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1.
Heart Rhythm ; 2021 Feb 25.
Artigo em Inglês | MEDLINE | ID: mdl-33640446

RESUMO

Our knowledge of associated cardiotoxicities from novel therapeutics in oncology continues to expand. These include arrhythmias from cancer-therapy induced cardiomyopathy resulting from both direct and indirect effects on cardiomyocytes and other mechanisms that can adversely impact cardiovascular outcomes and overall mortality. In this review, we focus on both the arrhythmias of various classes of oncologic agents as well as the use of cardiac implantable electronic devices (cardioverter-defibrillators, permanent pacemakers, and cardiac resynchronization therapy) in cardio-oncology patients.

2.
Int J Cardiol ; 331: 333-339, 2021 05 15.
Artigo em Inglês | MEDLINE | ID: mdl-33524462

RESUMO

BACKGROUND: QTc interval monitoring, for the prevention of drug-induced arrhythmias is necessary, especially in the context of coronavirus disease 2019 (COVID-19). For the provision of widespread use, surrogates for 12­lead ECG QTc assessment may be useful. This prospective observational study compared QTc duration assessed by artificial intelligence (AI-QTc) (Cardiologs®, Paris, France) on smartwatch single­lead electrocardiograms (SW-ECGs) with those measured on 12­lead ECGs, in patients with early stage COVID-19 treated with a hydroxychloroquine-azithromycin regimen. METHODS: Consecutive patients with COVID-19 who needed hydroxychloroquine-azithromycin therapy, received a smartwatch (Withings Move ECG®, Withings, France). At baseline, day-6 and day-10, a 12­lead ECG was recorded, and a SW-ECG was transmitted thereafter. Throughout the drug regimen, a SW-ECG was transmitted every morning at rest. Agreement between manual QTc measurement on a 12­lead ECG and AI-QTc on the corresponding SW-ECG was assessed by the Bland-Altman method. RESULTS: 85 patients (30 men, mean age 38.3 ± 12.2 years) were included in the study. Fair agreement between manual and AI-QTc values was observed, particularly at day-10, where the delay between the 12­lead ECG and the SW-ECG was the shortest (-2.6 ± 64.7 min): 407 ± 26 ms on the 12­lead ECG vs 407 ± 22 ms on SW-ECG, bias -1 ms, limits of agreement -46 ms to +45 ms; the difference between the two measures was <50 ms in 98.2% of patients. CONCLUSION: In real-world epidemic conditions, AI-QTc duration measured by SW-ECG is in fair agreement with manual measurements on 12­lead ECGs. Following further validation, AI-assisted SW-ECGs may be suitable for QTc interval monitoring. REGISTRATION: ClinicalTrial.govNCT04371744.

4.
Am Heart J ; 235: 158-162, 2021 Feb 15.
Artigo em Inglês | MEDLINE | ID: mdl-33596412

RESUMO

The WiSE system is a novel, leadless endocardial system that can provide cardiac resynchronization therapy in patients who cannot be treated with a conventional epicardial left ventricular lead. Safety and efficacy were being evaluated in the pivotal, randomized, double-blind SOLVE-CRT Trial (Stimulation of the Left Ventricular Endocardium for Cardiac Resynchronization Therapy.) The trial was initiated in 2018; however, patient enrollment was significantly impacted by the COVID-19 pandemic necessitating a change in design. This article describes the revised trial and the scientific rationale for the specific changes in the protocol.

5.
Circ Arrhythm Electrophysiol ; 14(2): e009203, 2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-33591816

RESUMO

Cardiac sarcoidosis is a component of an often multiorgan granulomatous disease of still uncertain cause. It is being recognized with increasing frequency, mainly as the result of heightened awareness and new diagnostic tests, specifically cardiac magnetic resonance imaging and 18F-fluorodeoxyglucose positron emission tomography scans. The purpose of this case-based review is to highlight the potentially life-saving importance of making the early diagnosis of cardiac sarcoidosis using these new tools and to provide a framework for the optimal care of patients with this disease. We will review disease mechanisms as currently understood, associated arrhythmias including conduction abnormalities, and atrial and ventricular tachyarrhythmias, guideline-directed diagnostic criteria, screening of patients with extracardiac sarcoidosis, and the use of pacemakers and defibrillators in this setting. Treatment options, including those related to heart failure, and those which may help clarify disease mechanisms are included.

