RESUMO
BACKGROUND: Prescription opioids are a major contributor to the ongoing epidemic of persistent opioid use (POU). The incidence of POU among opioid-naïve patients after cardiac implantable electronic device (CIED) procedures is unknown. METHODS: This retrospective cohort study used data from a national administrative claims database from 2004 to 2018 of patients undergoing CIED procedures. Adult patients were included if they were opioid-naïve during the 180-day period before the procedure and did not undergo another procedure with anesthesia in the next 180 days. POU was defined by filling an additional opioid prescription >30 days after the CIED procedure. RESULTS: Of the 143 400 patients who met the inclusion criteria, 15 316 (11%) filled an opioid prescription within 14 days of surgery. Among these patients, POU occurred in 1901 (12.4%) patients 30 to 180 days after surgery. The likelihood of developing POU was increased for patients who had a history of drug abuse (odds ratio, 1.52; P=0.005), preoperative muscle relaxant (odds ratio, 1.52; P<0.001) or benzodiazepine (odds ratio, 1.23; P=0.001) use, or opioid use in the previous 5 years (OR, 1.76; P<0.0001). POU did not differ after subcutaneous implantable cardioverter defibrillator or other CIED procedures (11.1 versus 12.4%; P=0.5). In a sensitivity analysis excluding high-risk patients who were discharged to a facility or who had a history of drug abuse or previous opioid, benzodiazepine, or muscle relaxant use, 8.9% of the remaining cohort had POU. Patients prescribed >135 mg of oral morphine equivalents had a significantly increased risk of POU. CONCLUSIONS: POU is common after CIED procedures, and 12% of patients continued to use opioids >30 days after surgery. Higher initially prescribed oral morphine equivalent doses were associated with developing POU.
Assuntos
Analgésicos Opioides/uso terapêutico , Desfibriladores Implantáveis , Cuidados Pós-Operatórios , Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/efeitos adversos , Tomada de Decisão Clínica , Bases de Dados Factuais , Gerenciamento Clínico , Prescrições de Medicamentos/normas , Prescrições de Medicamentos/estatística & dados numéricos , Duração da Terapia , Pesquisas sobre Atenção à Saúde , Humanos , Vigilância em Saúde PúblicaRESUMO
Recent technological advances have facilitated and diversified the options available for the diagnosis of cardiac arrhythmias. Ranging from simple resting or exercise electrocardiograms to more sophisticated and expensive smartphones and implantable cardiac monitors. These tests and devices may be used for varying periods of time depending on symptom frequency. The choice of the most appropriate heart rhythm test should be guided by clinical evaluation and optimized following accurate characterization of underlying symptoms, 'red flags', risk factors, and consideration of cost-effectiveness of the different tests. This review provides evidence-based guidance for assessing suspected arrhythmia in patients who present with symptoms or in the context of screening, such as atrial fibrillation or advanced conduction disturbances following transcatheter aortic valve implantation in high-risk groups. This is intended to help clinicians choose the most appropriate diagnostic tool to facilitate the management of patients with suspected arrhythmias.
Assuntos
Fibrilação Atrial , Eletrocardiografia , Humanos , Fibrilação Atrial/diagnóstico , Teste de Esforço , Smartphone , Programas de RastreamentoRESUMO
INTRODUCTION: Data on the mechanisms of atrial arrhythmias (AAs) and outcomes of catheter ablation (CA) in lung transplantation (LT) patients are insufficient. We evaluated the electrophysiologic features and outcomes of CA of AAs in LT patients. METHODS AND RESULTS: We conducted a retrospective study of all the LT patients who underwent CA for AAs at our institution between 2004 and 2019. A total of 15 patients (43% males, age: 61 ± 10 years) with a history of LT (60% bilateral and 40% unilateral) were identified. All patients had documented organized AA on surface electrocardiogram and seven patients also had atrial fibrillation (AF; 47% with >1 clinical arrhythmia). At electrophysiological study, 19 organized AAs were documented (48% focal and 52% macro-re-entrant). Focal atrial tachycardias/flutters were targeted along the pulmonary vein (PV) anastomotic site at the left inferior PV (n = 2), ridge and carina of the left superior PV (n = 2), left atrium (LA) posterior wall (n = 3), LA roof (n = 1), and tricuspid annulus (n = 1). Macro-re-entrant AAs included cavotricuspid isthmus-dependent flutter (n = 2), incisional LA flutter (n = 4), LA roof-dependent flutter (n = 1), and mitral annular flutter (n = 3). In patients with LA mapping (n = 13), PV reconnection on the side of the LT was found in six patients (40%, all with clinically documented AF), with a mean of 2.1 ± 0.9 PVs reconnected per patient. Patients with AF underwent successful PV isolation. After a median follow-up of 19 months (range: 6-86 months), 75% of patients remained free from recurrent AAs. No procedural major complications occurred. CONCLUSION: In patients with prior LT, recurrent AAs are typically associated with substrate surrounding the surgical anastomotic lines and/or chronically reconnected PVs. CA of AAs in this population is safe and effective to achieve long-term arrhythmia control.
