Angelo A. V. de Paola

Comparison of antiarrhythmic drug therapy and radiofrequency catheter ablation in patients with paroxysmal atrial fibrillation: A randomized controlled trial

CONTEXT Antiarrhythmic drugs are commonly used for prevention of recurrent atrial fibrillation (AF) despite inconsistent efficacy and frequent adverse effects. Catheter ablation has been proposed as an alternative treatment for paroxysmal AF. OBJECTIVE To determine the efficacy of catheter ablation compared with antiarrhythmic drug therapy (ADT) in treating symptomatic paroxysmal AF. DESIGN, SETTING, AND PARTICIPANTS A prospective, multicenter, randomized (2:1), unblinded, Bayesian-designed study conducted at 19 hospitals of 167 patients who did not respond to at least 1 antiarrhythmic drug and who experienced at least 3 AF episodes within 6 months before randomization. Enrollment occurred between October 25, 2004, and October 11, 2007, with the last follow-up on January 19, 2009. INTERVENTION Catheter ablation (n = 106) or ADT (n = 61), with assessment for effectiveness in a comparable 9-month follow-up period. MAIN OUTCOME MEASURES Time to protocol-defined treatment failure. The proportion of patients who experienced major treatment-related adverse events within 30 days of catheter ablation or ADT was also reported. RESULTS At the end of the 9-month effectiveness evaluation period, 66% of patients in the catheter ablation group remained free from protocol-defined treatment failure compared with 16% of patients treated with ADT. The hazard ratio of catheter ablation to ADT was 0.30 (95% confidence interval, 0.19-0.47; P < .001). Major 30-day treatment-related adverse events occurred in 5 of 57 patients (8.8%) treated with ADT and 5 of 103 patients (4.9%) treated with catheter ablation. Mean quality of life scores improved significantly in patients treated by catheter ablation compared with ADT at 3 months; improvement was maintained during the course of the study. CONCLUSION Among patients with paroxysmal AF who had not responded to at least 1 antiarrhythmic drug, the use of catheter ablation compared with ADT resulted in a longer time to treatment failure during the 9-month follow-up period. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00116428.

Mapping and Ablation of Idiopathic Ventricular Fibrillation

Background— Ventricular fibrillation is the main mechanism of sudden cardiac death. The feasibility of eliminating recurrent episodes by catheter ablation has not been reported. Methods and Results— Twenty-seven patients without known heart disease (13 men, 14 women, 41±14 years of age) were studied after being resuscitated from recurrent (10±12) episodes of primary idiopathic ventricular fibrillation; 23 had received a defibrillator. The first initiating beat of ventricular fibrillation had an identical electrocardiographic morphology and coupling interval (297±41 ms) to preceding isolated premature beats typically noted in the aftermath of resuscitation. These triggers were localized by mapping the earliest electrical activity and ablated by local radiofrequency delivery. Outcome was assessed by Holter and defibrillator memory interrogation. Premature beats were elicited from the Purkinje conducting system in 23 patients: from the left ventricular septum in 10, from the anterior right ventricle in 9, an...

Qualidade de vida de pacientes hipertensos em tratamento ambulatorial

BACKGROUND: The main cause of mortality in braziliam population is the cardiovascular disease and arterial hypertension (AH) the most prevalent one. The antihypertensive treatment is effective however it is not well known how affects the quality of life (QOL) in patients afterwards. OBJECTIVE: To comparatively assess the QOL in patients submitted to an antihypertensive treatment. METHODS: One-hundred patients with AH were studied of which 46 had complied with a standard treatment regimen (group A) and 54 (group B control) were about to start the same regimen. We collected clinical and sociodemographic data and questions focusing sexuality, self-perception of QOL, number and types of medication taken and their influence on sex life. The questionnaire SF-36 was also administered. The data were analyzed using the tests chi-square, Students t, Pearson correlation and Tukey. RESULTS: No differences were detected between group A and B in any of the SF-36 domains. There was an association between the question on self-perception of QOL and the SF-36 domains, emotional aspects excepted. As regards sexuality, there was difference in the quality of sex life between the groups, which was less satisfactory for group A. CONCLUSION: When the SF-36 was administered no changes in QOL were detected between the groups because it is an asymptomatic chronic disease. The SF-36 did not properly assess emotional aspects in our case series of hypertensive patients that had high behavior variability. Group A showed lower quality sex life; however, this was not related to the number and type of medication used.