6.
Europace ; 2021 Jan 26.
Artigo em Inglês | MEDLINE | ID: mdl-33496319

RESUMO

AIMS: Response to cardiac resynchronization therapy (CRT) is associated with improved survival, and reduction in heart failure hospitalization, and ventricular arrhythmia (VA) risk. However, the impact of CRT super-response [CRT-SR, increase in left ventricular ejection fraction (LVEF) to ≥ 50%] on VA remains unclear. METHODS AND RESULTS: We undertook a meta-analysis aimed at determining the impact of CRT response and CRT-SR on risk of VA and all-cause mortality. Systematic search of PubMed, EMBASE, and Cochrane databases, identifying all relevant English articles published until 31 December 2019. A total of 34 studies (7605 patients for VA and 5874 patients for all-cause mortality) were retained for the meta-analysis. The pooled cumulative incidence of appropriate implantable cardioverter-defibrillator therapy for VA was significantly lower at 13.0% (4.5% per annum) in CRT-responders, vs. 29.0% (annualized rate of 10.0%) in CRT non-responders, relative risk (RR) 0.47 [95% confidence interval (CI) 0.39-0.56, P < 0.0001]; all-cause mortality 3.5% vs. 9.1% per annum, RR of 0.38 (95% CI 0.30-0.49, P < 0.0001). The pooled incidence of VA was significantly lower in CRT-SR compared with CRT non-super-responders (non-responders + responders) at 0.9% vs. 3.8% per annum, respectively, RR 0.22 (95% CI 0.12-0.40, P < 0.0001); as well as all-cause mortality at 2.0% vs. 4.3%, respectively, RR 0.47 (95% CI 0.33-0.66, P < 0.0001). CONCLUSIONS: Cardiac resynchronization therapy super-responders have low absolute risk of VA and all-cause mortality. However, there remains a non-trivial residual absolute risk of these adverse outcomes in CRT responders. These findings suggest that among CRT responders, there may be a continued clinical benefit of defibrillators.

9.
JACC Clin Electrophysiol ; 6(9): 1171-1181, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32972554

RESUMO

OBJECTIVES: This study compared clinical outcomes between an increased electrical delay in the left ventricular region (QLV)-based LV lead implantation approach (QLV arm) and anatomical implantation approach (control arm) in patients with non-left bundle branch block. BACKGROUND: Limited data exist on cardiac resynchronization therapy effectiveness in patients with non-left bundle branch block. Clinicians generally deliver cardiac resynchronization therapy through an anatomical implantation approach; however, targeting the QLV may serve as an individualized implantation strategy in non-left bundle branch block patients. METHODS: The study enrolled 248 subjects at 29 U.S. centers. Subjects were randomized in a 2:1 ratio between a QLV-based implantation approach and anatomical implantation approach and were implanted with a St. Jude Medical quadripolar cardiac resynchronization therapy defibrillator system. The primary endpoint was the clinical composite score after 12 months of follow-up. RESULTS: The study analyzed 191 available subjects at 12 months of follow-up (128 QLV arm, 63 control arm). Of these, 39 subjects (26 in the QLV arm and 13 in the control arm) had heart failure events (8 cardiac deaths and 31 heart failure hospitalizations). Aside from New York Heart Association functional class, there were no other significant differences in baseline characteristics between the 2 arms. The responder rate at 12 months measured by the clinical composite score was 67.2% in the QLV arm and 73.0% in the control arm (p = 0.506). CONCLUSIONS: Although patient-tailored left ventricular lead placement guided by QLV is promising, we observed no difference in outcome between the QLV-based implantation approach and the conventional anatomical implantation approach.