Assuntos
Fibrilação Atrial , Ablação por Cateter , Transplante de Pulmão , Veias Pulmonares , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/cirurgia , Ablação por Cateter/efeitos adversos , Criança , Feminino , Humanos , Transplante de Pulmão/efeitos adversos , Masculino , Veias Pulmonares/diagnóstico por imagem , Veias Pulmonares/cirurgia , Recidiva , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: We have previously demonstrated the feasibility of a nurse-led risk factor modification (RFM) program for improving weight loss and obstructive sleep apnea (OSA) care among patients with atrial fibrillation (AF). OBJECTIVE: We now report its impact on arrhythmia outcomes in a subgroup of patients undergoing catheter ablation. METHODS: Participating patients with obesity and/or need for OSA management (high risk per Berlin Questionnaire or untreated OSA) underwent in-person consultation and monthly telephone calls with the nurse for up to 1 year. Arrhythmias were assessed by office ECGs and ≥2 wearable monitors. Outcomes, defined as Arrhythmia control (0-6 self-terminating recurrences, with ≤1 cardioversion for nonparoxysmal AF) and Freedom from arrhythmias (no recurrences on or off antiarrhythmic drugs), were compared at 1 year between patients undergoing catheter ablation who enrolled and declined RFM. RESULTS: Between 1 November 2016 and 1 April 2018, 195 patients enrolled and 196 declined RFM (body mass index, 35.1 ± 6.7 vs 34.3 ± 6.3 kg/m2 ; 50% vs 50% paroxysmal AF; P = NS). At 1 year, enrolled patients demonstrated significant weight loss (4.7% ± 5.3% vs 0.3% ± 4.4% in declined patients; P < .0001) and improved OSA care (78% [n = 43] of patients diagnosed with OSA began treatment). However, outcomes were similar between enrolled and declined patients undergoing ablation (arrhythmia control in 80% [n = 48] vs 79% [n = 38]; freedom from arrhythmia in 58% [n = 35] vs 71% [n = 34]; P = NS). CONCLUSION: Despite improving weight loss and OSA care, our nurse-led RFM program did not impact 1-year arrhythmia outcomes in patients with AF undergoing catheter ablation.
Assuntos
Fibrilação Atrial/cirurgia , Ablação por Cateter , Papel do Profissional de Enfermagem , Obesidade/enfermagem , Comportamento de Redução do Risco , Apneia Obstrutiva do Sono/enfermagem , Idoso , Antiarrítmicos , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/fisiopatologia , Índice de Massa Corporal , Ablação por Cateter/efeitos adversos , Dieta Saudável/enfermagem , Exercício Físico , Feminino , Nível de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Obesidade/diagnóstico , Obesidade/fisiopatologia , Educação de Pacientes como Assunto , Avaliação de Programas e Projetos de Saúde , Recidiva , Fatores de Risco , Sono , Apneia Obstrutiva do Sono/diagnóstico , Apneia Obstrutiva do Sono/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Redução de PesoRESUMO
BACKGROUND: Noninducibility of ventricular tachycardia (VT) at noninvasive programmed stimulation performed shortly following ablation (negative NIPS) predicts low risk of the medium-term recurrence. This study aimed to evaluate long-term rate and mode of recurrence following negative NIPS. METHODS: We extended follow-up on patients in whom no VT could be induced at NIPS following ablation between 2008 and 2010. Recurrent VTs were categorized as "Original clinical" if they matched VT that had occurred spontaneously prior to the index ablation; "Original nonclinical" if they matched VT that was induced during the index ablation but had not occurred spontaneously; or "New." Among those undergoing repeat ablation, the area ablated to treat the recurrent VT was categorized as "Targeted initial scar" if it was targeted during the index procedure; "Untargeted initial scar" if it was present but not targeted during the index procedure; or "New scar" if it was not present during the index procedure. RESULTS: Of 60 patients with negative NIPS, 18 (30%) had recurrent VT and nine underwent repeat ablation over (4.1 ± 3.2) years follow-up. Of 23 recurrent VTs, 18 (78%) were "New." During repeat ablations, six (46%) of the 13 recurrent VTs were ablated in "untargeted initial scar" and four (31%) in "new scar." CONCLUSIONS: When spontaneous or inducible VTs are eliminated with ablation and no longer inducible during NIPS, these VTs are unlikely to recur during long-term follow-up. More commonly, new VTs occur, which are either associated with areas of scar not present or not targeted during the initial ablation.
