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1.
Phys Ther ; 98(12): 973-979, 2018 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-30257003

RESUMO

Background and Purpose: Sudden cardiac death causes an estimated 200,000 to 450,000 deaths per year in the USA. Although permanent implantation of an internal cardiac defibrillator offers a preventive intervention, the required assessment period for determining need creates vulnerability for patients who will benefit from this protection. The use of a wearable cardioverter defibrillator (WCD) for interim protection is rapidly increasing. There are no rehabilitation guidelines for patients wearing a WCD. This article reviews the WCD's purpose, considers implications and current challenges for use during rehabilitation, and illustrates this with a case report. Case Description: A 51-year-old male with coronary artery disease following prolonged hospitalization was fitted with a WCD during evaluation for an internal cardiac defibrillator. During inpatient rehabilitation, the therapy plan required unique considerations because of the presence of the WCD. Outcomes: Recapitulating the patient's rehabilitation course illustrates the WCD's challenges, the benefits to exercise progression, and the safety measures used. The patient gained functional independence, with uninterrupted care, in the presence of the WCD. Discussion: Knowledgeable clinicians, attention to safety, and sufficient patient/caregiver education are essential for uninterrupted and successful rehabilitative care for WCD-wearing patients. Because of increasing clinical prevalence of WCDs in rehabilitation, it is critically important to share clinical experience and eventually conduct a systematic assessment.


Assuntos
Reabilitação Cardíaca/métodos , Morte Súbita Cardíaca/prevenção & controle , Cardioversão Elétrica/instrumentação , Modalidades de Fisioterapia/normas , Dispositivos Eletrônicos Vestíveis/normas , Doença da Artéria Coronariana , Desfibriladores Implantáveis , Cardioversão Elétrica/normas , Humanos , Pacientes Internados , Masculino , Pessoa de Meia-Idade , Fatores de Tempo
2.
Int J Cardiol ; 272: 179-184, 2018 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-30121177

RESUMO

OBJECTIVES: To evaluate the effectiveness of wearable cardioverter defibrillator (WCD) use in protecting patients from sudden cardiac arrest (SCA) while they were treated in nonhospital settings until re-implantation of an Implantable cardioverter-defibrillator (ICD) was feasible. We sought to determine whether the WCD could be successfully utilized long term (≥1 year) after ICD extraction in patients at continued risk of SCD in which ICD re-implantation was not practical. BACKGROUND: ICDs have proven to improve mortality in patients for both secondary and primary prevention of SCA. Increased ICD implantation in older patients with comorbid conditions has resulted in higher rates of cardiac device infections. Currently, a wearable cardioverter defibrillator (WCD) is an alternative management for SCA prevention in specific cases. METHODS: This a retrospective analysis based on consecutive WCD patients who underwent ICD explant due to device-related infections or mechanical reasons between April 2007 and July 2014. A total of 102 patients were identified from the national database maintained by ZOLL (Pittsburgh, PA, USA). We analyzed the reason for WCD use, demographic information, device data, compliance and duration of WCD use, detected arrhythmias and therapies, and reason for discontinuing WCD use. RESULTS: In these long term WCD users, average length of WCD use was 638 ±â€¯361 days. Nine patients (8.8%) had a sustained ventricular arrhythmia that was successfully resuscitated by the WCD. Six patients (5.8%) experienced inappropriate shocks. Two patients (1.9%) died of asystole events while wearing the WCD and an additional 10 patients died while not monitored by the WCD. Thirty-nine patients (38.2%) ended WCD use when a new ICD was implanted and 15 patients (14.7%) were still wearing the WCD at the time of analysis. CONCLUSIONS: We found that extending use of the WCD to ≥1 year is a safe and effective alternative treatment for patients with explanted ICDs who are not pacemaker dependent.


Assuntos
Morte Súbita Cardíaca/prevenção & controle , Desfibriladores/tendências , Cardioversão Elétrica/instrumentação , Cardioversão Elétrica/tendências , Dispositivos Eletrônicos Vestíveis/tendências , Adulto , Idoso , Desfibriladores/normas , Cardioversão Elétrica/normas , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Tempo , Dispositivos Eletrônicos Vestíveis/normas
3.
JACC Clin Electrophysiol ; 4(7): 936-943, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-30025695