11.
Echocardiography ; 37(10): 1557-1565, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32914427

RESUMO

BACKGROUND: Cardiac resynchronization therapy (CRT) improves left heart geometry and function in nonischemic cardiomyopathy (NICMP). We aimed to detail the effects of CRT on left ventricular (LV) and mitral valve (MV) remodeling using 2-dimensional transthoracic echocardiography. METHODS: Forty-five consecutive patients with NICMP who underwent CRT implantation between 2009 and 2012, and had pre-CRT and follow-up echocardiograms available, were included. Paired t test, linear and logistic regression, and Kaplan-Meier survival analyses were used for statistical assessment. RESULTS: The mean age and QRS duration were 60 years and 157 ms, respectively, and 13 (28.9%) were female. At a mean follow-up of 3 years, there were 22 (48.9%) "CRT responders" (≥15% reduction in LV end-systolic volume index [LVESVi]). Significant improvements were observed in LV ejection fraction (26.3% vs 34.3%) and LVESVi (87.7 vs 71.1 mL/m2 ), as well as mitral regurgitation vena contracta width, MV tenting height and area, and end-systolic interpapillary muscle distance. Five-year actuarial survival was 87.5%. Multivariate regression analyses revealed the pre-CRT LVESVi (ß = 0.52), and MV coaptation length (ß = -0.34) and septolateral annular diameter (ß = 0.25) as good correlates of follow-up LVESVi. Variables associated with CRT response were pre-CRT MV coaptation length (OR 1.75, 95% CI 1.0-3.1) and posterior leaflet tethering angle (OR 1.07, 95% CI 1.0-1.14), irrespective of baseline QRS morphology and duration (all P < .05). CONCLUSIONS: Cardiac resynchronization therapy improves LV and MV geometry and function in half of patients with NICMP, which is paralleled by decreased mitral regurgitation severity. The extent of pre-CRT LV remodeling and MV tethering are associated with CRT response.

12.
Heart Fail Rev ; 2020 Jul 27.
Artigo em Inglês | MEDLINE | ID: mdl-32720083

RESUMO

Machine learning (ML) algorithms "learn" information directly from data, and their performance improves proportionally with the number of high-quality samples. The aim of our systematic review is to present the state of the art regarding the implementation of ML techniques in the management of heart failure (HF) patients. We manually searched MEDLINE and Cochrane databases as well the reference lists of the relevant review studies and included studies. Our search retrieved 122 relevant studies. These studies mainly refer to (a) the role of ML in the classification of HF patients into distinct categories which may require a different treatment strategy, (b) discrimination of HF patients from the healthy population or other diseases, (c) prediction of HF outcomes, (d) identification of HF patients from electronic records and identification of HF patients with similar characteristics who may benefit form a similar treatment strategy, (e) supporting the extraction of important data from clinical notes, and (f) prediction of outcomes in HF populations with implantable devices (left ventricular assist device, cardiac resynchronization therapy). We concluded that ML techniques may play an important role for the efficient construction of methodologies for diagnosis, management, and prediction of outcomes in HF patients.

