Systemic sarcoidosis presenting as complete heart block in a patient with normal chest radiography.

A previously healthy 44-year-old Caucasian man presented with recurrent syncope and was found to have a complete heart block with a ventricular rate of 24 bpm. No biochemical abnormalities were identified. Tick borne illnesses were ruled out. Paced echocardiogram revealed left ventricular systolic dysfunction with septal hypokinesis. Chest radiography and subsequent CT scan did not reveal adenopathy. However, a positron emission tomography scan demonstrated increased fluorodeoxyglucose uptake in the spleen, a right retro-clavicular lymph node, right ventricle and the interventricular septum of the heart. Excision biopsy of the retro-clavicular lymph node revealed non-caseating granulomas consistent with sarcoidosis. Complete heart block persisted despite steroid treatment. A pacemaker/biventricular implantable cardioverter defibrillator was placed for complete heart block and primary prevention of ventricular tachycardia and sudden cardiac death.

Status of cardiac arrhythmia services in Africa in 2018: a PASCAR Sudden Cardiac Death Task Force report.

BACKGROUND: There is limited information on the availability of health services to treat cardiac arrhythmias in Africa. METHODS: The Pan-African Society of Cardiology (PASCAR) Sudden Cardiac Death Task Force conducted a survey of the burden of cardiac arrhythmias and related services over two months (15 October to 15 December) in 2017. An electronic questionnaire was completed by general cardiologists and electrophysiologists working in African countries. The questionnaire focused on availability of human resources, diagnostic tools and treatment modalities in each country. RESULTS: We received responses from physicians in 33 out of 55 (60%) African countries. Limited use of basic cardiovascular drugs such as anti-arrhythmics and anticoagulants prevails. Non-vitamin K-dependent oral anticoagulants (NOACs) are not widely used on the continent, even in North Africa. Six (18%) of the sub-Saharan African (SSA) countries do not have a registered cardiologist and about one-third do not have pacemaker services. The median pacemaker implantation rate was 2.66 per million population per country, which is 200-fold lower than in Europe. The density of pacemaker facilities and operators in Africa is quite low, with a median of 0.14 (0.03-6.36) centres and 0.10 (0.05-9.49) operators per million population. Less than half of the African countries have a functional catheter laboratory with only South Africa providing the full complement of services for cardiac arrhythmia in SSA. Overall, countries in North Africa have better coverage, leaving more than 110 million people in SSA without access to effective basic treatment for cardiac conduction disturbances. CONCLUSION: The lack of diagnostic and treatment services for cardiac arrhythmias is a common scenario in the majority of SSA countries, resulting in sub-optimal care and a subsequent high burden of premature cardiac death. There is a need to improve the standard of care by providing essential services such as cardiac pacemaker implantation.

Prognostic impact of defibrillator shocks in a Colombian cohort / Impacto pronóstico de las descargas del desfibrilador en una cohorte colombiana

Abstract: Introduction: The implantable cardioverter defibrillator (ICD) has become the first-line treatment option for SCD prevention. In Colombia, while ICD therapy has been available for several years, extensive registries or studies documenting the impact of ICD therapy are lacking. Objective: To evaluate the association between appropriate and inappropriate ICD therapies and mortality in Colombian patients. Methods: Prospective observational cohort study including 530 patients with cardiomyopathy of varied etiology, from eight clinics in Medellin, Colombia, from 2013 to 2016. Adjusted and survival analyses were performed. Results: Of all participating patients, 72.1% were men, and median age was 64 years. Mean follow-up time was 1.5 ± 0.92 years, with a follow-up rate of 353.3 patients/year. The most common indication for ICD implantation was ischemic heart disease (48.7%), and indication of primary prevention (63.4%). Mortality was 12.8%, and patients with ischemic etiology had 1.8-times greater risk of death compared to non-ischemic patients. 14% of the patients received appropriate therapies, while 13.6% were inappropriate. There was a 65% greater risk of appropriate therapies in patients with ischemic heart disease. High blood pressure, being over 61 years of age, and having left ventricular ejection fraction < 35%, were risk factors for death, while use of beta-blockers was associated with a reduced risk of death. Conclusions: The main indication for ICD was ischemic etiology and primary prevention. Mortality is higher in patients with ischemic etiology, who in addition have increased risk of presenting appropriate therapies. The frequency of device therapies was decreased compared to previous reports.(AU)

