David F. Katz

Oral Anticoagulant Therapy Prescription in Patients With Atrial Fibrillation Across the Spectrum of Stroke Risk: Insights From the NCDR PINNACLE Registry

IMPORTANCE Patients with atrial fibrillation (AF) are at a proportionally higher risk of stroke based on accumulation of well-defined risk factors. OBJECTIVE To examine the extent to which prescription of an oral anticoagulant (OAC) in US cardiology practices increases as the number of stroke risk factors increases. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional registry study of outpatients with AF enrolled in the American College of Cardiology National Cardiovascular Data Registrys PINNACLE (Practice Innovation and Clinical Excellence) Registry between January 1, 2008, and December 30, 2012. As a measure of stroke risk, we calculated the CHADS2 score and the CHA2DS2-VASc score for all patients. Using multinomial logistic regression models adjusted for patient, physician, and practice characteristics, we examined the association between increased stroke risk score and prescription of an OAC. MAIN OUTCOMES AND MEASURES The primary outcome was prescription of an OAC with warfarin sodium or a non-vitamin K antagonist OAC. RESULTS The study cohort comprised 429 417 outpatients with AF. Their mean (SD) age was 71.3 (12.9) years, and 55.8% were male. Prescribed treatment consisted of an OAC (192 600 [44.9%]), aspirin only (111 134 [25.9%]), aspirin plus a thienopyridine (23 454 [5.5%]), or no antithrombotic therapy (102 229 [23.8%]). Each 1-point increase in risk score was associated with increased odds of OAC prescription compared with aspirin-only prescription using the CHADS2 score (adjusted odds ratio, 1.158; 95% CI, 1.144-1.172; P < .001) and the CHA2DS2-VASc score (adjusted odds ratio, 1.163; 95% CI, 1.157-1.169; P < .001). Overall, OAC prescription prevalence did not exceed 50% even in higher-risk patients with a CHADS2 score exceeding 3 or a CHA2DS2-VASc score exceeding 4. CONCLUSIONS AND RELEVANCE In a large quality improvement registry of outpatients with AF, prescription of OAC therapy increased with a higher CHADS2 score and CHA2DS2-VASc score. However, a plateau of OAC prescription was observed, with less than half of high-risk patients receiving an OAC prescription.

Longitudinal Shortening Accounts for the Majority of Right Ventricular Contraction and Improves After Pulmonary Vasodilator Therapy in Normal Subjects and Patients With Pulmonary Arterial Hypertension

BACKGROUND The right ventricle has a unique contraction pattern, with a greater portion of the shortening occurring in the longitudinal plane. However, the relative contributions of longitudinal and transverse shortening to overall right ventricular (RV) function have not been quantified. We sought to quantify the proportions of longitudinal and transverse shortening to RV function in normal subjects and in patients with pulmonary arterial hypertension (PAH) at baseline and following PAH-specific therapy. METHODS The normal cohort comprised 90 subjects with normal clinical echocardiograms, whereas the PAH cohort included 36 patients, of whom 25 had echocardiograms before and after initiation of PAH-specific therapy. Assessment of RV function included tricuspid annular plane systolic excursion, RV fractional area change (RVFAC), and relative change in RV area in longitudinal and transverse planes. RESULTS Longitudinal fractional area change (LFAC) accounted for the majority of total RVFAC (77% ± 14%) in normal subjects. Among patients with PAH, longitudinal shortening still represented the majority of RVFAC, even though it was less than in normal subjects (63% ± 18%, P < .0001). Following PAH therapy, overall RV function improved (RVFAC, 30% ± 13% to 36% ± 9%; P = .026), solely because of an increase in longitudinal area change. As a result, the proportion of longitudinal shortening increased (LFAC, 58% ± 18% to 69% ± 17%; P = .002), whereas transverse shortening fell (transverse fractional area change, 42% ± 18% vs 31% ± 17%; P = .002). CONCLUSIONS Longitudinal shortening accounts for the majority of RV contraction in normal subjects and patients with PAH, although less so in PAH. Improved RV function following pulmonary vasodilator therapy occurs solely from improvements in longitudinal contraction, suggesting that longitudinal shortening may represent the afterload-responsive element of RV functional recovery.

