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AIMS: Obesity is associated with higher electrical cardioversion (ECV) failure in persistent atrial fibrillation (PeAF). For ease-of-use, many centers prefer patches over paddles. We assessed the optimum modality and shock vector, as well as the safety and efficacy of the Manual Pressure Augmentation (MPA) technique. METHODS: Patients with obesity (BMI ≥ 30) and PeAF undergoing ECV using a biphasic defibrillator were randomized into one of four arms by modality (adhesive patches or handheld paddles) and shock vector (anteroposterior [AP] or anteroapical [AA]). If the first two shocks (100 and 200 J) failed, then patients received a 200-J shock using the alternative modality (patch or paddle). Shock vector remained unchanged. In an observational substudy, 20 patients with BMI of 35 or more, and who failed ECV at 200 J using both patches/paddles underwent a trial of MPA. RESULTS: In total, 125 patients were randomized between July 2016 and March 2018. First or second shock success was 43 of 63 (68.2%) for patches and 56 of 62 (90.3%) for paddles (P = 0.002). There were 20 crossovers from patches to paddles (12 of 20 third shock success with paddles) and six crossovers from paddles to patches (three of six third shock success with patches). Paddles successfully cardioverted 68 of 82 patients compared with 46 of 69 using patches (82.9% vs 66.7%; P = 0.02). Shock vector did not influence first or second shock success rates (82.0% AP vs 76.6% AA; P = 0.46). MPA was successful in 16 of 20 (80%) who failed in both (patches/paddles), with 360 J required in six of seven cases. CONCLUSION: Routine use of adhesive patches at 200 J is inadequate in obesity. Strategies that improve success include the use of paddles, MPA, and escalation to 360 J.
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Fibrilação Atrial/terapia , Índice de Massa Corporal , Cardioversão Elétrica/métodos , Obesidade/complicações , Idoso , Fibrilação Atrial/complicações , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/fisiopatologia , Estudos Cross-Over , Desfibriladores , Cardioversão Elétrica/efeitos adversos , Cardioversão Elétrica/instrumentação , Desenho de Equipamento , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Obesidade/diagnóstico , Obesidade/fisiopatologia , Estudos Prospectivos , Retratamento , Falha de Tratamento , VitóriaRESUMO
BACKGROUND: Coronary allograft vasculopathy (CAV) remains a significant cause of morbidity and mortality after heart transplantation. The use of aspirin for CAV prophylaxis has recently garnered interest as a possible therapeutic adjunct in this setting. METHODS: This 2-center retrospective cohort study included 372 patients who underwent heart transplantation between January 2009 and March 2018 and were stratified according to the commencement of aspirin during their index transplant admission. The primary outcome was the development of moderate or severe CAV (International Society for Heart and Lung Transplantation grade ≥2) at surveillance coronary angiography. Secondary endpoints included mortality at follow-up. RESULTS: There were no differences in age, sex, and cause of heart failure. In the early aspirin group, the preponderant risk factors included use of ventricular assist devices, pretransplant smoking, and mild or moderate rejection. Multivariable analyses to assess for independent predictors of CAV development and mortality demonstrated that aspirin was associated with reduced mortality (adjusted hazard ratioâ =â 0.19; 95% confidence interval, 0.08-0.47, Pâ <â 0.01) and a trend toward a protective effect against the development of moderate or severe CAV (adjusted hazard ratioâ =â 0.24; 95% confidence interval, 0.54-1.19; Pâ =â 0.08). CONCLUSIONS: In this retrospective risk-adjusted 2-center cohort study, early aspirin administration was associated with reduced risk of death and a trend toward a protective effect against CAV development. These findings warrant validation in prospective randomized trials.
