2017 ACC Expert Consensus Decision Pathway for Periprocedural Management of Anticoagulation in Patients With Nonvalvular Atrial Fibrillation: A Report of the American College of Cardiology Clinical Expert Consensus Document Task Force.

Periprocedural management of anticoagulation is a common clinical conundrum that involves a multidisciplinary team, cuts across many specialties, and varies greatly between institutions in the way it is practiced. Nowhere is this more evident than in the management of patients with nonvalvular atrial fibrillation. Although they have been found to improve patient outcomes, standardized evidence-based protocols are infrequently in place. The frequency of anticoagulant interruption in preparation for a procedure is high, with an estimated 250,000 patients undergoing temporary interruption annually in North America alone. Knowledge about risk of bleeding and short-term thrombotic risk resides in many specialties, further complicating the issue. Our goal in creating this pathway is to help guide clinicians in the complex decision making in this area. In this document, we aim to: 1) validate the appropriateness of the decision to chronically anticoagulate; 2) guide clinicians in the decision of whether to interrupt anticoagulation; 3) provide direction on how to interrupt anticoagulation with specific guidance for vitamin K antagonists and direct-acting oral anticoagulants; 4) evaluate whether to bridge with a parenteral agent periprocedurally; 5) offer advice on how to bridge; and 6) outline the process of restarting anticoagulation post-procedure.

Practical management of anticoagulation in patients with atrial fibrillation.

Anticoagulation for atrial fibrillation has become more complex due to the introduction of new anticoagulant agents, the number and kinds of patients requiring therapy, and the interactions of those patients in the matrix of care. The management of anticoagulation has become a "team sport" involving multiple specialties in multiple sites of care. The American College of Cardiology, through the College's Anticoagulation Initiative, convened a roundtable of experts from multiple specialties to discuss topics important to the management of patients requiring anticoagulation and to make expert recommendations on issues such as the initiation and interruption of anticoagulation, quality of anticoagulation care, management of major and minor bleeding, and treatment of special populations. The attendees continued to work toward consensus on these topics, and present the key findings of this roundtable in a state-of- the-art review focusing on the practical aspects of anticoagulation care for the patient with atrial fibrillation.

Appropriate evaluation and treatment of heart failure patients after implantable cardioverter-defibrillator discharge: time to go beyond the initial shock.

Multiple clinical trials support the use of implantable cardioverter-defibrillators (ICDs) for prevention of sudden cardiac death in patients with heart failure (HF). Unfortunately, several complicating issues have arisen from the universal use of ICDs in HF patients. An estimated 20% to 35% of HF patients who receive an ICD for primary prevention will experience an appropriate shock within 1 to 3 years of implant, and one-third of patients will experience an inappropriate shock. An ICD shock is associated with a 2- to 5-fold increase in mortality, with the most common cause being progressive HF. The median time from initial ICD shock to death ranges from 168 to 294 days depending on HF etiology and the appropriateness of the ICD therapy. Despite this prognosis, current guidelines do not provide a clear stepwise approach to managing these high-risk patients. An ICD shock increases HF event risk and should trigger a thorough evaluation to determine the etiology of the shock and guide subsequent therapeutic interventions. Several combinations of pharmacologic and device-based interventions such as adding amiodarone to baseline beta-blocker therapy, adjusting ICD sensitivity, and employing antitachycardia pacing may reduce future appropriate and inappropriate shocks. Aggressive HF surveillance and management is required after an ICD shock, as the risk of sudden cardiac death is transformed to an increased HF event risk.

Benefit of cardiac resynchronization in elderly patients: results from the Multicenter InSync Randomized Clinical Evaluation (MIRACLE) and Multicenter InSync ICD Randomized Clinical Evaluation (MIRACLE-ICD) trials.

