ABSTRACT
AIMS: Left atrial thrombosis (LAT) is usually detected by transesophageal echocardiography (TEE). The aim of the present study was to identify clinical and echocardiographic factors associated with left atrial thrombosis in atrial fibrillation (AF) patients undergoing early electrical cardioversion (ECV) in order to create scores that can predict LAT, in a non-invasive way. METHODS: A consecutive cohort of patients with persistent AF scheduled for ECV was evaluated by transthoracic echocardiography and TEE. By a logistic regression model, variables significantly associated with LAT were assessed and introduced in predictive models to develop both a clinical and an echocardiographic prediction score for the presence of LAT. RESULTS: In total, 125 patients [median 71 (range 49-88) years, 60.0% males] were enrolled. Transesophageal echocardiography showed LAT in 35 patients (28%). The clinical variables significantly associated with LAT were previous stroke (OR = 4.17), higher CHA2 DS2 -VASc score (OR = 1.93), lower estimated glomerular filtration rate (OR = 0.80), and higher brain natriuretic peptide levels (OR = 1.44). Among echocardiographic parameters, E/e' ratio was directly associated with LAT (OR = 2.25), while an inverse correlation was detected with left ventricular ejection fraction (OR = 0.43) and total global left atrial strain (OR = 0.59). Two prediction scores (clinical and echocardiographic) were developed. The positive predictive values of the clinical and the echocardiographic score were 80% and 100%, respectively, while the negative predictive values were 98% and 94%, respectively. Combined use of the scores reached a positive and negative predictive value of 100%. CONCLUSIONS: When providing concordant information the two scores are able to correctly identify patients with or without LAT. An external validation is necessary to demonstrate their usefulness in the clinical practice.
Subject(s)
Atrial Fibrillation , Thrombosis , Atrial Fibrillation/complications , Atrial Fibrillation/diagnostic imaging , Atrial Fibrillation/therapy , Echocardiography , Electric Countershock , Female , Humans , Male , Risk Factors , Stroke Volume , Thrombosis/diagnostic imaging , Thrombosis/etiology , Ventricular Function, LeftABSTRACT
An 88-year-old male with nonvalvular atrial fibrillation (NVAF) and severe congestive heart failure (HF), was admitted to the Neurological Intensive Care Unit because of the acute onset of aphasia and left hemiplegia. Transthoracic echocardiography revealed a left atrial (LA) cavity thrombus. Its "fatal" distal embolization to abdominal aorta occurred in a few days. These observations should lead to a cautious approach in proposing a percutaneous closure of LA appendage in older NVAF patients, with HF and/or left ventricular dysfunction and larger LA volumes, who are not adequately anticoagulated.
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BACKGROUND: Atrial fibrillation induces reversible electrical and mechanical modifications (atrial remodeling). Atrial stunning is a mechanical dysfunction with preserved bioelectrical function, occurring after successful atrial fibrillation electrical cardioversion (ECV). Two-dimensional speckle tracking echocardiography is a new technology for evaluating atrial mechanical function. We assessed atrial mechanical function after ECV with serial two-dimensional speckle tracking echocardiography evaluations. The investigated outcome was left atrium mechanical recovery within 3 months. METHODS: A total of 36 patients [mean age 73 (7.9) years, 23 males] with persistent atrial fibrillation underwent conventional transthoracic and transesophageal echocardiography before ECV. Positive global atrial strain (GSA+) was assessed at 3âh, 1, 2, 3, 4 weeks and 3 months after ECV. Mechanical recovery was defined as the achievement of a GSA+ value of 21%. RESULTS: Independent predictors of GSA+ immediately after ECV (basal GSA+) were E/e' ratio and left atrial appendage anterograde flow velocity. During the follow-up, 25% of patients suffered atrial fibrillation recurrence. In 12/36 patients (33%) left atrium mechanical recovery was detected (mechanical recovery group), while in 15/36 (42%) recovery did not occur (no atrial mechanical recovery group). At univariate analysis, the variables associated with recovery, were basal GSA+ (Pâ=â0.015) and maximal velocity left atrial appendage (Pâ=â0.022). Female sex (Pâ=â0.038), N-terminal pro-B type natriuretic peptide (Pâ=â0.013), E/e' (Pâ=â0.042) and the indexed left atrium volume (Pâ=â0.019) were associated with the lack of left atrium mechanical recovery. CONCLUSION: In almost half of the patients, the left atrium did not resume mechanical activity within the 3 months after ECV, despite sinus rhythm recovery. The left atrium of these patients was larger, stiffer and their E/E' was higher, suggesting a higher endocavitary pressure compared with mechanical recovery patients. These findings might suggest an increased thromboembolic risk.
