Identification of cavotricuspid isthmus voltage patterns in typical atrial flutter ablation.

Background: Electroanatomical mapping is an essential tool in the ablation of typical AFL. Objectives: To identify the existence of voltage patterns in the CTI voltage maps and their relevance for typical AFL ablation. Methods: A voltage map of the CTI was made prior to ablation, identifying the areas of maximum voltage and their location along the CTI, allowing classification into patterns according to their distribution. A stepwise ablation approach targeting the areas of maximum voltage was conducted. The ablation characteristics were compared based on the pattern obtained. Results: Two voltage patterns were identified, with differences in ablation time to bidirectional CTI block. No complications occurred. Conclusions: Voltage mapping identifies patterns in the CTI with implications for typical AFL ablation.

Cardiac magnetic resonance outperforms echocardiography to predict subsequent implantable cardioverter defibrillator therapies in ST-segment elevation myocardial infarction patients.

Background: Implantable cardioverter defibrillators (ICD) are effective as a primary prevention measure of ventricular tachyarrhythmias in patients with ST-segment elevation myocardial infarction (STEMI) and depressed left ventricular ejection fraction (LVEF). The implications of using cardiac magnetic resonance (CMR) instead of echocardiography (Echo) to assess LVEF prior to the indication of ICD in this setting are unknown. Materials and methods: We evaluated 52 STEMI patients (56.6 ± 11 years, 88.5% male) treated with ICD in primary prevention who underwent echocardiography and CMR prior to ICD implantation. ICD implantation was indicated based on the presence of heart failure and depressed LVEF (≤ 35%) by echocardiography, CMR, or both. Prediction of ICD therapies (ICD-T) during follow-up by echocardiography and CMR before ICD implantation was assessed. Results: Compared to echocardiography, LVEF was lower by cardiac CMR (30.2 ± 9% vs. 37.4 ± 7.6%, p < 0.001). LVEF ≤ 35% was detected in 24 patients (46.2%) by Echo and in 42 (80.7%) by CMR. During a mean follow-up of 6.1 ± 4.2 years, 10 patients received appropriate ICD-T (3.16 ICD-T per 100 person-years): 5 direct shocks to treat very fast ventricular tachycardia or ventricular fibrillation, 3 effective antitachycardia pacing (ATP) for treatment of ventricular tachycardia, and 2 ineffective ATP followed by shock to treat ventricular tachycardia. Echo-LVEF ≤ 35% correctly predicted ICD-T in 4/10 (40%) patients and CMR-LVEF ≤ 35% in 10/10 (100%) patients. CMR-LVEF improved on Echo-LVEF for predicting ICD-T (area under the curve: 0.76 vs. 0.48, p = 0.04). Conclusion: In STEMI patients treated with ICD, assessment of LVEF by CMR outperforms Echo-LVEF to predict the subsequent use of appropriate ICD therapies.

Transient narrowing of a wide QRS tachycardia. What is the mechanism?

Electrocardiogram showing a regular wide QRS tachycardia with left branch block (LBBB) like in morphology at 200 beats per minute (bpm). During electrophysiology study, it suddenly gets narrow and faster. What is the mechanism of the switch from a broad complex to a narrow complex tachycardia?

Estrategias diuréticas en insuficiencia cardiaca aguda con disfunción renal: terapia convencional frente a guiada por el antígeno carbohidrato 125. Diseño de ensayo clínico / Diuretic strategies in acute heart failure and renal dysfunction: conventional vs carbohydrate antigen 125-guided strategy. Clinical trial design