RESUMO

OBJECTIVES: The purpose of this study was to analyze course of defibrillation threshold (DFT) with growth. BACKGROUND: Data on regular DFT testing after extracardiac implantable cardioverter-defibrillator (ICD) placement in infants and small children is still limited. METHODS: An extracardiac ICD was placed in 23 pediatric patients (median age 6.1 years; median body weight 21 kg, median length 120 cm). The defibrillator lead was tunneled pleurally, and the device was placed as "active can" in the right upper abdomen or in a horizontal position between the diaphragm and the pericardium, respectively. DFT was verified intraoperatively, 3 months later, and every 12 months thereafter. The aim was to achieve DFT <15 J allowing ICD programming with a double safety margin above DFT. RESULTS: In all 23 patients, an intraoperative DFT <15 J could be accomplished. Serial DFT testing showed an increase from a median DFT of 10 J intraoperatively to 15 J after 1 year. During mean follow-up of 2.0 years, a significant correlation between DFT and body length, but not body weight, was observed. In 4 of 23 (17%) patients, surgical revision was required because of a DFT increase >20 J during regular DFT testing. No complications regarding DFT testing were noted. CONCLUSIONS: After extracardiac ICD placement in infants and small children, DFT increase related to body length was evident during mid-term follow-up. Routine serial DFT testing was a safe procedure and identified a significant DFT increase in 4 of 23 patients. Serial DFT testing during follow-up in these patients is recommended.


Assuntos
Desfibriladores Implantáveis , Cardioversão Elétrica/normas , Estatura/fisiologia , Criança , Pré-Escolar , Seguimentos , Humanos , Lactente , Segurança do Paciente
4.
Resuscitation ; 130: 41-43, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-29883678

RESUMO

INTRODUCTION: Modern automated external defibrillators (AEDs) are designed to prevent shock delivery when excessive motion produces rhythm disturbances mimicking ventricular fibrillation (VF). This has been reported as a safety issue in airline operations, where turbulent motion is commonplace. We aimed to evaluate whether all seven AEDs can deliver shock appropriately in a flight simulator under turbulent conditions. METHODS: The study was performed in a Boeing 747-400 full motion flight simulator in Hong Kong. An advanced life support manikin and arrhythmia generator were used to produce sinus rhythm (SR), asystole, and five amplitudes of VF, with a programmed change to SR in the event of an effective shock being delivered. All rhythms were tested at rest (no turbulence) and at four levels of motion (ground taxi vibration, and mild, moderate and severe in-flight turbulence). Success was defined as: 1. effective shock being delivered where the rhythm was VF successfully converted to SR; 2. no inappropriate shock being delivered for asystole or SR. RESULTS: Five AEDs produced acceptable results at all levels of turbulence. Another was satisfactory for VF except at very fine amplitudes. One model was deemed unsatisfactory for in-flight use as its motion detector inhibited shocks at all levels of turbulence. CONCLUSION: Some AEDs designed primarily for ground use may not perform well under turbulent in-flight conditions. AEDs for possible in-flight or other non-terrestrial use should be fully evaluated by manufacturers or end-users before introduction to service.


Assuntos
Desfibriladores , Cardioversão Elétrica , Fibrilação Ventricular/prevenção & controle , Medicina Aeroespacial/métodos , Aeronaves , Desfibriladores/efeitos adversos , Desfibriladores/normas , Cardioversão Elétrica/métodos , Cardioversão Elétrica/normas , Humanos , Manequins , Teste de Materiais/métodos , Projetos de Pesquisa
5.
Europace ; 20(FI2): f249-f253, 2018 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-29878156

RESUMO

Prevention of sudden cardiac death (SCD) remains a partly unsolved task in cardiology. The European Society of Cardiology (ESC) guidelines on management of patients with ventricular arrhythmias and prevention of SCD published in 2015 considered the new insights of the natural history of diseases predisposing to SCD. The guidelines improved strategies for management of patients at risk of SCD and included both drug and device therapies. The intention of this survey was to evaluate the extent of the disparities between daily clinical practice and the 2015 SCD ESC guidelines among electrophysiology centres in Europe. The results suggest that the adherence to guidelines is reasonably high and strategies for the management of ischaemic disease are well-established. Implantable cardioverter-defibrillator indications for primary prevention are a difficult topic, particularly in non-ischaemic dilated cardiomyopathy. Disparities in the use of genetic testing are probably due to differences in local availability.


