michigan) administrative claims dataset from April 2008 to March 2013, including U.S. patients with private and Medicare supplemental insurance. Patients who underwent an outpatient atrial ablation procedure and a diagnosis of AF were identified. Total health care cost was calculated for 1 year before and after the ablation. Patients were categorized as having undergone a repeat ablation if an additional ablation was performed in the following year. RESULTS: Of 12,027 patients included in the study, repeat ablation was performed in 2,066 (17.2%) within 1 year. Patients with repeat ablation had higher rates of emergency department visits (43.4% vs. 32.2%; < 0.001) and subsequent hospitalization (35.6% vs. 21.5%; p < 0.001), after excluding hospitalizations for the repeat procedure. Total medical cost was higher for patients with repeat ablation ($52,821 vs. $13,412; p < 0.001), and it remained 46% higher even after excluding the cost associated with additional ablations ($19,621 vs. $13,412; p < 0.001). CONCLUSIONS: Health care costs are significantly higher for patients with a repeat ablation for AF than for patients with only a single ablation procedure, even though both groups have similar baseline characteristics. The increased costs persist even after excluding the cost of the repeat ablation itself. These results emphasize the economic benefit of procedural success in AF ablation.

Benefit of the Wearable Cardioverter-Defibrillator in Protecting Patients After Implantable-Cardioverter Defibrillator Explant: Results From the National Registry.

OBJECTIVES: This study reports on the time course of reimplantation and benefits of the wearable cardioverter-defibrillator (WCD) in patients post implantable cardioverter-defibrillator (ICD) explantation. BACKGROUND: The WCD is used to treat patients at high risk for ventricular tachycardia (VT) and ventricular fibrillation (VF), including patients with ICD-related infections who undergo device removal and cannot be immediately reimplanted. METHODS: This retrospective study included consecutive patients from 2002 to 2014 who underwent ICD removal because of device-related infection and were prescribed a WCD. WCD-stored electrocardiograms were reviewed. Event outcome was assessed through either the manufacturer WCD registry or the Social Security death index search. RESULTS: A total of 8,058 patients (mean age 62 ± 14 years, 75% male) were included in the analysis. Median time to reimplantation of an ICD was 50 days (interquartile range: 24 to 83 days). While wearing the WCD, 334 patients (4%) experienced 406 VT/VF events, of which 348 events were treated. Shocks were averted in 54 events by conscious patients. The overall 24-h survival, both treated and nontreated, was 93% (312 of 334). VT/VF occurrence was the highest in the initial weeks after ICD removal (0.9%, 0.7%, and 0.7% per week for weeks 1, 2, and 3, respectively). The 12-month cumulative event rate was 10%. For all patients, the 30-day post-event survival was 81%. An ICD was reimplanted in 80% of patients. CONCLUSIONS: The risk of VT/VF reaches 4% during the first 2 months and 10% at 1 year after ICD removal. WCD demonstrated a high efficacy for protecting patients from VT/VF. Clinicians may use the WCD as an ICD alternative when reimplantation is medically delayed.

Cost-Effectiveness and Clinical Effectiveness of the Risk Factor Management Clinic in Atrial Fibrillation: The CENT Study.