Subject(s)
Atrial Fibrillation/therapy , Atrial Function, Left , Atrial Remodeling , Echocardiography , Electric Countershock , Aged , Aged, 80 and over , Atrial Fibrillation/diagnostic imaging , Atrial Fibrillation/physiopathology , Electric Countershock/adverse effects , Female , Humans , Male , Middle Aged , Predictive Value of Tests , Recovery of Function , Recurrence , Risk Factors , Time Factors , Treatment OutcomeABSTRACT
BACKGROUND: Hemodialysis (HD) sessions induce changes in plasma electrolytes that lead to modifications of QT interval, virtually associated with dangerous arrhythmias. It is not known whether such a phenomenon occurs even during peritoneal dialysis (PD). The aim of the study is to analyze the relationship between dialysate and plasma electrolyte modifications and QT interval during a PD exchange. METHODS: In 15 patients, two manual PD 4-h exchanges were performed, using two isotonic solutions with different calcium concentration (Ca++1.25 and Ca1.75++ mmol/L). Dialysate and plasma electrolyte concentration and QT interval (ECG Holter recording) were monitored hourly. A computational model simulating the ventricular action potential during the exchange was also performed. RESULTS: Dialysis exchange induced a significant plasma alkalizing effect (p < 0.001). Plasma K+ significantly decreased at the third hour (p < 0.05). Plasma Na+ significantly decreased (p < 0.001), while plasma Ca++ slightly increased only when using the Ca 1.75++ mmol/L solution (p < 0.01). The PD exchange did not induce modifications of clinical relevance in the QT interval, while a significant decrease in heart rate (p < 0.001) was observed. The changes in plasma K+ values were significantly inversely correlated to QT interval modifications (p < 0.001), indicating that even small decreases of K+ were consistently paralleled by small QT prolongations. These results were perfectly confirmed by the computational model. CONCLUSIONS: The PD exchange guarantees a greater cardiac electrical stability compared to the HD session and should be preferred in patients with a higher arrhythmic risk. Moreover, our study shows that ventricular repolarization is extremely sensitive to plasma K+ changes, also in normal range.