Safety of Ventricular Tachycardia Ablation in Clinical Practice

Background—Outcomes of ventricular tachycardia (VT) ablation have been described in clinical trials and single-center studies. We assessed the safety of VT ablation in clinical practice. Methods and Results—Using administrative hospitalization data between 1994 and 2011, we identified hospitalizations with primary diagnosis of VT (International Classification of Diseases-9 Clinical Modification code: 427.1) and cardiac ablation (International Classification of Diseases-9 Clinical Modification code: 37.34). We quantified in-hospital adverse events (AEs), including death, stroke, intracerebral hemorrhage, pericardial complications, hematoma or hemorrhage, blood transfusion, or cardiogenic shock. Secondary outcomes included major AEs (stroke, tamponade, or death) and death. Multivariable mixed effects models identified patient and hospital characteristics associated with AEs. Of 9699 hospitalizations with VT ablations (age, 56.5±17.6; 60.1% men), AEs were reported in 825 (8.5%), major AEs in 295 (3.0%), and death in 110 (1.1%). Heart failure had the strongest association with death (odds ratio, 5.52; 95% confidence interval, 2.97–10.3) and major AE (odds ratio, 2.99; 95% confidence interval, 2.15–4.16). Anemia (odds ratio, 4.84; 95% confidence interval, 3.79–6.19) and unscheduled admission (odds ratio, 1.64; 95% confidence interval, 1.37–1.97) were associated with AEs. During the study period, incidence of AEs increased from 9.2% to 12.8% as did the burden of AE risk factors (0.034 patient/y; P<0.001). Hospital volume >25 cases/y was associated with fewer AEs compared with lower volume centers (6.4% versus 8.8%; P=0.008). Conclusions—VT ablation–associated AE rates in clinical practice are similar to those reported in the literature. Over time rates have increased as have the number of AE risk factors per patient. Ablations done electively and at hospitals with higher procedural volume are associated with lower incidence of AEs.

Trends in reporting methadone-associated cardiac arrhythmia, 1997-2011: an analysis of registry data.

BACKGROUND Long-acting opioids are a leading cause of accidental death in the United States, and methadone is associated with greater mortality rates. Whether this increase is related to the proarrhythmic properties of methadone is unclear. OBJECTIVE To describe methadone-associated arrhythmia events reported in the U.S. Food and Drug Administration Adverse Event Reporting System (FAERS). DESIGN Description of national adverse event registry data before and after publication of a 2002 report describing an association between methadone and arrhythmia. SETTING FAERS, November 1997 and June 2011. PATIENTS Adults with QTc prolongation or torsade de pointes and ventricular arrhythmia or cardiac arrest. MEASUREMENTS FAERS reports before and after the 2002 report. RESULTS 1646 cases of ventricular arrhythmia or cardiac arrest and 379 cases of QTc prolongation or torsade de pointes were associated with methadone. Monthly reports of QTc prolongation or torsade de pointes increased from a mean of 0.3 (95% CI, 0.1 to 0.5) before the 2002 publication to a mean of 3.5 (CI, 2.5 to 4.8) after it. After 2000, methadone was the second-most common primary suspect in cases of QTc prolongation or torsade de pointes after dofetilide (a known proarrhythmic drug) and was associated with disproportionate reporting similar to that of antiarrhythmic agents known to promote torsade de pointes. Antiretroviral drugs for HIV were the most common coadministered drugs. LIMITATION Reports to FAERs are voluntary and selective, and incidence rates cannot be determined from spontaneously reported data. CONCLUSION Since 2002, reports to FAERS of methadone-associated arrhythmia have increased substantially and are disproportionately represented relative to other events with the drug. Coadministration of methadone with antiretrovirals in patients with HIV may pose particular risk. PRIMARY FUNDING SOURCE Colorado Clinical and Translational Sciences Institute, National Institutes of Health, and Agency for Healthcare Research and Quality.

