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1.
Lancet ; 394(10216): 2255-2262, 2020 12 21.
Artigo em Inglês | MEDLINE | ID: mdl-31862250

RESUMO

BACKGROUND: More than 80% of public-access defibrillation attempts do not result in sustained return of spontaneous circulation in patients who have had an out-of-hospital cardiac arrest (OHCA) and a shockable heart rhythm before arrival of emergency medical service (EMS) personnel. Neurological and survival outcomes in such patients have not been evaluated. We aimed to assess the neurological status and survival outcomes in such patients. METHODS: This is a retropective analysis of a cohort study from a prospective, nationwide, population-based registry of 1 299 784 patients who had an OHCA event between Jan 1, 2005, and Dec 31, 2015 in Japan. The primary outcome was favourable neurological outcome (Cerebral Performance Category of 1 or 2) at 30 days after the OHCA and the secondary outcome was survival at 30 days following the OHCA. This study is registered with the University Hospital Medical Information Network Clinical Trials Registry, UMIN000009918. FINDINGS: We identified 28 019 patients with bystander-witnessed OHCA and shockable heart rhythm who had received CPR from a bystander. Of these, 2242 (8·0%) patients did not achieve return of spontaneous circulation with CPR plus public-access defibrillation, and 25 087 (89·5%) patients did not achieve return of spontaneous circulation with CPR alone before EMS arrival. The proportion of patients with a favourable neurological outcome was significantly higher in those who received public-access defibrillation than those who did not (845 [37·7%] vs 5676 [22·6%]; adjusted odds ratio [OR] after propensity score-matching, 1·45 [95% CI 1·24-1·69], p<0·0001). The proportion of patients who survived at 30 days after the OHCA was also significantly higher in those who received public-access defibrillation than those who did not (987 [44·0%] vs 7976 [31·8%]; adjusted OR after propensity score-matching, 1·31 [95% CI 1·13-1·52], p<0·0001). INTERPRETATION: Our findings support the benefits of public-access defibrillation and greater accessibility and availability of automated external defibrillators in the community. FUNDING: None.


Assuntos
Reanimação Cardiopulmonar/instrumentação , Cardioversão Elétrica/instrumentação , Doenças do Sistema Nervoso/etiologia , Parada Cardíaca Extra-Hospitalar/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Reanimação Cardiopulmonar/métodos , Desfibriladores , Cardioversão Elétrica/métodos , Serviços Médicos de Emergência , Feminino , Humanos , Japão/epidemiologia , Masculino , Pessoa de Meia-Idade , Doenças do Sistema Nervoso/epidemiologia , Razão de Chances , Parada Cardíaca Extra-Hospitalar/complicações , Parada Cardíaca Extra-Hospitalar/mortalidade , Pontuação de Propensão , Estudos Prospectivos , Logradouros Públicos , Recuperação de Função Fisiológica , Sistema de Registros , Estudos Retrospectivos
2.
Emergencias (Sant Vicenç dels Horts) ; 31(5): 335-340, oct. 2019. graf, tab
Artigo em Espanhol | IBECS | ID: ibc-184123

RESUMO

Objetivo. Analizar la seguridad de la cardioversión de la fibrilación auricular (FA) de reciente comienzo realizada en un servicio de urgencias hospitalario (SUH). Método. Estudio observacional, retrospectivo y analítico en un SUH. Se recogieron de forma consecutiva los episodios de FA de menos de 48 horas de evolución y hemodinámicamente estables, en los que se realizó una cardioversión urgente (CVU) y los episodios derivados para valorar cardioversión programada ambulatoria (CVP). La variable de resultado fue la presencia de eventos embólicos (EE) o hemorrágicos (EH) a los 90 días. Resultados. Se analizaron 718 cardioversiones en 570 pacientes. La edad media fue de 64 años (DE 13,5). Se realizaron 479 (66,7%) CVU y 239 (33,3%) CVP. Se recogieron un total de 11 (1,5%) eventos: dos EE (0,3%) y 9 EH (1,3%). Todos los EH fueron hemorragias menores. No se encontraron diferencias estadísticamente significativas entre ambos grupos. Conclusión. La CVU de la FA de reciente comienzo en los SUH es una estrategia segura


Objective. To analyze the safety of electric cardioversion performed for recent-onset atrial fibrillation in a hospital emergency department. Methods. Observational retrospective analysis of consecutive emergency department cases of atrial fibrillation of less than 48 hours’ duration in hemodynamically stable patients. All included cases were either treated with emergency electric cardioversion or referred for evaluation and scheduling of outpatient cardioversion. The outcome variable was the occurrence of a thromboembolic or hemorrhagic event within 90 days. Results. A total of 718 cardioversions in 570 patients were analyzed. The mean (SD) age of the patients was 64 (13.5) years. Four hundred seventy-nine emergency cardioversions (66.7%) and 239 (33.3%) scheduled cardioversions were performed. Eleven adverse events (1.5% of the cohort) occurred: 2 were thromboembolic events (0.3%) and 9 were hemorrhagic (1.3%). All bleeds were minor. There were no statistically significant differences in the rate of adverse events between the emergency and scheduled cardioversion groups. Conclusion. Emergency cardioversion for recent-onset atrial fibrillation is safe