Influence of left ventricular dysfunction on flecainide therapy

Seventy-six patients with ventricular tachyarrhythmias (40 sustained and 36 nonsustained) were treated with oral flecainide. Radionuclide left ventricular ejection fraction was 30% or less in 33 patients and greater than 30% in 43 patients. Before flecainide, compensated heart failure was present in 23 patients (ejection fraction less than or equal to 30% in 15 and greater than 30% in 8). Flecainide mean dose was 150 mg twice daily and mean plasma concentration was 720 ng/ml. New or worsened congestive heart failure occurred in seven patients on flecainide therapy, all with an ejection fraction of less than 30%; six had a previous history of compensated heart failure and of these, three died. Ejection fraction was the only independent variable that significantly influenced efficacy and tolerance of flecainide. After 1 year of therapy, efficacy and tolerance was 58% (25 of 43) in patients with an ejection fraction greater than 30% and 12% (4 of 33) in patients with an ejection fraction of 30% or less (p less than 0.001). Thus, congestive heart failure can occur during flecainide therapy, particularly in patients with a previous history of congestive heart failure and ejection fraction of less than 30%, and may particularly limit therapy in these patients. Clinical efficacy and tolerance were significantly lower in patients with an ejection fraction of less than 30%.

Angiographic and electrophysiologic substrates of ventricular tachycardia in chronic Chagasic myocarditis

Forty-three consecutive symptomatic patients with chronic Chagasic myocarditis and ventricular tachycardia (VT) underwent clinical evaluation, 24-hour Holter monitoring, left ventricular angiography and electrophysiologic testing including programmed ventricular stimulation at 3 drive cycle lengths at 2 sites in the right ventricle. The mean ejection fraction was 42 +/- 10%. Sixteen patients had clinical sustained VT and 27 nonsustained VT. VT was reproducibly initiated in 13 of 16 (81%) patients with sustained VT and in 14 of 27 (52%) patients with nonsustained VT. Electrocardiographic conduction disturbances were seen in 15 of 16 (94%) patients with sustained VT and in 17 of 27 (63%) patients with nonsustained VT (p less than 0.05). Five of 16 (31%) sustained VT and none of nonsustained VT patients had left ventricular aneurysms (p less than 0.05). These data indicate that VT is frequently inducible in patients with sustained VT and nonsustained VT and chronic Chagasic myocarditis. An association appears to be present between conduction disturbances on the electrocardiogram, left ventricular aneurysms and development of sustained ventricular arrhythmias.

Cysteine A Potential Biomarker for Obstructive Sleep Apnea

OBJECTIVE Obstructive sleep apnea (OSA) is a risk factor for a number of cardiovascular conditions. Although homocysteine (Hcy) and cysteine (Cys) are regarded as cardiovascular risk factors, few studies have analyzed Hcy and Cys plasma concentrations in patients with OSA. The aim of this study was to evaluate the role of Hcy and Cys in OSA in comparison with subjects without OSA and to determine the possible influence of obesity on these variables. METHODS Patients who submitted to polysomnography studies were recruited to engage in an 8-h fasting period for blood sample withdrawal, physical examination, ECG, and echocardiogram. A subgroup of lean patients with OSA (BMI < 25 kg/m(2)) were analyzed to rule out the influence of obesity. Fifteen patients were randomly assigned to participate in a continuous positive airway pressure (CPAP) protocol to assess the influence of OSA treatment on the obtained measurements. RESULTS A total of 75 patients and 75 control subjects matched for age and sex were analyzed. The Cys plasma levels were higher in patients with OSA compared with control subjects (490.16 ± 67.00 μmol/L vs 439.81 ± 76.12 μmol/L, respectively, P < .01); however, the Hcy plasma levels did not differ between groups. Cys plasma levels were also higher in the OSA lean subgroup when compared with lean control subjects (484.21 ± 71.99 μmol/L vs 412.01 ± 70.73 μmol/L, respectively, P = .009). There was a significant decrease of Cys plasma levels after 6 months of CPAP effective therapy. CONCLUSION Cys is a potential biomarker of OSA in obese and nonobese patients and is reduced after effective OSA treatment.

Sinus node artery occlusion for treatment of chronic nonparoxysmal sinus tachycardia

Abstract Chronic nonparoxysmal sinus tachycardia has been described as an inappropriate and persistent sinus tachycardia that is not related to organic, physiologic and adrenergic states or automatic dysfunction. Some cases are very symptomatic and refractory to conventional therapy. In this report, we describe an unusual therapy for a refractory case of chronic nonparoxysmal sinus tachycardia.

