Rhythmos (E-Journal - First Department of Cardiology / Evagelismos General Hospital of Athens)
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“Warm-up” and “Cool-Down” Phenomenon
Get PDFA 14-year-old was diagnosed with recurrent bouts of narrow-QRS complex tachycardia displaying the phenomenon of “warm-up” and “cool-down” that aided in the differential diagnosis. Rhythmos 2017;12(3):52
Cardiology News / Recent Literature Review / First Quarter 2017
Get PDFHRS Scientific sessions: Chicago, 10-13/5/2017EHRA Europace-Cardiostim: Vienna, 18-21/6/2017ESC Congress: Barcelona, 26-30/8/2017TCT Congress: Denver, Colorado, 29/10-2/11/2017AHA Meeting: Anaheim, Ca, 11-15/11/2017Anterior T-Wave Inversion (ATWI), Present in 2.3% of Young Whites, More Common in Women and in Athletes, 77% Confined to Leads V1 - V2, Could be a Normal Variant in Asymptomatic Individuals Without a Family History of Cardiomyopathy or Premature SCD / In Contrast, ATWI Extending Beyond V2, Present in only 1% of Females and 0.2% in Men, May Justify Further Evaluation, Particularly when Preceded by J-Point or ST-Segment Depression Among 14,646 individuals 16 to 35 years of age, including 4,720 females (32%) and 2,958 athletes (20%), ATWI was detected in 338 individuals (2.3%) and was more common in women than in men (4.3% vs. 1.4%, respectively; p< 0.0001) and more common among athletes than in nonathletes (3.5% vs 2%, respectively; p<0.0001). T-wave inversion was predominantly confined to leads V1 to V2 (77%). Only 1.2% of women and 0.2% of men exhibited ATWI beyond V2. No one with ATWI fulfilled diagnostic criteria for ARVC after further evaluation. Over 23.1±12.2 months none of the individuals with ATWI experienced an adverse event (Malhotra A et al, J Am Coll Cardiol 2017;69:1-9).Alcohol Abuse Increases the Risk of AF, MI, and Heart Failure to an Extent Similar to that of Other Strong Risk Factors, and Affects Healthier Individuals Disproportionately / Protective Effects of Alcohol Against MI are Outweighed at Heavy Levels of Consumption by its Adverse Effects Among 14,727,591 patients, 268,084 (1.8%) had alcohol abuse, which was associated with an increased risk of incident atrial fibrillation (AF) (hazard ratio -HR: 2.14; p<0.0001), myocardial infarction (MI) (HR: 1.45; p< 0.0001), and heart failure (HF) (HR: 2.34; p<0.0001). Individuals without conventional risk factors for cardiovascular disease exhibited a disproportionately enhanced risk of each outcome. The population-attributable risk of alcohol abuse on each outcome was of similar magnitude to other well-recognized modifiable risk factors (Whitman IR et al, J Am Coll Cardiol 2017;69:13-24).LEADERS FREE Trial: in Patients at High Risk of Bleeding Undergoing PCI Followed by 1 Month of Dual Antiplatelet Therapy (DAPT), Polymer-Free Drug-Coated Stents (DCS) are both Safer and More Effective Than Bare Metal Stents (BMS) at 2 Years Among 2,466 high bleeding risk patients randomized to a drug-coated stent (DCS) or a BMS followed by 1-month DAPT, at 2 years, the primary safety endpoint (cardiac death, MI, or stent thrombosis) had occurred in 147 DCS (12.6%) and 180 BMS patients (15.3%) (hazard ratio-HR: 0.80; p = 0.039). Clinically driven target lesion revascularization occurred in 77 DCS (6.8%) and 136 BMS patients (12%) (HR: 0.54; p< 0.0001). Major bleeding occurred in 8.9% of DCS and 9.2% of BMS patients (p= 0.95), and a coronary thrombotic event (MI and/or stent thrombosis) occurred in 8.2% of DCS and 10.6% of BMS patients (p= 0.045). One-year mortality was 27.1% for a major bleed and 26.3% for a thrombotic event. At 2 years, multivariate correlates of major bleeding were age >75 years, anemia, increased creatinine, and long-term anticoagulation. Correlates of the primary safety endpoint were age, anemia, heart failure, multivessel disease, number of stents, and use of a BMS (Garot P et al, J Am Coll Cardiol 2017;69:162-171)... (excerpt)Rhythmos 2017;12(2):33-37
Cardiology News / Recent Literature Review / Second Quarter 2017
Get PDFESC Congress: Barcelona, 26-30/8/2017HCS 2017, 28th Panhellenic Cardiology Congress: Athens, 19-21/10/2017TCT Congress: Denver, Colorado, 29/10-2/11/2017AHA Meeting: Anaheim, Ca, 11-15/11/2017ACC.18 Congress: Orlando, FL, 10-12/3/2018Rhythmos 2017;12(3):53-57In CRT-Eligible Heart Failure Patients with no History of Ventricular Arrhythmias, Addition of ICD Conveys Survival Benefit in Patients with Ischemic Cardiomyopathy (CM) but not in Those with Nonischemic CM According to an observational, multicenter, European cohort study of 5,307 consecutive patients with dilated or ischemic CM, no history of sustained ventricular arrhythmias, who underwent CRT implantation with (n=4,037) or without (n=1,270) a defibrillator, over 41.4 ± 29.0 months, patients with ischemic (not dilated) CM had better survival when receiving CRT-D compared with those who received CRT-P (hazard ratio-HR: 