Introducción y objetivos: El tratamiento óptimo de pacientes con insuficiencia cardiaca aguda (ICA) y síndrome cardiorrenal tipo 1 (SCR-1) no está bien definido. La hipoperfusión arterial y la congestión venosa tienen un papel fundamental en la fisiopatología del SCR-1. El antígeno carbohidrato 125 (CA125) ha emergido como marcador indirecto de sobrecarga de volumen en la ICA. El objetivo de este estudio es evaluar la utilidad del CA125 para el ajuste del tratamiento diurético de pacientes con SCR-1. Métodos: Ensayo clínico multicéntrico, abierto y paralelo, que incluye a pacientes con ICA y creatinina ≥ 1,4 mg/dl al ingreso, aleatorizados a: a) estrategia convencional: titulación basada en la evaluación clínica y bioquímica habitual, o b) estrategia basada en CA125: dosis altas de diuréticos si CA125 > 35 U/ml y bajas en caso contrario. El objetivo principal es el cambio en la función renal a las 24 y las 72 h tras el comienzo del tratamiento. Como objetivos secundarios: a) cambios clínicos y bioquímicos a las 24 y las 72 h, y b) cambios en la función renal y eventos clínicos mayores a 30 días. Resultados: Los resultados de este estudio aportarán datos relevantes sobre la utilidad del CA125 para guiar el tratamiento diurético en el SCR-1. Además, permitirá ampliar el conocimiento de la fisiopatología de esta compleja entidad clínica. Conclusiones: La hipótesis del presente estudio es que las concentraciones de CA125 aumentadas pueden identificar a una población de pacientes con SCR-1 para quienes una estrategia diurética más intensa puede ser beneficiosa. Por el contrario, las concentraciones bajas de esta glucoproteína seleccionarían a los pacientes para los que serían perjudiciales las dosis altas de diuréticos (AU)

Introduction and objectives: The optimal treatment of patients with acute heart failure (AHF) and cardiorenal syndrome type 1 (CRS-1) is far from being well-defined. Arterial hypoperfusion in concert with venous congestion plays a crucial role in the pathophysiology of CRS-I. Plasma carbohydrate antigen 125 (CA125) has emerged as a surrogate of fluid overload in AHF. The aim of this study was to evaluate the clinical usefulness of CA125 for tailoring the intensity of diuretic therapy in patients with CRS-1. Methods: Multicenter, open-label, parallel clinical trial, in which patients with AHF and serum creatinine ≥ 1.4 mg/dL on admission will be randomized to: a) standard diuretic strategy: titration-based on conventional clinical and biochemical evaluation, or b) diuretic strategy based on CA125: high dose if CA125 > 35 U/mL, and low doses otherwise. The main endpoint will be renal function changes at 24 and 72 hours after therapy initiation. Secondary endpoints will include: a) clinical and biochemical changes at 24 and 72 hours, and b) renal function changes and major clinical events at 30 days. Results: The results of this study will add important knowledge on the usefulness of CA125 for guiding diuretic treatment in CRS-1. In addition, it will pave the way toward a better knowledge of the pathophysiology of this challenging situation. Conclusions: We hypothesize that higher levels of CA125 will identify a patient population with CRS-1 who could benefit from the use of a more intense diuretic strategy. Conversely, low levels of this glycoprotein could select those patients who would be harmed by high diuretic doses (AU)

Diálisis peritoneal en pericarditis constrictiva: a propósito de 3 casos / Peritoneal dialysis in constrictive pericarditis: a report of three cases

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Diuretic Strategies in Acute Heart Failure and Renal Dysfunction: Conventional vs Carbohydrate Antigen 125-guided Strategy. Clinical Trial Design.