Assuntos
Humanos , Pessoa de Meia-Idade , Cardioversão Elétrica/instrumentação , Fibrilação Atrial/terapia , Serviços Médicos de Emergência , Cardioversão Elétrica/métodos , Cardioversão Elétrica/tendências , Segurança do Paciente , Estudos de Coortes , Estudos Retrospectivos , Análise Multivariada
5.
Emergencias (Sant Vicenç dels Horts) ; 31(4): 227-233, ago. 2019. graf, tab
Artigo em Espanhol | IBECS | ID: ibc-182762

RESUMO

Objetivos: Este estudio analiza el control del ritmo en los servicios de urgencias (SUH) y sus resultados en pacientes con fibrilación auricular (FA) de reciente comienzo, para identificar áreas de mejora en el manejo. Método: Estudio multicéntrico, observacional, prospectivo y transversal desarrollado en 124 SUH representativos del sistema sanitario español basado en el registro HERMES-AF (estrategias de manejo en el servicio de urgencias hospitalario de la FA) del 23 de mayo al 5 de junio de 2011. Se incluyeron pacientes con FA sintomática con menos de 48 h de evolución en los cuales se tomó la decisión de restaurar el ritmo sinusal. Resultados: Se incluyeron 337 pacientes, se optó por cardioversión farmacológica en 311 pacientes (92,3%), y por cardioversión eléctrica en 52 (15%), la mitad de los casos tras fracaso de los fármacos. Se obtuvo ritmo sinusal (RS) en 278 pacientes (82,5%) y el alivio de los síntomas en 297 (94%), con una tasa de efectos adversos del 0,9%, ninguno grave. Amiodarona se asoció de manera independiente a una menor tasa de RS al alta (OR = 0,442; IC 95% 0,238-0,823; p = 0,01), al contrario que la cardioversión eléctrica (OR = 4,0; IC 95% 1,2-13,3; p = 0,024). Los fármacos I-C se asociaron con una mayor proporción de altas en < 6 h (OR 2,6; IC 95% 1,6-4,3; p < 0,001) y amiodarona con más estancias prolongadas de > 24 h (OR 2,7, IC 95% 1,5-4,8; p < 0,003). Conclusiones: En los SUH, la restauración del RS en la FA de reciente comienzo es segura, efectiva y asocia beneficios clínicos para los pacientes. Reemplazar amiodarona por técnicas más efectivas y rápidas como la cardioversión eléctrica o los fármacos I-C es un área de mejora de la calidad asistencial


Objectives: To analyze heart rate control in hospital emergency departments and outcomes in patients with recent onset atrial fibrillation (AF) so that targets for improvement can be identified. Methods: Multicenter, prospective observational cross-sectional study in a representative sample of 124 hospitals of the Spanish health services, based on records in the HERMES-AF database (Hospital Emergency Department Management Strategies for AF) for May 23 to June 5, 2011. Patients with symptomatic AF within 48 hours of onset were enrolled when the decision was made to attempt restoration of sinus rhythm. Results: We included 337 patients. Chemical cardioversion was used in 311 (92.3%) and electrical cardioversion in 52 (15%), after drugs had failed in half the cases. Sinus rhythm was restored in 278 patients (82.5%), and symptoms resolved in 94%. Adverse effects were recorded in 0.9% but none were serious. Amiodarone was independently associated with a lower rate of restored sinus rhythm (odds ratio [OR], 0.442; 95% CI, 0.238-0.823; P=.01) than electrical cardioversion (OR, 4.0; 95% CI, 1.2-13.3; P=.024). The use of class Ic antiarrhythmic agents was associated with a higher percentage of discharges in less than 6 hours (OR, 2.6; 95% CI, 1.6-4.3; P<.001), and amiodarone was associated with hospital stays longer than 24 hours (OR, 2.7; 95% CI, 1.5-4.8; P<.003). Conclusions: Emergency department restoration of sinus rhythm in patients with AF is safe, effective, and associated with clinical benefits. Quality of care could be improved by replacing the use of amiodarone with faster and more effective treatments such as electrical cardioversion or the use of class Ic agents


Assuntos
Humanos , Feminino , Pessoa de Meia-Idade , Cardioversão Elétrica/métodos , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/terapia , Serviços Médicos de Emergência , Ritmo Circadiano/efeitos dos fármacos , Sistema de Registros/normas , Cardioversão Elétrica/tendências , Estudos Prospectivos , Estudos Transversais , Espanha , Antiarrítmicos/administração & dosagem , Sistemas de Saúde/organização & administração
6.
Crit Care Nurs Clin North Am ; 31(3): 437-452, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31351560

RESUMO

Cardiac surgical patients risk arrest from tamponade, profound bleeding, and hypovolemia, typically occurring within hours of intensive care admission and associated with diminished response to cardiopulmonary resuscitation (CPR). The Society of Thoracic Surgeons' evidence-based Expert Consensus Statement establishes a new standard for postsurgery arrest management, prioritizing defibrillation or pacing before CPR, restricting epinephrine use, and calling for prompt resternotomy if initial efforts fail. The protocol is summarized in a simple algorithm replacing advanced cardiac life support. This US cardiac surgical resuscitation standard is aligned with worldwide guidelines. Important information for protocol adoption and training is provided.