PURPOSE: Heart failure (HF) affects five million patients each year with both prevalence and incidence increasing with age. At least 20% of hospital admissions in patients > age 65 are due to HF. Cardiac resynchronization therapy (CRT) has been shown to improve HF symptoms and decrease mortality. However, little data are available which specifically address the effects of CRT in the elderly (>65). METHODS: We performed an analysis of the NYHA III/IV 839 patients randomized in the MIRACLE (n = 470) and MIRACLE-ICD (n = 369) trials. Both included patients with moderate to severe HF, ejection fraction (EF) or=130 msec. Patients were grouped by age <65, 65-75, and >75 years. For each group, patients with CRT activated (ON) were compared with patients with CRT inactivated (OFF) for end points at 6 months, including New York Heart Association (NYHA) functional class and EF. RESULTS: Of the 839 patients, 368 were <65, 297 were 65-75, and 174 were >75 years old. Compared with controls, patients from all three age groups, whose CRT was activated, had statistically significant improvements in NYHA class (-0.84 for age <65, -0.78 for age 65-75, and -0.78 for age >75). All age groups with CRT ON also had statistically significant improvements in left ventricular EF (5.23%, 2.98%, and 4.03% respectively). There were no between group differences by age in LVEF improvement. CONCLUSIONS: In elderly patients enrolled in the MIRACLE and MIRACLE-ICD trials, CRT resulted in significant improvements in NYHA class and LVEF, regardless of age. These data suggest that the full age range of patients with appropriate indications for implantation can benefit from CRT.

Current of injury predicts adequate active lead fixation in permanent pacemaker/defibrillation leads.

OBJECTIVES: The aim of this study was to determine whether current of injury can guide adequate placement of active-fixation pacing leads. BACKGROUND: Active-fixation leads cause injury to the myocardium at the time of fixation, manifested as a current of injury (COI) that may result in acute elevation of pacing thresholds. The relationship of COI to subsequent improvement in pacing thresholds is not clear. METHODS: Sixty-five patients undergoing active-fixation lead implantation were enrolled. Current of injury was characterized as the duration of the intracardiac electrogram (EGM) and the magnitude of ST-segment elevation. Pacing parameters were measured up to 10 min after fixation. RESULTS: A total of 96 active-fixation leads were studied, and 76 leads had a current of injury. From baseline to the time of fixation, the duration of the intracardiac EGM in ventricular leads increased from 150 +/- 31 ms to 200 +/- 25 ms (p < 0.001), and the ST-segment increased from 1.5 +/- 0.2 mV to 10.0 +/- 2.0 mV (p < 0.001), with subsequent improvement in pacing thresholds from 1.5 +/- 0.4 V to 0.8 +/- 0.3 V (p < 0.001) at 10 min. Atrial leads with a current of injury had similar findings. Of the 20 leads without a COI, 5 dislodged acutely and 15 had high pacing thresholds at 10 min, requiring repositioning. CONCLUSIONS: The development of a COI indicates that within 10 min of fixation, pacing threshold will return to an acceptable range even if the initial measurement is high. Conversely, without a COI, lead fixation is not adequate and the lead should be repositioned.

Risks and benefits of rate control versus maintenance of sinus rhythm.

There are 2 fundamental approaches to managing patients with recurrent atrial fibrillation (AF): to restore and maintain sinus rhythm with cardioversion and/or antiarrhythmic drugs, or to control the ventricular rate only. Over the past few years, there have been several important prospective clinical trials comparing rate control with rhythm control in patients with recurrent AF. The Pharmacological Intervention in Atrial Fibrillation (PIAF) trial was the first prospective randomized study to test the hypothesis of equivalency between the 2 management strategies for AF. The trial demonstrated that rate control was not inferior to rhythm control with respect to symptoms, quality of life, or number of hospitalizations in patients with persistent AF. The Strategies of Treatment in Atrial Fibrillation (STAF) trial was a pilot study that enrolled approximately 200 patients with AF who were randomized to either ventricular rate control or cardioversion and maintenance of sinus rhythm. The results showed that over a 1-year period there was little difference in outcome in terms of morbidity or symptoms. In the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial, patients with AF and risk factors for stroke were randomized to either rhythm control or rate control, with both groups receiving anticoagulation with warfarin. There was no difference in the composite end point of death, disabling stroke or anoxic encephalopathy, major bleeding, or cardiac arrest between the 2 arms. In addition, no major differences were noted in functional status or quality of life. The Rate Control Versus Electrical Cardioversion (RACE) trial also reached a similar conclusion. Thus, rate control is an acceptable primary strategy for management of patients with recurrent AF.