Assuntos
Ablação por Cateter/métodos , Taquicardia Ventricular/fisiopatologia , Taquicardia Ventricular/cirurgia , Eletrocardiografia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , RecidivaRESUMO
Aims: Benefits of automatic remote home monitoring (HM) among implantable cardioverter defibrillator (ICD) patients may require high transmission frequency. However, transmission reliability and effects on battery longevity remain uncertain. We hypothesized that HM would have high transmission success permitting punctual guideline based follow-up, and improve battery longevity. This was tested in the prospective randomized TRUST trial. Methods and results: Implantable cardioverter defibrillator patients were randomized post-implant 2:1 to HM (n = 908) (transmit daily) or to Conventional in-person monitoring [conventional management (CM), n = 431 (HM disabled)]. In both groups, five evaluations were scheduled every 3 months for 15 months. Home Monitoring technology performance was assessed by transmissions received vs. total possible, and number of scheduled HM checks failing because of missed transmissions. Battery longevity was compared in HM vs. CM at 15 months, and again in HM 3 years post-implant using continuously transmitted data. Transmission success per patient was 91% (median follow-up of 434 days). Overall, daily HM transmissions were received in 315 795 of a potential 363 450 days (87%). Only 55/3759 (1.46%) of unsuccessful scheduled evaluations in HM were attributed to transmission loss. Shock frequency and pacing percentage were similar in HM vs. CM. Fifteen month battery longevity was 12% greater in HM (93.2 ± 8.8% vs. 83.5 ± 6.0% CM, P < 0.001). In extended follow-up of HM patients, estimated battery longevity was 50.9 ± 9.1% (median 52%) at 36 months. Conclusion: Automatic remote HM demonstrated robust transmission reliability. Daily transmission load may be sustained without reducing battery longevity. Home Monitoring conserves battery longevity and tracks long term device performance. Clinical trial registration: ClinicalTrials.gov; NCT00336284.
Assuntos
Desfibriladores Implantáveis , Cardioversão Elétrica/instrumentação , Fontes de Energia Elétrica , Técnicas Eletrofisiológicas Cardíacas/instrumentação , Telemedicina/instrumentação , Telemetria/instrumentação , Automação , Cardioversão Elétrica/efeitos adversos , Desenho de Equipamento , Falha de Equipamento , Humanos , Valor Preditivo dos Testes , Estudos Prospectivos , Reprodutibilidade dos Testes , Fatores de Tempo , Resultado do Tratamento , Estados UnidosRESUMO
The wearable cardioverter-defibrillator has been available for over a decade and now is frequently prescribed for patients deemed at high arrhythmic risk in whom the underlying pathology is potentially reversible or who are awaiting an implantable cardioverter-defibrillator. The use of the wearable cardioverter-defibrillator is included in the new 2015 ESC guidelines for the management of ventricular arrhythmias and prevention of sudden cardiac death. The present review provides insight into the current technology and an overview of this approach.
