Kristen K. Patton

N-terminal pro-B-type natriuretic peptide is a major predictor of the development of atrial fibrillation: the Cardiovascular Health Study.

Background— Atrial fibrillation (AF), the most common cardiac rhythm abnormality, is associated with significant morbidity, mortality, and healthcare expenditures. Elevated B-type natriuretic peptide levels have been associated with the risk of heart failure, AF, and mortality. Methods and Results— The relation between N-terminal pro-B-type natriuretic peptide (NT-proBNP) and AF was studied in 5445 Cardiovascular Health Study participants with the use of relative risk regression for predicting prevalent AF and Cox proportional hazards for predicting incident AF. NT-proBNP levels were strongly associated with prevalent AF, with an unadjusted prevalence ratio of 128 for the highest quintile (95% confidence interval, 17.9 to 913.3; P<0.001) and adjusted prevalence ratio of 147 for the highest quintile (95% confidence interval, 20.4 to 1064.3; P<0.001) compared with the lowest. After a median follow-up of 10 years (maximum of 16 years), there were 1126 cases of incident AF (a rate of 2.2 per 100 person-years). NT-proBNP was highly predictive of incident AF, with an unadjusted hazard ratio of 5.2 (95% confidence interval, 4.3 to 6.4; P<0.001) for the development of AF for the highest quintile compared with the lowest; for the same contrast, NT-proBNP remained the strongest predictor of incident AF after adjustment for an extensive number of covariates, including age, sex, medication use, blood pressure, echocardiographic parameters, diabetes mellitus, and heart failure, with an adjusted hazard ratio of 4.0 (95% confidence interval, 3.2 to 5.0; P<0.001). Conclusions— In a community-based population of older adults, NT-proBNP was a remarkable predictor of incident AF, independent of any other previously described risk factor.

2015 HRS/EHRA/APHRS/SOLAECE expert consensus statement on optimal implantable cardioverter-defibrillator programming and testing

Implantable cardioverter-defibrillator (ICD) therapy is clearly an effective therapy for selected patients in definable populations. The benefits and risks of ICD therapy are directly impacted by programming and surgical decisions. This flexibility is both a great strength and a weakness, for which there has been no prior official discussion or guidance. It is the consensus of the four continental electrophysiology societies that there are four important clinical issues for which there are sufficient ICD clinical and trial data to provide evidence-based expert guidance. This document systematically describes the >80% (83–100%, mean: 96%) required consensus achieved for each recommendation by official balloting in regard to the programming of (i) bradycardia mode and rate, (ii) tachycardia detection, (iii) tachycardia therapy, and (iv) the intraprocedural testing of defibrillation efficacy. Representatives nominated by the Heart Rhythm Society (HRS), European Heart Rhythm Association (EHRA), Asian Pacific Heart Rhythm Society (APHRS), and the Sociedad Latinoamericana de Estimulacion Cardiaca y Electrofisiologia (SOLAECE)-Latin American Society of Cardiac Pacing and Electrophysiology participated in the project definition, the literature review, the recommendation development, the writing of the document, and its approval. The 32 recommendations were balloted by the 35 writing committee members and were approved by an …

HRS Expert Consensus Statement on remote interrogation and monitoring for cardiovascular implantable electronic devices