Assuntos
Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Cardioversão Elétrica/métodos , Guias como Assunto , Parada Cardíaca/terapia , Reanimação Cardiopulmonar/efeitos adversos , Cuidados Críticos , Humanos
7.
Taiwan J Obstet Gynecol ; 58(4): 552-556, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31307750

RESUMO

OBJECTIVE: Patients with Long QT syndrome (LQTS) P may present with torsades de pointes, ventricular tachycardia (VT), or ventricular fibrillation (VF) and are at risk of sudden cardiac death. MATERIALS AND METHODS: A 38 y/o female patient with uterus myoma developed VF during laparoscopic assisted vaginal hysterectomy surgery. Defibrillation was delivered and the electrocardiogram (ECG) returned to sinus rhythm after CPR. RESULTS: Patient survived and implantable cardioverter-defibrillator was implanted and received beta-blocker therapy. ECG obtained in out-patient clinic still showed QT interval prolongation, but revealed no prolongation few months after persistent beta-blocker therapy. LQTS type 8 (CACNA1C E768del mutation) was identified by genetic DNA sequencing study. CONCLUSIONS: Patients with concealed LQTS may have normal QT interval unless exposing to stress or specific stimuli. Unexpected ventricular arrhythmia may happen during any medical management. We should avoid triggers of QT prolongation, and get familiar with management of the episode.


Assuntos
Morte Súbita Cardíaca , Cardioversão Elétrica/métodos , Histerectomia/métodos , Leiomioma/cirurgia , Síndrome do QT Longo/complicações , Neoplasias Uterinas/cirurgia , Adulto , Anestesia Geral/efeitos adversos , Anestesia Geral/métodos , Reanimação Cardiopulmonar/métodos , Desfibriladores Implantáveis , Eletrocardiografia/métodos , Feminino , Humanos , Laparoscopia/métodos , Leiomioma/complicações , Leiomioma/diagnóstico , Síndrome do QT Longo/congênito , Síndrome do QT Longo/diagnóstico , Prognóstico , Medição de Risco , Índice de Gravidade de Doença , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/etiologia , Taquicardia Ventricular/terapia , Resultado do Tratamento , Neoplasias Uterinas/complicações , Neoplasias Uterinas/diagnóstico
8.
Biomed Res Int ; 2019: 6539050, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31309111

RESUMO

Objective: To determine whether the administration of intra-arrest cyclosporine (CCY) and methylprednisolone (MP) preserves left ventricular ejection fraction (LVEF) and cardiac output (CO) after return of spontaneous circulation (ROSC). Methods: Eleven, 25-30kg female swine were randomized to receive 10mg/kg CCY + 40mg MP or placebo, anesthetized and given a transthoracic shock to induce ventricular fibrillation. After 8 minutes, standard CPR was started. After two additional minutes, the experimental agent was administered. Animals with ROSC were supported for up to 12h with norepinephrine as needed. Echocardiography was performed at baseline, and 1, 2, 6 and 12h post-ROSC. Analysis was performed using generalized estimating equations (GEE) after downsampling continuously sampled data to 5 minute epochs. Results: Eight animals (64%) achieved ROSC after a median of 7 [IQR 5-13] min of CPR, 2 [ IQR 1-3] doses of epinephrine and 2 [IQR 1-5] defibrillation shocks. Animals receiving CCY+MP had higher post ROSC MAP (GEE coefficient -10.2, P = <0.01), but reduced cardiac output (GEE coefficient 0.8, P = <0.01) compared to placebo. There was no difference in LVEF or vasopressor use between arms. Conclusions: Intra-arrest cyclosporine and methylprednisolone decreased post-arrest cardiac output and increased mean arterial pressure without affecting left ventricular ejection fraction.


Assuntos
Cardiomiopatias/tratamento farmacológico , Ciclosporina/farmacologia , Parada Cardíaca/tratamento farmacológico , Metilprednisolona/farmacologia , Animais , Débito Cardíaco/efeitos dos fármacos , Reanimação Cardiopulmonar/métodos , Ecocardiografia/métodos , Cardioversão Elétrica/métodos , Epinefrina/farmacologia , Feminino , Ventrículos do Coração/efeitos dos fármacos , Suínos , Vasoconstritores/farmacologia , Fibrilação Ventricular/tratamento farmacológico
9.
Am J Med Sci ; 358(2): 143-148, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31200920

RESUMO

BACKGROUND: The influence of time to defibrillation in patients with shockable in-hospital cardiac arrest (IHCA) has not been fully assessed. This study investigated the association between time to defibrillation and neurologic outcome in shockable IHCA survivors. MATERIALS AND METHODS: A 7-year retrospective cohort study was conducted using a prospectively collected registry of adult IHCA patients. Patients whose first documented rhythm was pulseless ventricular tachycardia or ventricular fibrillation and who received defibrillation within 5 minutes were included. RESULTS: Among 1,683 IHCA patients, 261 patients were included. At 28 days, a good neurologic outcome (Cerebral Performance Category score 1 or 2) according to time to defibrillation was seen in 49.0%, 21.1%, 13.4% and 16.5% of patients treated at <2 minutes (n = 128), 2-3 minutes (n = 55), 3-4 minutes (n = 35) and 4-5 minutes (n = 43) after IHCA, respectively. After adjusting for clinical characteristics, a graded inverse association was found after 3 minutes. CONCLUSIONS: A graded inverse association between time to defibrillation and neurologic outcome was observed beyond 3 minutes following cardiac arrest. A target time to defibrillation of <3 minutes may be a practical target goal in resource-limited hospitals.