Assuntos
Arritmias Cardíacas/terapia , Morte Súbita Cardíaca/prevenção & controle , Desfibriladores , Cardioversão Elétrica/instrumentação , Arritmias Cardíacas/economia , Arritmias Cardíacas/mortalidade , Arritmias Cardíacas/fisiopatologia , Análise Custo-Benefício , Desfibriladores/economia , Difusão de Inovações , Cardioversão Elétrica/efeitos adversos , Cardioversão Elétrica/economia , Cardioversão Elétrica/mortalidade , Desenho de Equipamento , Custos de Cuidados de Saúde , Humanos , Cooperação do Paciente , Satisfação do Paciente , Fatores de Risco , Resultado do TratamentoRESUMO
INTRODUCTION: The incidence of unscheduled encounters and problem occurrence between ICD implant and first in-person evaluation (IPE) recommended at 12 weeks is unknown. Automatic remote home monitoring (HM) may be useful in this potentially unstable period. METHODS AND RESULTS: ICD patients were randomized 2:1 to HM enabled post-implant (n = 908) or to conventional monitoring (CM; n = 431). Groups were compared between implant and prior to first scheduled IPE for IPE incidence, causes, and actionability (reprogramming, system revision, medication changes) and event detection time. HM and CM patients were similar (mean age 63 years, 72% male, LVEF 29%, primary prevention 73%, DDD 57%). In the post-implant interval assessed (HM 100 ± 21.3 days vs. CM 101 ± 20.8 days, P = 0.54), 85.4% (776/908) HM patients and 87.7% CM (378/431) patients had no cause for IPE (P = 0.31). When IPE occurred, actionability in HM (64/177 [36.2%]) was greater versus CM (15/62 [24.2%], P = 0.12). Actionable items were discovered sooner with HM (P = 0.025). Device reprogramming or lead revision was triggered following 53/177 (29.9%) IPEs in HM versus 9/62 (14.5%) in CM (P = 0.018). Arrhythmia detection was enhanced by HM: 276 atrial and ventricular episodes were detected in 135 follow-ups in contrast to CM (65 episodes at 17 IPEs). More silent arrhythmic episodes were discovered by HM (7.2% vs. 1.5% [P = 0.15]). Since 27/42 (64.3%) IPEs driven by HM alerts were actionable, event notification was a valuable method for problem detection. Importantly, HM did not increase incidence of non-actionable IPEs (P = 0.72). CONCLUSION: Activation of automatic remote monitoring should be encouraged soon post-ICD implant.
Assuntos
Arritmias Cardíacas/diagnóstico , Arritmias Cardíacas/fisiopatologia , Desfibriladores Implantáveis , Eletrocardiografia Ambulatorial/métodos , Visita a Consultório Médico , Tecnologia sem Fio , Idoso , Arritmias Cardíacas/terapia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Visita a Consultório Médico/tendências , Estudos ProspectivosRESUMO
INTRODUCTION: Pacing-induced cardiomyopathy (PICM) is an important cause of heart failure in patients exposed to frequent right ventricular (RV) pacing. While echocardiography is diagnostic, the optimal surveillance strategy remains unknown. We sought to identify clinical and electrocardiographic factors associated with the presence of PICM to guide further testing. METHODS AND RESULTS: We retrospectively studied 1,750 consecutive patients undergoing pacemaker implantation 2003-2012. Patients were included if baseline LVEF was normal, single chamber ventricular or dual chamber pacemaker (but not ICD or cardiac resynchronization therapy device) was implanted, frequent (≥20%) RV pacing was present and repeat echocardiogram was available following implantation. PICM was defined as ≥10% decrease in LVEF, resulting in LVEF <50%. Patients with alternative causes of cardiomyopathy were excluded. Clinical and electrocardiographic indicators of PICM were identified using multivariate logistic regression. Of 184 patients meeting study criteria, 42 (22.8%) developed PICM, with decrease in mean LVEF from 62.1% to 35.3% over mean follow-up 2.5 years. Longer follow-up paced QRS duration was associated with the presence of PICM (multivariate odds ratio 1.34 per 10 millisecond increase, 95% CI 1.06-1.63, p = 0.01). Paced QRS duration ≥150 milliseconds was 95% sensitive for PICM. Only half of patients with PICM had heart failure signs or symptoms at the time of echocardiographic diagnosis. CONCLUSION: Patients with frequent RV pacing and paced QRS duration ≥150 milliseconds should be screened by echocardiogram to assess for PICM. Patients with paced QRS duration <150 milliseconds likely do not require screening, in the absence of heart failure signs or symptoms.