Subject(s)
Electrolytes/blood , Kidney Failure, Chronic/blood , Kidney Failure, Chronic/therapy , Peritoneal Dialysis , Uremia/therapy , Aged , Aged, 80 and over , Calcium/analysis , Calcium/blood , Computer Simulation , Dialysis Solutions/chemistry , Electrocardiography, Ambulatory , Female , Heart Rate , Humans , Isotonic Solutions/chemistry , Kidney Failure, Chronic/complications , Male , Middle Aged , Potassium/blood , Sodium/blood , Uremia/blood , Uremia/etiologySubject(s)
Arterial Pressure , Cardiomyopathy, Hypertrophic/etiology , Hypertension, Pulmonary/etiology , Pneumonia/complications , Pulmonary Artery/physiopathology , Acute Disease , Anti-Bacterial Agents/therapeutic use , Cardiomyopathy, Hypertrophic/diagnosis , Cardiomyopathy, Hypertrophic/physiopathology , Diagnosis, Differential , Humans , Hypertension, Pulmonary/diagnosis , Hypertension, Pulmonary/physiopathology , Male , Middle Aged , Pneumonia/diagnosis , Pneumonia/drug therapy , Pneumonia/physiopathology , Predictive Value of Tests , Treatment Outcome , Ventricular Function, Left , Ventricular Function, RightABSTRACT
BACKGROUND: Left atrial strain and strain rate parameters, measured by bidimensional-speckle tracking echocardiography, have been proposed as predictors of atrial fibrillation, stroke, congestive heart failure and cardiovascular death. However, they have not yet been tested in hypertensive disorders of pregnancy. The aim of this study was to assess the prognostic role of global left atrial peak strain (GLAPS) in a population of pregnant women with new-onset hypertension in a medium-term follow-up. METHODS: Twenty-seven consecutive women with new-onset hypertension after 20 weeks pregnancy and 23 age-matched, race-matched and gestational week-matched consecutive normotensive pregnant women were enrolled in this prospective study. All participants underwent a complete echocardiographic study with bidimensional-speckle tracking echocardiography and carotid examination. At 1-year follow-up, we evaluated the occurrence of persistent hypertension. RESULTS: In comparison with normotensive women, those hypertensive had a higher burden of cardiovascular risk factors, similar left atrial volume indexed (Pâ=â0.14), but severely impaired left atrial strain (Pâ<â0.0001) and strain rate values (Pâ<â0.0001). At 1-year follow-up, persistent hypertension was documented in 59.3% of patients. At the univariate Cox analysis, the variables associated with the occurrence of the investigated outcome in all hypertensive pregnancies were SBP (hazard ratio 1.04, Pâ=â0.04), DBP (hazard ratio 1.11, Pâ=â0.01), mean arterial pressure (hazard ratio 1.09, Pâ=â0.01) values and the GLAPS value (hazard ratio 0.85, Pâ=â0.0019). The latter was significantly associated with the investigated outcome both in preeclamptic (hazard ratio 0.84, Pâ=â0.02) and nonpreeclamptic pregnant women (hazard ratio 0.83, Pâ=â0.04). The receiver operating characteristics curve analysis highlighted that a GLAPS value of 23.5% or less predicted persistent hypertension with sensitivity of 100% and specificity of 90.90%. CONCLUSION: In hypertensive pregnant women a GLAPS value of 23.5% or less reveals a greater severity of atrial cardiomyopathy and might predict postpregnancy persistent hypertension.
Subject(s)
Heart Atria , Hypertension, Pregnancy-Induced/diagnosis , Cardiomyopathies , Echocardiography , Female , Heart Atria/diagnostic imaging , Heart Atria/physiopathology , Humans , Pregnancy , Prognosis , Prospective StudiesSubject(s)
Endocarditis, Bacterial/microbiology , Methicillin-Resistant Staphylococcus aureus/isolation & purification , Pulmonary Embolism/microbiology , Pulmonary Valve/microbiology , Sepsis/microbiology , Streptococcal Infections/microbiology , Aged , Anti-Bacterial Agents/therapeutic use , Bacteriological Techniques , Echocardiography, Transesophageal , Endocarditis, Bacterial/complications , Endocarditis, Bacterial/diagnostic imaging , Endocarditis, Bacterial/drug therapy , Female , Humans , Methicillin-Resistant Staphylococcus aureus/drug effects , Pulmonary Embolism/diagnostic imaging , Pulmonary Embolism/drug therapy , Pulmonary Valve/diagnostic imaging , Sepsis/diagnostic imaging , Sepsis/drug therapy , Streptococcal Infections/complications , Streptococcal Infections/diagnostic imaging , Streptococcal Infections/drug therapy , Tomography, X-Ray Computed , Treatment OutcomeABSTRACT
Prognostic stratification of acute ischemic stroke (AIS) patients without atrial fibrillation (AF) remains a challenge. Two-dimensional speckle tracking echocardiography (2D-STE) has recently been introduced for dynamic evaluation of left atrial function. However only few data are actually available regarding the application of 2D-STE in AIS patients. The aim of our study was to assess the prognostic role of global left atrial peak strain (GLAPS), measured by 2D-STE, in AIS patients without AF history. Eighty-five AIS patients (mean age 74.1 ± 12.1 years, 49 males) with normal sinus rhythm on ECG and without AF history were enrolled in the prospective study. All patients underwent a complete echocardiographic study with 2D-STE. At 1 year follow-up, we evaluated the occurrence of a composite endpoint of all-cause mortality plus cardiovascular re-hospitalizations. GLAPS was markedly reduced in AIS patients (15.71 ± 4.70%), without any statistically significant difference between the stroke subtypes. At 1-year follow-up, 14 deaths and 17 hospital readmissions were detected in AIS subjects. On a multivariate Cox model, variables independently associated with the occurrence of the composite endpoint were the "Rankin in" Scale (HR 1.69, p = 0.001), GFR (HR 0.98, p = 0.03) and the GLAPS value (HR 0.78, p < 0.0001). A GLAPS value ≤ 15.5% predicted the composite endpoint with sensitivity of 100% and specificity of 80%. A GLAPS value ≤ 15.5% reflects a more advanced atrial cardiomyopathy and might provide a reliable and useful prognostic risk stratification of AIS patients without AF history.