INTRODUCTION AND OBJECTIVES: The optimal treatment of patients with acute heart failure (AHF) and cardiorenal syndrome type 1 (CRS-1) is far from being well-defined. Arterial hypoperfusion in concert with venous congestion plays a crucial role in the pathophysiology of CRS-I. Plasma carbohydrate antigen 125 (CA125) has emerged as a surrogate of fluid overload in AHF. The aim of this study was to evaluate the clinical usefulness of CA125 for tailoring the intensity of diuretic therapy in patients with CRS-1. METHODS: Multicenter, open-label, parallel clinical trial, in which patients with AHF and serum creatinine ≥ 1.4mg/dL on admission will be randomized to: a) standard diuretic strategy: titration-based on conventional clinical and biochemical evaluation, or b) diuretic strategy based on CA125: high dose if CA125 > 35 U/mL, and low doses otherwise. The main endpoint will be renal function changes at 24 and 72hours after therapy initiation. Secondary endpoints will include: a) clinical and biochemical changes at 24 and 72hours, and b) renal function changes and major clinical events at 30 days. RESULTS: The results of this study will add important knowledge on the usefulness of CA125 for guiding diuretic treatment in CRS-1. In addition, it will pave the way toward a better knowledge of the pathophysiology of this challenging situation. CONCLUSIONS: We hypothesize that higher levels of CA125 will identify a patient population with CRS-1 who could benefit from the use of a more intense diuretic strategy. Conversely, low levels of this glycoprotein could select those patients who would be harmed by high diuretic doses.

Efecto diferencial de la glucohemoglobina y el tratamiento antidiabético sobre el riesgo de reingreso a 30 días después de un ingreso por insuficiencia cardiaca aguda / Differential effect of glycosylated hemoglobin value and antidiabetic treatment on the risk of 30-day readmission following a hospitalization for acute heart failure

Introducción y objetivos: En los pacientes con insuficiencia cardiaca y diabetes tipo 2, las cifras bajas de glucohemoglobina se han relacionado con un riesgo más elevado de mortalidad, pero la información relativa a la morbilidad es escasa. El objetivo de este estudio fue evaluar la asociación existente entre la glucohemoglobina y el reingreso en un plazo de 30 días en los pacientes con diabetes tipo 2 e insuficiencia cardiaca aguda. Métodos: Se determinó la glucohemoglobina antes del alta en 835 pacientes consecutivos con insuficiencia cardiaca aguda y diabetes tipo 2. Se utilizó un análisis de regresión de Cox adaptado para eventos competitivos. Resultados: La media de edad fue de 72,9 ± 9,6 años y la mediana de la glucohemoglobina fue de 7,2% (6,5-8,0%). Los pacientes tratados con insulina o con insulina/sulfonilurea/meglitinidas constituyeron un 41,1 y un 63,2% de la cohorte, respectivamente. A los 30 días del alta, 109 (13,1%) pacientes habían tenido un reingreso en el hospital. El análisis multivariante reveló que el efecto de la glucohemoglobina sobre el riesgo de reingreso en 30 días se veía afectado de manera diferente según el tipo de tratamiento (p para la interacción < 0,01). La glucohemoglobina (por cada 1% de disminución) presentaba una asociación inversa con un mayor riesgo en los pacientes tratados con insulina (hazard ratio = 1,45; intervalo de confianza del 95%, 1,13-1,86; p = 0,003) o con insulina/sulfonilurea/meglitinidas (hazard ratio= 1,44; intervalo de confianza del 95%, 1,16-1,80; p = 0,001). En cambio, la glucohemoglobina (por cada 1% de aumento) no tenía efecto alguno en la diabetes no insulinodependiente (hazard ratio = 1,01; intervalo de confianza del 95%, 0,87-1,17; p = 0,897) o mostraba incluso un efecto positivo en los pacientes no tratados con insulina/sulfonilurea/meglitinidas (hazard ratio = 1,12; intervalo de confianza del 95%, 1,03-1,22; p = 0,011). Conclusiones: En la insuficiencia cardiaca aguda, la glucohemoglobina mostró una asociación inversa con el riesgo de reingreso en 30 días en los pacientes insulinodependientes o en los tratados con insulina/sulfonilurea/meglitinidas. En el resto de pacientes se observó un efecto marginal. En futuros estudios deberá esclarecerse si esa asociación refleja un efecto relacionado con el tratamiento o bien es un indicador indirecto de una enfermedad más avanzada (AU)