Assuntos
Arritmias Cardíacas/terapia , Estimulação Cardíaca Artificial/efeitos adversos , Cardiomiopatias/diagnóstico , Eletrocardiografia , Sistema de Condução Cardíaco/fisiopatologia , Disfunção Ventricular Esquerda/diagnóstico , Função Ventricular Direita , Potenciais de Ação , Idoso , Idoso de 80 Anos ou mais , Arritmias Cardíacas/diagnóstico , Arritmias Cardíacas/fisiopatologia , Estimulação Cardíaca Artificial/métodos , Cardiomiopatias/epidemiologia , Cardiomiopatias/fisiopatologia , Distribuição de Qui-Quadrado , Ecocardiografia , Feminino , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/fisiopatologia , Frequência Cardíaca , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Valor Preditivo dos Testes , Prevalência , Estudos Retrospectivos , Fatores de Risco , Volume Sistólico , Fatores de Tempo , Resultado do Tratamento , Disfunção Ventricular Esquerda/epidemiologia , Disfunção Ventricular Esquerda/fisiopatologia , Função Ventricular EsquerdaRESUMO
PURPOSE OF REVIEW: Cardiovascular implantable electronic devices are widely used to treat symptomatic arrhythmias, prevent sudden cardiac death, and improve symptoms and cardiac function. Continued population growth and expanding indications have resulted in a progressive increase in the number of cardiovascular implantable electronic device implantations. Mirroring this growth, an increasing number of leads require removal because of a variety of indications. Transvenous lead extraction continues to evolve with better techniques and risk-management strategies. This review highlights the indications, techniques, procedural outcomes, and future directions of arrhythmia device management and extraction. RECENT FINDINGS: Indications for extractions are reviewed in light of newly published data. Same day contralateral reimplantation has been shown to be safe in patients with localized pocket infection. Alternative extraction techniques, utilizing the femoral and internal jugular veins, provide additional routes for device removal as stand-alone procedures or in cases of difficult extraction via the subclavian vein. Preprocedural imaging to identify adherence sites and cardiac perforation can help to reduce complications. Routine capsulectomy at generator change does not seem to reduce the risk of device infection, and multiple trials are underway to assess other methods of reducing infections as part of a lead management strategy. SUMMARY: Improvement in technology, alternative routes of extraction and preprocedural imaging continue to add to procedural efficacy and reduce complication rates of lead extraction.
Assuntos
Desfibriladores Implantáveis/efeitos adversos , Remoção de Dispositivo/métodos , Remoção de Dispositivo/normas , Marca-Passo Artificial/efeitos adversos , Guias de Prática Clínica como Assunto , Infecções Relacionadas à Prótese/cirurgia , Humanos , Infecções Relacionadas à Prótese/etiologiaRESUMO
PURPOSE: Patients initiating warfarin therapy generally experience a dose-titration period of weeks to months, during which time they are at higher risk of both thromboembolic and bleeding events. Accurate prediction of prolonged dose titration could help clinicians determine which patients might be better treated by alternative anticoagulants that, while more costly, do not require dose titration. METHODS: A prediction model was derived in a prospective cohort of patients starting warfarin (n = 390), using Cox regression, and validated in an external cohort (n = 663) from a later time period. Prolonged dose titration was defined as a dose-titration period >12 weeks. Predictor variables were selected using a modified best subsets algorithm, using leave-one-out cross-validation to reduce overfitting. RESULTS: The final model had five variables: warfarin indication, insurance status, number of doctor's visits in the previous year, smoking status, and heart failure. The area under the ROC curve (AUC) in the derivation cohort was 0.66 (95%CI 0.60, 0.74) using leave-one-out cross-validation, but only 0.59 (95%CI 0.54, 0.64) in the external validation cohort, and varied across clinics. Including genetic factors in the model did not improve the area under the ROC curve (0.59; 95%CI 0.54, 0.65). Relative utility curves indicated that the model was unlikely to provide a clinically meaningful benefit compared with no prediction. CONCLUSIONS: Our results suggest that prolonged dose titration cannot be accurately predicted in warfarin patients using traditional clinical, social, and genetic predictors, and that accurate prediction will need to accommodate heterogeneities across clinical sites and over time. Copyright © 2016 John Wiley & Sons, Ltd.
