Manejo de los pacientes con fibrilación auricular en los servicios de urgencias hospitalarios (actualización 2012) / Atrial fibrillation management in the hospital emergency department: 2012 update

La fibrilación auricular (FA) es la arritmia sostenida de mayor prevalencia en los servicios de urgencias (SHU), que presentan una frecuentación elevada y creciente en España. La FA es una enfermedad grave, que incrementa la mortalidad y asocia una relevante morbilidad e impacto en la calidad de vida de los pacientes y en el funcionamiento de los servicios sanitarios. La diversidad de aspectos clínicos a considerar y el elevado número de opciones terapéuticas posibles justifican la implementación de estrategias de actuación coordinadas entre los diversos profesionales implicados, con el fin de incrementar la adecuación del tratamiento y optimizar el uso de recursos. Este documento recoge las recomendaciones para el manejo de la FA, basadas en la evidencia disponible, y adaptadas a las especiales circunstancias de los SUH. En él se analizan con detalle las estrategias de tromboprofilaxis, control de frecuencia y control del ritmo, y los aspectos logísticos y diagnósticos relacionados (AU)

Atrial fibrillation is the most frecuently sustained arrhythmia managed in emergency departments, and accounts for a high and increasing prevalence in Spain. Atrial fibrillation is increases mortality, is associated with substantial complications and, therefore, has a relevant impact in running of the health care system. Management requires consideration of diverse clinical variables and a large number of possible therapeutic approaches, justifying action plans that coordinate the work of medical staff in the interest of providing appropriate care and optimizing resources. These evidence-based guidelines contain recommendations for managing atrial fibrillation in the special circumstances of hospital emergency departments. Stroke prohylaxis, rate control, rhtyhm control, and related diagnostic and logistic issues are discussed in detail (AU)

[Radiofrequency ablation as the first line of treatment in patients with common atrial flutter. The arguments pro]. / La ablación con radiofrecuencia como primer tratamiento de elección en pacientes con aleteo auricular común. Argumentos a favor.

Radiofrequency ablation of atrial flutter may be performed nowadays with 90% probability of success, 10% of recurrences and a very low risk of complications; thus the indications of the procedure have lately expanded. However, there are still many discrepancies among different groups in the way to approach the acute and the chronic therapy for atrial flutter. Acute as well as chronic antiarrhythmic therapy has a limited effectivity and carries a risk of proarrythmia and extracardiac secondary effects. On the other hand, the potential risk of embolism during chronic therapy and after cardioversion is often underestimated. Another important issue often neglected is the tachycardiomyopathy secondary to the sustained high rate at the atrium and also at the ventricular level. The delay in the definitive therapy worsens the atrial remodelling and may promote the development of atrial fibrillation. We consider that radiofrequency ablation of atrial flutter is the first therapeutic option, and it should be attempted when the patient is seen, without further delay. In that way, the above mentioned potential risks are avoided, and for this reason, this is our common approach to therapy.

Clinical usefulness of head-up tilt test in patients with syncope and intraventricular conduction defect.

Head-up tilt test was performed in 99 patients with syncope of unknown origin and intraventricular conduction defect. Twenty-five per cent had a positive response to tilt with reproduction of spontaneous clinical symptoms. Holter recording revealed paroxysmal atrioventricular (AV) block in three patients. Carotid sinus massage was positive in four patients. An electrophysiological study was performed in 76 patients with abnormal findings in 17 (22%). Thus, vasovagal syncope was the discharge diagnosis in 25 patients (25%). Therefore, tilt test should be considered in patients with intraventricular conduction defect presenting with syncope of unknown origin, especially if clinical findings suggest the possibility of a vasovagal mechanism, or if the results of the electrophysiological study are inconclusive.

[Treatment of cardiac arrhythmia with radiofrequency in pediatrics]. / Tratamiento de arritmias cardíacas con radiofrecuencia en pediatría.

OBJECTIVE: The use of radiofrequency ablation of cardiac arrhythmias in pediatrics requires demonstration that the technique is effective and devoid of significant complications. In this study we present our experience in the ablation of cardiac arrhythmias in children and adolescents. PATIENTS AND METHODS: Between January 1992 and January 1997 we performed a total of 1,543 radiofrequency ablation procedures. Of these, 130 were performed in 117 patients younger than 18 years of age (58 were younger than 14 years old). Indication for ablation was the presence of drug refractory recurrent paroxysmal supraventricular tachycardia in 112 patients and permanent ventricular preexcitation in 5 asymptomatic patients. Final diagnosis in the 112 symptomatic patients was: 4 atrial tachycardias, 21 atrio-ventricular nodal reentrant tachycardias, 53 Wolff-Parkinson-White (WPW) syndromes, 33 orthodromic tachycardias using a concealed accessory pathway and 1 idiopathic left ventricular tachycardia. RESULTS: The initial ablation procedure was effective in 109/117 patients (93%) with a total duration of 90 +/- 31 minutes, using 16 +/- 11 minutes of radioscopy and a median of 4 radiofrequency applications. During follow-up, recurrence occurred in 9 patients (8%). In 7 of them and in 6 of those with an unsuccessful initial procedure, a second effective procedure was performed in 11/13 patients. Finally, radiofrequency ablation was effective in 111/117 patients (95%). We observed a single complication in a 15 year old girl who presented a thrombosis of the right femoral artery requiring balloon recanalization. Comparison of these results with those in the adult population showed no difference in terms of effectiveness, recurrences or complications. CONCLUSIONS: Radiofrequency ablation of cardiac arrhythmias in pediatric and young patients can be safely and effectively done. Results are similar to those obtained in adults suggesting that indications for ablation can also be similar.

[An analysis of the responses to the tilt-table test depending on the clinical characteristics of the syncopal episodes in patients without apparent cardiopathy]. / Análisis de las respuestas a la prueba en tabla basculante en función de las características clínicas de los episodios sincopales en pacientes sin cardiopatía aparente.

Seventy-six consecutive patients were evaluated to assess whether the response to head-up tilt test was related to the type of clinical presentation in patients with syncope of unknown origin and free from heart disease. The syncopal attacks were clinically characterized in a prospective fashion before the tilt test. In 44 patients (group I) syncope had been preceded by autonomic symptoms or was associated with recent or static sustained orthostatism. In 32 patients (group II), syncope had been sudden, without prodromal or autonomic symptoms. Mean age was 49 +/- 17 years in group I patients and 47 +/- 17 years in group II patients (NS). The degree of tilt was 75 degrees. During 30 min no drugs were administered, and then isoproterenol was infused for an additional 20 min (1-5 micrograms/min until a maximal heart rate of 140 bpm was achieved). Tilt test was considered as positive when the patient developed syncope or presyncope with hypotension. Tilt test was positive in 33 patients from group I (75%) and 12 from group II (37.5%)(p = 0.001). The positive response developed within the 30 initial min of the test (without isoproterenol infusion) in 19 of 33 patients from group I (57%) and in 3 of 12 patients from group II (25%) (p = 0.053). It is concluded that the response to tilt test is related to the clinical features of syncopal attacks.