Introduction and objectives: In patients with heart failure and type 2 diabetes, low glycosylated hemoglobin has been related with higher risk of mortality but information regarding morbidity is scarce. We sought to evaluate the association between glycosylated hemoglobin and 30-day readmission in patients with type 2 diabetes and acute heart failure. Methods: Glycosylated hemoglobin was measured before discharge in 835 consecutive patients with acute heart failure and type 2 diabetes. Cox regression analysis adapted for competing events was used. Results: Mean (standard deviation) age was 72.9 (9.6) years and median glycosylated hemoglobin was 7.2% (6.5%-8.0%). Patients treated with insulin or insulin/sulfonylurea/meglitinides were 41.1% and 63.2% of the cohort, respectively. At 30 days post-discharge, 109 (13.1%) patients were readmitted. A multivariate analysis revealed that the effect of glycosylated hemoglobin on the risk of 30-day readmission was differentially affected by the type of treatment (P for interaction < .01). Glycosylated hemoglobin (per 1% decrease) was inversely associated with higher risk in those receiving insulin (hazard ratio = 1.45; 95% confidence interval, 1.13-1.86; P = .003) or insulin/sulfonylurea/ meglitinides (hazard ratio = 1.44; 95% confidence interval, 1.16-1.80; P = .001). Conversely, glycosylated hemoglobin (per 1% increase) had no effect in non-insulin dependent diabetes (hazard ratio = 1.01; 95% confidence interval, 0.87-1.17; P = .897) or even a positive effect in patients not receiving insulin/ sulfonylurea/meglitinides (hazard ratio = 1.12; 95% confidence interval, 1.03-1.22; P = .011). Conclusions: In acute heart failure, glycosylated hemoglobin showed to be inversely associated to higher risk of 30-day readmission in insulin-dependent or those treated with insulin/sulfonylurea/meglitinides. A marginal effect was found in the rest. Whether this association reflects a treatment-related effect or a surrogate of more advanced disease should be clarified in further studies (AU)

Differential Effect of Glycosylated Hemoglobin Value and Antidiabetic Treatment on the Risk of 30-day Readmission Following a Hospitalization for Acute Heart Failure.

INTRODUCTION AND OBJECTIVES: In patients with heart failure and type 2 diabetes, low glycosylated hemoglobin has been related with higher risk of mortality but information regarding morbidity is scarce. We sought to evaluate the association between glycosylated hemoglobin and 30-day readmission in patients with type 2 diabetes and acute heart failure. METHODS: Glycosylated hemoglobin was measured before discharge in 835 consecutive patients with acute heart failure and type 2 diabetes. Cox regression analysis adapted for competing events was used. RESULTS: Mean (standard deviation) age was 72.9 (9.6) years and median glycosylated hemoglobin was 7.2% (6.5%-8.0%). Patients treated with insulin or insulin/sulfonylurea/meglitinides were 41.1% and 63.2% of the cohort, respectively. At 30 days post-discharge, 109 (13.1%) patients were readmitted. A multivariate analysis revealed that the effect of glycosylated hemoglobin on the risk of 30-day readmission was differentially affected by the type of treatment (P for interaction<.01). Glycosylated hemoglobin (per 1% decrease) was inversely associated with higher risk in those receiving insulin (hazard ratio = 1.45; 95% confidence interval, 1.13-1.86; P=.003) or insulin/sulfonylurea/meglitinides (hazard ratio = 1.44; 95% confidence interval, 1.16-1.80; P=.001). Conversely, glycosylated hemoglobin (per 1% increase) had no effect in non-insulin dependent diabetes (hazard ratio = 1.01; 95% confidence interval, 0.87-1.17; P=.897) or even a positive effect in patients not receiving insulin/sulfonylurea/meglitinides (hazard ratio = 1.12; 95% confidence interval, 1.03-1.22; P=.011). CONCLUSIONS: In acute heart failure, glycosylated hemoglobin showed to be inversely associated to higher risk of 30-day readmission in insulin-dependent or those treated with insulin/sulfonylurea/meglitinides. A marginal effect was found in the rest. Whether this association reflects a treatment-related effect or a surrogate of more advanced disease should be clarified in further studies.

