RESUMO
Background: Cerebral thromboembolism during atrial fibrillation (AF) ablation is an infrequent (0.17%) complication in part owing to strict adherence to intraprocedural anticoagulation. Failure to maintain therapeutic anticoagulation can lead to an increase in events, including silent cerebral ischemia. Objective: To evaluate a computerized, clinical decision support system (CDSS) to dose intraprocedural anticoagulation and determine if it leads to improved intraprocedural anticoagulation outcomes during AF ablation. Methods: The Digital Intern dosing algorithm is an adaptive, rule-based CDSS for heparin dosing. The initial dose is calculated from the patient's weight, baseline activated clotting time (ACT), and outpatient anticoagulant. Subsequent recommendations adapt based on individual patient ACT changes. Outcomes from 50 cases prior to algorithm introduction were compared to 139 cases using the algorithm. Results: Procedures using the dosing algorithm reached goal ACT (over 300 seconds) faster (17.6 ± 11.1 minutes vs 33.3 ± 23.6 minutes pre-algorithm, P < .001). ACTs fell below goal while in the LA (odds ratio 0.20 [0.10-0.39], P < .001) and rose above 400 seconds less frequently (odds ratio 0.21 [0.07-0.59], P = .003). System Usability Scale scores were excellent (96 ± 5, n = 7, score >80.3 excellent). Preprocedure anticoagulant, weight, baseline ACT, age, sex, and renal function were potential predictors of heparin dose to achieve ACT >300 seconds and final infusion rate. Conclusion: A heparin dosing CDSS based on rules and adaptation to individual patient response improved maintenance of therapeutic ACT during AF ablation and was rated highly by nurses for usability.
RESUMO
Since the widespread implementation of implantable cardioverter-defibrillators (ICDs), their effectiveness in various situations has become well-established. However, despite many advances in both the technology and its utilization, inappropriate therapy remains a risk. Here, we review ICD shocks, their effect on outcomes, and current methods to reduce inappropriate therapy, finding overall that inappropriate ICD shocks are common and associated with adverse outcomes. However, strategies do exist to minimize inappropriate shock rates including device selection and programming, medication, catheter ablation, and remote monitoring. Overall, ICDs are useful in reducing the risk of sudden cardiac death, but many patients with an ICD will receive an inappropriate shock. Understanding strategies to prevent inappropriate shocks is crucial to improving the care of patients with ICDs.