DavidSlotwiner,MD, FHRS, FACC(Chair),Niraj Varma,MD,PhD, FRCP(Co-chair), JosephG.Akar,MD,PhD, George Annas, JD, MPH, Marianne Beardsall, MN/NP, CCDS, FHRS, Richard I. Fogel, MD, FHRS, Nestor O. Galizio, MD, Taya V. Glotzer, MD, FHRS, FACC, Robin A. Leahy, RN, BSN, CCDS, FHRS, Charles J. Love, MD, CCDS, FHRS, FACC, FAHA, Rhondalyn C. McLean, MD, Suneet Mittal, MD, FHRS, Loredana Morichelli, RN, MSN, Kristen K. Patton, MD, Merritt H. Raitt, MD, FHRS, Renato Pietro Ricci, MD, John Rickard, MD, MPH, Mark H. Schoenfeld, MD, CCDS, FHRS, FACC, FAHA, Gerald A. Serwer, MD, FHRS, FACC, Julie Shea, MS, RNCS, FHRS, CCDS, Paul Varosy, MD, FHRS, FACC, FAHA, Atul Verma, MD, FHRS, FRCPC, Cheuk-Man Yu, MD, FACC, FRCP, FRACP From the Hofstra School of Medicine, North Shore Long Island Jewish Health System, New Hyde Park, New York, Cleveland Clinic, Cleveland, Ohio, Yale University School of Medicine, New Haven, Connecticut, Boston University School of Public Health, Boston, Massachusetts, Southlake Regional Health Centre, Newmarket, Ontario, Canada, St. Vincent Medical Group, Indianapolis, Indiana, Favaloro Foundation University Hospital, Buenos Aires, Argentina, Hackensack University Medical Center, Hackensack, New Jersey, Sanger Heart & Vascular Institute, Carolinas HealthCare System, Charlotte, North Carolina, New York University Langone Medical Center, New York City, New York, University of Pennsylvania Health System, Philadelphia, Pennsylvania, The Arrhythmia Institute at Valley Hospital, New York, New York, Department of Cardiovascular Diseases, San Filippo Neri Hospital, Rome, Italy, University of Washington, Seattle, Washington, VA Portland Health Care System, Oregon Health & Science University, Knight Cardiovascular Institute, Portland, Oregon, Johns Hopkins University, Baltimore, Maryland, Yale University School of Medicine, Yale-New Haven Hospital Saint Raphael Campus, New Haven, Connecticut, University of Michigan Congenital Heart Center, University of Michigan Health Center, Ann Arbor, Michigan, Brigham and Women’s Hospital, Boston, Massachusetts, Veterans Affairs Eastern Colorado Health Care System, University of Colorado, Denver, Colorado, and Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China.

Prophylaxis of contrast-induced nephropathy in patients undergoing coronary angiography.

Contrast‐induced nephropathy (CIN) is a common complication of cardiac catheterization, reported to result in a 15% incidence of acute renal failure. Convincing evidence supports the prophylactic use of prehydration and low volumes of contrast medium. Recently, the antioxidant acetylcysteine has been shown to have a potential preventive role. The aim of this study was to examine the hypothesis that acetylcysteine prevents CIN. Patients undergoing cardiac catheterization with a serum creatinine ≥ 1.5 mg/dl were prospectively randomized to receive acetylcysteine or placebo. A total of five doses of acetylcysteine 600 mg b.i.d. or placebo was administered, commencing on the day of the procedure. All patients were prehydrated with 0.45% saline and during the catheterization a nonionic low‐osmolality contrast medium was used. Serum creatinine and urea were measured at 24, 48, and 72 hr postprocedure. A total of 43 patients were studied. There was no significant difference between the groups in terms of baseline characteristics, including baseline renal function. No adverse events were experienced with acetylcysteine treatment. Serum creatinine levels at 48 and 72 hr remained largely unchanged in the acetylcysteine group but continued to rise at 48 and 72 hr in the placebo group. By 72 hr, the incidence of CIN, defined as a 25% increase in baseline creatinine, was significantly lower in the acetylcysteine arm compared to placebo (5% for acetylcysteine vs. 32% for placebo; P = 0.046). In patients with mild to moderate renal impairment undergoing cardiac catheterization, prophylactic treatment with oral acetylcysteine reduces the incidence of contrast‐induced nephropathy. Catheter Cardiovasc Interv 2003;60:458–461.

Mutations in the long QT gene, KCNQ1, are an uncommon cause of atrial fibrillation

Atrial fibrillation (AF) is the most common clinical arrhythmia and a major source of morbidity and mortality.1 The underlying mechanisms for AF are highly heterogeneous and often related to associated structural heart disease.2 However, in several large studies 10–30% of subjects have no obvious heart disease, and are labelled as primary or lone AF.1 The identification of extended families with lone AF, and the mapping of discrete genetic loci in such families, raises the possibility that the heritable predisposition to this form of the arrhythmia is accessible.3,4 Recently, the first gene for an inherited form of AF was identified in a family with autosomal dominant transmission.5 A mutation was found in the first transmembrane spanning domain of the potassium channel gene, KCNQ1, resulting in serine-glycine substitution (S140G). Mutations in other residues throughout this gene cause long QT syndrome type 1 (LQT1). Co-expression of the S140G mutant allele with KCNE1 in cells results in a gain of function with increased current density, and an alteration of channel activation and inactivation. These observations contrast with the reduction in current density seen with LQT1 associated mutations. The unique phenotype associated with this activating mutation includes persistent AF and, surprisingly, QT prolongation. This …