Assuntos
Reanimação Cardiopulmonar , Estado de Consciência/fisiologia , Cardioversão Elétrica , Parada Cardíaca/terapia , Hospitalização , Idoso , Reanimação Cardiopulmonar/métodos , Reanimação Cardiopulmonar/estatística & dados numéricos , Estudos de Coortes , Cardioversão Elétrica/métodos , Cardioversão Elétrica/estatística & dados numéricos , Feminino , Parada Cardíaca/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Centros de Atenção Terciária , Fatores de Tempo
10.
N Z Med J ; 132(1496): 39-46, 2019 06 07.
Artigo em Inglês | MEDLINE | ID: mdl-31170132

RESUMO

AIMS: Guidelines recommend initial rate control in haemodynamically stable patients with atrial fibrillation (AF) or atrial flutter (AFL) and acute decompensated heart failure (ADHF). There is limited data on early inpatient rhythm control. We investigated the outcomes of patients managed with early TOE-guided DC cardioversion (DCCV) or ablation. METHODS: We retrospectively analysed patients admitted to a single centre with AF or AFL and ADHF with LVEF≤40% that underwent inpatient TOE-guided DCCV or ablation. The primary endpoint was the one year composite outcome of mortality or rehospitalisation for heart failure. RESULTS: We identified 79 patients, including 33 with AF (32 DCCV, one ablation) and 46 with AFL (22 DCCV, 24 ablation). The primary endpoint occurred in 20%. One-year mortality was 2.5%. There were significantly fewer rehospitalisations for arrhythmia or heart failure with AFL-ablation compared to AFL-DCCV (21% vs 64%, p=<0.01). Clinical recurrence of AF or AFL was 43%. At follow-up LV assessment, LVEF>40% was found in 75% (p=<0.01), including 87% of patients without known cardiomyopathy and 82% of patients in sinus rhythm. CONCLUSION: Early inpatient DCCV or ablation for AF or AFL and ADHF had low mortality rates and rehospitalisation for heart failure with substantial improvement in LV function at follow-up.


Assuntos
Fibrilação Atrial/terapia , Flutter Atrial/terapia , Ablação por Cateter/métodos , Ecocardiografia Transesofagiana/métodos , Cardioversão Elétrica/métodos , Idoso , Fibrilação Atrial/diagnóstico por imagem , Fibrilação Atrial/mortalidade , Flutter Atrial/diagnóstico por imagem , Flutter Atrial/mortalidade , Ablação por Cateter/mortalidade , Distribuição de Qui-Quadrado , Estudos de Coortes , Ecocardiografia/métodos , Cardioversão Elétrica/mortalidade , Feminino , Insuficiência Cardíaca/prevenção & controle , Humanos , Masculino , Pessoa de Meia-Idade , Nova Zelândia , Readmissão do Paciente/estatística & dados numéricos , Seleção de Pacientes , Prognóstico , Recidiva , Estudos Retrospectivos , Medição de Risco , Índice de Gravidade de Doença , Estatísticas não Paramétricas , Taxa de Sobrevida , Resultado do Tratamento
11.
PLoS One ; 14(5): e0216756, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31107876

RESUMO

Early defibrillation by an automated external defibrillator (AED) is key for the survival of out-of-hospital cardiac arrest (OHCA) patients. ECG feature extraction and machine learning have been successfully used to detect ventricular fibrillation (VF) in AED shock decision algorithms. Recently, deep learning architectures based on 1D Convolutional Neural Networks (CNN) have been proposed for this task. This study introduces a deep learning architecture based on 1D-CNN layers and a Long Short-Term Memory (LSTM) network for the detection of VF. Two datasets were used, one from public repositories of Holter recordings captured at the onset of the arrhythmia, and a second from OHCA patients obtained minutes after the onset of the arrest. Data was partitioned patient-wise into training (80%) to design the classifiers, and test (20%) to report the results. The proposed architecture was compared to 1D-CNN only deep learners, and to a classical approach based on VF-detection features and a support vector machine (SVM) classifier. The algorithms were evaluated in terms of balanced accuracy (BAC), the unweighted mean of the sensitivity (Se) and specificity (Sp). The BAC, Se, and Sp of the architecture for 4-s ECG segments was 99.3%, 99.7%, and 98.9% for the public data, and 98.0%, 99.2%, and 96.7% for OHCA data. The proposed architecture outperformed all other classifiers by at least 0.3-points in BAC in the public data, and by 2.2-points in the OHCA data. The architecture met the 95% Sp and 90% Se requirements of the American Heart Association in both datasets for segment lengths as short as 3-s. This is, to the best of our knowledge, the most accurate VF detection algorithm to date, especially on OHCA data, and it would enable an accurate shock no shock diagnosis in a very short time.