Exercise Capacity and Obstructive Sleep Apnea in Lean Subjects

BACKGROUND Conflicting data regarding exercise capacity and obstructive sleep apnea (OSA) have been published, which may be partially explained by the difficulty of controlling all of the confounding factors. The aim of this study is to evaluate the exercise, anthropometric, and blood parameters in lean, sedentary patients with OSA compared with controls. METHODS Fifty-four lean subjects (including 27 patients with OSA and 27 controls) were selected. The control group was matched for age and gender. All subjects underwent polysomnography, anthropometric measures, a cardiorespiratory exercise test, two-dimensional transthoracic echocardiography, and spirometry. RESULTS The mean age was 52.9 +/- 7.9 years in subjects with OSA and 52.8 +/- 8.1 years in controls (P = .95). The cervical circumference was greater in the lean OSA group when compared with the controls (33.7 +/- 3.5 cm vs 31.4 +/- 2.8 cm; P = .01). There were statistical differences in the apnea-hypopnea index, minimal oxygen saturation, and mean oxygen saturation in the lean patients with OSA. Glycemia was higher in the lean OSA group (115.1 +/- 50.1 mg/dL vs 94.2 +/- 9.8 mg/dL; P = .04). There were no differences between groups in the peak oxygen consumption (Vo(2)), anaerobic threshold (AT), respiratory exchange ratio (RER), BP, and heart rate. CONCLUSION High glycemia and cervical circumference enlargement are the main characteristics of lean patients with OSA. Exercise performance is similar between groups, considering the peak Vo(2), AT, and RER. These results suggest that OSA does not impair functional capacity in lean subjects and that obesity probably participates in the diminished cardiopulmonary capacity observed in patients with OSA.

Naproxen as Prophylaxis against Atrial Fibrillation after Cardiac Surgery: The NAFARM Randomized Trial

PURPOSE We sought to assess the effect of naproxen versus placebo on prevention of atrial fibrillation after coronary artery bypass graft (CABG) surgery. METHODS In this randomized, double-blind, placebo-controlled, single-center trial of 161 consecutive patients undergoing CABG surgery, patients received naproxen 275 mg every 12 hours or placebo at the same dosage and interval over 120 hours immediately after CABG surgery. The primary outcome was the occurrence of atrial fibrillation in the first 5 postoperative days. RESULTS The incidence of postoperative atrial fibrillation was 15.2% (12/79) in the placebo versus 7.3% (6/82) in the naproxen group (P=.11). The duration of atrial fibrillation episodes was significantly lower in the naproxen (0.35 hours) versus placebo group (3.74 hours; P=.04). There was no difference in the overall days of hospitalization between placebo (17.23±7.39) and naproxen (18.33±9.59) groups (P=.44). Intensive care unit length of stay was 4.0±4.57 days in the placebo and 3.23±1.25 days in the naproxen group (P=.16). The trial was stopped by the data monitoring committee before reaching the initial target number of 200 patients because of an increase in renal failure in the naproxen group (7.3% vs 1.3%; P=.06). CONCLUSIONS Postoperative use of naproxen did not reduce the incidence of atrial fibrillation but decreased its duration, in a limited sample of patients after CABG surgery. There was a significant increase in acute renal failure in patients receiving naproxen 275 mg twice daily. Our study does not support the routine use of naproxen after CABG surgery for the prevention of atrial fibrillation.

Effectiveness and costs of chemical versus electrical cardioversion of atrial fibrillation

BACKGROUND Atrial fibrillation is the most common sustained cardiac arrhythmia and has an important impact on costs of medical assistance. Traditional interventions to convert atrial fibrillation to sinus rhythm are antiarrhythmic drugs and external electrical cardioversion. However, the best option for starting the cardioversion is not well established. METHODS In a multicentre randomised trial of 139 patients with persistent atrial fibrillation lasting less than 6 months, we compared the effectiveness and the cost-effectiveness ratio of initial treatment with chemical or electrical cardioversion. Subjects who did not achieve sinus rhythm with chemical cardioversion were considered to undergo electrical cardioversion and vice-versa. RESULTS The efficacy of the initial attempt for cardioversion was similar with chemical or electrical cardioversion (74 vs. 73%, P=0.95). However, the strategy of starting with antiarrhythmic drugs was more effective than with electrical procedure (96 vs. 84%, P=0.0016). Initiating with chemical cardioversion was also less expensive than with electrical cardioversion (1240 US dollars vs. 1917 US dollars ; P=0.002). Life-threatening complications occurred only during chemical cardioversion (5%), all of them in patients with structural heart disease. CONCLUSIONS In patients with persistent atrial fibrillation of less than 6 months, initial chemical or electrical cardioversion appear to be similar but the strategy of starting the cardioversion with antiarrhythmic drugs is more effective and less expensive than starting with the electrical procedure. Patients with structural heart disease undergoing chemical cardioversion seem to be more susceptible to severe complications.