Assuntos
Arritmias Cardíacas/terapia , Cardiologistas/normas , Morte Súbita Cardíaca/prevenção & controle , Cardioversão Elétrica/normas , Fidelidade a Diretrizes/normas , Guias de Prática Clínica como Assunto/normas , Padrões de Prática Médica/normas , Prevenção Primária/normas , Arritmias Cardíacas/diagnóstico , Arritmias Cardíacas/mortalidade , Morte Súbita Cardíaca/epidemiologia , Desfibriladores Implantáveis/normas , Cardioversão Elétrica/efeitos adversos , Cardioversão Elétrica/instrumentação , Cardioversão Elétrica/mortalidade , Europa (Continente)/epidemiologia , Testes Genéticos/normas , Pesquisas sobre Serviços de Saúde , Disparidades em Assistência à Saúde/normas , Humanos , Prevenção Primária/instrumentação , Medição de Risco , Fatores de Risco , Resultado do Tratamento
6.
Circ J ; 82(6): 1546-1551, 2018 05 25.
Artigo em Inglês | MEDLINE | ID: mdl-29643282

RESUMO

BACKGROUND: The entirely subcutaneous implantable cardioverter defibrillator (S-ICD) was introduced as a new alternative to conventional transvenous ICD (TV-ICD) in Japan in February 2016, but its safety and efficacy are unclear.Methods and Results:A total of 60 patients (48 men, median age, 60 years; IQR, 44-67 years; primary prevention, n=24) underwent S-ICD implantation between February 2016 and August 2017. The device pocket was formed in the intermuscular space between the serratus anterior muscle and the latissimus dorsi muscle, and the parasternal S-ICD lead was placed according to pre-implant screening. Defibrillation test was performed in 56 patients (93%). Ventricular fibrillation (VF) was induced in 55 patients and terminated by a single 65-J shock in all patients. The median time to shock therapy was 13.4 s (IQR, 12.1-14.9 s) and the median post-shock impedance of the S-ICD lead was 64 Ω (IQR, 58-77 Ω). There were no operation-related complications or subsequent infectious complications. During follow-up (median, 275 days; IQR, 107-421 days), 1 patient (1.7%) had appropriate shock for VF with successful termination, whereas 5 patients (8.3%) had inappropriate shock due to oversensing of myopotential (n=3) or T-wave (n=1), and detection of supraventricular tachycardia (n=1). CONCLUSIONS: S-ICD is a safe and effective alternative to conventional TV-ICD. The long-term safety and efficacy of the S-ICD need further investigation.


Assuntos
Morte Súbita Cardíaca/prevenção & controle , Desfibriladores Implantáveis/normas , Fibrilação Ventricular/terapia , Adulto , Idoso , Desfibriladores Implantáveis/efeitos adversos , Cardioversão Elétrica/métodos , Cardioversão Elétrica/normas , Feminino , Humanos , Japão , Masculino , Pessoa de Meia-Idade , Prevenção Primária/métodos , Prevenção Primária/normas , Prevenção Secundária/métodos , Prevenção Secundária/normas , Taquicardia/diagnóstico , Resultado do Tratamento , Fibrilação Ventricular/diagnóstico
7.
J Emerg Med ; 54(1): 54-63, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-29100652

RESUMO

BACKGROUND: Out-of-hospital cardiac arrest has high rates of morbidity and mortality, and a growing body of evidence is redefining our approach to the resuscitation of these high-risk patients. OBJECTIVES: Team-focused cardiopulmonary resuscitation (TFCPR), most commonly deployed and described by prehospital care providers, is a focused approach to cardiac arrest care that emphasizes early defibrillation and high-quality, minimally interrupted chest compressions while de-emphasizing endotracheal intubation and intravenous drug administration. TFCPR is associated with statistically significant increases in survival to hospital admission, survival to hospital discharge, and survival with good neurologic outcome; however, the adoption of similar streamlined resuscitation approaches by emergency physicians has not been widely reported. In the absence of a deliberately streamlined approach, such as TFCPR, other advanced therapies and procedures that have not shown similar survival benefit may be prioritized at the expense of simpler evidence-based interventions. DISCUSSION: This review examines the current literature on cardiac arrest resuscitation. The recent prehospital success of TFCPR is highlighted, including the associated improvements in multiple patient-centered outcomes. The adaptability of TFCPR to the emergency department (ED) setting is also discussed in detail. Finally, we discuss advanced interventions frequently performed during ED cardiac arrest resuscitation that may interfere with early defibrillation and effective high-quality chest compressions. CONCLUSION: TFCPR has been associated with improved patient outcomes in the prehospital setting. The data are less compelling for other commonly used advanced resuscitation tools and procedures. Emergency physicians should consider incorporating the TFCPR approach into ED cardiac arrest resuscitation to optimize delivery of those interventions most associated with improved outcomes.