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INTRODUCTION: To determine the prevalence, severity, and change in symptoms experienced by dialysis patients following the introduction of use of a symptom-reporting questionnaire in nephrology clinic. METHODS: This is an observational study of 160 prevalent dialysis patients. Palliative care Outcome Scale symptom (POS-renal) questionnaires modified for patients with end-stage kidney disease were completed at baseline and follow-up (median 3 months), with results available to nephrologists at clinic appointments. FINDINGS: The baseline prevalence of individual symptoms ranged from 15% to 66%. The most common symptoms were lack of energy (66%) and poor mobility (58%). The median number of symptoms was 7/17 (interquartile range [IQR]: 4-10). Forty-nine percent of patients rated at least 1 symptom as severe or overwhelming. At follow-up, the median number of symptoms experienced was unchanged at 7/17 (IQR: 3-10). However, there was considerable flux in symptom severity. On average, individual symptoms that were present at baseline improved in 56% of patients and worsened in 18%; only 26% had stable symptom severity. Individual symptoms newly occurred in 8% to 20% of patients between time points, with 77% of patients experiencing at least 1 new symptom. The percent of patients rating at least 1 symptom as severe or overwhelming was reduced from 49% to 39% (P = .040). CONCLUSIONS: Use of the POS-renal questionnaire identified a high symptom burden. The presence and severity of symptoms changed dramatically over a short follow-up period, highlighting the need for regular surveillance of symptoms in the dialysis population. Routine use of a symptom questionnaire in clinic may be useful for the identification and management of symptoms in dialysis patients.
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Falência Renal Crônica/terapia , Diálise Renal/efeitos adversos , Índice de Gravidade de Doença , Avaliação de Sintomas/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Inquéritos e QuestionáriosRESUMO
Despite improved understanding of heart failure (HF) and advances in medical treatments, its prevalence continues to rise, and the role of implantable devices continues to evolve. While cardiac resynchronization therapy (CRT) is an accepted form of treatment for many suffering from HF, there is an ever-evolving body of evidence examining novel indications, optimization of lead placement and device programming, with several competing technologies now also on the horizon. This review aims to take a clinical perspective on the major trials, current indications, controversies and emerging aspects of CRT in the treatment of HF.
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Terapia de Ressincronização Cardíaca/métodos , Insuficiência Cardíaca/terapia , Fibrilação Atrial/fisiopatologia , Fibrilação Atrial/terapia , Estimulação Cardíaca Artificial/métodos , Terapia de Ressincronização Cardíaca/tendências , Desfibriladores Implantáveis , Eletrocardiografia , Insuficiência Cardíaca/diagnóstico por imagem , Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/fisiopatologia , Humanos , Guias de Prática Clínica como Assunto , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de TempoRESUMO
Prisoners are a particularly vulnerable minority group whose healthcare needs and management differ substantially from the general population. The overall burden of disease of prisoners is well documented; however, little is known regarding the aetiology and frequency of prisoners' acute medical complaints requiring an ED visit. Objectives of the review were to identify, review and appraise existing literature regarding prisoners' presentations to EDs. We performed systematic electronic searches in MEDLINE, EMBASE, PsycINFO, PubMed, Cochrane, and Web of Science using MeSH terms and keywords. Two reviewers abstracted data and conducted quality appraisal using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Nine articles met the predefined inclusion criteria. Apart from two European studies in the past 5 years, there is a scarcity of literature primarily addressing the common presenting complaints to EDs by prisoners. Existing studies demonstrated that prisoners have a disproportionately high burden of traumatic, infectious and psychiatric disease requiring emergency treatment. With the increasing number of emergency presentations made by prisoners each year, it is vital that further research is undertaken to identify trends of these acute medical complaints in order to ensure optimal therapeutic outcomes for prisoners.