BACKGROUND: Atrial fibrillation (AF) imposes a substantial cost burden on the healthcare system. Weight and risk factor management (RFM) reduces AF burden and improves the outcomes of AF ablation. OBJECTIVES: This study sought to evaluate the cost and clinical effectiveness of integrating RFM into the overall management of AF. METHODS: Of 1,415 consecutive patients with symptomatic AF, 825 patients had body mass index ≥27 kg/m2. After screening for exclusion criteria, the final cohort comprised 355 patients: 208 patients who opted for RFM and 147 control subjects and were followed by 3 to 6 monthly clinic review, 7-day Holter monitoring, and AF Symptom Score. A decision analytical model calculated the incremental cost-effectiveness ratios of cost per unit of global well-being gained and unit of AF burden reduced. RESULTS: There were no differences in baseline characteristics or follow-up duration (p = NS). Arrhythmia-free survival was better in the RFM compared with control subjects (Kaplan-Meier: 79% vs. 44%; p < 0.001). At follow-up, RFM group had less unplanned specialist visits (0.19 ± 0.40 vs. 1.94 ± 2.00; p < 0.001), hospitalizations (0.74 ± 1.3 vs. 1.05 ± 1.60; p = 0.03), cardioversions (0.89 ± 1.50 vs. 1.51 ± 2.30; p = 0.002), emergency presentations (0.18 ± 0.50 vs. 0.76 ± 1.20; p < 0.001), and ablation procedures (0.60 ± 0.69 vs. 0.72 ± 0.86; p = 0.03). Antihypertensive (0.53 ± 0.70 vs. 0.78 ± 0.60; p = 0.04) and antiarrhythmic (0.26 ± 0.50 vs. 0.91 ± 0.60; p = 0.003) use declined in RFM. The RFM group had an increase of 0.1930 quality-adjusted life years and a cost saving of $12,094 (incremental cost-effectiveness ratios of $62,653 saved per quality-adjusted life years gained). CONCLUSIONS: A structured physician-directed RFM program is clinically effective and cost saving.

Efficacy and safety of ablation for people with non-paroxysmal atrial fibrillation.

BACKGROUND: The optimal rhythm management strategy for people with non-paroxysmal (persistent or long-standing persistent) atrial fibrilation is currently not well defined. Antiarrhythmic drugs have been the mainstay of therapy. But recently, in people who have not responded to antiarrhythmic drugs, the use of ablation (catheter and surgical) has emerged as an alternative to maintain sinus rhythm to avoid long-term atrial fibrillation complications. However, evidence from randomised trials about the efficacy and safety of ablation in non-paroxysmal atrial fibrillation is limited. OBJECTIVES: To determine the efficacy and safety of ablation (catheter and surgical) in people with non-paroxysmal (persistent or long-standing persistent) atrial fibrillation compared to antiarrhythmic drugs. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE Ovid, Embase Ovid, conference abstracts, clinical trial registries, and Health Technology Assessment Database. We searched these databases from their inception to 1 April 2016. We used no language restrictions. SELECTION CRITERIA: We included randomised trials evaluating the effect of radiofrequency catheter ablation (RFCA) or surgical ablation compared with antiarrhythmic drugs in adults with non-paroxysmal atrial fibrillation, regardless of any concomitant underlying heart disease, with at least 12 months of follow-up. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies and extracted data. We evaluated risk of bias using the Cochrane 'Risk of bias' tool. We calculated risk ratios (RRs) for dichotomous data with 95% confidence intervals (CIs) a using fixed-effect model when heterogeneity was low (I² <= 40%) and a random-effects model when heterogeneity was moderate or substantial (I² > 40%). Using the GRADE approach, we evaluated the quality of the evidence and used the GRADE profiler (GRADEpro) to import data from Review Manager 5 to create 'Summary of findings' tables. MAIN RESULTS: We included three randomised trials with 261 participants (mean age: 60 years) comparing RFCA (159 participants) to antiarrhythmic drugs (102) for non-paroxysmal atrial fibrillation. We generally assessed the included studies as having low or unclear risk of bias across multiple domains, with reported outcomes generally lacking precision due to low event rates. Evidence showed that RFCA was superior to antiarrhythmic drugs in achieving freedom from atrial arrhythmias (RR 1.84, 95% CI 1.17 to 2.88; 3 studies, 261 participants; low-quality evidence), reducing the need for cardioversion (RR 0.62, 95% CI 0.47 to 0.82; 3 studies, 261 participants; moderate-quality evidence), and reducing cardiac-related hospitalisation (RR 0.27, 95% CI 0.10 to 0.72; 2 studies, 216 participants; low-quality evidence) at 12 months follow-up. There was substantial uncertainty surrounding the effect of RFCA regarding significant bradycardia (or need for a pacemaker) (RR 0.20, 95% CI 0.02 to 1.63; 3 studies, 261 participants; low-quality evidence), periprocedural complications, and other safety outcomes (RR 0.94, 95% CI 0.16 to 5.68; 3 studies, 261 participants; very low-quality evidence). AUTHORS' CONCLUSIONS: In people with non-paroxysmal atrial fibrillation, evidence suggests a superiority of RFCA to antiarrhythmic drugs in achieving freedom from atrial arrhythmias, reducing the need for cardioversion, and reducing cardiac-related hospitalisations. There was uncertainty surrounding the effect of RFCA with significant bradycardia (or need for a pacemaker), periprocedural complications, and other safety outcomes. Evidence should be interpreted with caution, as event rates were low and quality of evidence ranged from moderate to very low.