Assuntos
Reanimação Cardiopulmonar/métodos , Serviços Médicos de Emergência/métodos , Serviços Médicos de Emergência/normas , Equipe de Assistência ao Paciente/normas , Reanimação Cardiopulmonar/normas , Cardioversão Elétrica/métodos , Cardioversão Elétrica/normas , Serviço Hospitalar de Emergência/organização & administração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Humanos , North Carolina , Parada Cardíaca Extra-Hospitalar/terapia , Assistência Centrada no Paciente/métodos , Análise de Sobrevida
8.
Europace ; 20(2): 301-307, 2018 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-28339659

RESUMO

Aims: We aimed to examine the use of guideline recommended beta-blocker therapy prior to and after primary prevention implantable cardioverter defibrillator (ICD) implantation in a 'real-life' setting. Methods and results: From the Danish Pacemaker and ICD Registry we identified all 1st-time primary prevention ICD and cardiac resynchronization therapy defibrillator (CRT-D) implantations in Denmark from 2007-12 (n = 2935). Use of beta-blocker, type and dose was acquired through the Danish Prescription Registry. According to guideline recommendations, we defined target daily doses as ≥50 mg carvedilol and ≥200 mg metoprolol. Prior to implantation 2427 of 2935 (83%) patients received beta-blocker therapy, with 2166 patients (89%) having initiated treatment 3 months or more prior to implantation. The majority of patients was prescribed carvedilol (52%) or metoprolol (41%). Patients on carvedilol reached target dosages more frequently than patients on metoprolol, with 39% of patients on carvedilol and 26% of patients on metoprolol at the time of implantation (P < 0.001 for all time-points). Increase in proportion of patients reaching target daily doses was observed for both carvedilol and metoprolol after ICD implantation. Carvedilol treatment was a strong predictor for being on target dose of BB at time of implant, as was treatment with angiotensin-converting enzyme inhibitors and/or spironolactone, no history of myocardial infarction, younger age and less pronounced heart failure symptoms. Conclusion: In a real-life setting of primary prevention ICD patients, 39% and 26% of patients were titrated to optimal target dose of carvedilol or metoprolol prior to implantation. A higher proportion of patients on carvedilol reached target dose, as compared with metoprolol.


Assuntos
Antagonistas Adrenérgicos beta/administração & dosagem , Carbazóis/administração & dosagem , Morte Súbita Cardíaca/prevenção & controle , Desfibriladores Implantáveis , Cardioversão Elétrica/instrumentação , Metoprolol/administração & dosagem , Guias de Prática Clínica como Assunto , Prevenção Primária/métodos , Propanolaminas/administração & dosagem , Antagonistas Adrenérgicos beta/efeitos adversos , Idoso , Carbazóis/efeitos adversos , Carvedilol , Desfibriladores Implantáveis/normas , Dinamarca , Cardioversão Elétrica/efeitos adversos , Cardioversão Elétrica/normas , Feminino , Fidelidade a Diretrizes/normas , Humanos , Masculino , Metoprolol/efeitos adversos , Pessoa de Meia-Idade , Padrões de Prática Médica/normas , Prevenção Primária/normas , Propanolaminas/efeitos adversos , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento
9.
Intern Emerg Med ; 13(1): 87-93, 2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-28025766

RESUMO

Currently, there is no unified consensus on short-term anticoagulation after cardioversion of atrial fibrillation lasting less than 48 h in low-cardioembolic-risk patients. The aim of this study is to evaluate the rate of transient ischemic attacks, stroke and death in this subset of patients after cardioversion without post-procedural anticoagulation. In a prospective observational study, patients with recent-onset AF undergoing cardioversion attempts in the Emergency Department were evaluated over the past 3 years. Inclusion criteria were conversion to sinus rhythm, low thromboembolic risk defined by a CHA2DS2VASc score of 0-1 points for males (0-2 points for females aged over 65 years), and hospital discharge without anticoagulant treatment. Patients with severe valvular heart disease, underlying systemic causes of AF, and those discharged with anticoagulant therapy were excluded. The main outcomes measured were TIA, stroke and death at thirty days' follow-up after discharge. During the study period, 218 successful cardioversions, obtained both electrically and pharmacologically, were performed on 157 patients. One hundred and eleven patients were males (71%), the mean age was 55.2 years (±standard deviation 10.7), 99 patients (63%) reported a CHA2DS2VASc score of 0, and the remaining 58 (37%) had a risk profile of 1 point. Of these, latter 8 were females (5%) older than 65 years (risk score 2 points). At the thirty days outcome, none of the 150 enrolled patients who completed a follow-up visit has reported TIA or stroke, nor died, in the overall 211 successful cardioversions evaluated. In our study, the rate of thromboembolic events after cardioversion of recent-onset AF of less than 48 h duration, in patients with a 0-1 CHA2DS2VASc risk profile (females 0-2), appeared to be extremely low even in absence of post-procedural anticoagulation. These findings seem to confirm data from previous studies, and suggest that routine post-procedural short-term anticoagulation may be considered as an overtreatment in this very low-risk subset of patients.