0.76; p=0.005). Compared with recipients of ICD, the excess mortality in patients who did not receive ICDs was related to sudden cardiac death in 8% among those with ischemic CM but in only 0.4% of those with dilated CM (Barra S et al, J Am Coll Cardiol 2017; 69:1669-1678).SELECT-LV Study: In a Population of Failed Conventional CRT Patients, Cardiac Resynchroniza-tion With Endocardial LV Stimulation via a Novel Leadless Pacing Electrode was Technically Feasible and EfficaciousAmong 35 patients indicated for CRT who had “failed” conventional CRT, implantation of an LV endocardial leadless pacing electrode and a subcutaneous pulse generator was successful in 97.1% (n=34). The most common indications for endocardial LV pacing were difficult CS anatomy (n=12), failure to respond to conventional CRT (n=10), and a high CS pacing threshold or phrenic nerve stimulation (n=5). The primary performance endpoint, biventricular pacing on the 12-lead ECG at 1 month, was achieved in 33 of 34 patients. A total of 28 patients (84.8%) had improvement in the clinical composite score at 6 months, and 21 (66%) demonstrated a positive echocardiographic CRT response (≥5% absolute increase in LV ejection fraction). There were no pericardial effusions, but serious procedure/device-related events occurred in 3 patients (8.6%) within 24 h, and 8 patients (22.9%) between 24 h and 1 month (Reddy VY et al, J Am Coll Cardiol 2017;69:2119-29).Improvements in both Survival and Heart Failure Hospitalizations with CRT-D were Greatest in Patients with a QRSD ≥180 ms with or without LBBBAnalysis of 24,960 patients receiving CRT-D and matched to patients with ICD indicated that among those with LBBB, patients with a QRSD ≥180 ms had a greater survival benefit with CRT-D vs standard ICD (hazard ration -HR for death: 0.65) compared with those having a QRSD 120 to 149 ms (HR: 0.85) and 150 to 179 ms (HR: 0.87). CRT-D vs ICD was associated with an improvement in survival in those with non-LBBB and a QRSD≥180 ms (HR for death: 0.78), but not in those with non-LBBB and a QRSD 150 to 179 ms (HR for death: 1.06) (Sundaram V et al, J Am Coll Cardiol 2017;69: 2026–36)... (excerpt
Atrial Flutter Ablation Using a Three-Dimensional Electroanatomical Mapping System
Get PDFTypical atrial flutter ablation is usually performed conventionally, by creating a line across the cavotricuspid isthmus under fluoroscopic guidance. In this article, we present the case of a middle-aged male who was submitted to flutter ablation through use of a three-dimensional electroanatomical mapping system, yielding highly accurate and pedantic images.
Sequential Activation of Vulnerable Plaques Endorsing the Inflammatory Hypothesis of Atherosclerosis
Get PDFA case of sequential activation of vulnerable plaques in two different coronary vessels over the course of 2 days is being presented probably related to inflammation inciting these acute coronary events. Rhythmos 2017;12(4): 69-70
Diagnosis and Treatment of Inappropriate Sinus Tachycardia
Get PDFInappropriate sinus tachycardia (IST) is a syndrome of cardiac and extracardiac symptoms characterized by rapid sinus heart rate at rest (>100 bpm) or with minimal activity and disproportionate to the physiologic demands. Patients with this unique and puzzling arrhythmia may require restriction from physical activity. The responsible mechanisms for IST are not completely understood. IST and postural orthostatic tachycardia syndrome (POTS) are the 2 sides of the same coin. It is important to distinguish IST from so-called appropriate sinus tachycardia and from POTS, with which an overlap may occur. As the long-term outcome seems to be benign, treatment may be unnecessary, or may be as simple as physical training. However, for patients with intolerable symptoms, therapeutic measures are warranted. Beta-adrenergic blockers, considered a first-line therapy, are usually ineffective even at high doses; the same applies for most other medical therapies. Ivabradine seems to be more effective than beta-blockers especially in the non- hypertensive patients. In rare instances, catheter- or surgically- based right atrial or sinus node modification may be helpful, but even this is fraught with limited efficacy and potential complications. Overtreatment, in an attempt to reduce symptoms, can be difficult to avoid, but is discouraged. In this report, we will be review IST, explore its mechanisms and evaluate possible management strategies
Cardiology News / Recent Literature Review / Last Quarter 2016