Gender, Racial, and Health Insurance Differences in the Trend of Implantable Cardioverter-Defibrillator (ICD) Utilization: A United States Experience Over the Last Decade.

Prior studies have highlighted disparities in cardiac lifesaving procedure utilization, particularly among women and in minorities. Although there has been a significant increase in implantable cardioverter-defibrillator (ICD) insertion, socioeconomic disparities still exist in the trend of ICD utilization. With the use of the Nationwide Inpatient Sample from 2003 through 2011, we identified subjects with ICD insertion (procedure code 37.94) and cardiac resynchronization defibrillator (procedure code 00.50, 00.51) as codified by the International Classification of Diseases, Ninth Revision, Clinical Modification. Overall, 1 020 076 ICDs were implanted in the United States from 2003 to 2011. We observed an initial increase in ICD utilization by 51%, from 95 062 in 2003 to 143 262 in 2006, followed by a more recent decline. The majority of ICDs were implanted in men age ≥65 years. Implantation of ICDs was 2.5× more common in men than in women (402 per million vs 163 per million). Approximately 95% of the ICDs were implanted in insured patients, and 5% were used in the uninsured population. There has been a significant increase in ICD implantation in blacks, from 162 per million in 2003 to 291 per million in 2011. We found a significant difference in the volume of ICD implants between the insured and the uninsured patient populations. Racial disparities have narrowed significantly in comparison with those noted in earlier studies and are now more reflective of the population demographics at large. On the other hand, significant gender disparities continue to exist.

Comparative Effectiveness of CRT-D Versus Defibrillator Alone in HF Patients With Moderate-to-Severe Chronic Kidney Disease.

BACKGROUND: Patients with moderate-to-severe chronic kidney disease (CKD) are poorly represented in clinical trials of cardiac resynchronization therapy (CRT). OBJECTIVES: This study sought to assess the real-world comparative effectiveness of CRT with defibrillator (CRT-D) versus implantable cardioverter-defibrillator (ICD) alone in CRT-eligible patients with moderate-to-severe CKD. METHODS: We conducted an inverse probability-weighted analysis of 10,946 CRT-eligible patients (ejection fraction <35%, QRS >120 ms, New York Heart Association functional class III/IV) with stage 3 to 5 CKD in the National Cardiovascular Data Registry (NCDR) ICD Registry, comparing outcomes between patients who received CRT-D (n = 9,525) versus ICD only (n = 1,421). Outcomes were obtained via Medicare claims and censored at 3 years. The primary endpoint of heart failure (HF) hospitalization or death and the secondary endpoint of death were assessed with Cox proportional hazards models. HF hospitalization, device explant, and progression to end-stage renal disease were assessed using Fine-Gray models. RESULTS: After risk adjustment, CRT-D use was associated with a reduction in HF hospitalization or death (hazard ratio [HR]: 0.84; 95% confidence interval [CI]: 0.78 to 0.91; p < 0.0001), death (HR: 0.85; 95% CI: 0.77 to 0.93; p < 0.0004), and HF hospitalization alone (subdistribution HR: 0.84; 95% CI: 0.76 to 0.93; p < 0.009). Subgroup analyses suggested that CRT was associated with a reduced risk of HF hospitalization and death across CKD classes. The incidence of in-hospital, short-term, and mid-term device-related complications did not vary across CKD stages. CONCLUSIONS: In a nationally representative population of HF and CRT-eligible patients, use of CRT-D was associated with a significantly lower risk of the composite endpoint of HF hospitalization or death among patients with moderate-to-severe CKD in the setting of acceptable complication rates.