Assuntos
Fibrilação Atrial/terapia , Cardioversão Elétrica/normas , Segurança do Paciente/normas , Tromboembolia/prevenção & controle , Terapia Trombolítica/normas , Adulto , Idoso , Anticoagulantes/uso terapêutico , Fibrilação Atrial/epidemiologia , Cardioversão Elétrica/métodos , Feminino , Mortalidade Hospitalar/tendências , Humanos , Ataque Isquêmico Transitório/epidemiologia , Masculino , Pessoa de Meia-Idade , Medição de Risco , Acidente Vascular Cerebral/epidemiologia , Tromboembolia/tratamento farmacológico , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/estatística & dados numéricos
10.
Australas Emerg Care ; 21(3): 81-86, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30998882

RESUMO

INTRODUCTION: International guidelines recommend that interruptions to chest compressions are minimised during defibrillation. As a result, some resuscitation educators have adopted a more structured approach to defibrillation. One such approach is the 'C.O.A.C.H.E.D.' cognitive aid (Continue compressions, Oxygen away, All others away, Charging, Hands off, Evaluate, Defibrillate or Disarm). To date, there are no studies assessing the use of this cognitive aid. METHODS: This study utilised an Emergency Department in situ simulated model of cardiac arrest. The defibrillator used was a proprietary R-Series (Zoll, PA, USA) connected to a CS1201 rhythm generator (Symbio, Beaverton, OR, USA). The study cohorts were interdisciplinary advanced life support (ALS) providers. Paired providers were enrolled in a mechanical CPR (M-CPR) training programme with no feedback related to defibrillation performance. As part of this 6-month programme, serial defibrillation performance was assessed. The outcome measures were the length of 'peri-shock' pause and 'safety' of defibrillation practice. Comparative statistical analysis using the Mann-Whitney U-test was made between groups of providers with 'correct use or near correct' or 'entirely incorrect or absent' use of the cognitive aid. RESULTS: The C.O.A.C.H.E.D. cognitive aid was applied correctly in 92 of 109 defibrillations. Providers with correct cognitive aid use had a median length of peri-shock pause time of 6.0s (IQR 5.0-7.0). Providers with 'entirely incorrect or absent' cognitive aid use had a peri-shock pause time of 8.0s (IQRF 6.6-10.0) (p≤0.001). No unsafe defibrillation practices were observed. CONCLUSION: In this observational study of defibrillation performance, the use of the C.O.A.C.H.E.D. cognitive aid was associated with a significant decrease in the length of peri-shock pause. Therefore, we conclude that the use of a cognitive aid is appropriate for teaching and performing defibrillation.


Assuntos
Técnicas de Apoio para a Decisão , Cardioversão Elétrica/métodos , Cardioversão Elétrica/normas , Reanimação Cardiopulmonar/métodos , Reanimação Cardiopulmonar/normas , Serviço Hospitalar de Emergência/organização & administração , Guias como Assunto , Humanos , Estudos Prospectivos , Ensino/normas , Ensino/tendências , Austrália Ocidental
12.
Singapore Med J ; 58(7): 354-359, 2017 07.
Artigo em Inglês | MEDLINE | ID: mdl-28741000

RESUMO

The most common initial rhythm in a sudden cardiac arrest is ventricular fibrillation or pulseless ventricular tachycardia. This is potentially treatable with defibrillation, especially if provided early. However, any delay in defibrillation will result in a decline in survival. Defibrillation requires coordination with the cardiopulmonary resuscitation component for effective resuscitation. These two components, which form the key links in the chain of survival, have to be brought to the cardiac victim in a timely fashion. An effective chain of survival is needed in both the institution and community settings.


Assuntos
Cardioversão Elétrica/normas , Reanimação Cardiopulmonar/normas , Desfibriladores/normas , Serviços Médicos de Emergência/normas , Humanos , Singapura
13.
Singapore Med J ; 58(7): 373-390, 2017 07.
Artigo em Inglês | MEDLINE | ID: mdl-28741003

RESUMO

We present the revised 2016 Singapore paediatric resuscitation guidelines. The International Liaison Committee on Resuscitation's Pediatric Taskforce Consensus Statements on Science and Treatment Recommendations, as well as the updated resuscitation guidelines from the American Heart Association and European Resuscitation Council released in October 2015, were debated and discussed by the workgroup. The final recommendations for the Singapore Paediatric Resuscitation Guidelines 2016 were derived after carefully reviewing the current available evidence in the literature and balancing it with local clinical practice.