Assuntos
Aprendizado Profundo , Diagnóstico por Computador/métodos , Fibrilação Ventricular/diagnóstico , Algoritmos , Bases de Dados Factuais/estatística & dados numéricos , Desfibriladores/estatística & dados numéricos , Diagnóstico por Computador/estatística & dados numéricos , Cardioversão Elétrica/métodos , Cardioversão Elétrica/estatística & dados numéricos , Eletrocardiografia/estatística & dados numéricos , Eletrocardiografia Ambulatorial/estatística & dados numéricos , Humanos , Memória de Curto Prazo , Parada Cardíaca Extra-Hospitalar/diagnóstico , Parada Cardíaca Extra-Hospitalar/terapia , Processamento de Sinais Assistido por Computador , Máquina de Vetores de Suporte
13.
Am J Ther ; 26(4): e469-e480, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30946044

RESUMO

BACKGROUND: The optimal management for the prevention of recurrent ventricular tachycardia in patients with implantable cardioverter-defibrillators (ICDs) offers a challenge with no set guidelines regarding which therapy offers a best safety and efficacy profile. STUDY QUESTION: Which therapeutic strategy, among antiarrhythmic drugs and catheter ablation (CA), offers the most effective and safe approach in patients with ICDs? DATA SOURCES: Randomized controlled trials (RCTs) comparing the efficacy and safety of antiarrhythmic drugs or CA against a placebo group. RCTs were identified from a comprehensive search in PubMed, Embase, and Cochrane library. STUDY DESIGN: Our outcomes of interest were reductions in appropriate ICD shocks, inappropriate ICD shocks, and overall mortality. We used the event rates in both groups, and then using a frequentist approach employing a graph theory methodology, we constructed a network meta-analysis model. RESULTS: Fourteen RCTs with 3815 participants and 6 different interventions treatments were included in our network meta-analysis. The most effective treatment for the prevention of recurrent ventricular tachycardia after ICD is amiodarone followed by CA. Amiodarone is most effective in the reduction of appropriate and inappropriate ICD shocks with an odds ratio (OR) of 0.29 [95% confidence interval (CI), 0.11-0.74] and 0.15 (95% CI, 0.04-0.60), respectively. CA was effective in the reduction of appropriate ICD shocks (OR, 0.41; 95% CI, 0.20-0.87), whereas sotalol was effective in the reduction of inappropriate ICD shocks (OR, 0.46; 95% CI, 0.22-0.95). There was no significant reduction in the overall mortality from any therapy. There was a trend of increased mortality associated with amiodarone therapy (OR, 2.40; 95% CI, 0.92-6.26). CONCLUSIONS: Amiodarone remains the most efficacious therapy for the reduction of appropriate and inappropriate shocks in patients with ICD. No therapy resulted in mortality reduction, but amiodarone showed a trend toward increased mortality.


Assuntos
Desfibriladores Implantáveis , Insuficiência Cardíaca/prevenção & controle , Prevenção Secundária/métodos , Taquicardia Ventricular/prevenção & controle , Antiarrítmicos/administração & dosagem , Antiarrítmicos/efeitos adversos , Ablação por Cateter/efeitos adversos , Ablação por Cateter/métodos , Cardioversão Elétrica/efeitos adversos , Cardioversão Elétrica/métodos , Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/mortalidade , Humanos , Meta-Análise em Rede , Recidiva , Taquicardia Ventricular/complicações , Taquicardia Ventricular/mortalidade , Resultado do Tratamento
14.
Int J Cardiol ; 284: 33-37, 2019 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-30917880

RESUMO

BACKGROUND: Due to barriers to accessing timely elective electrical cardioversion (CV) for persistent AF (PeAF), we adopted a policy of instructing patients to present directly to the Emergency Department (ED) for CV. OBJECTIVE: We compare a strategy of Emergency CV (ED-CV) versus Elective CV (EL-CV) for treatment of symptomatic PeAF. METHODS: Between 2014 and 7, we evaluated 150 patients undergoing CV for PeAF. ED-CV patients were provided an AF action plan for recurrent symptoms and advised to present to ED within 36 h. EL-CV patients followed standard care, including cardiologist referral and placement on an elective hospital waiting list. Follow-up was 12 months. RESULTS: We included 75 consecutive ED-CV patients and 75 consecutive EL-CV patients. ED-CV patients had a significantly shorter median AF duration prior to CV (1 day vs 3 months; p < 0.01) and less overall AF-related symptoms at 12 months (modified EHRA symptom score ≥ 2a in 44% vs 72%; p = 0.005). Time to next AF recurrence was longer in the ED-CV group (295 ±â€¯15 vs 245 ±â€¯15 days; logrank p = 0.001), as was time to AF ablation referral (314 ±â€¯13 vs 276 ±â€¯15 days; logrank p = 0.01). Baseline LA area was similar (ED-CV 27 ±â€¯4 cm2 vs EL-CV 28 ±â€¯11 cm2; p = 0.67), however EL-CV had larger atria at follow-up (31 ±â€¯8 vs 26 ±â€¯6 cm2; p = 0.01). There were no complications in either group. CONCLUSION: ED-CV is an acceptable strategy for symptomatic PeAF. In addition to reduced time spent in AF and improved symptom scores, this strategy may also slow progression of atrial substrate & delay onset of next AF episode.


