Karen Friday

2015 Heart Rhythm Society Expert Consensus Statement on the Diagnosis and Treatment of Postural Tachycardia Syndrome, Inappropriate Sinus Tachycardia, and Vasovagal Syncope

Robert S. Sheldon, Blair P. Grubb II, Brian Olshansky, Win-Kuang Shen, Hugh Calkins, Michele Brignole, Satish R. Raj, Andrew D. Krahn, Carlos A. Morillo, Julian M. Stewart, Richard Sutton, Paola Sandroni, Karen J. Friday, Denise Tessariol Hachul, Mitchell I. Cohen, Dennis H. Lau, Kenneth A. Mayuga, Jeffrey P. Moak, Roopinder K. Sandhu, Khalil Kanjwal

Feasibility of Extended Ambulatory Electrocardiogram Monitoring to Identify Silent Atrial Fibrillation in High‐risk Patients: The Screening Study for Undiagnosed Atrial Fibrillation (STUDY‐AF)

Identification of silent atrial fibrillation (AF) could prevent stroke and other sequelae.

Semantic Confusion: The Case of Early Repolarization and the J Point

0002-9343/

Unidirectional Conduction Block at Cavotricuspid Isthmus Created by Radiofrequency Catheter Ablation in Patients With Typical Atrial Flutter

-see front matter Published by Elsevier Inc. doi:10.1016/j.amjmed.2011.08.024 oint or QRS end and do not classify J waves or slurring for he statement of nonspecific ST elevation or “early repolarzation.” Furthermore, although J waves or slurs have been noted to occur along with ST elevation as part of classic early repolarization, the clinical focus has been on ST elevation because it also can be confused with myocardial injury or ischemia and pericarditis (Figure). The semantic confusion can be traced back to 2 articles in The New England Journal of Medicine from 2009. he authors were allowed to co-opt these old and respected erms with good intent, armed with hypotheses, elegant

Clinical Reminders to Providers of Patients with Reduced Left Ventricular Ejection Fraction Increase Defibrillator Referral: A Randomized Trial

Unidirectional Block at Cavotricuspid Isthmus. Introduction: Although unidirectional conduction block at the cavotricuspid isthmus can be created by radiofrequency ablation for atrial flutter, its underlying mechanism has not been elucidated.

Clinical Reminders to Providers of Patients With Reduced Left Ventricular Ejection Fraction Increase Defibrillator ReferralClinical Perspective

Background— Many patients who are candidates for implantable cardioverter defibrillators (ICDs) are not referred for potential implantation. We sought to determine if a simple provider reminder would increase referrals. Methods and Results— We identified consecutive patients from January 2007 through July 2010 in the VA Palo Alto Health Care System with a left ventricular ejection fraction <35% on echocardiography. Patients were excluded using available administrative data only (no chart review) if they were known to have an ICD, if they were ≥80 years old, or if they did not have a current primary care or cardiology provider within the system. We randomized patients to no intervention or a clinical note to the provider in the medical record. The outcomes were referral for consideration of defibrillator implantation (primary) and documented discussion (secondary). Of 330 patients with left ventricular ejection fraction ⩽35%, 128 were known to have an ICD, 85 were no longer followed in the healthcare system, and 28 were ≥80 years old, leaving 89 patients to be randomized. Forty-six patients were randomized to intervention and 43 to control. Eleven of 46 (24%) intervention patients were referred for consideration of ICD implantation during the following 6 months versus 1 of 43 (2%) control patients (P=0.004). Overall, 31 of 46 (67%) intervention patients versus 19 of 43 (44%) control patients had documentation discussing potential candidacy for defibrillators (P=0.05). Conclusions— In patients with low left ventricular ejection fraction, a simple electronic medical record–based intervention directed to their providers improved the rates of referral for ICD implantation. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT01217827.

Limited predictive value of inducible sustained ventricular tachycardia for future occurrence of spontaneous ventricular tachycardia in patients with coronary artery disease and relatively preserved cardiac function.