Resumen: Introducción: El desfibrilador cardioversor implantable (DCI) se ha convertido en la opción de primera línea de tratamiento para la prevención de la MCS. En Colombia, aunque la terapia DCI ha estado disponible durante varios años, faltan extensos registros o estudios que documenten el impacto de la terapia DCI. Objetivo: Evaluar la asociación entre las terapias apropiadas e inapropiadas de DCI y la mortalidad en pacientes colombianos. Métodos: Estudio prospectivo observacional de cohorte que incluye 530 pacientes con cardiomiopatía de etiología variada, de ocho clínicas en Medellín, Colombia, de 2013 a 2016. Se realizaron análisis ajustados y de supervivencia. Resultados: De todos los pacientes participantes, el 72.1% fueron hombres y la edad mediana fue de 64 años. El tiempo medio de seguimiento fue de 1.5 ± 0.92 años, con una tasa de seguimiento de 353.3 pacientes/año. La indicación más común para la implantación del DCI fue la cardiopatía isquémica (48.7%) y la indicación de prevención primaria (63.4%). La mortalidad fue del 12.8% y los pacientes con etiología isquémica tuvieron un riesgo de muerte 1.8 veces mayor en comparación con los pacientes no isquémicos. Catorce por ciento de los pacientes recibieron terapias apropiadas, mientras que el 13.6% fueron inapropiadas. Hubo un riesgo 65% mayor de terapias apropiadas en pacientes con cardiopatía isquémica. La hipertensión arterial, el tener más de 61 años de edad y haber dejado la fracción de eyección ventricular < 35%, fueron factores de riesgo de muerte, mientras que el uso de betabloqueantes se asoció con un menor riesgo de muerte. Conclusiones: La principal indicación para la DCI fue etiología isquémica y prevención primaria. La mortalidad es mayor en pacientes con etiología isquémica, que además tienen mayor riesgo de presentar terapias apropiadas. La frecuencia de las terapias con dispositivos se redujo en comparación con los informes anteriores.(AU)

Inequity of access to implantable cardioverter defibrillator therapy in England: possible causes of geographical variation in implantation rates.

AIMS: There is marked geographical variation in implantable cardioverter defibrillator (ICD) implantation rates in England. This study examined factors which might explain this variation. METHODS AND RESULTS: Detailed data relating to 1510 patients who received an implanted defibrillator and who were reported to a national pacemaker and implantable defibrillator registry in 2002 were examined and correlated with factors which have been suggested as affecting ICD implantation. None of the factors examined, which included factors related both to the need for ICD implantation and service provision, in addition to socio-economic deprivation, was found to correlate with regional ICD implantation rates. CONCLUSION: There appears to have been no systematic planning of ICD services. Whether this has led to the marked regional variation and in inequity of service provision is not clear.

Inequitable distribution of implantable cardioverter defibrillators in Ontario.

OBJECTIVES: Implantable cardioverter defibrillator (ICD) therapy reduces the risk of sudden death in patients with ischemic cardiomyopathy, but their novelty and cost may represent barriers to utilization. The objective of this study was to examine the influence of age, gender, place of residence, and socioeconomic status on rates of ICD implantation for the primary prevention of death. METHODS: We conducted a population-based retrospective cohort study involving the entire province of Ontario, Canada. Patients were eligible if they had survived following hospitalization for heart failure from 1 January 1993, to 31 March 2004, and previously sustained an acute coronary syndrome within 5 years. Patients with an existing ICD or a documented history of cardiac arrest were excluded, as were patients who died in the hospital. Primary outcome was ICD implantation. RESULTS: We identified 48,426 patients hospitalized for heart failure who survived to hospital discharge. Of these, 440 received an ICD, with a gradual 30-fold increase in implantation rates over the study period (.12-3.9 percent). ICD recipients were more likely to be men (odds ratio [OR]=4.14; 95 percent confidence interval [CI], 3.24-5.30), younger than 75 years of age (OR=3.19; 95 percent CI, 2.57-3.96), reside in a metropolitan area (OR=1.42; 95 percent CI, 1.04-1.9), and live in a higher socioeconomic neighborhood (OR=1.32; 95 percent CI, 1.08-1.61). CONCLUSIONS: Among patients with heart failure and a previous myocardial infarction, ICD use is increasing in Ontario. However, the application of this technology is characterized by major sociodemographic inequities. The causes and consequences of the pronounced age and gender discrepancies, in particular, warrant further investigation.