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Serviço Hospitalar de Emergência/estatística & dados numéricos , Necessidades e Demandas de Serviços de Saúde , Prisioneiros , Humanos , Infecções/terapia , Transtornos Mentais/terapia , Ferimentos e Lesões/terapiaRESUMO
BACKGROUND: Due to barriers to accessing timely elective electrical cardioversion (CV) for persistent AF (PeAF), we adopted a policy of instructing patients to present directly to the Emergency Department (ED) for CV. OBJECTIVE: We compare a strategy of Emergency CV (ED-CV) versus Elective CV (EL-CV) for treatment of symptomatic PeAF. METHODS: Between 2014 and 7, we evaluated 150 patients undergoing CV for PeAF. ED-CV patients were provided an AF action plan for recurrent symptoms and advised to present to ED within 36â¯h. EL-CV patients followed standard care, including cardiologist referral and placement on an elective hospital waiting list. Follow-up was 12â¯months. RESULTS: We included 75 consecutive ED-CV patients and 75 consecutive EL-CV patients. ED-CV patients had a significantly shorter median AF duration prior to CV (1â¯day vs 3â¯months; pâ¯<â¯0.01) and less overall AF-related symptoms at 12â¯months (modified EHRA symptom scoreâ¯≥â¯2a in 44% vs 72%; pâ¯=â¯0.005). Time to next AF recurrence was longer in the ED-CV group (295⯱â¯15 vs 245⯱â¯15â¯days; logrank pâ¯=â¯0.001), as was time to AF ablation referral (314⯱â¯13 vs 276⯱â¯15â¯days; logrank pâ¯=â¯0.01). Baseline LA area was similar (ED-CV 27⯱â¯4â¯cm2 vs EL-CV 28⯱â¯11â¯cm2; pâ¯=â¯0.67), however EL-CV had larger atria at follow-up (31⯱â¯8 vs 26⯱â¯6â¯cm2; pâ¯=â¯0.01). There were no complications in either group. CONCLUSION: ED-CV is an acceptable strategy for symptomatic PeAF. In addition to reduced time spent in AF and improved symptom scores, this strategy may also slow progression of atrial substrate & delay onset of next AF episode.
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Fibrilação Atrial/terapia , Função do Átrio Esquerdo/fisiologia , Remodelamento Atrial/fisiologia , Cardioversão Elétrica/métodos , Átrios do Coração/fisiopatologia , Sistema de Condução Cardíaco/fisiopatologia , Fibrilação Atrial/fisiopatologia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva , Estudos Retrospectivos , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Early studies demonstrated relatively low success rates for pulmonary vein isolation (PVI) alone in patients with persistent atrial fibrillation (PeAF). However, the advent of new technologies and the observation that additional substrate ablation does not improve outcomes have created a new focus on PVI alone for treatment of PeAF. OBJECTIVE: The purpose of this study was to systematically review the recent medical literature to determine current medium-term outcomes when a PVI-only approach is used for PeAF. METHODS: An electronic database search (MEDLINE, Embase, Web of Science, PubMed, Cochrane) was performed in August 2016. Only studies of PeAF patients undergoing a "PVI only" ablation strategy using contemporary radiofrequency (RF) technology or second-generation cryoballoon (CB2) were included. A random-effects model was used to assess the primary outcome of pooled single-procedure 12-month arrhythmia-free survival. Predictors of recurrence were also examined and a meta-analysis performed if ≥4 studies examined the parameter. RESULTS: Fourteen studies of 956 patients, of whom 45.2% underwent PVI only with RF and 54.8% with CB2, were included. Pooled single-procedure 12-month arrhythmia-free survival was 66.7% (95% confidence interval [CI] 60.8%-72.2%), with the majority of patients (80.5%) off antiarrhythmic drugs. Complication rates were very low, with cardiac tamponade occurring in 5 patients (0.6%) and persistent phrenic nerve palsy in 5 CB2 patients (0.9% of CB2). Blanking period recurrence (hazard ratio 4.68, 95% CI 1.70-12.9) was the only significant predictor of recurrence. CONCLUSION: A PVI-only strategy in PeAF patients with a low prevalence of structural heart disease using contemporary technology yields excellent outcomes comparable to those for paroxysmal AF ablation.