Assuntos
Fibrilação Atrial/terapia , Função do Átrio Esquerdo/fisiologia , Remodelamento Atrial/fisiologia , Cardioversão Elétrica/métodos , Átrios do Coração/fisiopatologia , Sistema de Condução Cardíaco/fisiopatologia , Fibrilação Atrial/fisiopatologia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento
15.
Am J Cardiovasc Drugs ; 19(4): 421-427, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30838557

RESUMO

INTRODUCTION: Atrial fibrillation (AF) is associated with an increased risk of thromboembolic events. OBJECTIVES: This study compared the long-term efficacy and safety of apixaban with that of uninterrupted vitamin K antagonist (VKA) therapy in patients with AF scheduled for transesophageal echocardiogram (TEE)-guided direct current cardioversion (DCC) from June 2014 to September 2016. METHODS: We enrolled consecutive patients with persistent nonvalvular AF scheduled to undergo DCC. Patients received apixaban 5 mg or 2.5 mg twice daily (bid) or VKA at therapeutic doses for at least 3 weeks before and 4 weeks after DCC. All patients underwent anamnestic, clinical, electrocardiographic, and echocardiographic evaluation at each follow-up visit and were followed-up for 12 months. The primary efficacy endpoint was the composite of stroke/transient ischemic attack and systemic embolism. The primary safety endpoint was major bleeding. RESULTS: After propensity score matching, comparative treatment groups comprised 182 (75.8%) patients receiving apixaban 5 mg bid and 182 receiving VKA. A low incidence of atrial thrombus (0.5%) at TEE was found in both groups. The acute cardioversion success rate was 86.1% in the apixaban group (156/181) and 83.9% in the VKA group (152/181). During the follow-up period, a similarly low incidence of thromboembolic events (1.1%) was reported in both groups; the bleeding safety profile tended to favor apixaban over VKA (1.1 vs. 1.6%; p = 0.3). CONCLUSIONS: Newly initiated anticoagulation with apixaban in patients with nonvalvular AF scheduled for TEE-guided DCC seems to be as effective and safe as uninterrupted VKA therapy during 12 months of follow-up.


Assuntos
Anticoagulantes/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Inibidores do Fator Xa/uso terapêutico , Pirazóis/uso terapêutico , Piridonas/uso terapêutico , Vitamina K/antagonistas & inibidores , Idoso , Cardioversão Elétrica/métodos , Embolia/tratamento farmacológico , Inibidores do Fator Xa/efeitos adversos , Feminino , Fibrinolíticos/uso terapêutico , Hemorragia/induzido quimicamente , Humanos , Masculino , Pessoa de Meia-Idade , Pontuação de Propensão , Estudos Prospectivos , Pirazóis/efeitos adversos , Piridonas/efeitos adversos , Acidente Vascular Cerebral/tratamento farmacológico , Tromboembolia/tratamento farmacológico
16.
BMJ ; 364: l430, 2019 Feb 28.
Artigo em Inglês | MEDLINE | ID: mdl-30819685

RESUMO

OBJECTIVE: To determine survival associated with advanced airway management (AAM) compared with no AAM for adults with out-of-hospital cardiac arrest. DESIGN: Cohort study between January 2014 and December 2016. SETTING: Nationwide, population based registry in Japan (All-Japan Utstein Registry). PARTICIPANTS: Consecutive adult patients with out-of-hospital cardiac arrest, separated into two sub-cohorts by their first documented electrocardiographic rhythm: shockable (ventricular fibrillation or pulseless ventricular tachycardia) and non-shockable (pulseless electrical activity or asystole). Patients who received AAM during cardiopulmonary resuscitation were sequentially matched with patients at risk of AAM within the same minute on the basis of time dependent propensity scores. MAIN OUTCOME MEASURES: Survival at one month or at hospital discharge within one month. RESULTS: Of the 310 620 patients eligible, 8459 (41.2%) of 20 516 in the shockable cohort and 121 890 (42.0%) of 290 104 in the non-shockable cohort received AAM during cardiopulmonary resuscitation. After time dependent propensity score sequential matching, 16 114 patients in the shockable cohort and 236 042 in the non-shockable cohort were matched at the same minute. In the shockable cohort, survival did not differ between patients with AAM and those with no AAM: 1546/8057 (19.2%) versus 1500/8057 (18.6%) (adjusted risk ratio 1.00, 95% confidence interval 0.93 to 1.07). In the non-shockable cohort, patients with AAM had better survival than those with no AAM: 2696/118 021 (2.3%) versus 2127/118 021 (1.8%) (adjusted risk ratio 1.27, 1.20 to 1.35). CONCLUSIONS: In the time dependent propensity score sequential matching for out-of-hospital cardiac arrest in adults, AAM was not associated with survival among patients with shockable rhythm, whereas AAM was associated with better survival among patients with non-shockable rhythm.