Assuntos
Ressuscitação/normas , Suporte Vital Cardíaco Avançado/normas , Fatores Etários , Reanimação Cardiopulmonar/normas , Criança , Cuidados Críticos/normas , Cardioversão Elétrica/normas , Hidratação/normas , Parada Cardíaca/diagnóstico , Parada Cardíaca/terapia , Massagem Cardíaca/normas , Humanos , Intubação Intratraqueal/normas , Máscaras Laríngeas/normas , Singapura
15.
Arch Cardiovasc Dis ; 110(3): 188-195, 2017 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-28139454

RESUMO

Brugada syndrome is a rare inherited arrhythmia syndrome leading to an increased risk of sudden cardiac death, despite a structurally normal heart. Diagnosis is based on a specific electrocardiogram pattern, observed either spontaneously or during a sodium channel blocker test. Among affected patients, risk stratification remains a challenge, despite recent insights from large population cohorts. As implantable cardiac defibrillators - the main therapy in Brugada syndrome - are associated with a high rate of complications in this population, the main challenge is risk stratification of patients with Brugada syndrome. Aside from the two main predictors of arrhythmia (symptoms and spontaneous electrocardiogram pattern), many risk factors have been recently suggested for stratifying risk of sudden cardiac death in Brugada syndrome. We have reviewed these data and discuss current guidelines in light of recent progress in this complex field.


Assuntos
Síndrome de Brugada/terapia , Morte Súbita Cardíaca/prevenção & controle , Desfibriladores Implantáveis , Cardioversão Elétrica/instrumentação , Síndrome de Brugada/complicações , Síndrome de Brugada/diagnóstico , Síndrome de Brugada/mortalidade , Morte Súbita Cardíaca/etiologia , Desfibriladores Implantáveis/normas , Cardioversão Elétrica/efeitos adversos , Cardioversão Elétrica/normas , Eletrocardiografia , Técnicas Eletrofisiológicas Cardíacas , Humanos , Guias de Prática Clínica como Assunto , Valor Preditivo dos Testes , Medição de Risco , Fatores de Risco , Resultado do Tratamento
16.
Intern Emerg Med ; 12(6): 853-859, 2017 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-27384766

RESUMO

The acute management of recent-onset (<48 h) atrial fibrillation (AF) is still debated. Aim of our study was to compare efficacy and safety of intravenously administered class IC antidysrhythmic agents vs amiodarone in a propensity score matched series of patients acutely treated for AF in the emergency department. During a 3-year period, we retrospectively evaluated all episodes of recent-onset (<48 h) AF pharmacologically treated for sinus rhythm restoration in the emergency department. By means of a propensity score matching considering the main statistically different covariates, we selected two accurately matched treatment groups. We analysed the differences between amiodarone and class IC group in terms of efficacy and safety that is conversion to sinus rhythm rates within 12 and 48 h after starting treatment, time to conversion, and adverse drug effects. An overall number of 817 episodes of recent-onset AF were collected (amiodarone group = 406, class IC group = 411). After matching, we obtained 358 episodes equally divided (amiodarone group = 179 and class IC group = 179). Conversion rates within 12 h were 139 (53.1 %) in amiodarone group and 95 (72.6 %) in class IC group (p < 0.05). Median time for cardioversion was 420 min (331.6-508.3 CI 95 %) in amiodarone and 55 min (44.9-65.1 CI 95 %) in class IC group (p < 0.05). The incidence of adverse events in both groups was very low and equally distributed (p = ns). Intravenously administration of class IC agents, when compared with amiodarone, proved to be more rapid and effective, and equally safe in the acute management of recent-onset AF.


