Management of Atrial Tachyarrhythmias in Heart Failure-an Interventionalist's Point of View.

PURPOSE OF REVIEW: Atrial fibrillation (AF) and heart failure (HF) are commonly encountered clinical disorders that often co-exist, accelerating disease progression and adverse outcomes. It is known that restoration of sinus rhythm positively impacts this population; however, the complex comorbidity profile associated with HF introduces intricacies not encountered in other patient populations. The current review focuses on the safety and efficacy of an interventional-based management for atrial tachyarrhythmias in HF. RECENT FINDINGS: While pharmacotherapy has been the standard treatment of cardiac dysrhythmias in the HF population, recent evidence suggests catheter ablation is more effective and causes less harm than antiarrhythmic drugs (AADs) in the HF population. For the maintenance of sinus rhythm, catheter ablation results in improved freedom from recurrent arrhythmia, with secondary benefit on mortality and hospitalization in those with HF and reduced ejection fraction. For those with permanent AF, cardiac resynchronization therapy and atrioventricular junction ablation result in improved quality of life, physical functioning, and cardiac function.

Medical Assistance in Dying: A Point of Care Educational Framework For Attending Physicians.

Issue: Medical assistance in dying (MAID) became legal in Quebec on December 10, 2015, and in the rest of Canada on June 17, 2016. This enabled 6,749 deaths through physician-assisted suicide or euthanasia between December 10, 2015 and October 31, 2018. While the death of a patient is a common experience for medical trainees, those that occur through MAID have unique features related to the methods, the timeline, the intended role of the physician in causing the death, and the request of the patient that initiates the process. These aspects necessitate a distinct approach to MAID medical education. Evidence: Despite the legalization of MAID in a growing number of jurisdictions, there is virtually no literature to guide MAID education in clinical practice. The cumulative evidence regarding the impact of patient death on medical students, residents, and attending physicians suggests a need for supported discussion and debriefing to process and reflect on the emotional experiences that follow patient death. This is especially important with MAID, in which there are unique ethical and psychological issues related to the physician's direct role in causing the death of a patient. There is little published research on the impact such deaths have on physicians who provide MAID, or on others who are indirectly involved. However, there is evidence that learners desire MAID-specific education tailored to their unique needs. Didactic education about the medical and legal domains of MAID alone is insufficient to support learners' needs. Experiential case-based learning with supervisory support has the potential to enhance training in end-of-life care in general, and specifically in MAID. The authors' first clinical experience with a patient requesting MAID on an internal medicine clinical teaching unit (CTU) highlighted gaps in their preparedness to meet the associated professional and personal demands. Reflecting on these perceived gaps, and on the needs of learners identified in the literature on patient death and MAID education, the authors created a framework to guide learning at the point of care of a patient requesting MAID. Represented in a MAID Education Cogwheel and discussion guide, this framework specifies learning objectives and methods in six domains: medical, legal, moral, ethical, cultural, and psychosocial. Implications: Following a MAID request, attending physicians can use the framework to guide learners in ongoing conversations addressing these domains. Inter-professional participation can include such disciplines as psychiatry, palliative care, bioethics, pharmacy, nursing, physical and occupational therapy, social work, and spiritual care. Further research is necessary to test this framework to determine its' feasibility, efficacy, and generalizability.