Subject(s)
Atrial Function, Left , Brain Ischemia/diagnostic imaging , Echocardiography, Doppler , Heart Atria/diagnostic imaging , Stroke/diagnostic imaging , Aged , Aged, 80 and over , Brain Ischemia/pathology , Brain Ischemia/physiopathology , Brain Ischemia/therapy , Female , Heart Atria/physiopathology , Humans , Male , Middle Aged , Patient Readmission , Predictive Value of Tests , Prognosis , Prospective Studies , Risk Factors , Stroke/mortality , Stroke/physiopathology , Stroke/therapyABSTRACT
Background: Centenarians are increasingly being encountered in clinical practice. The aim of the study was to characterize centenarians' clinical features and cardiovascular system. Methods: A prospective, observational, cross-sectional, case-control study included 118 hospitalized >100-year-old patients compared to 50 octogenarians, selected in Milan (Italy) from December 2010 to December 2017, to assess their clinical and echocardiographic characteristics. Results: Centenarians were mostly women with small body surface area; long history of hypertension; chronic renal failure; and low incidence of smoking, diabetes, dyslipidemia, hyperuricemia, coronary artery disease, atrial fibrillation, and cerebrovascular disease. They showed high prevalence of severe cognitive impairment and disability. Almost half of patients (46%) were hospitalized for congestive heart failure (HF), mostly diastolic (80% of cases). Centenarians' hearts had reduced left ventricular end-diastolic dimensions (25.3 ± 3.8 mm/m^2), increased septal thickness (13.3 ± 1.9 mm), and higher relative wall thickness (0.58 ± 0.1). The ejection fraction was usually normal and rarely depressed (57.1% ± 11.7%), whereas the E/e' ratio was considerably increased (17.0 ± 6.0). Noninvasive evaluation of ventricular-arterial coupling parameters revealed significantly higher values of LV end-diastolic elastance in all centenarians versus octogenarians (0.4 ± 01 mm Hg/mL/m^2 vs 0.18 ± 0.2 mm Hg/mL/m^2, P < .0001) and in centenarians with HF versus those without HF (0.5 ± 0.1 mm Hg/mL/m^2 vs 0.34 ± 0.1 mm Hg/mL/m^2, P < .0001). Conclusions: The centenarians' cardiovascular system manifested a significant increase in LV diastolic stiffness with consequent susceptibility to diastolic HF. A progressive afterload increase and a passive load independent mechanism could have contributed to such changes.