Assuntos
Amiodarona/efeitos adversos , Antiarrítmicos/efeitos adversos , Fibrilação Atrial/tratamento farmacológico , Cardioversão Elétrica/normas , Fenômenos Farmacológicos , Resultado do Tratamento , Idoso , Idoso de 80 Anos ou mais , Amiodarona/uso terapêutico , Antiarrítmicos/uso terapêutico , Cardioversão Elétrica/métodos , Feminino , Flecainida/efeitos adversos , Flecainida/uso terapêutico , Humanos , Masculino , Pessoa de Meia-Idade , Propafenona/efeitos adversos , Propafenona/uso terapêutico , Pontuação de Propensão , Estudos Retrospectivos
17.
Europace ; 19(7): 1187-1192, 2017 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-27738061

RESUMO

Aims: The validity of registry data on defibrillator lead performance is described only sparsely, despite its clinical importance. This study investigated the validity of defibrillator lead performance registry data in a nationwide and population-based registry. Methods and results: We identified all reported surgical interventions due to defibrillator lead events in the Danish Pacemaker and ICD Register (DPIR) from 2000 to 2013. Medical records of all patients (n = 753) were examined blinded for 5 predefined intervention types and 18 reasons for lead intervention. The overall level of agreement for the types of lead intervention had a positive predictive value (PPV) of 89.4% [95% confidence interval (CI): 87.0-91.5%] and an adjusted agreement (κ value) of 0.81 (95% CI: 0.77-0.85) representing an almost perfect match. Regarding the reasons for lead intervention, the overall PPV was 63.0% (95% CI: 54.8-61.7%) with a κ value of 0.60 (95% CI: 0.55-0.64) representing a moderate match with only few subcategories having low PPV. By redistribution of the specific reasons for lead interventions into three categories commonly used to report lead performance, the overall PPV improved to 87.9% (95% CI: 85.2-90.2%) with a κ value of 0.82 (95% CI:0.78-0.86) representing an almost perfect match. Conclusion: The validity of data on defibrillator lead performance recorded in the DPIR is excellent for the specific types of lead intervention and good for the specific reasons for defibrillator lead intervention. The validity of the less detailed overall reasons for lead interventions commonly used to report lead performance is also excellent. These findings indicate high registry data quality appropriate for scientific analysis and industry-independent post-marketing surveillance.


Assuntos
Arritmias Cardíacas/terapia , Confiabilidade dos Dados , Morte Súbita Cardíaca/prevenção & controle , Desfibriladores Implantáveis/normas , Cardioversão Elétrica/instrumentação , Cardioversão Elétrica/normas , Sistema de Registros/normas , Idoso , Arritmias Cardíacas/complicações , Arritmias Cardíacas/diagnóstico , Arritmias Cardíacas/mortalidade , Morte Súbita Cardíaca/etiologia , Dinamarca , Cardioversão Elétrica/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Desenho de Prótese , Falha de Prótese , Reprodutibilidade dos Testes , Fatores de Tempo , Resultado do Tratamento
18.
J Emerg Med ; 52(4): 484-492, 2017 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-27751700

RESUMO

BACKGROUND: Ventricular tachycardia (VT) and ventricular fibrillation are the causes of approximately 300,000 deaths per year in the United States. VT is classified based on hemodynamic status and appearance. Stable, monomorphic VT treatment is controversial. OBJECTIVE: Our aim was to provide emergency physicians with an evidence-based review of the medical management of stable, monomorphic VT. DISCUSSION: Stable, monomorphic VT is part of a larger class of ventricular dysrhythmias defined by a rate of at least 120 beats/min with QRS > 120 ms without regularly occurring P:QRS association. Little controversy exists for the treatment of hemodynamically unstable VT. The medical management of hemodynamically stable monomorphic VT is surrounded by controversy. Direct current cardioversion is most efficacious. Guidelines for the treatment of stable VT from the American Heart Association provide a IIa recommendation for procainamide, compared with a IIb recommendation for both amiodarone and sotalol. Studies evaluating procainamide, lidocaine, amiodarone, and sotalol suffer from poor design, difference in inclusion and exclusion criteria, small sample size, and outcome determination. Procainamide demonstrates the greatest efficacy. If procainamide is selected, a maximum dose of 10 mg/kg at 50-100 mg/min intravenous (IV) over 10-20 min should be provided with monitoring of blood pressure and electrocardiogram. Monomorphic VT with acute myocardial ischemia requires further study. CONCLUSIONS: Optimal management of stable, monomorphic VT includes direct current cardioversion. If medical management is chosen, procainamide is most efficacious, though current literature suffers from poor design.