The epidemiology and management of recent-onset atrial fibrillation and flutter presenting to the Emergency Department.

OBJECTIVES: Atrial fibrillation (AF) and flutter are common tachyarrhythmias seen in the Emergency Department (ED). The management of recent-onset AF remains poorly defined. Two management strategies have been proposed: rhythm control versus rate control. The aims of this study were to investigate the epidemiology and management of recent-onset AF presenting to one large tertiary ED. METHODS: Retrospective analysis of ED records was carried out using the ED PAS database to identify eligible patients presenting between 1 July 2009 and 30 June 2011 with onset of AF in the previous 7 days. Patients were included for analysis if it was their first presentation, first diagnosis or a paroxysm of atrial fibrillation. RESULTS: A total of 494 patients (625 presentations) were analysed. AF (n=564; 90.2%) and flutter (n=61; 9.8%) were the presenting rhythms. In all, 374 (53.8%) presentations were paroxysmal atrial fibrillation. For patients with AF, rhythm control was attempted in 171 (55.0%) patients presenting less than 48 h after symptom onset. Pharmacotherapy was the approach in 105 (31.4%) patients, compared with direct current cardioversion (n=45; 26.3%). Twenty-one patients received both. Flecainide (n=85) and amiodarone (n=33) were the main first-line pharmacotherapies, restoring sinus rhythm in 81.3 and 81.4% of patients, respectively. The overall efficacy of direct current cardioversion in restoring sinus rhythm was similar (78.8%). Eighty-one patients presented more than 48 h after symptom onset. Of those patients managed in the ED (n=38; 71.7%) were managed with rate control. The majority of patients with atrial flutter presented less than 48 h after symptom onset (n=48; 78.7%). Sixteen of these patients were managed with rhythm control strategies in the ED. CONCLUSION: The epidemiology of recent-onset AF in this series is comparable with previous publications. Rhythm control was only attempted in approximately half of all eligible patients. There was no single-favoured management strategy. Our results mirror the literature in emphasizing the variation in management and the lack of robust evidence guiding the management of recent-onset AF and flutter.

Evaluation of practice patterns in the treatment of atrial fibrillation among the commercially insured.

OBJECTIVE: The management of atrial fibrillation (AF) involves two choices: (1) rate control versus rhythm control, and (2) anticoagulation treatment based upon risk of stroke. The objective of the study was to describe practice patterns in both of these treatment areas in patients with newly diagnosed AF among a commercially insured population. METHODS: This retrospective administrative claims analysis included patients with ≥2 AF claims between 1 January 2008 and 30 September 2010. Patients with AF claims within a year prior to the index date (i.e., the first AF diagnosis date) were excluded. The primary outcome was the proportion of patients treated with rate control (i.e., beta blockers, calcium channel blockers, digoxin) versus rhythm control (i.e., electrical cardioversion, left atrial catheter ablation [LACA], and/or surgical ablation) and the use of anticoagulants stratified by risk of stroke based on CHADS2 score. RESULTS: Of 48,814 patients with a diagnosis of AF, 38,502 (78.9%) received treatment. Of those treated, the majority received only pharmacologic treatment (73.4%), of which beta blockers were predominantly used in the initial regimen (66.7%). Antiarrhythmic drugs were used in 23.9% of patients, but within the initial regimen in only 11.7% of patients. Direct current cardioversion occurred in 18.2% of patients, with the majority being either first-line (8.5%) or second-line (9.1%) therapy. LACA was used in only 5.2% of patients and was typically reserved for use after pharmacologic treatment or direct current cardioversion. Of 1924 patients who received LACA, 14.6% received a repeat procedure and 53.4% of the repeat procedures occurred within 6 months of the initial one. A little more than half of all patients (57.0%) received anticoagulant therapy (predominantly warfarin); of those at high risk for stroke, 63.8% with a CHADS2 score ≥2 received anticoagulants. KEY LIMITATIONS: It is a retrospective analysis using administrative claims data from a commercially insured population only. Identification of the first episode of AF may be inaccurate, and we cannot differentiate between paroxysmal and persistent AF. CONCLUSIONS: Debate continues regarding whether the preferred management of most patients with AF is through rate control or restoration of normal sinus rhythm. Our retrospective study found that treatments to restore normal heart rhythm, including LACA, which could be considered aggressive initial treatment, were typically reserved as second- or third-line alternatives. Initial standard of care for the majority patients was beta blockers. Though use of anticoagulation may be higher than other observational studies, opportunities exist to increase treatment in high risk patients.

