Risk Factors for Failure of Direct Current Cardioversion in Patients with Type 2 Diabetes Mellitus and Atrial Fibrillation.

INTRODUCTION: Type 2 diabetes mellitus (T2DM) is a well-recognised risk factor for cardiovascular disease and the prevalence of atrial fibrillation (AF) is higher among patients with T2DM. Direct current cardioversion (DCCV) is an important management option in persistent AF. We sought to determine independent risk factors for immediate and short-term outcomes of DCCV for treatment of AF in patients with T2DM. METHODS: Retrospective outcome analysis of DCCV for persistent AF in 102 T2DM patients compared with 102 controls. RESULTS: DCCV was successful in 68 (66.6%) people with T2DM compared to 86 (84.3%) in the control group (P = 0.003). After initial successful cardioversion, only 38 (37.2%) T2DM patients remained in sinus rhythm compared to 63 (61.8%) in the control group (P = 0.007) at a median follow-up of 74.5 days (IQR 69.4-77.4). Multiple logistic regression analysis showed that the presence of T2DM (P = 0.014), digoxin use (P = 0.01), statin use (P = 0.005), left-atrial size (P = 0.01), and LV ejection fraction (P = 0.008) were independent risk factors for immediate DCCV failure. T2DM (P = 0.034) was an independent risk factor for AF relapse. Among patients with T2DM, previous DCCV (P = 0.033), digoxin use (P = 0.035), left-atrial size (P = 0.01), LV ejection fraction (P = 0.036), and HbA1c (P = 0.011) predicted immediate failure of DCCV whilst digoxin use (P = 0.026) was an independent risk factor for relapse of AF. CONCLUSION: T2DM, higher HbA1c, digoxin treatment, and structural and functional cardiac abnormalities are independent risk factors for immediate DCCV failure and AF relapse.

Temporal arteritis with erythrocyte sedimentation rate <50 mm/h: a clinical reminder.

Temporal arteritis, also known as giant cell arteritis (GCA), is a systemic vasculitis that predominantly involves the temporal arteries. It is a medical emergency and should be treated promptly as it can lead to permanent loss of vision. It is very commonly associated with a raised erythrocyte sedimentation rate (ESR), usually >50 mm/h, one of the essential criteria defined by the American College of Rheumatology classification of GCA. Here, we describe the case of a 73-year-old male presenting with a 2-day history of a sudden onset of a severe left-sided headache, which had the signs and symptoms consistent with GCA but he had an ESR of only 27 mm/h. The patient was urgently treated with prednisolone 60 mg per day, and his symptoms dramatically improved within 24 hours of therapy. Temporal artery biopsy results were consistent with an inflammatory response, and withdrawal of treatment led to a relapse of the symptoms. The patient was slowly tapered off the high steroid dose and is now currently managed on a low steroid dose. We should keep a high index of suspicion for GCA in patients presenting with clinical symptoms of GCA even though the ESR is <50 mm/h as stated in the criteria for GCA diagnosis.