13.
J Am Heart Assoc ; 9(12): e012405, 2020 Jun 16.
Artigo em Inglês | MEDLINE | ID: mdl-32476539

RESUMO

Background There are conflicting data regarding the benefit of primary prevention implantable cardioverter-defibrillators (ICDs) in patients with diabetes mellitus and heart failure (HF) with reduced ejection fraction. We aimed to assess the comparative effectiveness of ICD placement in patients with diabetes mellitus and HF with reduced ejection fraction. Methods and Results Data were obtained from the Get With the Guidelines-Health Failure registry, linked with claims from the Centers for Medicare & Medicaid Services. We used a Cox proportional hazards model censored at 5 years with propensity score matching. Of the 17 186 patients with HF with reduced ejection fraction from the Centers for Medicare & Medicaid Services claims database (6540 with diabetes mellitus; 38%), 1677 (646 with diabetes mellitus; 39%) received an ICD during their index HF hospitalization or were prescribed an ICD at discharge. Patients with diabetes mellitus and an ICD (n=646), as compared with those without an ICD (n=1031), were more likely to be younger (74 versus 78 years of age) and have coronary artery disease (68% versus 60%). After propensity matching, ICD use among patients with diabetes mellitus, as compared with those without an ICD, was associated with a reduced risk of all-cause mortality at 5 years after HF discharge (54% versus 59%; multivariable hazard ratio, 0.73; 95% CI, 0.64-0.82; P<0.0001). Ischemic heart disease did not modify the association between ICD use and all-cause mortality (P=0.95 for interaction). Similar results were seen in patients without diabetes mellitus. Conclusions Primary prevention ICD use among older patients with HF with reduced ejection fraction and diabetes mellitus was associated with a reduced risk of all-cause mortality. Our analysis supports current guideline recommendations for implantation of primary prevention ICDs among older patients with diabetes mellitus and HF with reduced ejection fraction.

14.
Circ Arrhythm Electrophysiol ; 13(6): e008186, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32434448

RESUMO

BACKGROUND: Repolarization alternans (RA) has been implicated in the pathogenesis of ventricular arrhythmias and sudden cardiac death. METHODS: We have developed a real-time, closed-loop system to record and analyze RA from multiple intracardiac leads, and deliver dynamically R-wave triggered pacing stimuli during the absolute refractory period. We have evaluated the ability of this system to control RA and reduce arrhythmia susceptibility, in vivo. RESULTS: R-wave triggered pacing can induce RA, the magnitude of which can be modulated by varying the amplitude, pulse width, and size of the pacing vector. Using a swine model (n=9), we demonstrate that to induce a 1 µV change in the alternans voltage on the body surface, coronary sinus and left ventricle leads, requires a delivered charge of 0.04±0.02, 0.05±0.025, and 0.06±0.033 µC, respectively, while to induce a one unit change of the Kscore, requires a delivered charge of 0.93±0.73, 0.32±0.29, and 0.33±0.37 µC, respectively. For all body surface and intracardiac leads, both Δ(alternans voltage) and ΔKscore between baseline and R-wave triggered paced beats increases consistently with an increase in the pacing pulse amplitude, pulse width, and vector spacing. Additionally, we show that the proposed method can be used to suppress spontaneously occurring alternans (n=7), in the presence of myocardial ischemia. Suppression of RA by pacing during the absolute refractory period results in a significant reduction in arrhythmia susceptibility, evidenced by a lower Srank score during programmed ventricular stimulation compared with baseline before ischemia. CONCLUSIONS: We have developed and evaluated a novel closed-loop method to dynamically modulate RA in a swine model. Our data suggest that suppression of RA directly reduces arrhythmia susceptibility and reinforces the concept that RA plays a critical role in the pathophysiology of arrhythmogenesis.


Assuntos
Potenciais de Ação , Arritmias Cardíacas/prevenção & controle , Estimulação Cardíaca Artificial/métodos , Sistema de Condução Cardíaco/fisiopatologia , Período Refratário Eletrofisiológico , Animais , Arritmias Cardíacas/etiologia , Arritmias Cardíacas/fisiopatologia , Modelos Animais de Doenças , Frequência Cardíaca , Isquemia Miocárdica/complicações , Isquemia Miocárdica/fisiopatologia , Sus scrofa , Fatores de Tempo
15.
JACC Clin Electrophysiol ; 6(5): 467-483, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32439031

RESUMO

The autonomic nervous system plays a central role in the pathogenesis of multiple cardiac arrhythmias, including atrial fibrillation and ventricular tachycardia. As such, autonomic modulation represents an attractive therapeutic approach in these conditions. Notably, autonomic modulation exploits the plasticity of the neural tissue to induce neural remodeling and thus obtain therapeutic benefit. Different forms of autonomic modulation include vagus nerve stimulation, tragus stimulation, renal denervation, baroreceptor activation therapy, and cardiac sympathetic denervation. This review seeks to highlight these autonomic modulation therapeutic modalities, which have shown promise in early preclinical and clinical trials and represent exciting alternatives to standard arrhythmia treatment. We also present an overview of the various methods used to assess autonomic tone, including heart rate variability, skin sympathetic nerve activity, and alternans, which can be used as surrogate markers and predictors of the treatment effect. Although the use of autonomic modulation to treat cardiac arrhythmias is supported by strong preclinical data and preliminary studies in humans, in light of the disappointing results of a number of recent randomized clinical trials of autonomic modulation therapies in heart failure, the need for optimization of the stimulation parameters and rigorous patient selection based on appropriate biomarkers cannot be overemphasized.