Background— Many patients who are candidates for implantable cardioverter defibrillators (ICDs) are not referred for potential implantation. We sought to determine if a simple provider reminder would increase referrals. Methods and Results— We identified consecutive patients from January 2007 through July 2010 in the VA Palo Alto Health Care System with a left ventricular ejection fraction <35% on echocardiography. Patients were excluded using available administrative data only (no chart review) if they were known to have an ICD, if they were ≥80 years old, or if they did not have a current primary care or cardiology provider within the system. We randomized patients to no intervention or a clinical note to the provider in the medical record. The outcomes were referral for consideration of defibrillator implantation (primary) and documented discussion (secondary). Of 330 patients with left ventricular ejection fraction ⩽35%, 128 were known to have an ICD, 85 were no longer followed in the healthcare system, and 28 were ≥80 years old, leaving 89 patients to be randomized. Forty-six patients were randomized to intervention and 43 to control. Eleven of 46 (24%) intervention patients were referred for consideration of ICD implantation during the following 6 months versus 1 of 43 (2%) control patients (P=0.004). Overall, 31 of 46 (67%) intervention patients versus 19 of 43 (44%) control patients had documentation discussing potential candidacy for defibrillators (P=0.05). Conclusions— In patients with low left ventricular ejection fraction, a simple electronic medical record–based intervention directed to their providers improved the rates of referral for ICD implantation. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT01217827.

Abrupt bradycardia and grouped beating during treadmill testing: A mimic of upper rate behavior

To evaluate the significance of inducible sustained ventricular tachycardia (VT) in patients with coronary artery disease and relatively preserved cardiac function, 33 patients who met the following criteria were studied; documented nonsustained VT but no history of life-threatening arrhythmia, inducible sustained VT at electrophysiologic study, and implantation of a cardioverter-defibrillator. Eighteen patients developed clinical sustained VT within 2 years. By univariate analysis, left ventricular ejection fraction (EF) and the cycle length of induced VT were associated with clinical VT occurrence. By multivariate analysis, however, EF was the only independent predictor. Among 23 patients with EF <or=40%, 16 patients developed clinical sustained VT compared to 2 of 10 patients with EF >40% (P <.01). In coronary artery disease patients with relatively preserved EF, the incidence of clinical VT is considerably low even though sustained VT is inducible. Inducible VT is therefore not appropriate for risk stratification in this patient population.

Clinical Reminders to Providers of Patients With Reduced Left Ventricular Ejection Fraction Increase Defibrillator ReferralClinical Perspective: A Randomized Trial

p t t Case summary A 67-year-old man with a biventricular implantable cardioverter-defibrillator (Medtronic Concerto C1540WK) presented for exercise treadmill testing. The patient had an ischemic cardiomyopathy and prior anterior infarction with a left ventricular ejection fraction of 25%. One year prior to this presentation, the patient presented with sustained monomorphic ventricular tachycardia and had catheter ablation for ventricular tachycardia, followed by implantation of the current device. An exercise treadmill test (ETT) was performed by using a ramp protocol. During the ETT, at peak exercise, his peak heart rate abruptly dropped and the ETT was stopped (data not shown). The device was again interrogated Programmed settings and measurements are shown in Table 1; the lower rate limit was 60 beats/min. No alerts or episodes were recorded during the ETT. To assess device function, the ETT was repeated with wireless device telemetry engaged. The preexercise 12-lead electrocardiogram and device rhythm strip at rest are shown in Figure 1A, demonstrating baseline atrial-paced and biventricular-paced rhythm. Figure 1B shows electrograms (EGMs) measured on the right ventricular channel of the device and the marker channel during early exercise. During the ETT, the abrupt bradycardia was again observed, this time with a drop from the peak heart rate of 107 to 56 beats/min (Figure 2). Stress testing was quickly terminated,

Myocardial Regions of Slow Conduction Participating in the Reentrant Circuit of Multiple Ventricular Tachycardias: Report on Ten Patients

Background— Many patients who are candidates for implantable cardioverter defibrillators (ICDs) are not referred for potential implantation. We sought to determine if a simple provider reminder would increase referrals. Methods and Results— We identified consecutive patients from January 2007 through July 2010 in the VA Palo Alto Health Care System with a left ventricular ejection fraction <35% on echocardiography. Patients were excluded using available administrative data only (no chart review) if they were known to have an ICD, if they were ≥80 years old, or if they did not have a current primary care or cardiology provider within the system. We randomized patients to no intervention or a clinical note to the provider in the medical record. The outcomes were referral for consideration of defibrillator implantation (primary) and documented discussion (secondary). Of 330 patients with left ventricular ejection fraction ⩽35%, 128 were known to have an ICD, 85 were no longer followed in the healthcare system, and 28 were ≥80 years old, leaving 89 patients to be randomized. Forty-six patients were randomized to intervention and 43 to control. Eleven of 46 (24%) intervention patients were referred for consideration of ICD implantation during the following 6 months versus 1 of 43 (2%) control patients (P=0.004). Overall, 31 of 46 (67%) intervention patients versus 19 of 43 (44%) control patients had documentation discussing potential candidacy for defibrillators (P=0.05). Conclusions— In patients with low left ventricular ejection fraction, a simple electronic medical record–based intervention directed to their providers improved the rates of referral for ICD implantation. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT01217827.