Rhythmos (E-Journal - First Department of Cardiology / Evagelismos General Hospital of Athens)
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What is New in the ESC Guidelines for the Management of Atrial Fibrillation
Get PDFThe European Society of Cardiology (ESC) and the European Heart Rhythm Association (EHRA) have developed the 2010 Clinical Practice Guidelines covering atrial fibrillation (AF), the most common cardiac arrhythmia occurring in 1-2% of the general population. Advance has been made regarding the dynamic development of AF from a preclinical state to an irreversible cardiac arrhythmia and a novel classification of AF has been adopted based on the presentation and duration of the arrhythmia: first diagnosed, paroxysmal, persistent, long-standing persistent and permanent AF are the 5 types of AF in use for clinical management of patients with AF.Structural and electrical remodelling are hallmarks of the pathophysiological changes facilitating the initiation and perpetuation of AF. While atrial fibrosis was the main cause of nonhomogeneity of conduction according to earlier ESC guidelines, nowadays any kind of structural abnormality (inflammatory changes, amyloid deposit, apoptosis, necrosis, hypertrophy, microvascular changes, etc.) is believed to trigger the electrical dissociation between muscle bundles and permit small re-entrant circuits to stabilize the arrhythmia. The adage ‘atrial fibrillation begets atrial fibrillation’ describes electrical remodelling due to shortening of atrial refractory period, which is attributed to down-regulation of the L-type Ca2+ inward current and up-regulation of inward rectifier K+ currents. Although the exact role of the genome in the pathogenesis of AF is not known, numerous inherited cardiac syndromes and mutations have lately been associated with AF and should be elucidated. Mutations in the gene coding for atrial natriuretic peptide, loss of function mutations in the cardiac sodium channel gene SCN5A or gain of function mutations in the cardiac potassium channel are related to familial AF and genetic loci close to the PITX2 and ZFHX3 genes are currently associated with enhanced risk for cardioembolic stroke... (excerpt
ECG Quiz
Get PDFThis pacemaker ECG (Figure) belongs to a patient who received the device (Symphony DR 2550, Sorin Group) due to sick sinus syndrome combined with atrioventricular (AV) conduction disturbances. Is the pacemaker malfunctioning given the fact that it encorporates a specific algorithm to minimize ventricular pacing? ...(excerpt
Cardiology News /Recent Literature Review
Get PDFThe ACC Annual Congress is slated for April 3-5, 2011 in New Orleans The HRS Annual Meeting is scheduled for May 4-7, 2011 in San Francisco Euro-PCR will take place in Paris on May 17-20, 2011 The ESC Annual Congress is slated for 27-31/8/2011 in Paris The TCT Annual Conference will be held in San Francisco 7-11/11/2011 The AHA Annual Scientific Sessions are scheduled for 12-16/11/2011 in Orlando Athens Cardiology Update 2012 is slated for April 5-7, 2012 Local Atrial Inflammation Present in Paroxysmal AF Atrial biopsies were obtained from 70 patients (age 60 ± 12 years, 49 males) undergoing radiofrequency catheter ablation for AF and 10 patients with Wolff-Parkinson-White syndrome, all undergoing trans-septal puncture. Biopsies were obtained by washing the dilator and needle used for trans-septal puncture with 20 mL sterile phosphate-buffered saline, and formalin fixed specimen were examined by immunohistochemistry for the presence of intracytoplasmic C-reactive protein. C-reactive protein was revealed in isolated atrial cardiomyocytes in 11 (73%) of 15 patients with paroxysmal AF as compared with 2 (25%) of 8 patients with persistent AF (P= 0.02). This technique for obrtaining biopsy specimen was safe and feasible. In this study, local atrial inflammation as assessed by C-reactive protein present in atrial myocytes, is more likely involved in paroxysmal rather than in persistent AF (Narducci ML et al, Europace. 2011 Mar 29. [Epub ahead of print])... (excerpt
Cardiac Resynchronization Therapy in Heart Failure: Patients with Narrow QRS