Assuntos
Anticoagulantes/administração & dosagem , Modelos Teóricos , Varfarina/administração & dosagem , Adulto , Idoso , Algoritmos , Anticoagulantes/efeitos adversos , Relação Dose-Resposta a Droga , Feminino , Insuficiência Cardíaca/epidemiologia , Humanos , Seguro Saúde/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Estudos Prospectivos , Fumar/epidemiologia , Fatores de Tempo , Varfarina/efeitos adversosAssuntos
Arritmias Cardíacas/terapia , Tomada de Decisão Clínica , Segurança Computacional , Recall de Dispositivo Médico , Marca-Passo Artificial , Design de Software , Adulto , Idoso , Idoso de 80 Anos ou mais , Arritmias Cardíacas/diagnóstico , Arritmias Cardíacas/fisiopatologia , Aprovação de Equipamentos , Eletrocardiografia , Feminino , Disparidades em Assistência à Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Marca-Passo Artificial/efeitos adversos , Segurança do Paciente , Medição de Risco , Fatores de Risco , Estados Unidos , United States Food and Drug AdministrationRESUMO
INTRODUCTION: Following myocardial infarction (MI), left ventricular function is determined by cardiac remodeling occurring in both infarcted and noninfarcted myocardium (NIM). Unipolar voltage mapping may detect remodeling changes in NIM that are associated with the left ventricular ejection fraction (LVEF). We aimed to identify (1) unipolar voltage characteristics in patients with chronic MI, and (2) association of voltage abnormalities with degree of left ventricular dysfunction (LVD). METHODS AND RESULTS: Two groups of patients with ischemic cardiomyopathy (ICM) who underwent LV endocardial mapping during catheter ablation for ventricular tachycardia (VT) between January 2010 and December 2012 were studied. The first group (19 males) had mild to moderate LVD (M-LVD, LVEF >35%) and was matched for age, sex, infarction size, and infarction location with 10 males who had severe LVD (S-LVD, LVEF <35%). Both bipolar and unipolar endocardial abnormal voltage areas were measured and compared between groups. Abnormal bipolar area was comparable in both groups (30 ± 8% in the S-LVD group vs 28 ± 8% in the M-LVD group; P = 0.5). Total abnormal unipolar voltage area was significantly larger in the S-LVD group (57 ± 14% vs 43 ± 13%; P = 0.02). The abnormal unipolar voltage area within the normal bipolar voltage area was greater in the S-LVD group (26 ± 11% vs 15 ± 16%; P = 0.03). In receiver operating characteristic curve analysis, an 18.0% cut-off value for abnormal unipolar area within NIM identified severe LVD, with 90% sensitivity and 79% specificity (area under the curve 0.821). CONCLUSIONS: Patients with ICM and severe LVD have larger areas of unipolar voltage abnormality in the noninfarcted tissue than patients with M-LVD.
Assuntos
Mapeamento Potencial de Superfície Corporal/métodos , Cardiomiopatias/fisiopatologia , Isquemia Miocárdica/fisiopatologia , Disfunção Ventricular Esquerda/fisiopatologia , Idoso , Cardiomiopatias/diagnóstico , Cardiomiopatias/cirurgia , Ablação por Cateter/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Isquemia Miocárdica/diagnóstico , Isquemia Miocárdica/cirurgia , Resultado do Tratamento , Disfunção Ventricular Esquerda/diagnóstico , Disfunção Ventricular Esquerda/cirurgiaRESUMO
AIMS: Digoxin is recommended for long-term rate control in paroxysmal, persistent, and permanent atrial fibrillation (AF). While some analyses suggest an association of digoxin with a higher mortality in AF, the intrinsic nature of this association has not been examined in propensity-matched cohorts, which is the objective of the current study. METHODS AND RESULTS: In Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM), 4060 patients with paroxysmal and persistent AF were randomized to rate (n = 2027) vs. rhythm (n = 2033) control strategies. Of these, 1377 received digoxin as initial therapy and 1329 received no digoxin at baseline. Propensity scores for digoxin use were estimated for each of these 2706 patients and used to assemble a cohort of 878 pairs of patients receiving and not receiving digoxin, who were balanced on 59 baseline characteristics. Matched patients had a mean age of 70 years, 40% were women, and 11% non-white. During the 3.4 years of the mean follow-up, all-cause mortality occurred in 14 and 13% of matched patients receiving and not receiving digoxin, respectively [hazard ratio (HR) associated with digoxin use: 1.06; 95% confidence interval (CI): 0.83-1.37; P = 0.640]. Among matched patients, digoxin had no association with all-cause hospitalization (HR: 0.96; 95% CI: 0.85-1.09; P = 0.510) or incident non-fatal cardiac arrhythmias (HR: 0.90; 95% CI: 0.37-2.23; P = 0.827). Digoxin had no multivariable-adjusted or propensity score-adjusted associations with these outcomes in the pre-match cohort. CONCLUSIONS: In patients with paroxysmal and persistent AF, we found no evidence of increased mortality or hospitalization in those taking digoxin as baseline initial therapy.