Subject(s)
Cardiovascular Diseases/physiopathology , Heart Ventricles/physiopathology , Stroke Volume/physiology , Ventricular Function, Left/physiology , Age Factors , Aged, 80 and over , Cardiovascular Diseases/epidemiology , Cross-Sectional Studies , Diastole , Disease Progression , Echocardiography, Doppler/methods , Female , Follow-Up Studies , Humans , Italy/epidemiology , Male , Morbidity/trends , Prospective Studies , Survival Rate/trendsABSTRACT
BACKGROUND: Chronic kidney disease (CKD) is associated with adverse outcomes in presence of atrial fibrillation (AF). However, the literature shows limited data on non-pharmacological management of AF in CKD patients. AIM: summarizing the available data on outcomes associated with electrical cardioversion (ECV) and AF catheter ablation (CA) in CKD patients. METHODS: We searched MEDLINE and the Cochrane Central Register of Controlled Trials and performed a metaanalysis. The primary outcome was recurrence of AF. The secondary outcomes were occurrence of thromboembolic events (TEs) and estimated glomerular filtration rate (eGFR) modification. RESULTS: Literature search yielded 26 eligible papers: 22 on CA and 4 concerning ECV. CKD patients presented more AF recurrences 30 days after ECV (OR 2.62, 95%CI 1.28-5.34; p <0.001). Patients with eGFR<60-68 ml/min and on dialysis presented a higher incidence of AF recurrences after CA, median follow up 26.0 and 29.9 months (HR 1.75, 95%CI 1.46-2.09, p <0.001; and HR 1.69, 95%CI 1.22-2.33, p <0.001; respectively). Periprocedural TEs were rare and not associated with CKD or dialysis. However, patients with CKD were at increased risk for delayed TEs after CA (HR 2.61, 95%CI 1.04-6.54; p <0.001). No significant modification of eGFR was associated with ECV or CA in the overall population. CONCLUSION: ECV and CA for sinus rhythm restoration/maintenance in AF patients, albeit theoretically promising, seem to be associated with lower efficacy at medium to long-term in patients with CKD. Further studies are needed to better define the role of ECV and CA in CKD.
Subject(s)
Atrial Fibrillation/complications , Catheter Ablation/adverse effects , Electric Countershock/adverse effects , Renal Insufficiency, Chronic/complications , HumansSubject(s)
Cardiomyopathy, Dilated/diagnostic imaging , Echocardiography, Doppler, Pulsed , Stroke/etiology , Thromboembolism/etiology , Thrombosis/diagnostic imaging , Aged , Cardiomyopathy, Dilated/complications , Cardiomyopathy, Dilated/physiopathology , Humans , Male , Predictive Value of Tests , Recurrence , Risk Assessment , Risk Factors , Stroke/diagnostic imaging , Stroke/physiopathology , Thromboembolism/diagnostic imaging , Thromboembolism/physiopathology , Thrombosis/complications , Thrombosis/physiopathology , Tomography, X-Ray ComputedABSTRACT
To validate a new modified method for measuring the anthropometric Haller index (HI), obtained without radiological exposure. This new method was based on the use of a rigid ruler and of a 2.5 MHz ultrasound transducer for the assessment of latero-lateral and antero-posterior chest diameters, respectively. We enrolled 100 consecutive patients (mean age 67.9 ± 14.5 years, 55% males), who underwent a two-plane CXR, for any clinical indication, over a four-month period. In all patients, the same radiologist calculated the conventional radiological HI (mean value 1.93 ± 0.35) and the same cardiologist used the above described new technique to measure the modified HI (mean value 1.99 ± 0.26). The Bland-Altman analysis showed tight limits of agreement (+ 0.37; - 0.51) between the two measurement methods, with a mild systematic overestimation of the new method as compared to the standard radiological HI. The Pearson's correlation analysis highlighted a strong correlation between the two methods (r = 0.81, p < 0.0001), while the Student's t test demonstrated a not statistically difference between the means (p = 0.12). The modified HI might allow a quick description of the chest conformation without radiological exposure and a more immediate comprehension of its possible influence on the cardiac kinetics and function, as assessed by echocardiography or other imaging modalities.
