A. McGavigan

The impact of atrial fibrillation type on the risk of thromboembolism, mortality, and bleeding: a systematic review and meta-analysis.

AIMS Thromboembolic risk stratification schemes and clinical guidelines for atrial fibrillation (AF) regard risk as independent of classification into paroxysmal (PAF) and non-paroxysmal atrial fibrillation (NPAF). The aim of the current study was to conduct a systematic review evaluating the impact of AF type on thromboembolism, bleeding, and mortality. METHODS AND RESULTS PubMed was searched through 27 November 2014 for randomized controlled trials, cohort studies, and case series reporting prospectively collected clinical outcomes stratified by AF type. The incidence of thromboembolism, mortality, and bleeding was extracted. Atrial fibrillation clinical outcome data were extracted from 12 studies containing 99 996 patients. The unadjusted risk ratio (RR) for thromboembolism in NPAF vs. PAF was 1.355 (95% CI: 1.169-1.571, P < 0.001). In the study subset off oral anticoagulation, unadjusted RR was 1.689 (95% CI: 1.151-2.480, P = 0.007). The overall multivariable adjusted hazard ratio (HR) for thromboembolism was 1.384 (95% CI: 1.191-1.608, P < 0.001). The overall unadjusted RR for all-cause mortality was 1.462 (95% CI: 1.255-1.703, P < 0.001). Multivariable adjusted HR for all-cause mortality was 1.217 (95% CI: 1.085-1.365, P < 0.001). Rates of bleeding were similar, with unadjusted RR 1.00 (95% CI: 0.919-1.087, P = 0.994) and adjusted HR 1.025 (95% CI: 0.898-1.170, P = 0.715). CONCLUSION Non-paroxysmal atrial fibrillation is associated with a highly significant increase in thromboembolism and death. These data suggest the need for new therapies to prevent AF progression and further studies to explore the integration of AF type into models of thromboembolic risk.

Anxiety, depression, and stress as risk factors for atrial fibrillation after cardiac surgery

OBJECTIVE We sought to determine whether preoperative and postoperative anxiety, depression, and stress symptoms were associated with atrial fibrillation (AF) after cardiac surgery. METHODS Two hundred and twenty-six cardiac surgery patients completed measures of depression, anxiety, and general stress before surgery, and 222 patients completed these measures after surgery. The outcome variable was new-onset AF, confirmed before the median day of discharge (day 5) after cardiac surgery during the index hospitalization. RESULTS Fifty-six (24.8%) patients manifested incident AF, and they spent more days in hospital (mean [M], 7.3; standard deviation [SD], 4.6) than patients without AF (M, 5.5; SD, 1.4; P < .001). No baseline psychological predictors were associated with AF. When postoperative distress measures were considered, anxiety was associated with increased odds of AF (odds ratio, 1.09; 95% confidence interval, 1.00 to 1.18; P = .05). This analysis also showed that age was significantly associated with AF (odds ratio, 1.07; 95% confidence interval, 1.03 to 1.12; P < .001). Analyses specific to the symptomatic expression of anxiety indicated that somatic (ie, autonomic arousal) and cognitive-affective (ie, subjective experiences of anxious affect) symptoms were associated with incident AF. CONCLUSION Anxiety symptoms in the postoperative period were associated with AF. Hospital staff in acute cardiac care and cardiac rehabilitation settings should observe anxiety as related to AF after cardiac surgery. It is not clear how anxious cognitions influence the experience of AF symptoms, and whether symptoms of anxiety commonly precede AF.

Left Ventricular Outflow Tract Ventricular Tachycardia Originating from the Noncoronary Cusp: Electrocardiographic and Electrophysiological Characterization and Radiofrequency Ablation

Noncoronary cusp (NCC) ventricular tachycardia is a rare form of monomorphic outflow tract tachycardia, and its electrocardiographic and electrophysiological characteristics have not been well described previously. The NCC should be considered for catheter ablation if attempts to eliminate ventricular tachyarrhythmia were unsuccessful in the other common anatomical sites of the left ventricular outflow tract.

Troponin-positive chest pain with unobstructed coronary arteries: incremental diagnostic value of cardiovascular magnetic resonance imaging

AIMS Troponin-positive chest pain patients with unobstructed coronaries represent a clinical dilemma. Cardiovascular magnetic resonance (CMR) imaging has an increasingly prominent role in the assessment of these patients; however, its utility in addition to expert clinical judgement is unclear. We sought to determine the incremental diagnostic value of CMR and the heterogeneity in diagnoses by experienced cardiologists when presented with blinded clinical and investigative data in this population. METHODS AND RESULTS A total of 125 consecutive patients presenting to a tertiary centre between 2010 and 2014 with cardiac chest pain, elevated troponin (>29 ng/L), and unobstructed coronaries were enrolled and underwent CMR. A panel of three experienced cardiologists unaware of the CMR diagnosis and blinded to each others assessment provided a diagnosis based on clinical and investigative findings. A consensus panel diagnosis was defined as two or more cardiologists sharing the same clinical diagnosis. Findings were classified into acute myocarditis, Takotsubo cardiomyopathy, acute myocardial infarction (AMI), or indeterminate. CMR provided a diagnosis in 87% of patients. Consensus panel diagnosis and CMR were concordant in 65/125 (52%) patients. There was an only moderate level of agreement between the three cardiologists (k = 0.47, P < 0.05) and a poor level of agreement between the consensus panel and CMR (k = 0.38, P < 0.05) with the most disagreement seen in patients with AMI diagnosed on CMR. CONCLUSION The clinical diagnosis of patients with non-obstructive coronaries and positive troponin remains a challenge. The concordance between CMR and clinical diagnosis is poor. CMR provides a diagnosis in majority of these patients.