Assuntos
Antiarrítmicos/efeitos adversos , Fibrilação Atrial/tratamento farmacológico , Digoxina/efeitos adversos , Insuficiência Cardíaca/mortalidade , Idoso , Fibrilação Atrial/mortalidade , Causas de Morte , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Estimativa de Kaplan-Meier , Masculino , Pontuação de Propensão , Resultado do TratamentoRESUMO
BACKGROUND: Premature ventricular complexes (PVCs) are common and associated with worse outcomes in patients with heart failure. Class 1C antiarrhythmic drugs (AADs) effectively suppress PVCs, but guidelines currently restrict their use in structural heart disease. OBJECTIVES: This study aimed to assess the safety and efficacy of class 1C AADs in patients with nonischemic cardiomyopathy (NICM) and implantable cardioverter-defibrillators (ICDs). METHODS: All patients with NICM and an ICD treated with flecainide or propafenone at the Hospital of the University of Pennsylvania between 2014 and 2022 were identified. PVC burden, left ventricular ejection fraction (LVEF), and biventricular pacing percentage were compared before and during class 1C AAD treatment. Safety outcomes included sustained atrial and ventricular arrhythmias, heart failure admissions, and death. RESULTS: We identified 34 patients, 23 receiving flecainide and 11 propafenone. Most patients (62%) had failed other AADs or catheter ablation (68%) prior to class 1C AAD initiation. PVC burden decreased from 20% ± 13% to 6% ± 7% (P < 0.001), LVEF increased from 33% ± 9% to 37% ± 10% (P = 0.01), and biventricular pacing percentage increased from 85% ± 9% to 93% ± 7% (P = 0.01). Sustained ventricular tachycardia (2 vs 9 patients) and admissions for decompensated heart failure (2 vs 3 patients) decreased compared with the 12 months prior to class 1C AAD initiation. CONCLUSIONS: Class 1C AADs effectively suppressed PVCs in patients with NICM and ICDs, leading to increases in LVEF and biventricular pacing percentage. In this limited sample, their use was safe. Larger studies are needed to confirm the safety of this approach.
Assuntos
Antiarrítmicos , Cardiomiopatias , Desfibriladores Implantáveis , Flecainida , Complexos Ventriculares Prematuros , Humanos , Masculino , Feminino , Antiarrítmicos/uso terapêutico , Cardiomiopatias/terapia , Cardiomiopatias/complicações , Pessoa de Meia-Idade , Idoso , Flecainida/uso terapêutico , Propafenona/uso terapêutico , Estudos Retrospectivos , Volume Sistólico/fisiologia , Resultado do TratamentoRESUMO
BACKGROUND: There is growing interest in the possibility of discontinuing oral anticoagulation following successful catheter ablation of atrial fibrillation (AF). However, it remains unknown whether patients can accurately detect arrhythmia recurrences following ablation. We therefore sought to characterize the accuracy of pulse checking and arrhythmia symptoms for the identification of AF following ablation. METHODS: This prospective cohort study included patients at the Hospital of the University of Pennsylvania with an insertable cardiac monitor (ICM) treated with catheter ablation for AF who recorded the results from minimum twice daily pulse checks and additionally with arrhythmia symptoms into a diary for 2 months following their procedure. Accuracy of this self-assessment protocol was determined by comparison to ICM-detected AF. RESULTS: A total of 55 patients (age 69 ± 8 years, 30 (55%) male, CHA2DS2VASc score 3.2 ± 1. 5) were included. Patients recorded a total of 5911 pulse checks, and there were 280 episodes of ICM-documented AF among 26 patients with an average duration of 2.5 ± 3.3 h. Among 362 episodes of patient-suspected AF, 134 correlated with ICM-identified AF (37% true positive rate). Of the 5549 pulse checks that did not identify AF, 196 correlated with ICM-identified AF (4% false negative rate). Twice daily pulse checking had a sensitivity of 47% and a specificity of 96% for identifying each episode of AF. CONCLUSIONS: Our data indicate that a strategy of pulse checks and symptom assessment is insufficient to identify all episodes of AF in many patients following catheter ablation.
