Rhythmos (E-Journal - First Department of Cardiology / Evagelismos General Hospital of Athens)
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Echocardiographic Criteria for CRT Patient Selection: Is There Still a Role?
Get PDFCardiac resynchronization therapy (CRT) is a relatively new therapeutic option for patients with systolic heart failure (HF) and electrocardiographic evidence of dyssynchrony. However, with current selection guidelines, still a proportion of patients do not respond to this interventional therapy. Several echocardiographic criteria have been proposed to address this issue, but research so far has failed to provide a single and simple measurement with adequate accuracy for CRT candidate selection. While investigation for this subject is still under way, new possible roles of echocardiography in CRT implementation arise, such as assistance in selecting the site of left ventricular (LV) pacing lead and optimizing CRT device programming during follow up visits
New (2014) Guidelines for Managing Patients with Non–ST-Elevation Acute Coronary Syndromes
Get PDFThe American Heart Association (AHA) and the American College of Cardiology (ACC) have just issued (September 23, 2014) new guidelines for the management of patients with non-ST elevation (NSTE) acute coronary syndromes (ACS).1 They start with definitions. Absence of persistent ST elevation defines NSTE-ACS (except in patients with true posterior myocardial infarction –MI). Further classification of NSTE-ACS is based on whether cardiac troponin is elevated (NSTEMI) or not (unstable angina - UA). ST depression, transient ST elevation, and/or T-wave inversion may be present but are not required for a diagnosis of NSTEMI. Abnormalities on the electrocardiogram (ECG) and elevated cardiac troponins in isolation are insufficient to make the diagnosis of ACS but must be interpreted in the appropriate clinical context.1,2 Thus, UA and NSTEMI differ primarily by whether ischemia causes myocardial damage with a detectable cardiac biomarker. With the increasing sensitivity of cardiac troponin assays, biomarker-negative ACS (UA) is becoming rarer... (excerpt
Cardiology News /Recent Literature Review / Third Quarter 2014
Get PDFHCS Annual Meeting: Athens, 23-25/10/2014 AHA: Chicago, 15-19/11/14 20th Annual Boston AF Symposium: Orlando, 8-10/1/15 HCS Working Groups Seminar: Ioannina, 2/2015 ACC: San Diego, 14-16/3/15 HRS: Boston, 13-16/5/15 EuroPCR: Paris, 19-22/5/15 Europace: Milan, 21-24/6/15 ESC: London, 29/8-2/9/15 Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC): ICDs Save Lives & Antitachycardia Pacing (ATP) is Highly Successful Regardless of Heart RateOf 137 patients enrolled in a prospective North American ARVC registry, 108 received implantable cardioverter defibrillators (ICDs); 48 had 502 sustained episodes of ventricular arrhythmias (VAs) (489 monomorphic and 13 polymorphic). In the ICD patients, independent predictors of VAs in follow-up included spontaneous sustained VAs before ICD implantation and T-wave inversions inferiorly. The only independent predictor for life-threatening VAs, defined as sustained ventricular tachycardia (VT) ≥240 beats/min or ventricular fibrillation, was a younger age at enrollment. Anti-tachycardia pacing (ATP), independent of VT cycle length, was successful in terminating 92% of VT episodes. The authors concluded that in ARVC most VAs at follow-up are monomorphic. Risk factors for VAs were spontaneous VAs before enrollment and a younger age at ICD implantation. ATP is highly successful in terminating VT, and all ICDs should be programmed for ATP, even for rapid VT (Link M et al, J Am Coll Cardiol 2014;64:119-125). PREVAIL: Left Atrial Appendage (LAA) Occlusion a Reasonable Alternative to Warfarin for Stroke Prevention in Non-Valvular Atrial Fibrillation?In the PROTECT AF trial in patients with nonvalvular atrial fibrillation (NVAF), LAA occlusion with the Watchman device was noninferior to warfarin for stroke prevention, but procedural safety was questionable. The PREVAIL study further assessed efficacy and safety of this device in patients with NVAF who had a CHADS2 score ≥1-2. At 1½ years, the rate of first primary efficacy endpoint (composite of stroke, systemic embolism [SE], and cardiovascular/ unexplained death) was 0.064 in the device group (n=269) vs 0.063 in the control group (n=138) and did not achieve noninferiority criteria. The rate for the second primary efficacy endpoint (stroke or SE >7 days’ post-randomization) was 0.0253 vs 0.0200 (risk difference 0.0053), achieving noninferiority. Early safety events occurred in 2.2% of the device arm (lower than in PROTECT AF). All adverse effects were lower in PREVAIL trial than in PROTECT AF (4.2% vs 8.7%; p = 0.004). Pericardial effusions requiring surgery decreased from 1.6% to 0.4% (p= 0.027), and those requiring peri-cardiocentesis decreased from 2.9% to 1.5% (p=NS). The authors concluded that LAA occlusion was noninferior to warfarin for ischemic stroke prevention or SE >7 days’ post-procedure. Noninferiority was not achieved for overall efficacy but procedural safety improved (Holmes DR et al, J Am Coll Cardiol 2014;64:1-12)... (excerpt
Moderate Intake of Flavonoid-Rich Tea, Green or Black, Confers Cardiovascular Protection