Fibroblast Growth Factor-23 and Incident Atrial Fibrillation: The Multi-Ethnic Study of Atherosclerosis (MESA) and the Cardiovascular Health Study (CHS)

Background— Fibroblast growth factor-23 (FGF-23) is a hormone that promotes urinary phosphate excretion and regulates vitamin D metabolism. Circulating FGF-23 concentrations increase markedly in chronic kidney disease and are associated with increased risk of clinical cardiovascular events. FGF-23 may promote atrial fibrillation (AF) by inducing left ventricular hypertrophy and diastolic and left atrial dysfunction. Methods and Results— We tested the associations of circulating FGF-23 concentration with incident AF among 6398 participants in the Multi-Ethnic Study of Atherosclerosis (MESA) and 1350 participants in the Cardiovascular Health Study (CHS), all free of clinical cardiovascular disease at baseline. Over a median of 7.7 and 8.0 years of follow-up, we observed 291 and 229 incident AF events in MESA and CHS, respectively. In multivariable Cox proportional hazards models, each 2-fold-higher FGF-23 concentration was associated with a 41% higher risk of incident AF in MESA (hazard ratio, 1.41; 95% confidence interval, 1.13–1.76; P =0.003) and a 30% higher risk of incident AF in CHS (hazard ratio, 1.30; 95% confidence interval, 1.05–1.61; P =0.016) after adjustment for potential confounding characteristics, including kidney disease. Serum phosphate concentration was significantly associated with incident AF in MESA (hazard ratio, 1.15 per 0.5 mg/dL; 95% confidence interval, 1.02–1.31; P =0.023) but not CHS. In MESA, an association of low estimated glomerular filtration rate with incident AF was partially attenuated by adjustment for FGF-23. Conclusion— Higher circulating FGF-23 concentration is associated with incident AF and may, in part, explain the link between chronic kidney disease and AF. # CLINICAL PERSPECTIVE {#article-title-54}Background— Fibroblast growth factor-23 (FGF-23) is a hormone that promotes urinary phosphate excretion and regulates vitamin D metabolism. Circulating FGF-23 concentrations increase markedly in chronic kidney disease and are associated with increased risk of clinical cardiovascular events. FGF-23 may promote atrial fibrillation (AF) by inducing left ventricular hypertrophy and diastolic and left atrial dysfunction. Methods and Results— We tested the associations of circulating FGF-23 concentration with incident AF among 6398 participants in the Multi-Ethnic Study of Atherosclerosis (MESA) and 1350 participants in the Cardiovascular Health Study (CHS), all free of clinical cardiovascular disease at baseline. Over a median of 7.7 and 8.0 years of follow-up, we observed 291 and 229 incident AF events in MESA and CHS, respectively. In multivariable Cox proportional hazards models, each 2-fold-higher FGF-23 concentration was associated with a 41% higher risk of incident AF in MESA (hazard ratio, 1.41; 95% confidence interval, 1.13–1.76; P=0.003) and a 30% higher risk of incident AF in CHS (hazard ratio, 1.30; 95% confidence interval, 1.05–1.61; P=0.016) after adjustment for potential confounding characteristics, including kidney disease. Serum phosphate concentration was significantly associated with incident AF in MESA (hazard ratio, 1.15 per 0.5 mg/dL; 95% confidence interval, 1.02–1.31; P=0.023) but not CHS. In MESA, an association of low estimated glomerular filtration rate with incident AF was partially attenuated by adjustment for FGF-23. Conclusion— Higher circulating FGF-23 concentration is associated with incident AF and may, in part, explain the link between chronic kidney disease and AF.

N-terminal pro-B-type natriuretic peptide as a predictor of incident atrial fibrillation in the Multi-Ethnic Study of Atherosclerosis: the effects of age, sex and ethnicity