Red blood cell distribution width is longitudinally associated with mortality and anemia in heart failure patients.

BACKGROUND: Red blood cell distribution width (RDW) has been found to be an independent predictor for adverse outcome in patients with heart failure (HF), but there are no data on the association of longitudinal RDW with all-cause mortality and occurrence of anemia. METHODS AND RESULTS: 1,702 patients discharged from a previous admission for acute HF (AHF) were included. RDW was measured during the available longitudinal history of the patient. Joint modeling and Multistate Markov were used for the analysis. The median RDW at baseline was 15.0% (IQR: 14.0-16.5), and 45.6% of patients had anemia. At a median follow-up of 1.5 years (IQR: 0.45-3.25), 713 patients died. The last RDW-trajectory value and cumulative RDW-trajectory mean were predictive of mortality (HR, 1.18; 95% CI: 1.12-1.24; and HR, 1.12; 95% CI: 1.08-1.16, respectively; P<0.001 for both). This effect, however, varied according the anemia status (P for interaction<0.001), being more pronounced in absence of anemia [HR=1.31 (95% CI: 1.22-1.42) and HR=1.48 (95% CI: 1.33-1.64)] compared to those with anemia [HR=1.08 (95% CI: 1.04-1.13), 1.12 (95% CI: 1.06-1.18)]. Longitudinal RDW (per 1% increasing) was also independently associated with incident anemia [HR=1.10 (95% CI: 1.03-1.18) P=0.002]. CONCLUSIONS: Following an admission for AHF, higher longitudinal RDW values over time were associated to an increased risk for both developing anemia and dying. The effect on mortality was more pronounced among non-anemic patients.

Echocardiographic estimation of pulmonary arterial systolic pressure in acute heart failure. Prognostic implications.

BACKGROUND: Prognostic implications of echocardiographic assessment of pulmonary hypertension (PH) in non-selected patients hospitalized for acute heart failure (AHF) are not clearly defined. The aim of this study was to evaluate the association between echocardiography-derived PH in AHF and 1-year all-cause mortality. METHODS: We prospectively included 1210 consecutive patients admitted for AHF. Patients with significant heart valve disease were excluded. Pulmonary arterial systolic pressure (PASP) was estimated using transthoracic echocardiography during hospitalization (mean time after admission 96±24h). Patients were categorized as follows: non-measurable, normal PASP (PASP≤35mmHg), mild (PASP 36-45mmHg), moderate (PASP 46-60mmHg) and severe PH (PASP >60mmHg). The independent association between PASP and 1-year mortality was assessed with Cox regression analysis. RESULTS: At 1-year follow-up, 232 (19.2%) deaths were registered. PASP was measured in 502 (41.6%) patients with a median of 46 [38-55] mmHg. The distribution of population was: 708 (58.5%), 76 (6.3%), 147 (12.1%), 190 (15.7%) and 89 (7.4%) for non-measurable, normal PASP, mild, moderate and severe PH, respectively. One-year mortality was lower for patients with normal PASP (1.32 per 10 person-years), intermediate for patients with non-measurable, mild and moderate PH (2.48, 2.46 and 2.62 per 10 persons-year, respectively) and higher for those with severe PH (4.89 per 10 person-years). After multivariate adjustment, only patients with PASP >60mmHg displayed significant adjusted increase in the risk of 1-year all-cause mortality, compared to patients with normal PASP (HR=2.56; CI 95%: 1.05-6.22, p=0.038). CONCLUSIONS: In AHF, severe pulmonary hypertension derived by echocardiography is an independent predictor of 1-year-mortality.