Cardiovascular magnetic resonance‐GUIDEd management of mild to moderate left ventricular systolic dysfunction (CMR GUIDE): Study protocol for a randomized controlled trial

The majority of sudden cardiac death (SCD) in patients with heart failure occurs in those with mild‐moderate left ventricular (LV) systolic dysfunction (LVEF 36–50%) who under current guidelines are ineligible for primary prevention implantable cardiac defibrillator (ICD) therapy. Recent data suggest that cardiac magnetic resonance (CMR) evidence of replacement fibrosis forms a substrate for malignant arrhythmia and therefore potentially identifies a subgroup at increased risk of SCD. Our hypothesis is that among patients with mild‐moderate LV systolic dysfunction, a CMR‐guided management strategy for ICD insertion based on the presence of scar or fibrosis is superior to a current strategy of standard care.

Paroxysmal bidirectional ventricular tachycardia with tachycardiomyopathy in a pregnant woman.

Palpitations in pregnancy are not an uncommon complaint.We present a case of palpitations in the third trimester related to bidirectional ventricular tachycardia with evidence of left ventricular systolic dysfunction. The case was successfully managed with flecainide therapy and urgent elective caesarean section. The rhythm stabilised to sinus rhythm and left ventricular systolic function normalised. We discuss the possible underlying diagnosis of catecholaminergic polymorphic ventricular tachycardia with resultant tachycardiomyopathy. A literature review of bidirectional ventricular tachycardia is presented. This is the first reported case of bidirectional VT producing LV systolic dysfunction, which normalised following stabilisation of rhythm.The complex issues of management of this case in particular with regard to the pregnancy are discussed.

Requirement for cardiac telemetry during intravenous phenytoin infusion: guideline fact or guideline fiction?

Guidelines recommend the use of cardiac telemetry when phenytoin is administered intravenously. Clinical areas where telemetry is available may not always be the most suitable place to monitor and treat these sick patients. We sought to clarify the evidence regarding the need for cardiac telemetry during intravenous infusion of phenytoin.

Right Ventricular Septal Pacing—Can We See the Wood for the Trees?

Increasing recognition of the potentially deleterious effects on left ventricular (LV) systolic function of long-term pacing at the right ventricular (RV) apex has fuelled interest in alternative RV pacing sites. While the last decade has seen the publication of many studies comparing nonapical sites to apical pacing, there is a paucity of robust data, and the limited amount available can be interpreted in many ways, often eliciting passionate debate in the pacing community. There have been 12 acute studies of apical versus the most commonly reported nonapical sites, the RV outflow tract (RVOT) and the RV septum (RVS),1 of which only three provided positive data on LV systolic function.2–4 However, acute hemodynamic studies are of limited relevance given the time-dependent phenomenon of apical pacing on LV systolic function.5,6 It is therefore surprising that there are only five longer term studies of alternative site pacing,1 of which two showed a positive effect of RVOT or RVS pacing on LV function.7,8 Given the limitations of the published literature, there has been no real consensus on whether alternate site pacing is preferable to apical pacing, and if so, where is the optimum site to pace and how best to achieve it. In this issue of Pacing and Clinical Electrophysiology, Kaye et al. provide details on the design of three medium to long-term randomized multicenter trials comparing RV septal versus apical pacing.9 However, will these trials’ be robust enough to answer these questions? As with any trial, the devil is in the details, and there are many laudable features of these studies. The first is the expected enrollment numbers, which is strengthened by the decision to prospectively pool data. To date, only 175 patients have been enrolled in any nonacute trial of RVOT/RVS pacing, and mean follow-up has been a matter of months rather than years. These trials will enroll 800 patients with a mean followup of 24–36 months, providing data on more than

Cardiac Resynchronisation Therapy in Patients with Atrioventricular Nodal Disease and Reduced Ejection Fraction - Can We Afford it?

BACKGROUND Recent pacing guidelines from the European Society of Cardiology recommend cardiac resynchronisation therapy (CRT) in patients with an atrioventricular (AV) nodal pacing indication and reduced ejection fraction (EF). However, concerns over added expenditure may limit its widespread implementation. We investigate the potential incremental cost of biventricular over right ventricular pacing if such a practice was adopted. METHODS Retrospective analysis was performed of devices implanted over eight years. The database was analysed for device type, pacing indication and EF. Cost analysis was performed. RESULTS 1751 devices were implanted over eight years at an averaged cost of AUD

Tissue Doppler Derived Mechanical Dyssynchrony Does Not Change after Cardiac Resynchronization Therapy

1,369,125 per year. 172 with CRT were excluded. 25.4 (11.6%) patients per year had an EF≤50% and AV nodal disease. 18.4 were in sinus rhythm (SR) and 7.0 in atrial fibrillation (AF). Of these, 13.5 (6.2%) had EF≤45% (9.9 SR, 3.6 AF) and 8.2 (3.8%) had EF≤35% (5.6 SR, 2.6 AF). Based on an incremental cost of