Get PDFA variety of dietary supplements have been proposed for the management of hypertension and other cardiovascular diseases, but the evidence for their efficacy is meagre.1 However, over the last few years, there is growing interest in the potential benefit of tea in cardiovascular protection. 2-4 Tea is the extract of Camellia sinensis, and one of the most widely enjoyed drinks.2,3 The leaves of the plant are rich in flavonoids, containing several phytochemicals including phenols and catechins, to which potent antioxidant, free radical scavenging, appetite-modifying and hypolipidemic effects have been ascribed.2-7 Long-term consumption of beverages containing catechins inhibits the formation of oxidized lipids and decreases body fat.5-9 Over 70% of flavonoids in green tea are catechins. Epigallocatechin-3-gallate (EGCG) is the cardinal (65%) catechin in green tea. In-vitro studies have shown that the epigallocatechins in green tea have angiotensin converting enzyme inhibitor properties,10 and vasodilatory actions. 11 Molecular and animal studies have demonstrated that green tea catechins enhance processes, thought to stimulate bile acid production, decrease cholesterol concentration in the hepatocytes, inhibit intestinal absorption of lipids and upregulate low-density lipoprotein (LDL) receptors in the liver, mechanisms all leading to favorable blood lipid profile. 2-4,12,13Black tea also contains small amounts of catechins. However, due to the fermentation process of black tea, its primary antioxidant polyphenols are theaflavins and thearubigins, equally effective antioxidants to catechins. 14... (excerpt
A Case of Anomalous Origin of the Right Coronary Artery from the Left Anterior Descending Artery
Get PDFA 34-year-old man, ex-smoker, with family history of coronary artery disease presented to the emergency room complaining of an episode of chest discomfort at rest, radiating to the arms, accompanied with palpitations, that started several hours earlier, lasted for several minutes and resolved with a syncopal episode. He did not mention any prior similar episodes and did not have angina or dyspnea on exertion, orthopnea or paroxysmal nocturnal dyspnea. At the time of presentation he was asymptomatic. His physical examination was unremarkable. However, his electrocardiogram revealed sinus rhythm with mild ST depression and T-wave inversion in leads I, avL, V4-V6. The patient was admitted to the coronary care unit with a possible diagnosis of an acute coronary syndrome. Cardiac markers remained normal in consecutive measurements. His echocardiogram was normal and a 24-hour Holter recording did not reveal any significant arrhythmic events. Coronary angiography was performed for further evaluation of the episode; it displayed normal courses of the left main coronary artery (LMCA), dominant left circumflex (LCX), and left anterior descending artery (LAD). An anomalous right coronary artery (RCA) as a separate small branch arose from the distal LAD with subsequent anterior course (Fig. 1 & 2)... (excerpt
Percutaneous Coronary Intervention Complications: Where do we Stand?
Get PDFCoronary angioplasty (or percutaneous coronary intervention, PCI) is a mature and widely diffused treatment technique for coronary artery disease. Over the last decades, great evolution has been realized concerning the related technology, the pharmacologic armamentarium and operators’ experience resulting in improved safety and success rates of PCI. Despite the fact that associated risks have declined over time, since PCIs are invasive procedures, complication rates have always been and still are a vexing reality. They concern the cardiologist who sets the indication, the interventionalist who performs the procedure but most importantly the patient who should be well informed for the anticipated benefits and risks before giving his written informed consent. A concise update on recent data about the most important issues regarding PCI complications is attempted herein
Totally Implantable Artificial Heart: Still a Major Challenge
Get PDFThe first mechanical heart was placed by Liotta and Cooley in 1969 in a dying patient at the Texas Heart Institute in Houston as a 2 ½-day bridge for a transplant, albeit the patient died 32 hours after transplantation.1 Years later (1982) a totally implantable artificial heart (model Jarvik-7) was permanently implanted in a patient by DeVries et al at the University of Utah Medical Center in Salt Lake City, Utah, USA and the patient lived for 112 days.2 Subsequent attempts of implantation of a total artificial heart (e.g. CardioWest/SynCardia models) have limited its use as a bridge to transplantation, like the left- or bi-ventricular assist devices (VADs).3-7 The SynCardia model (SynCardia Systems Inc., Tuscon, AZ) has been approved for compassionate use by the Food and Drug Administration (FDA) for patients with end-stage biventricular heart failure as a bridge to transplantation since 1985 and has had FDA approval since 2004.3-5 The SynCardia™ total artificial heart, weighing 180 g, providing a stroke volume of 70 cc, is a pneumatically driven, pulsatile system capable of flows of >9L/min. It is indicated for temporary use as a bridge to transplantation in patients with end-stage non-reversible bi-ventricular failure. Currently, the recipients of this device are hospital-bound and attached to a large pneumatic driver. The bridge to transplantation rate has been ~80% in >1100 implants. In 2010, the FDA gave conditional approval for an Investigational Device Exemption clinical study of the portable Freedom driver (SynCardia) (www.syncardia.com)... (excerpt