Assuntos
Manuseio das Vias Aéreas/mortalidade , Reanimação Cardiopulmonar/mortalidade , Cardioversão Elétrica/mortalidade , Serviços Médicos de Emergência/métodos , Parada Cardíaca Extra-Hospitalar/terapia , Adulto , Idoso , Manuseio das Vias Aéreas/métodos , Reanimação Cardiopulmonar/métodos , Estudos de Coortes , Cardioversão Elétrica/métodos , Feminino , Humanos , Japão , Masculino , Pessoa de Meia-Idade , Razão de Chances , Parada Cardíaca Extra-Hospitalar/complicações , Parada Cardíaca Extra-Hospitalar/mortalidade , Alta do Paciente/estatística & dados numéricos , Pontuação de Propensão , Sistema de Registros , Fatores de Tempo , Fibrilação Ventricular/etiologia , Fibrilação Ventricular/mortalidade , Fibrilação Ventricular/terapia
17.
Int Heart J ; 60(2): 318-326, 2019 Mar 20.
Artigo em Inglês | MEDLINE | ID: mdl-30745538

RESUMO

Implantable cardioverter-defibrillators (ICDs) improve survival in patients who are at risk of sudden death. However, inappropriate therapy is commonly given to ICD recipients, and this situation may be associated with an increased risk of death. This study aimed to construct a risk stratification scheme by using decision tree analysis in patients who received inappropriate ICD therapy.Mortality was calculated from a retrospective data analysis of a multicenter cohort involving 417 ICD recipients. Inappropriate therapy was defined as therapy for nonventricular arrhythmias, including sinus tachycardia, supraventricular tachycardia, atrial fibrillation/flutter, oversensing, and lead failure. Inappropriate therapy included antitachycardia pacing, cardioversion, and defibrillation. The prognostic factors were identified by a Cox proportional hazards regression analysis, and we constructed a decision tree.During an average follow-up of 5.2 years, 48 patients (12%) had all-cause death. A multivariate Cox hazard model revealed that the age (hazard ratio [HR] 1.06, P < 0.001), ln B-type natriuretic peptide (BNP) (HR 1.47, P = 0.02), nonsinus rhythm at implantation (HR 2.70, P < 0.05), and inappropriate therapy occurring during sedentary/awake conditions (HR 3.51, P = 0.001) correlated with an increased risk of mortality. An inappropriate therapy due to abnormal sensing (HR 0.16, P = 0.04) decreased the risk of mortality. Furthermore, a decision tree analysis stratified the patients well by using 4 covariates: BNP, activity at the time of inappropriate therapy, mechanism of inappropriate therapy, and baseline rhythm at ICD implantation (log-rank test, P < 0.0001).We identified the predictors of mortality in inappropriate ICD therapy recipients and constructed a risk stratification scheme by using decision tree analysis.


Assuntos
Arritmias Cardíacas , Morte Súbita Cardíaca , Desfibriladores Implantáveis/efeitos adversos , Cardioversão Elétrica/efeitos adversos , Falha de Equipamento/estatística & dados numéricos , Idoso , Arritmias Cardíacas/classificação , Arritmias Cardíacas/complicações , Arritmias Cardíacas/mortalidade , Arritmias Cardíacas/terapia , Morte Súbita Cardíaca/etiologia , Morte Súbita Cardíaca/prevenção & controle , Árvores de Decisões , Desfibriladores Implantáveis/estatística & dados numéricos , Cardioversão Elétrica/instrumentação , Cardioversão Elétrica/métodos , Análise de Falha de Equipamento/métodos , Feminino , Humanos , Japão/epidemiologia , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Medição de Risco/métodos , Fatores de Risco , Análise de Sobrevida
18.
Int Heart J ; 60(2): 466-469, 2019 Mar 20.
Artigo em Inglês | MEDLINE | ID: mdl-30745542

RESUMO

A 28-year-old female presented with fulminant lymphocytic myocarditis. She developed cardiogenic shock, frequent sustained ventricular tachycardia, and fibrillation (VT and VF). The left ventricular ejection fraction improved from 5% to 40% after medical therapy, but the right ventricular systolic dysfunction and enlargement persisted. In addition, sustained VTs, requiring direct current cardioversion, occurred during oral administration of amiodarone following intravenous amiodarone, even after percutaneous stellate ganglion block. Standard body surface electrocardiogram (ECG) screening for an implantation of a subcutaneous implantable cardioverter-defibrillator (S-ICD) (EMBLEM™ S-ICD, Boston Scientific, Marlborough, MA, USA) demonstrated that two of the three sensing vectors were eligible in spite of very low-amplitude QRS complexes in the body surface ECGs. After implantation of the S-ICD, the patient experienced repetitive, inappropriate shocks due to pectoral myopotential oversensing, which could not be resolved by reprogramming the device settings. Thus, the S-ICD lead was changed from the standard left parasternal position to the midline of the sternum to reduce muscular noise due to myopotentials. Thereafter, the patient experienced appropriate ICD shocks for sustained VT and VF but no inappropriate ICD sensing or shocks. Lead repositioning may be one of the feasible solutions in S-ICD patients with low-amplitude QRS complexes and inappropriate shocks due to myopotential oversensing which cannot be resolved by reprogramming the device settings.