16.
Circ Cardiovasc Qual Outcomes ; 13(5): e006043, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32393130

RESUMO

BACKGROUND: Reducing hospital readmission after acute myocardial infarction (AMI) has the potential to both improve quality and reduce costs. As such, readmission after AMI has been a target of financial penalties through Medicare. However, substantial concern exists about potential adverse effects and efficacious readmission-reduction strategies are not well validated. METHODS AND RESULTS: We started an AMI readmissions reduction program in November 2017. Between July 2016 and February 2019, hospital billing data were queried to detect all inpatient hospitalizations at the Massachusetts General Hospital for AMI. Thirty-day readmission was identified through hospital billing data, and mortality was extracted from our electronic health record. The data set was merged with claims data for patients in accountable care organizations to detect readmission at other hospitals. We performed segmented linear regression, adjusting for secular trend and case mix, to assess the independent association of our program on both outcome variables. After inclusion and exclusion criteria were applied, the study population included 2020 patients. The overall 30-day readmission rate was higher before the intervention than after the intervention (15.5% versus 10.7%, P=0.002). The overall 30-day mortality rate was similar in both time periods (1.8% versus 1.4%, P=0.457). The program was associated with initial reduction in 30-day readmission (-9.8%, P=0.0002) and 30-day mortality (-2.6%, P=0.041). The program did not change trend in 30-day readmission (+0.19% readmissions/mo, P=0.554) and trend in 30-day mortality (-0.21% deaths/mo, P=0.119). CONCLUSIONS: An AMI readmissions reduction program that increases outpatient and emergency department (ED) access to cardiology care is associated with reduced 30-day readmission and 30-day mortality. Similar statistical techniques can be used to conduct a rigorous, mechanistic program evaluation of other quality improvement initiatives.


Assuntos
Prestação Integrada de Cuidados de Saúde/tendências , Infarto do Miocárdio/terapia , Pacotes de Assistência ao Paciente/tendências , Readmissão do Paciente/tendências , Melhoria de Qualidade/tendências , Indicadores de Qualidade em Assistência à Saúde/tendências , Idoso , Idoso de 80 Anos ou mais , Assistência Ambulatorial/tendências , Boston , Serviço Hospitalar de Cardiologia/tendências , Serviço Hospitalar de Emergência/tendências , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/mortalidade , Avaliação de Programas e Projetos de Saúde , Fatores de Tempo , Resultado do Tratamento
18.
J Am Coll Cardiol ; 75(13): 1582-1592, 2020 04 07.
Artigo em Inglês | MEDLINE | ID: mdl-32241375

RESUMO

Ambulatory monitoring devices are enabling a new paradigm of health care by collecting and analyzing long-term data for reliable diagnostics. These devices are becoming increasingly popular for continuous monitoring of cardiac diseases. Recent advancements have enabled solutions that are both affordable and reliable, allowing monitoring of vulnerable populations from the comfort of their homes. They provide early detection of important physiological events, leading to timely alerts for seeking medical attention. In this review, the authors aim to summarize the recent developments in the area of ambulatory and remote monitoring solutions for cardiac diagnostics. The authors cover solutions based on wearable devices, smartphones, and other ambulatory sensors. The authors also present an overview of the limitations of current technologies, their effectiveness, and their adoption in the general population, and discuss some of the recently proposed methods to overcome these challenges. Lastly, we discuss the possibilities opened by this new paradigm, for the future of health care and personalized medicine.

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