Variabilidad entre comunidades autónomas en el uso de tres tecnologías cardiovasculares / Variations among spanish regions in the use of three cardiovascular technologies

Introducción y objetivos. Hay evidencia de variabilidad geográfica en el uso de tecnologías médicas no explicada por diferencias en la carga de enfermedad. El objetivo de este trabajo es describir la variabilidad entre comunidades autónomas en el uso de intervenciones coronarias percutáneas (ICP), desfibriladores automáticos implantables (DAI) y terapia de resincronización cardiaca (TRC), y tratar de explicar la variabilidad encontrada en las dos primeras. Métodos. Se construyen modelos de regresión lineal en los que se utilizan como variables dependientes el número de procedimientos realizados por millón de habitantes en cada comunidad autónoma en el año 2003. Como variables independientes se emplearon indicadores de oferta, de riqueza regional y de carga de enfermedad. Resultados. Para la ICP, la media para todo el país es de 1.038 procedimientos/106 habitantes, con una razón de variación de 1,95. El producto interior bruto explica el 21% de la variabilidad, sin que haya relación entre el número de procedimientos y la carga de enfermedad. En cuanto al DAI, el promedio de procedimientos realizados en todo el país es de 46/106 habitantes, con una razón de variación de 3,04. Al igual que en el caso de las ICP, la riqueza regional explica el 40% de la variabilidad, a la que no contribuye la carga de enfermedad. Respecto a la TRC, durante el año 2003 se realizó en España una media de 15 procedimientos/106 habitantes, con una razón de variación de 15,7. Conclusiones. Hay una importante variabilidad intercomunitaria en el uso de estas tecnologías que está fundamentalmente explicada por la riqueza regional, pero no por la carga de enfermedad

Introduction and objectives. There is evidence that some geographic variations in the use of medical technologies are not explained by differences in disease burden. The objectives of this study were to quantify variability in the use of percutaneous coronary intervention (PCI), implantable cardioverter-defibrillators (ICDs), and cardiac resynchronization therapy (CRT) in Spanish autonomous regions and to try to explain the variability found for the first two technologies. Methods. Linear regression models were developed in which the number of procedures performed per million population (pmp) in 2003 in each autonomous region was the dependent variable. Independent variables used included indices of technology provision, regional wealth, and disease burden. Results. For PCI, the mean utilization rate for the whole of Spain was 1038 procedures pmp, with a high-low ratio of 1.95. Differences in gross domestic product explained 21% of the variability, but there was no relationship between the number of procedures performed and disease burden. For ICDs, the mean number of procedures performed in the whole of Spain was 46 pmp, with a high-low ratio of 3.04. As for PCI, differences in regional wealth explained 40% of the variability, with disease burden making no contribution. For CRT, the mean number of procedures performed in Spain in 2003 was 15 pmp, with a high-low ratio of 15.7. Conclusions. The considerable regional variation that exists in the use of these three medical technologies is principally explained by differences in regional wealth and not in disease burden

Preventing sudden death with n-3 (omega-3) fatty acids and defibrillators.

BACKGROUND: Because interventions that prevent and treat events due to cardiovascular disease are applied to different, but overlapping, segments of the population, it can be difficult to estimate their effectiveness if formal calculations are not available. METHODS: Markov chain analysis, including sensitivity analysis, was used with a hypothetical population resembling that of Olmsted County, MN, aged 30 to 84 in the year 2000 to compare the estimated impact of three interventions to prevent sudden death: (1) raising blood levels of n-3 (omega-3) fatty acids, (2) distributing automated external defibrillators (AEDs), and (3) implanting cardioverter defibrillators (ICDs) in appropriate candidates. The analysis was performed in 2004, 2005, and 2006. RESULTS: Raising median n-3 fatty acid levels would be expected to lower total mortality by 6.4% (range from sensitivity analysis = 1.6% to 10.3%). Distributing AEDs would be expected to lower total mortality by 0.8% (0.2% to 1.3%), and implanting ICDs would be expected to lower total mortality by 3.3% (0.6% to 8.7%). Three fourths of the reduction in total mortality due to n-3 fatty acid augmentation would accrue from raising n-3 fatty acid levels in the healthy population. CONCLUSIONS: Based on central values of candidacy and efficacy, raising n-3 fatty acid levels would have about eight times the impact of distributing AEDs and two times the impact of implanting ICDs. Raising n-3 fatty acid levels would also reduce rates of sudden death among the subpopulation that does not qualify for ICDs.