Assuntos
Desfibriladores Implantáveis/efeitos adversos , Cardioversão Elétrica/instrumentação , Falha de Equipamento , Sistema de Condução Cardíaco/fisiopatologia , Miocardite/complicações , Ajuste de Prótese/métodos , Fibrilação Ventricular , Adulto , Cardiomiopatias/etiologia , Cardiomiopatias/fisiopatologia , Cardiomiopatias/terapia , Cardioversão Elétrica/efeitos adversos , Cardioversão Elétrica/métodos , Eletrocardiografia/métodos , Feminino , Humanos , Resultado do Tratamento , Disfunção Ventricular Direita/complicações , Disfunção Ventricular Direita/diagnóstico , Disfunção Ventricular Direita/etiologia , Fibrilação Ventricular/diagnóstico , Fibrilação Ventricular/etiologia , Fibrilação Ventricular/terapia
19.
Int Heart J ; 60(2): 470-473, 2019 Mar 20.
Artigo em Inglês | MEDLINE | ID: mdl-30745545

RESUMO

A 41-year-old man developed cardiac arrest. A resting 12-lead electrocardiogram showed a delta wave, suggestive of preexcitation syndrome. An electrophysiological test revealed the existence of inducible atrial fibrillation and a fasciculoventricular accessory pathway (FVAP). After these examinations, idiopathic ventricular arrhythmia was suspected. For evaluating concealed Brugada syndrome, pilsicainide was administered, which diminished the delta wave and no Brugada-like electrocardiogram was observed. Ventricular double extra-stimulation from the RV apex easily induced VF, which could not be defibrillated by an external defibrillator, and later stopped spontaneously. These results established the diagnosis of FVAP and idiopathic VF, and not pre-excited atrial fibrillation or Brugada syndrome.


Assuntos
Feixe Acessório Atrioventricular , Síndrome de Brugada/diagnóstico , Cardioversão Elétrica/métodos , Eletrocardiografia/métodos , Síndromes de Pré-Excitação , Fibrilação Ventricular/terapia , Feixe Acessório Atrioventricular/diagnóstico , Feixe Acessório Atrioventricular/fisiopatologia , Feixe Acessório Atrioventricular/terapia , Adulto , Morte Súbita Cardíaca/etiologia , Morte Súbita Cardíaca/prevenção & controle , Desfibriladores , Diagnóstico Diferencial , Técnicas Eletrofisiológicas Cardíacas/métodos , Humanos , Masculino , Síndromes de Pré-Excitação/diagnóstico , Síndromes de Pré-Excitação/fisiopatologia , Síndromes de Pré-Excitação/terapia , Remissão Espontânea , Falha de Tratamento
20.
J Am Coll Cardiol ; 73(5): 589-597, 2019 02 12.
Artigo em Inglês | MEDLINE | ID: mdl-30732713

RESUMO

BACKGROUND: Arrhythmias, conduction abnormalities, and intracardiac thrombus are common in patients with cardiac amyloidosis (CA). Outcomes of direct-current cardioversion (DCCV) for atrial arrhythmias in patients with CA are unknown. OBJECTIVES: This study sought to examine DCCV procedural outcomes in patients with CA. METHODS: Patients with CA scheduled for DCCV for atrial arrhythmias from January 2000 through December 2012 were identified and matched 2:1 with control patients by age, sex, type of atrial arrhythmia, and date of DCCV. RESULTS: CA patients (n = 58, mean age 69 ± 9 years, 81% male) were included. CA patients had a significantly higher cardioversion cancellation rate (28% vs. 7%; p < 0.001) compared with control patients, mainly due to intracardiac thrombus identified on transesophageal echocardiogram (13 of 16 [81%] vs. 2 of 8 [25%]; p = 0.02); 4 of 13 of the CA patients (31%) with intracardiac thrombus on transesophageal echocardiogram received adequate anticoagulation ≥3 weeks and another 2 of 13 (15%) had arrhythmia duration <48 h. DCCV success rate (90% vs. 94%; p = 0.4) was not different. Procedural complications were more frequent in CA versus control patients (6 of 42 [14%] vs. 2 of 106 [2%]; p = 0.007); complications in CA included ventricular arrhythmias in 2 and severe bradyarrhythmias requiring pacemaker implantation in 2. The only complication in the control group was self-limited bradyarrhythmias. CONCLUSIONS: Patients with CA undergoing DCCV had a significantly high cancellation rate mainly due to a high incidence of intracardiac thrombus even among patients who received adequate anticoagulation. Although the success rate of restoring sinus rhythm was high, tachyarrhythmias and bradyarrhythmias complicating DCCV were significantly more frequent in CA patients compared with control patients.


Assuntos
Amiloidose , Fibrilação Atrial , Cardioversão Elétrica , Cardiopatias , Trombose , Idoso , Amiloidose/complicações , Amiloidose/diagnóstico , Fibrilação Atrial/etiologia , Fibrilação Atrial/terapia , Contraindicações de Procedimentos , Ecocardiografia Transesofagiana/métodos , Cardioversão Elétrica/efeitos adversos , Cardioversão Elétrica/métodos , Feminino , Cardiopatias/complicações , Cardiopatias/patologia , Humanos , Masculino , Pessoa de Meia-Idade , Minnesota/epidemiologia , Estudos Retrospectivos , Risco Ajustado , Trombose/diagnóstico por imagem , Trombose/etiologia
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