Subject(s)
Anthropometry/methods , Echocardiography/methods , Funnel Chest/diagnosis , Thorax/pathology , Aged , Aged, 80 and over , Anatomic Landmarks , Female , Funnel Chest/diagnostic imaging , Humans , Male , Middle Aged , Patient Positioning , Predictive Value of Tests , Prospective Studies , Radiography, Thoracic , Reproducibility of Results , Thorax/diagnostic imagingABSTRACT
BACKGROUND/AIMS: This study aimed to evaluate total and sudden death (SD) in a cohort of dialysis patients, comparing hemodialysis (HD) vs. peritoneal dialysis (PD). METHODS: This is a multicenter retrospective cohort study. RESULTS: Deaths were 626 out of 1,823 in HD and 62 of 249 in PD patients. HD patients had a greater number of comorbidities (p < 0.05). PD patients had a lower risk of death than HD patients (p < 0.001); however, the advantage decreased with time (p < 0.001). Mortality predictors were left ventricular ejection fraction (LVEF) ≤35%, older age, ischemic heart disease, diabetes mellitus, previous stroke, and atrial fibrillation (p < 0.03). SDs were 84:71 in HD and 13 in PD population (12.1 and 22.8% of all causes of death, respectively). A non-significant risk of SD among PD compared to HD patients was detected. SD predictors were older age, ischemic heart disease, and LVEF ≤35% (p < 0.05). CONCLUSIONS: HD patients showed a greater presence of comorbidities and reduced survival compared to PD patients; however, the incidence of SD does not differ in the 2 populations. Video Journal Club "Cappuccino with Claudio Ronco" at http://www.karger.com/?doi=464347.
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BACKGROUND: The incidence of sudden death among dialysis patients is high, but end stage renal disease was an exclusion criterion in the trials that demonstrated the benefit of implantable cardioverter defibrillator (ICD) for sudden death prevention. METHODS: Dialysis patients alive on January 2010 or starting dialysis between January 2010 and January 2013 were enrolled and retrospectively evaluated. Patients were divided into three groups: No-Indication, Indication-With ICD and Indication-Without ICD. Cox and Fine and Gray regression models were used to estimate the total and cause-specific (sudden or non-sudden) mortality hazard ratio (HR, HR(cpRisk)), respectively. Survival was defined as the time from start of dialysis to the time of death. RESULTS: 154/2072 patients (7.4%) had indication for ICD implantation and 52 (33.8%) of them received the device; 688 (33.2%) deaths were recorded. Mortality was different among groups [Indication-With ICD vs No-Indication: HR 1.59 (95% CI 1.06-2.38) and Indication-Without ICD vs No-Indication: HR 2.67 (95% CI 2.09-3.39, p < 0.001)]. 84/688 (12.2%) were sudden deaths. The cumulative incidence of sudden death was higher in patients with ICD indication [Indication-With ICD vs No-Indication HR(cpRisk) 3.21 (95% CI 1.38-7.40) and Indication-Without ICD vs No-Indication: HR(cpRisk) 4.19 (95% CI 2.38-7.39), p < 0.001], but also No-Indication patients showed a high rate of sudden death [8.5% (95% CI.6.5-10.9) at 8 years of follow-up]. CONCLUSIONS: Dialysis patients with ICD indication had a worse survival than No-Indication subjects and the prognosis was particularly poor for the Indication-Without ICD group. Sudden death incidence was much higher than in the general population, even among No-Indication subjects.