Assuntos
Antiarrítmicos/uso terapêutico , Cardioversão Elétrica/normas , Literatura de Revisão como Assunto , Taquicardia Ventricular/tratamento farmacológico , Amiodarona/farmacologia , Amiodarona/uso terapêutico , Antiarrítmicos/farmacologia , Cardioversão Elétrica/métodos , Eletrocardiografia/métodos , Serviço Hospitalar de Emergência/organização & administração , Medicina Baseada em Evidências/métodos , Humanos , Lidocaína/farmacologia , Lidocaína/uso terapêutico , Procainamida/administração & dosagem , Procainamida/farmacologia , Procainamida/uso terapêutico , Pirimidinonas/farmacologia , Pirimidinonas/uso terapêutico , Sotalol/farmacologia , Sotalol/uso terapêutico , Taquicardia Ventricular/mortalidade
19.
Intern Emerg Med ; 12(5): 693-703, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-27905006

RESUMO

Several guidelines often exist on the same topic, sometimes offering divergent recommendations. For the clinician, it can be difficult to understand the reasons for this divergence and how to select the right recommendations. The aim of this study is to compare different guidelines on the management of atrial fibrillation (AF), and provide practical and affordable advice on its management in the acute setting. A PubMed search was performed in May 2014 to identify the three most recent and cited published guidelines on AF. During the 1-week school of the European School of Internal Medicine, the attending residents were divided in five working groups. The three selected guidelines were compared with five specific questions. The guidelines identified were: the European Society of Cardiology guidelines on AF, the Canadian guidelines on emergency department management of AF, and the American Heart Association guidelines on AF. Twenty-one relevant sub-questions were identified. For five of these, there was no agreement between guidelines; for three, there was partial agreement; for three data were not available (issue not covered by one of the guidelines), while for ten, there was complete agreement. Evidence on the management of AF in the acute setting is largely based on expert opinion rather than clinical trials. While there is broad agreement on the management of the haemodynamically unstable patient and the use of drugs for rate-control strategy, there is less agreement on drug therapy for rhythm control and no agreement on several other topics.


Assuntos
Fibrilação Atrial/tratamento farmacológico , Gerenciamento Clínico , Guias como Assunto/normas , Anticoagulantes/farmacologia , Anticoagulantes/uso terapêutico , Fibrilação Atrial/fisiopatologia , Educação Médica Continuada/métodos , Cardioversão Elétrica/métodos , Cardioversão Elétrica/normas , Serviço Hospitalar de Emergência/organização & administração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Medicina Baseada em Evidências/métodos , Frequência Cardíaca/efeitos dos fármacos , Hemodinâmica/efeitos dos fármacos , Humanos
20.
Scand Cardiovasc J ; 51(2): 88-94, 2017 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-27936942

RESUMO

OBJECTIVES: Implantable cardioverter defibrillator (ICD) treatment is effective among long QT syndrome (LQTS) patients at a high risk of sudden cardiac death. Previous studies show that the international guidelines are not always followed, and that risk stratification may be based on genotype rather than individual risk profile. We analysed data from the Swedish ICD & Pacemaker Registry and medical records to examine how international guidelines were followed with regards to phenotype and genotype. METHODS AND RESULTS: ICD treatment was used in 150 Swedish LQTS patients from 1989-2013. The annual number of implantations increased over the study period. A total of 109 patients were included in the analysis. Most patients (91%) were symptomatic before the implantation. Seventy percent of patients who received ICD treatment met the 2006 Class I or Class IIa recommendations for LQTS treatment. Thirty-one percent of the LQT3 patients received ICD treatment despite being asymptomatic. Among LQT1 patients, 45% received ICD treatment after syncope despite beta-blockers. CONCLUSIONS: Thirty percent of Swedish LQTS patients with ICD received the treatment without a strong indication based on international guidelines. LQT3 patients were over-represented among asymptomatic patients. Many LQT1 patients received ICD despite the known effect of beta-blockers in this group.


Assuntos
Desfibriladores Implantáveis , Cardioversão Elétrica/instrumentação , Fidelidade a Diretrizes , Síndrome do QT Longo/terapia , Guias de Prática Clínica como Assunto , Padrões de Prática Médica , Adolescente , Antagonistas Adrenérgicos beta/uso terapêutico , Adulto , Idoso , Criança , Pré-Escolar , Desfibriladores Implantáveis/normas , Cardioversão Elétrica/efeitos adversos , Cardioversão Elétrica/normas , Feminino , Predisposição Genética para Doença , Fidelidade a Diretrizes/normas , Humanos , Síndrome do QT Longo/diagnóstico , Síndrome do QT Longo/genética , Síndrome do QT Longo/fisiopatologia , Masculino , Registros Médicos , Pessoa de Meia-Idade , Seleção de Pacientes , Fenótipo , Guias de Prática Clínica como Assunto/normas , Padrões de Prática Médica/normas , Sistema de Registros , Estudos Retrospectivos , Suécia , Resultado do Tratamento , Adulto Jovem
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