Get PDFHeart failure remains a significant health problem in the Western countries despite the evolution achieved in terms of heart disease prevention and medical treatment. Its incidence and its prevalence reach 550,000/year and 5 million respectively in the United States. As a consequence, heart failure causes about 287,000 deaths in the US each year and puts a financial burden to the health system of $29.6 billion dollars due to the increasing number of hospitalizations especially in elderly patients.Cardiac resynchronization therapy (CRT) is a relatively recent advance in the management of heart failure patients, which has been very hopeful since its development. Large trials have established the efficacy of CRT in improving functional capacity (MUSTIC, MIRACLE) and reducing mortality (COMPANION, CARE HF) in patients with advanced heart failure (NYHA III-IV), reduced ejection fraction (EF<35%) and wide QRS complex >120 - 130 ms (MIRACLE). Data from meta-analyses also confirm the beneficial effect of CRT with respect to mortality from worsening heart failure and all cause mortality in patients with wide QRS complex.Nevetheless, not all patients suffering from heart failure have a prolonged QRS. On the contrary, it has been reported that nearly 50% of heart failure patients have a QRS < 120 ms. Moreover, CRT has been shown to improve haemodynamic variables in patients with heart failure and narrow QRS. Achilli et al, who studied 52 patients, reported that CRT produced similar clinical and functional benefit in patients with wide or narrow QRS, the cut-off point being 120 ms provided they had mechanical dyssynchrony. Bleeker at al came up with similar results when they compared 33 patients with normal QRS duration with an equal number of subjects with wide QRS. All participants ought to have mechanical dyssynchrony >65 ms on tissue Doppler imaging (TDI) study... (excerpt
Lethal Proarrhythmic Effect of Propafenone
Get PDFA 67-year-old man with history of paroxysmal atrial fibrillation and known ischemic cardiomyopathy, dyslipidemia, hypertension, and chronic renal failure, was admitted via the emergency room with complaints of palpitations. Past medical history was remarkable for prior myocardial infarction in 2007 followed by percutaneous coronary intervention in the left anterior descending and right coronary arteries. Recent echocardiography showed a left ventricular ejection fraction of 30-35%. During the admission he was found to be in atrial fibrillation with a ventricular rate of 110 bpm (Fig. 1) and was given orally a dose of 450 mg of propafenone... (excerpt
Cardiology News / Recent Literature Review
Get PDFThe ESC Annual Congress is slated for 27-31/8/2011 in Paris The TCT Annual Conference will be held in San Francisco 7-11/11/2011 The AHA Annual Scientific Sessions are scheduled for 12-16/11/2011 in Orlando The Athens Cardiology Update 2012 is slated for April 5-7, 2012 Reverse remodeling in cardiac resynchronization therapy reduces the risk of ventricular tachyarrhythmias in the MADIT-CRT trial The risk for ventricular tachyarrhythmias (VTA) (including ventricular tachycardia, ventricular fibrillation and ventricular flutter) was assessed in patients receiving cardiac resynchronization defribrillator therapy (CRT-D) or cardioverter-defribillator therapy (ICD) according to echocardiographic findings during 1-year follow-up. It was found that high responders to CRT-D (defined as ≥ 25% reduction in left ventricular end-systolic volume) experience a significant 55% reduction in the risk of VTA compared with ICD only patients (p<0.001), whereas the risk of VTA was not significantly different between low responders and ICD-only patients (p=0.21). (Barsheshet A et al, J Am Coll Cardiol 2011; 57: 2416-2423) High-dose atorvastatin does not prevent development of atrial fibrillation in patients with prior stroke or transient ischemic attack in the SPARCL trial Statins are included as upstream therapy for prevention of new-onset of atrial fibrillation (AF) in the 2010 guidelines for the management of AF. The SPARCL trial tested the hypothesis that long-term treatment with high-dose atorvastatin (80 mg) reduces the occurrence of AF in 4731 patients with prior stroke or transient ischemic attack who were followed up for a median of 4.8 years (patients with prior paroxysmal AF were excluded from the trial). It was concluded that the time from randomization to first occurrence of new AF did not differ between atorvastatin (139 cases of new AF) and placebo (122 cases) group (hazard ratio 1.15, 95% CI 0.90-1.46, P=0.26). (Schwartz GG et al, Am Heart J 2011; 161: 993-999)... (excerpt
Left Atrial Appendage Closure: Feasible but Still Risky / Will it Though Obviate the Need for Anticoagulation?