La desfibrilación temprana en la comunidad: romper barreras para salvar vidas / Early defibrillation in the community: breaking barriers to save lives

Se estima que en España se producen, cada año, mas de 24.500 paradas cardíacas extrahospitalarias (PC). Hasta el 85% de estas paradas están ocasionadas por una fibrilación ventricular y más del 90% podrían revertirse si se realizara una desfibrilación en el primer minuto, pero si ésta se retrasa las posibilidades de sobrevivir desaparecen en muy pocos minutos. A pesar de los avances de las últimas décadas no se han logrado unos resultados satisfactorios en el tratamiento de la PC, de forma que la tasa de supervivencia, al alta hospitalaria, no suele superar el 7%. Ante esta situación las Sociedades Científicas internacionales recomiendan que se acorte el retraso en la realización de la desfibrilación, aconsejando, como óptimo, un tiempo menor de 5 minutos entre la llamada al 112 y la descarga eléctrica. La incorporación de los desfibriladores semiautomáticos (DESA) en los Servicios de Emergencias Médicas (SEM) y su utilización por «primeros intervinientes» de los servicios de emergencias «no sanitarios» (policías, bomberos, etc.) contribuye a alcanzar este objetivo. Por ello, los SEM están modificando sus estrategias asistenciales para incorporar la desfibrilación temprana, como la «llave para la supervivencia». La literatura ha validado como efectiva la utilización de los DESA en los espacios públicos, pero su nivel de eficiencia es menor que el alcanzado con su uso por los Servicios de Emergencias. Su eficiencia depende de múltiples factores como el tipo de instalación, el nivel de accesibilidad para el SEM o la tasa de incidencia de muertes súbitas. Por ello su implantación debe estar precedida de un estudio coste-efectividad. Aún no está evaluada la efectividad de la utilización de los DESA en el hogar, que es donde se produce hasta el 80% de las PC. No obstante, en EE.UU. se ha autorizado su comercialización con esta indicación

It is considered that in Spain, every year, we have more than 24,500 out-of-hospital cardiac arrests. Around 85% of these are secondary to ventricular fibrillation, with possibility of reversion in more than 90% if defibrillation is performed in the first minute of arrhythmia. However, if we delay this defibrillation, survival possibilities disappear in a few minutes. Clinical advances in last decades have not achieved satisfactory results in the treatment of cardiac arrest as survival rates at hospital discharge do not exceed 7%. Aware of this situation, the International Scientific Societies are recommending decreasing time to defibrillation, advising, at best, a time less than five minutes between the 112-call (emergency) and adequate electric discharge. Development of automated defibrillators in Emergency Medical Systems and their use by «first responders» of «non-health care» emergency services (police, fire fighters, etc) contribute to reach this objective. Because of this, Emergency Medical Systems are modifying their assistance strategies, to implement the early defibrillation as «key to survival». Literature showed the effective value of automated defibrillators in the public areas but their efficiency level is less than that reached with the Emergency Services. Efficiency depends on multiple factors such as type of installation, accessibility level to emergency medical services or incidence rate of sudden cardiac arrest. Thus, their introduction should be preceded by a cost-effectiveness study. Effectiveness of automated defibrillators at home, where up to 80% of cardiac arrest are produced, has still not been evaluated. Nevertheless, in the USA, its marketing with this indication has been authorized

Improving patient access to novel medical technologies in Europe.

The European Society of Cardiology (ESC) organized a one-day workshop with clinicians, health economic experts, and health technology appraisal experts to discuss the equity of patient access to novel medical technologies in Europe. Two index technologies were considered: implantable cardioverter defibrillators (ICDs) and drug-eluting stents (DES). The use of ICDs range from 35 implants/million population in Portugal to 166 implants/million population in Germany, whereas for implants of DES (as percentage of total stents) it is lowest in Germany at 14% and high in Portugal at 65%. These differences can in part be explained by a lack of structured implementation of guidelines, the direct cost in relation to the overall healthcare budget, and to differences in procedures and models applied by Health Technology Assessment (HTA) agencies in Europe. The workshop participants concluded that physicians need to be involved in a more structured way in HTA and need to become better acquainted with its methods and terminology. Clinical guidelines should be systematically translated, explained, disseminated, updated, and adopted by cardiologists in Europe. Clinically appropriate, consistent and transparent health economic models need to be developed and high-quality international outcome and cost data should be used. A process for funding of a technology should be developed after a positive recommendation from HTA agencies. Both the ESC and the national cardiac societies should build-up health economic expertise and engage more actively in discussions with stakeholders involved in the provision of healthcare.

Downward delegation of implantable cardioverter defibrillator decision-making in a restricted-resource environment: the pitfalls of bedside rationing.