Endocardial Electrogram Characteristics of Epicardial Ventricular Arrhythmias

While most ventricular arrhythmias (VA) can be ablated successfully using an endocardial (endo) approach, epicardial (epi) mapping and ablation is sometimes required. There may be suggestive clues on the surface electrocardiogram; however, identification of an epi origin of VA with certainty remains problematic.

Use of stored implanted cardiac defibrillator electrograms in catheter ablation of ventricular fibrillation.

Ventricular fibrillation (VF) can be abolished by targeting triggering ventricular ectopy, most often originating in the Purkinje network or right ventricular outflow tract (RVOT). This strategy relies upon the induction of premature ventricular complex (PVC) and/or VF. We sought to evaluate a VF ablation strategy that utilizes analysis of stored implantable cardioverter defibrillator (ICD) electrograms.

An ECG-Based Cardiac Safety Initiative Is Well Received by Opioid Treatment Program Staff: Results from a Qualitative Assessment

Registry data on methadone reveal that QTc-prolongation is reported more often among opioid-dependent patients than chronic pain patients. This suggests that opioid treatment programs may be an important venue for implementing arrhythmia risk-reduction strategies. An electrocardiography-based strategy in the opioid treatment program setting demonstrated a reduction in the QTc-interval among patients with marked QTc-prolongation. However, the feasibility of program implementation remains uncertain. Therefore, we performed qualitative interviews among opioid treatment program staff to determine the barriers and benefits of implementation. Overall, the program was well received by staff; however, a need for training and algorithms was identified. No patient was denied access to care.

Seizure-induced asystole

A 48-year-old woman with pharmacologically intractable epilepsy was admitted for continuous electroencephalography for seizure characterisation and surgery. She had a long history of generalised tonic-type seizures for which a vagal nerve stimulator (VNS) was implanted. During electroencephalography monitoring, she experienced her typical visual aura with seizure onset, which was then …

Methadone Safety Guidelines: A New Care Delivery Paradigm

To the Editor: We applaud the recently published Methadone Safety Guidelines by Chou and colleagues for its comprehensive approachtoensuringpatientsafetyduringbothinitiation and maintenance phases of methadone treatment. 2 This guideline mirrors a previously published cardiac safety guideline inmethadonetreatment 5 focusedonprolongation of the QTc intervalandextendsits focus tomitigation oftherisksofrespiratorydepressionandopioidmisusevia routine urine drug testing. This is increasingly relevant since the distinction between opioid treatment for chronic pain and opioid dependency is not always clear in clinical practice. Most importantly, the directive to ‘‘start low and go slow’’ with regard to dose titration has the potential to limit the growing number of unintentional fatalities associated with methadone. A few issues specific to arrhythmia risk reduction in this guidelinemaybeusefultohighlighttoreaders.Thisguide

The Irregular Tachycardia That Was Not Atrial Fibrillation

A 49-YEAR-OLD WOMAN WAS ADMITTED TO THE inpatient cardiology service with complaints of palpitations, fatigue, and dyspnea on exertion. During a previous hospitalization she was noted to have a paroxysmal, irregular tachycardia with largely the same left bundle branch block that was seen during normal sinus rhythm; this arrhythmia was believed by her physicians to represent atrial fibrillation. At that time, findings from echocardiography were consistent with rheumatic mitral valve disease. Her outpatient medical regimen consisted of metoprolol tartrate and warfarin sodium for presumed valvular atrial fibrillation. An electrocardiogram (ECG) was obtained at the time of readmission (Figure 1). Question: What is the atrial rhythm and atrial rate recorded by the ECG?