Get PDFVarious studies and meta-analyses have suggested that in cases of left atrial thrombi in nonrheumatic atrial fibrillation (AF) patients, approximately 90% of them are located in the left atrial appendage (LAA). Patients are effectively protected from thromboembolism in this setting by anticoagulation therapy, shown to reduce the incidence by 60-70% with vitamin K antagonists and maybe more by the newer anticoagulants. However, anticoagulation therapy is limited by an increased risk of major bleeding, in addition to other hindrances, such as difficulty in monitoring anticoagulation therapy, several drug and food interactions for classical warfarin, or cost and bleeding issues with the newer drugs, all leading to limited use of anticoagulation in clinical practice with percentages reported at 30-50%. For these reasons, alternative device therapies with occlusion of the LAA, considered the most common source of thromboembolism in this cohort, have been recently pursued.In the European PLAATO (Percutaneous Left Atrial Appendage Transcatheter Occlusion) study, the first device ever used for this purpose, which, however, was subsequently withdrawn, had an initial implant success rate of 90% among 180 patients. However, there was a 1.1% mortality (2 patients) related to the procedure, while 6 cases of cardiac tamponade also occurred (3.3%). In two cases, surgical drainage of the tamponade was necessary (1.1%). In one patient the device embolized into the aorta after its release (0.6%) (at the end successfully snared and replaced). During follow-up, 3 strokes occurred (2.3% per year). The expected incidence of stroke according to the CHADS2-Score was 6.6% per year. The trial was halted prematurely during the follow-up phase, allegedly for financial considerations... (excerpt
Catheter Ablation of Incessant Ventricular Tachycardia in a Patient With Coronary Artery Disease
Get PDFA 67-year-old male with known coronary artery disease was referred to our hospital for catheter ablation of incessant ventricular tachycardia (VT). Transthoracic echocardiography revealed severe wall motion abnormalities of the left ventricle along with an apical aneurysm. Left ventricular voltage mapping showed a region with low voltage (<1.5 mV) at the left ventricular apex. Propagation mapping revealed a macro-reentry circuit around the apical aneurysm. Mid-diastolic potentials were recorded during the VT (Fig. 1, left panel, arrows), while entrainment mapping was excellent. The first radiofrequency energy application terminated the tachycardia. A circumferential lesion around the aneurysm was finally performed (Fig. 1, right panel, red dots). Ventricular tachycardia became non-inducible, and the patient is free from arrhythmic events during the last six months... (excerpt
An Example of Angiographic Projection “Fine Tuning” in Primary PCI for Acute Anterior Myocardial Infarction
Get PDFA 52-year-old gentleman was admitted with acute anterior myocardial infarction. He was submitted to emergency coronary angiography intending to perform primary percutaneous coronary intervention (PCI). The left anterior descending (LAD) coronary artery was missing. The standard initial angiographic projections failed to reveal the stump of the very proximally occluded LAD, which was consistently hidden by the proximal part of the left circumflex artery. Only the right anterior oblique cranial view, after slightly modifying the initial angle, finally delineated the LAD stump. Primary PCI was successfully performed and the patient had an uncomplicated in-hospital course
Discrepant Atrial Fibrillation Guidelines
Get PDFRecently, cardiological societies in Europe (ESC), US and Canada (CCS) have updated their guidelines for atrial fibrillation (AF). However, there are several discrepancies which have been identified and discussed. Among them, the following are the most blatant ones. • Anticoagulation. Atrial fibrillation confers a 5-fold increase in the risk of stroke if left without anticoagulation therapy and a 2-fold increase in the risk of death from such thromboembolic strokes. The US guidelines recommend anticoagulation for a patient with a CHADS2 score of ≥2, and either aspirin or anticoagulation for a patient with a CHADS2 score of 1, while the CCS and ESC guidelines recommend anticoagulation for a patient with ≥1 risk factor(s). The new anticoagulants are taken into consideration by the CCS guidelines, recommending dabigatran instead of vitamin K antagonists (VKA). The ESC guidelines make recommendations for future use of dabigatran (when approved in the EU) depending on the risk of bleeding; for low-risk patients it may be considered, while for higher risk patients the lower dose of 110 mg of dabigatran may be considered. Also patients with a CHADS2 score of 1 may receive the lower dose (110 mg) of dabigatran. The US guidelines issued an update for dabigatran, indicating that it is a useful alternative to VKA... (excerpt