Implantable cardioverter defibrillators have been shown to reduce all-cause mortality in some patient populations at risk of sudden death. New Canadian guidelines recommend implantable cardioverter defibrillator therapy for these patients. However, the need for these devices exceeds the funded volumes in many Canadian jurisdictions. As a result, rationing of this resource has been necessary. While rationing at the macro (Ministry of Health) and meso (hospital) levels has achieved some level of acceptance by society, the responsibility for the decisions taken at the micro (individual) patient level actually rests with the physician at the bedside. This 'bedside rationing' creates a moral dilemma for physicians, who are torn between their traditional fiduciary role as 'patient advocate' and the competing role of 'gatekeeper'. This 'downward delegation' of rationing decision-making obscures the reality that rationing occurs, and encourages covert, opaque and inconsistent approaches. The remedy is the development of fair, legitimate procedures for making rationing decisions that include guidelines that structure and constrain those decisions. Macro- and meso-level stakeholders must also recognize and take responsibility for their part in restricting resources in a broadly inclusive and transparent process.

The patient with an implantable cardioverter defibrillator.

Electrophysiologic technology developed over the past 20 years has improved the life expectancy of patients who have survived sudden cardiac death events. Use of an implantable cardioverter defibrillator (ICD) continues to increase as more indications for the device are researched. Patients with ICDs will be cared for in the postanesthesia care unit following cardiac and noncardiac surgery and require PACU nurses to be knowledgeable about this advanced and changing technology as well as provide for emotional and psychological needs.

Implantable cardioverter defibrillator utilization based on discharge diagnoses from Medicare and managed care patients.

INTRODUCTION: Implantable cardioverter defibrillators (ICDs) have become an accepted therapy for patients at high risk of sudden cardiac death. To assess the current utilization of this therapy, we estimated the number of patients at risk of sudden death using an historical claims-based study and compared these results to current ICD usage volumes. METHODS AND RESULTS: Managed care and Medicare databases (claims related to 4.6 million covered U.S. lives during a 12-month period) were analyzed to identify patients who had either a primary or secondary diagnosis of ventricular tachycardia, ventricular fibrillation, ventricular flutter, or cardiac arrest. These patients were further required to have a diagnosis code indicating a previous myocardial infarction or congestive heart failure. Patients who died during the study period or did not have medical insurance were excluded. In the base case scenario, 1,226 patients per million population were identified as potential ICD candidates. Sensitivity analyses reduced that value to a range from 736 to 1,140 ICD candidates per million population. Sensitivity factors considered included acute myocardial infarction, comorbidities, age, secondary ventricular tachycardia/ventricular fibrillation diagnosis, and varying degrees of left ventricular dysfunction. These results contrast with an ICD usage rate of 416 per million population in the United States and lower rates in other countries. CONCLUSION: This study suggests that, based on discharge diagnoses, many patients who could benefit from ICDs are not receiving this therapy. Diverse reasons for this underutilization should be addressed to improve access to, and appropriate use of, this therapy.

Use of a transurethral microwave thermotherapeutic device with permanent pacemakers and implantable defibrillators.

OBJECTIVE: To determine whether a device (Urologix Targis system) used for transurethral microwave treatment interferes with sensing, pacing, and arrhythmia detection by permanent pacemakers and implantable cardioverter-defibrillators (ICDs). METHODS: We tested 13 pacemakers in both bipolar and unipolar sensing configurations and 8 ICDs in vitro. Pacemakers and ICDs were programmed to their most sensitive settings. Energy outputs of the microwave device were typical of those used clinically. The probe of the microwave device was anchored 1.2 cm from the pacemaker or ICD being tested. RESULTS: No sensing, pacing, or arrhythmic interactions were noted with any ICD or any pacemaker programmed to the bipolar configuration. One pacemaker (Guidant Vigor 1230) showed intermittent tracking when programmed to the unipolar configuration. CONCLUSIONS: Most patients with permanent pacemakers or ICDs can safely undergo transurethral microwave therapy using the device tested. Pacemakers and ICDs should be programmed to the bipolar configuration (if available) during therapy. The pacemaker or ICD should be interrogated before and after therapy to determine whether programming changes occurred as a result of treatment. However, our findings suggest that this is unlikely.

[Implantable defibrillator. Update]. / Le défibrillateur implantable. Mise au point.

The implantable cardioverter-defibrillator is a device able to detect and efficiently treat life-threatening ventricular arrhythmias. Its decisive accomplishment in reducing sudden cardiac death and total cardiac mortality, opposed to the insufficient reliability of the traditional therapies explains its present ascendancy. In this review, the working principles and the implant techniques are developed, as well as the complications and the usual problems which could be encountered in implanted patients. Finally, the current indications are discussed in the light of recent clinical trials.