Cardiology News /Recent Literature Review / Fourth Quarter 2013
Get PDFACC Congress 2014: Washington, DC, 29-31/3/2014 Athens Cardiology Update 2014: Athens (Crown Plaza Hotel), 10-12/4/2014 HRS Meeting: San Francisco, 7-10/5/2014 EuroPCR: Paris, 20-23/5/2014 CardioStim 2014: Nice, 18-21/6/2014 ESC Congress 2014 (Barcelona, 30/8-3/9/14) Only One Fifth of the Sudden Cardiac Arrest Victims in the Community are Eligible for a Primary Prevention ICD Before the Event, but Among These, a Small Proportion (13%) are Actually Implanted According to data from the Oregon Sudden Unexpected Death study, among 2093 victims of sudden cardiac arrest (SCA) over a decade, of 448 having information about left ventricular ejection fraction (LVEF), 92 (20.5%) were eligible for primary ICD implantation, 304 (67.9%) were ineligible because of LVEF>35%, & the remainder (52, 11.6%) had LVEF ≤35% but were ineligible on the basis of clinical criteria. Among eligible subjects, only 12 (13%) received a primary ICD. Compared with recipients, ICD nonrecipients were older (age at LVEF assessment, 67.1±13.6 vs 58.5±14.8 years, P=0.05), with 20% aged ≥80 years (vs 0% among recipients, P=NS). Additionally, a subgroup (26%) had either a clinical history of dementia or were undergoing chronic dialysis. The authors concluded that only one fifth of the SCA cases in the community were eligible for a primary prevention ICD before the event, but among these, a small proportion (13%) were actually implanted. Although older age and comorbidity may explain nondeployment in a subgroup of these cases, other determinants such as socioeconomic factors, health insurance, patient preference, and clinical practice patterns may play a role (Narayanan K, et al, Circulation 2013;128:1733-1738).Appropriate ICD Therapies over 10 Years are More Prevalent in Symptomatic Brugada Syndrome (19-48%) but Still Occur in Asymptomatic Patients (12%)A total of 378 patients (310 men; aged 46±13 years) with a type 1 Brugada ECG pattern were implanted with an implantable cardioverter-defibrillator-ICD; 31 for aborted sudden cardiac arrest, 181 for syncope, and 166 asymptomatic. During a mean follow-up of 77±42 months for 363 patients, 7 patients (2%) died (1 as a result of an inappropriate shock), and 46 patients (12%) had appropriate device therapy (5±5 shocks per patient). Appropriate device therapy rates at 10 years were 48% for patients whose ICD indication was aborted sudden cardiac arrest, 19% for those with syncope, and 12% for the asymptomatic patients. At 10 years, rates of inappropriate shock and lead failure were 37% and 29%, respectively. Inappropriate shock occurred in 91 patients (24%) because of lead failure (n=38), supraventricular tachycardia (n=20), T-wave oversensing (n=14), or sinus tachycardia (n=12). Reduced inappropriate shocks were noted with introduction of remote monitoring, programming a high single ventricular fibrillation zone (>210–220 bpm), and a long detection time. The authors concluded that appropriate therapies are more prevalent in symptomatic Brugada syndrome but are not insignificant in asymptoma-tic patients (1%/y). Optimal ICD programming and remote monitoring dramatically reduce inappropriate shocks. However, lead failure remains a major problem in this population (Sacher F et al, Circulation 2013;128: 1739-1747)... (excerpt
Beta-Blockers in Post-MI Patients: Need to Re-consider?
Get PDFInternational clinical practice guidelines recommend early introduction and continued treatment with beta-blockers for all patients without contraindications after STEMI. Although there seemed to be little question that patients with STEMI, regardless of revascularization strategy, derive substantial benefits from both long- and short-term beta-blockade, there has been a paucity of high quality evidence supporting this notion and the majority of data predate modern reperfusion therapy and current medical management strategies with statins and antiplatelet agents. Recently published data question this “one-size-fits-all” approach, showing that the use of beta-blockers increased the risk of heart failure and cardiogenic shock with no mortality benefit
Catheter Ablation of Right Ventricular Outflow Tract Ventricular Tachycardia
Get PDFΑ 57-year-old female with repetitive monomorphic ventricular tachycardia was referred for an electrophysiological study. ECG during sinus rhythm was normal. ECG during tachycardia revealed a left bundle branch block (LBBB) pattern with inferior axis suggestive of an outflow tract tachycardia (Fig. 1). Structural heart disease was excluded. Transthoracic echocardiography and coronary angiography were unremarkable. The tachycardia was easily induced by atrial pacing (Fig. 2). This was suggestive of cyclic adenosine monophosphate (c-AMP) triggered activity as the pathophysiological basis of the arrhythmia. Activation mapping revealed the earliest activity at the posteroseptal region of the right ventricular outflow tract. A systolic pre-potential was recorded in this area, which is rarely seen in these type of arrhythmias (Fig. 3)... (excerpt