Get PDFAF Symposium: Orlando, 12-14/1/2017ACC.17: Washington, DC, 17-19/3/2017HRS Scientific sessions: Chicago, 10-13/5/2017EHRA Europace-Cardiostim: Vienna, 18-21/6/2017ESC Congress: Barcelona, 26-30/8/2017TOHP Study: Direct Linear Relationship of an Accurate Measure of Usual Sodium Intake to Total Mortality Over a Period of 23-26 Years, With Higher Risk at High Sodium Intake and no Evidence of a U or J Shape Based on multiple 24-h urine samples collected from pre-hypertensive adults 30 to 54 years of age, among 744 phase I and 2,382 phase II participants randomized to sodium reduction or control, 251 deaths occurred, representing a nonsignificant 15% lower risk in the active intervention (hazard ratio -HR: 0.85; p=NS). Among 2,974 participants not assigned to an active sodium intervention, 272 deaths occurred with a direct linear association between average sodium intake and mortality, with an HR of 0.75, 0.95, and 1.00 (references) and 1.07 (p trend= 0.30) for <2.3, 2.3 to <3.6, 3.6 to <4.8, and ≥4.8 g/24 h, respectively; and with an HR of 1.12 per 1 g/24 h (p = 0.05). There was no evidence of a J-shaped or nonlinear relationship. The HR per unit increase in sodium/ potassium ratio was 1.13 (p = 0.04) (Cook NR et al, J Am Coll Cardiol 2016;68:1609-1617).FRANCE-2 (FRench Aortic National CoreValve and Edwards) Registry: In High-Risk Patients With Aortic Stenosis Undergoing TAVI, Later Mortality is Due Mainly to Noncardiac Causes / Beyond the First Month After the Procedure, Prosthetic Valve Function Remains Stable, the Incidence of Clinical Events is Low, and Functional Improvement is Usually Sustained Among 4,201 patients undergoing TAVI, approaches were transfemoral 73%, transapical 18%, subclavian 6%, and transaortic or transcarotid 3% and median follow-up 3.8 years. The 3-year all-cause mortality was 42% and cardiovascular mortality 17.5%. Predictors of 3-year all-cause mortality were male gender (p< 0.001), low body mass index, (p< 0.001), AF (p< 0.001), dialysis (p< 0.001), NYHA class III or IV (p< 0.001), higher logistic EuroSCORE (p<0.001), transapical or subclavian approach (p< 0.001 for both vs transfemoral approach), need for permanent pacemaker implantation (p= 0.02), and post-implant periprosthetic aortic regurgitation grade ≥2 of 4 (p< 0.001). Severe events occurred mainly during the first month and subsequently in <2% of patients/year. Mean gradient, valve area, and residual aortic regurgitation were stable during follow-up (Gilard M et al, J Am Coll Cardiol 2016; 68:1637-1647)... (excerpt
Restarting Antithrombotic Drugs After Gastrointestinal Bleeding: An Unresolved Issue of Everyday Clinical Practice
Get PDFWith the evolution in cardiovascular disease understanding and the application of advanced interventional therapies, antithrombotic medication has become the cornerstone of the medical management of cardiovascular patients. However, as older and new trials have confirmed, these drugs carry a substantial risk for hemorrhagic complications, especially from the gastrointestinal (GI) tract, which are accompanied by a significant mortality risk. In case of such an event, the clinician must decide whether to discontinue or not the medication and for how long, and he is called to balance the potential risk of thrombosis and recurrent bleeding. In this brief review, we present the studies which address this issue in order to elicit practical conclusions. (Rhythmos 2017;12(3): 45-49)
Is Atherosclerosis Amenable to Anti-Inflammatory Compounds?
Get PDFThe hypothesis of an inflammatory component in the pathogenesis of atherosclerosis has been under investigation for a long time but the data have not been conclusive. No clinical trial of anti-inflammatory, anti-oxidant, or anti-bacterial agents has ever proven efficacious. However, the recent announcement and publication of the CANTOS trial has raised expectations. This pivotal trial showed for the first time that anti-inflammatory therapy targeting the interleukin-1β innate immunity pathway with subcutaneous injections of canakinumab every 3 months conferred significantly, albeit modestly (15%), lower rate of the composite end-point of nonfatal MI, nonfatal stroke and cardiovascular (CV) death than placebo, independent of lipid-level lowering, in patients with prior myocardial infarction (MI). An unexpected corollary of this investigation revealed significant concomitant reduction in lung cancer mortality. Despite the initial enthusiasm about the trial results, sceptics point to that fact that CV mortality was not affected, while the incidence of fatal infections was much higher with the drug compared with placebo, and the cost of this therapy remains currently prohibitive for wider use. Ongoing and future trials with similar or more convenient and less expensive anti-inflammatory agents may provide more data whether such results are reproducible and/or supportive or evidential of the inflammatory hypothesis of atherosclerosis. Rhythmos 2017; 12(4):63-68
Left Idiopathic Ventricular Tachycardia Amenable to Radiofrequency Ablation
Get PDFA case of idiopathic left posterior fascicular ventricular tachycardia is presented in a young patient, who was finally cured by radiofrequency ablation applied at the left inferoapical area of the left ventricle