Subject(s)
Death, Sudden/prevention & control , Defibrillators, Implantable , Kidney Failure, Chronic/mortality , Renal Dialysis , Adolescent , Adult , Aged , Aged, 80 and over , Child , Female , Humans , Kidney Failure, Chronic/therapy , Male , Middle Aged , Retrospective Studies , Young AdultABSTRACT
AIMS: To provide insights on the antiarrhythmic management of atrial fibrillation among patients enrolled in the Antithrombotic Agents in Atrial Fibrillation (ATA-AF) study, and to assess the adherence of the Italian cardiologists and internists to guidelines recommendations. METHODS AND RESULTS: The ATA-AF study is a multicenter, observational study with prospective data collection on the management and treatment of patients with atrial fibrillation. From March to July 2010, 6910 patients with atrial fibrillation were recruited in 164 Italian Cardiology (Card) and 196 Internal Medicine (IMed) centers. Permanent atrial fibrillation was diagnosed in 50.8%, persistent atrial fibrillation in 24.4%, paroxysmal in 15.5%, and first-detected atrial fibrillation in 9.3% of the patients. Rhythm control (rhyC) strategy was pursued in 27.5% (39.6% Card vs. 12.9% IMed; P < 0.0001) and rate control (raC) in 51.4% (43.7% Card vs. 60.7% IMed; P < 0.0001); in 21.1% the antiarrhythmic strategy was not defined. Patients assigned to rhyC were younger and with less comorbidities than those assigned to raC. Adjusted multivariable analysis showed that atrial fibrillation type, setting of management, age and site of patient discharge were the most important independent predictors of rhyC assignment. The severity of atrial fibrillation-related symptoms was not associated with rhyC assignment. At discharge, beta-blockers, amiodarone and class 1c antiarrhythmic drugs were the drugs mainly used in the Card centers; and beta-blockers, digitalis, amiodarone and diltiazem/verapamil were used in the IMed centers. Amiodarone was overused in both Card and IMed centers. CONCLUSION: In the present study, rhyC was the strategy mainly pursued by cardiologists and raC by internists; treatment strategy assignment and antiarrhythmic therapy often do not agree with the guideline recommendations.
Subject(s)
Atrial Fibrillation/drug therapy , Fibrinolytic Agents/therapeutic use , Aged , Aged, 80 and over , Anti-Arrhythmia Agents/therapeutic use , Atrial Fibrillation/complications , Atrial Fibrillation/physiopathology , Cardiology Service, Hospital/standards , Drug Therapy, Combination , Female , Guideline Adherence/statistics & numerical data , Hospitalization , Humans , Internal Medicine/methods , Internal Medicine/standards , Male , Middle Aged , Practice Guidelines as Topic , Practice Patterns, Physicians'/statistics & numerical data , Prospective Studies , Thromboembolism/etiology , Thromboembolism/prevention & controlABSTRACT
Atrial fibrillation (AF) incidence is high in end-stage renal disease (ESRD) patients, and haemodialysis (HD) session may induce paroxysmal AF episodes. Structural atrium remodelling is common in ESRD patients, moreover, HD session induces rapid plasma electrolytes and blood volume changes, possibly favouring arrhythmia onset. Therefore, HD session represents a unique model to study in vivo the mechanisms potentially inducing paroxysmal AF episodes. Here, we present the case report of a patient in which HD regularly induced paroxysmal AF. In four consecutive sessions, heart rate variability analysis showed a progressive reduction of low/high frequency ratio before the AF onset, suggesting a relative increase in vagal activity. Moreover, all AF episodes were preceded by a great increase of supraventricular ectopic beats. We applied computational modelling of cardiac cellular electrophysiology to these clinical findings, using plasma electrolyte concentrations and heart rate to simulate patient conditions at the beginning of HD session (pre-HD) and right before the AF onset (pre-AF), in a human atrial action potential model. Simulation results provided evidence of a slower depolarization and a shortened refractory period in pre-AF vs. pre-HD, and these effects were enhanced when adding acetylcholine effect. Paroxysmal AF episodes are induced by the presence of a trigger that acts upon a favourable substrate on the background of autonomic nervous system changes and in the described case report all these three elements were present. Starting from these findings, here we review the possible mechanisms leading to intradialytic AF onset.