Assuntos
Fibrilação Atrial , Ablação por Cateter , Humanos , Masculino , Pessoa de Meia-Idade , Idoso , Feminino , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/cirurgia , Estudos Prospectivos , Eletrocardiografia Ambulatorial/métodos , Frequência Cardíaca , Ablação por Cateter/métodosRESUMO
BACKGROUND: Epicardial (Epi) access is commonly required during ventricular tachycardia ablation. Conventional Epi (ConvEpi) access targets a "dry" pericardial space presenting technical challenges and risk of complications. Recently, intentional puncture of coronary venous branches with Epi carbon dioxide insufflation (EpiCO2) has been described as a technique to improve Epi access. The safety of this technique relative to conventional methods remains unproven. OBJECTIVES: The authors sought to compare the feasibility and safety of EpiCO2 to ConvEpi access. METHODS: All patients at a high-volume center undergoing Epi access between January 2021 and December 2023 were included and grouped according to ConvEpi or EpiCO2 approach. Access technique was according to the discretion of the operator. RESULTS: Epi access was attempted in 153 cases by 17 different operators (80 ConvEpi vs 73 EpiCO2). There was no difference in success rate whether the ConvEpi or EpiCO2 approach was used (76 [95%] cases vs 67 [91.8%] cases; P = 0.4). Total Epi access time was shorter in the ConvEpi group compared with the EpiCO2 group (16.3 ± 11.6 minutes vs 26.9 ± 12.7 minutes; P < 0.001), though the total procedure duration was similar. Major Epi access-related complications occurred in only the ConvEpi group (6 [7.5%] ConvEpi vs 0 [0%] EpiCo2; P = 0.02). Bleeding ≥80 mL was more frequently observed following ConvEpi access (14 [17.5%] cases vs 4 [5.5%] cases; P = 0.02). After adjusting for age, repeat Epi access, and antithrombotic therapy, EpiCO2 was associated with a reduction in bleeding ≥80 mL (OR: 0.27; 95% CI: 0.08-0.89; P = 0.03). CONCLUSIONS: EpiCO2 access is associated with lower rates of major complication and bleeding when compared with ConvEpi access.
Assuntos
Dióxido de Carbono , Ablação por Cateter , Insuflação , Pericárdio , Taquicardia Ventricular , Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Insuflação/métodos , Insuflação/efeitos adversos , Pericárdio/cirurgia , Taquicardia Ventricular/cirurgia , Ablação por Cateter/métodos , Ablação por Cateter/efeitos adversos , Idoso , Estudos Retrospectivos , Estudos de ViabilidadeRESUMO
BACKGROUND: Cardiac implantable electronic device (CIED) procedures can cause significant post-operative pain. Opioid use for post-operative pain is associated with risk of persistent use. The benefits of pectoral nerve blocks (PECs) have been established for other chest wall surgeries but adoption in electrophysiology has been limited. OBJECTIVES: To evaluate the efficacy of intraoperative ultrasound guided PECs performed at the time of CIED procedures by the implanting physician from within the device pocket. METHODS: Patients undergoing a pectoral CIED procedure at 7 centers from 2022-2023 were included. Patients underwent intraoperative PECs and subcutaneous local anesthetic vs subcutaneous local anesthetic only at the discretion of the operator. Patients were prospectively evaluated for post-operative pain. RESULTS: 610 patients (67±15 years old, 63% male) were enrolled and half (n=305) underwent PECs. Patients who underwent PECs were more likely to have a history of chronic pain (32 vs 11%, p<0.001). PECs was associated with lower pain scores in the 4 hours after the procedure (1.5±2.1 vs 4.5±2.5, p<0.001). Pain scores were not different after 24-hours (2.8±1.7 vs 3.1±2.2) and 2-weeks (0.9±1.4 vs 0.9±1.2). PECs patients were less likely to receive inpatient opioids (10 vs 48%, p<0.001) and to be discharged with an opioid prescription (15 vs 59%, p<0.001). In multivariable linear regression, PECs (p<0.001), age (p=0.002) and absence of chronic pain (p=0.009) were associated with lower acute post-operative pain. CONCLUSIONS: Intraoperative PECs can reduce post operative pain and opioid use. This procedure can be readily performed by the implanting physician from within the device pocket.