Objective Atrial fibrillation (AF) is a common source of medical costs, morbidity and mortality. NT pro-brain natriuretic peptide (BNP) is a remarkably strong predictor of AF in older whites; we aimed to assess if this biomarker was as predictive in other racial groups. Design We used covariate-adjusted Cox model regressions to estimate the HRs of developing AF as a function of NT proBNP, and tested for interactions of NT proBNP with age, gender and race/ethnicity. Setting The Multi-Ethnic Study of Atherosclerosis (MESA). Patients 5518 subjects were followed over a median of 7.6 years. During this time, 267 developed AF. Results NT proBNP was statistically significantly associated with incident AF; for ln NT proBNP, the adjusted HR was 2.2 (95% CI 1.9 to 2.5). Assessed by quintiles, the relationship between NT proBNP was strong and graded; the unadjusted HR for the highest quintile of NT proBNP was 23.7 (95% CI 11.1 to 50.6) and adjusted was 11.4 (95% CI 5.1 to 25.3). NT proBNP was an excellent predictor of incident AF in the younger and older age groups, in men and women and in the different race/ethnicity groups: the HR for ln NT proBNP as a predictor of incident AF ranged from 2.0 to 3.9 in each subgroup. Conclusions NT proBNP is a robust predictor of incident AF; its prognostic value is more significant in younger patients and women compared with older patients and men. NT proBNP was also as strongly predictive in black patients, Hispanics and Asian/Chinese as in white patients despite a lower incidence of arrhythmia.

Catheter Ablation of Peri-AV Nodal Atrial Tachycardia from the Noncoronary Cusp of the Aortic Valve

Introduction: Atrial tachycardias (AT) originating from the anteroseptal region of the aortic root, near the atrioventricular node can be challenging to eliminate safely by catheter ablation. In this study, we examine the characteristics of anteroseptal ATs in a cohort of patients at our centers, and demonstrate the long‐term efficacy and safety of targeting the arrhythmias from within the base of the noncoronary aortic valve cusp (NCC).

The impact of height on the risk of atrial fibrillation: the Cardiovascular Health Study.

AIMS Atrial fibrillation (AF) is the most common sustained arrhythmia. Increased body size has been associated with AF, but the relationship is not well understood. In this study, we examined the effect of increased height on the risk of AF and explore potential mediators and implications for clinical practice. METHODS AND RESULTS We examined data from 5860 individuals taking part in the Cardiovascular Health Study, a cohort study of older US adults followed for a median of 13.6 (women) and 10.3 years (men). Multivariate linear models and age-stratified Cox proportional hazards and risk models were used, with focus on the effect of height on both prevalent and incident AF. Among 684 (22.6%) and 568 (27.1%) incident cases in women and men, respectively, greater height was significantly associated with AF risk [hazard ratio (HR)(women) per 10 cm 1.32, confidence interval (CI) 1.16-1.50, P < 0.0001; HR(men) per 10 cm 1.26, CI 1.11-1.44, P < 0.0001]. The association was such that the incremental risk from sex was completely attenuated by the inclusion of height (for men, HR 1.48, CI 1.32-1.65, without height, and HR 0.94, CI 0.85-1.20, with height included). Inclusion of height in the Framingham model for incident AF improved discrimination. In sequential models, however, we found minimal attenuation of the risk estimates for AF with adjustment for left ventricular (LV) mass and left atrial (LA) dimension. The associations of LA and LV size measurements with AF risk were weakened when indexed to height. CONCLUSION Independent from sex, increased height is significantly associated with the risk of AF.

2017 HRS expert consensus statement on cardiovascular implantable electronic device lead management and extraction

Fred M. Kusumoto, MD, FHRS, FACC, Chair, Mark H. Schoenfeld, MD, FHRS, FACC, FAHA, CCDS, Vice-Chair, Bruce L. Wilkoff, MD, FHRS, CCDS, Vice-Chair, Charles I. Berul, MD, FHRS, Ulrika M. Birgersdotter-Green, MD, FHRS, Roger Carrillo, MD, MBA, FHRS, Yong-Mei Cha, MD, Jude Clancy, MD, Jean-Claude Deharo, MD, FESC, Kenneth A. Ellenbogen, MD, FHRS, Derek Exner, MD, MPH, FHRS, Ayman A. Hussein, MD, FACC, Charles Kennergren, MD, PhD, FETCS, FHRS, Andrew Krahn, MD, FRCPC, FHRS, Richard Lee, MD, MBA, Charles J. Love, MD, CCDS, FHRS, FACC, FAHA, Ruth A. Madden, MPH, RN, Hector Alfredo Mazzetti, MD, JoEllyn Carol Moore, MD, FACC, Jeffrey Parsonnet, MD, Kristen K. Patton, MD, Marc A. Rozner, PhD, MD, CCDS, Kimberly A. Selzman, MD, MPH, FHRS, FACC, Morio Shoda, MD, PhD, Komandoor Srivathsan, MD, Neil F. Strathmore, MBBS, FHRS, Charles D. Swerdlow, MD, FHRS, Christine Tompkins, MD, Oussama Wazni, MD, MBA