Subject(s)
Action Potentials , Atrial Fibrillation/physiopathology , Heart Conduction System/physiopathology , Heart Rate , Models, Cardiovascular , Myocytes, Cardiac , Animals , Computer Simulation , HumansABSTRACT
PURPOSE: Remote monitoring of cardiac implantable electronic devices has been demonstrated to safely reduce frequency of hospital visits. Limited studies are available evaluating the economic impact. The aim of this article is to highlight the social impact and costs for the patients associated with hospital visits for routine device follow-up at the enrollment visit for the TARIFF study (NCT01075516). METHODS: TARIFF is a prospective, cohort, observational study designed to compare the costs and impact on quality of life between clinic-based and remote care device follow-up strategies. RESULTS: Two hundred nine patients (85.2 % males) were enrolled in the study; 153 patients (73.2 %) were retired, 36 (17.2 %) were active workers, 18 (8.6 %) were housewives, and 2 (1.0 %) were looking for a job. Among active workers, 63.9 % required time off from work to attend the hospital visit, while 67.0 % of all patients had to interrupt daily activities. The majority of patients spent half a day or more attending the visit. A carer accompanied 77 % of patients. Among carers, 36.6 % required time off from work, and 77.6 % had to interrupt daily activities. Median distance traveled was 36 km. The average cost of travel was 10 euros with 25 % of patients spending more than 30 euros. CONCLUSIONS: Data from patients enrolled in the TARIFF registry confirm that there are social and economic impacts to patients attending routine device checks in hospital which can be significantly reduced by using a remote monitoring strategy.
Subject(s)
Cost of Illness , Defibrillators, Implantable/economics , Defibrillators, Implantable/psychology , Health Care Costs/statistics & numerical data , Outpatient Clinics, Hospital/economics , Quality of Life , Telemedicine/economics , Age Distribution , Aged , Cohort Studies , Defibrillators, Implantable/statistics & numerical data , Employment/economics , Employment/psychology , Employment/statistics & numerical data , Female , Follow-Up Studies , Humans , Italy/epidemiology , Male , Outpatient Clinics, Hospital/statistics & numerical data , Sex Distribution , Telemedicine/statistics & numerical data , Travel/economics , Travel/psychology , Travel/statistics & numerical dataABSTRACT
Cardiac resynchronization therapy (CRT) is indicated for patients with electrical dyssynchrony (QRS ≥120 ms). However, mechanical dyssynchrony may also occur in patients with narrow QRS. Echocardiographic criteria of intraventricular dyssynchrony are not univocal; moreover, responsiveness to CRT depends on the criteria utilized for judgment. A unique randomized trial compared CRT with no therapy in patients with heart failure and narrow QRS, but it failed to demonstrate increased peak oxygen consumption with CRT. The results of this study probably depend on the lack of correspondence between activation and contraction delays, at least in ischemic cardiomyopathy.
Subject(s)
Cardiac Resynchronization Therapy , Electrocardiography , Heart Failure/physiopathology , Heart Failure/therapy , HumansABSTRACT
AIMS: The aims of the study are to develop a cost-minimization analysis from the hospital perspective and a cost-effectiveness analysis from the third payer standpoint, based on direct estimates of costs and QOL associated with remote follow-ups, using Merlin@home and Merlin.net, compared with standard ambulatory follow-ups, in the management of ICD and CRT-D recipients. METHODS AND RESULTS: Remote monitoring systems can replace ambulatory follow-ups, sparing human and economic resources, and increasing patient safety. TARIFF is a prospective, controlled, observational study aimed at measuring the direct and indirect costs and quality of life (QOL) of all participants by a 1-year economic evaluation. A detailed set of hospitalized and ambulatory healthcare costs and losses of productivity that could be directly influenced by the different means of follow-ups will be collected. The study consists of two phases, each including 100 patients, to measure the economic resources consumed during the first phase, associated with standard ambulatory follow-ups, vs. the second phase, associated with remote follow-ups. CONCLUSION: Remote monitoring systems enable caregivers to better ensure patient safety and the healthcare to limit costs. TARIFF will allow defining the economic value of remote ICD follow-ups for Italian hospitals, third payers, and patients. The TARIFF study, based on a cost-minimization analysis, directly comparing remote follow-up with standard ambulatory visits, will validate the cost effectiveness of the Merlin.net technology, and define a proper reimbursement schedule applicable for the Italian healthcare system. TRIAL REGISTRATION: NCT01075516.