Gender differences in patients with atrial fibrillation.

AIMS: We aimed to compare gender differences with respect to presentation of consecutive ambulatory patients with atrial fibrillation (AF), management of their disease, and outcomes. METHODS: Post-hoc analysis of an observational (non-interventional) study performed by 616 office- and hospital-based cardiologists in Germany. Consecutive (mainly ambulatory) patients with Electrocardiography (ECG) -confirmed AF and available data from baseline (BL) and two follow-up visits at 6 and 12 months were assessed. RESULTS: A total of 2,742 patients (62.8% males, mean age 67.5 years; 37.2% women, mean age 71.2 years) were analysed. Women had more frequently paroxysmal and less frequently permanent AF. Quality of life scores were slightly worse in women compared to men, for all types of AF. For class III anti-arrhythmic drugs at baseline (more frequent in men), and for digitalis (less frequent in men at BL and 1 year) statistically significant differences were noted. Oral anti-coagulation (OAC) without anti-platelet drugs was given in 67.9% at BL and in 62.7% at 1 year (no differences between genders). During follow-up, drug conversions in men/women were reported in 12.3%/14.9% (p=0.054), and electrical conversions in 14.6%/11.7% (p=0.03). Hospitalisations occurred in 25.9% and strokes in 3.5%. Patients with higher CHA2DS2-VASc scores had increased stroke rates (0, 1 and ≥2 points: 0.0, 1.5 and 3.9%, respectively; with no significant gender differences). CONCLUSION: In everyday management of patients with AF, there were no differences in treatment and major outcomes, in particular stroke, between women and men. This finding is opposed to earlier studies reporting OAC undertreatment of women and higher stroke rates.

[Patients' characteristics and clinical management of atrial fibrillation in primary healthcare in Spain: FIATE Study]. / Características de los pacientes y abordaje terapéutico de la fibrilación auricular en atención primaria en España: Estudio FIATE.

BACKGROUND AND OBJECTIVES: The main therapeutic objective in atrial fibrillation (AF) patients is stroke prevention. This study is aimed to determine whether the anticoagulant therapy may be appropriate regarding to the Guidelines and patients' profile in primary healthcare in Spain. PATIENTS AND METHODS: A national, multicenter, cross-sectional study of AF patients attended in primary healthcare in Spain has been conducted. The study involved 185 family physicians whose patients were randomized. RESULTS: A total of 3,759 AF patients were randomized from the clinical records, and 2,070 were included in the study, at an average age of 74 (11) years old (50.7% female). Most of them (78%) had permanent AF and high comorbidity rates (hypertension 75%, obesity 30%, diabetes 27%, heart failure 20%, coronary heart disease 17%, and social risk 15%). Patients diagnosed in primary healthcare were more frequently asymptomatic than in hospital setting (36%; P<.001). The therapeutic strategy was based on the heart rate control in 4 out of 5 patients. Anticoagulation therapy was widely used (84%), more frequently in patients with permanent vs. non-permanent AF (91 vs. 60%, P<.001). Follow-up and monitoring was mainly performed in primary care (72%). The anticoagulation control was suboptimal, with a 66% of the international normalized ratio (INR) in therapeutic range, dropping to 33% when the last 3 available INR were included (P<.001). CONCLUSIONS: A high rate of patients with anticoagulant therapy in primary healthcare has been found in this research. INR control, however, remains suboptimal. Heart rate control is the most commonly used strategy. The decision about the anticoagulation should be based on the thromboembolic risk rather than in the arrhytmia type.