Michele Brignole

Assessment of Atrioventricular Junction Ablation and DDDR Mode-Switching Pacemaker Versus Pharmacological Treatment in Patients With Severely Symptomatic Paroxysmal Atrial Fibrillation A Randomized Controlled Study

BACKGROUNDnThe purpose of the study was to evaluate the effect of AV junction ablation and pacemaker implantation on quality of life and specific symptoms in patients with paroxysmal atrial fibrillation (AF) not controlled by drugs.nnnMETHODS AND RESULTSnWe performed a multicenter, randomized, 6-month evaluation of the clinical effects of AV junction ablation and DDDR mode-switching pacemaker (Abl+Pm) versus pharmacological treatment in 43 patients with intolerable, recurrent paroxysmal AF of three or more episodes in the previous 6 months not controlled with three or more antiarrhythmic drugs. Before completion of the study, 3 patients in the drug group withdrew because of the severity of their symptoms and 1 patient assigned to the Abl+Pm group in whom the ablation procedure failed. At the end of the 6 months, the 21 patients of the Abl+Pm group who completed the study showed, in comparison with the 18 of the drug group, lower scores in the Living with Heart Failure Questionnaire (-51%, P=.0006), palpitations (-71%, P=.0000), effort dyspnea (-36%, P=.04), exercise intolerance score (-46%, P=.001), and easy fatigue (-51%, P=.02). The scores for rest dyspnea, chest discomfort, and NYHA functional classification were also lower (-56%, -50%, and -17%, respectively) in the Abl+Pm group, although not significantly. At the end of the study, palpitations were no longer present in 81% of the Abl+Pm group and in 11% of the drug group (P=.0000). AF was documented in 31 of 122 visits (25%) in the Abl+Pm group and in 9 of 107 examinations (8%) in the drug group (P=.0005); chronic AF developed in 5 (24%) and 0 (0%) in the two groups, respectively (P=.04).nnnCONCLUSIONSnIn patients with paroxysmal AF not controlled by pharmacological therapy, Abl+Pm treatment is highly effective and superior to drug therapy in controlling symptoms and improving quality of life. The discontinuation of drug therapy exposes patients to further recurrences of paroxysmal AF and the risk of developing permanent AF.

Effects of Permanent Pacemaker and Oral Theophylline in Sick Sinus Syndrome The THEOPACE Study: A Randomized Controlled Trial

BACKGROUNDnPacemakers and theophylline are currently being used to relieve symptoms in patients with sick sinus syndrome (SSS). However, the impact of either therapy on the natural course of the disease is unknown. We conducted a randomized controlled trial to prospectively assess the effects of pacemakers and theophylline in patients with SSS.nnnMETHODS AND RESULTSnOne hundred seven patients with symptomatic SSS (age, 73 +/- 11 years) were randomized to no treatment (control group, n = 35), oral theophylline (n = 36), or dual-chamber rate-responsive pacemaker therapy (n = 36). They were followed for up to 48 months (mean, 19 +/- 14 months). During follow-up, the occurrence of syncope was lower in the pacemaker group than in the control group (P = .02) and tended to be lower than in the theophylline group (P = .07). Heart failure occurred less often in patients assigned to pacemaker therapy and theophylline than in control patients (both, P = .05), whereas the incidence of sustained paroxysmal tachyarrhythmias, permanent atrial fibrillation, and thromboembolic events did not show any apparent difference among the three groups. Heart rate was higher in the theophylline group than in the control group. Both pacemaker therapy and theophylline improved symptom scores after 3 months of treatment; however, a similar improvement was observed in the control group.nnnCONCLUSIONSnIn patients with symptomatic SSS, therapy with theophylline or dual-chamber pacemaker is associated with a lower incidence of heart failure; pacemaker therapy is also associated with a lower incidence of syncope. The therapeutic benefits of pacemakers and theophylline on symptoms are partly a result of spontaneous improvement of the disease.

Is sinus bradycardia a factor facilitating overt heart failure

. These factors include lack of compliancewith drugs or diet, uncontrolled hypertension, myo-cardial ischaemia, systemic or pulmonary infections,pulmonary embolism, physical, environmental andemotional excesses, endocrine and haematologicaldisorders, tachyarrhythmias and complete atrioven-tricular block.Sinus bradycardia is not commonly includedamong the factors precipitating overt heart failure

Syncope and transient loss of consciousness : multidisciplinary management

Syncope and Transient Loss of Consciousness - Libros de Medicina - Medicina de urgencias y emergencias - 93,60

Understanding Neurology - A Problem-Orientated Approach

History taking and Physical Examination Neurological Investigations The Problems: Blackouts Acute Confusional States Forgetfulness (memory) Speech and Language Problems Loss of Vision and Double Vision Dizziness and Vertigo Weakness Tremor and Other Involuntary Movements Poor Coordination Headache Neck Pain and Back Ache Numbness and Tingling MCQs Index

A randomized controlled trial of atrioventricular junction ablation and cardiac resynchronization therapy in patients with permanent atrial fibrillation and narrow QRS

AimsnWe tested the hypothesis that atrioventricular (AV) junction ablation in conjunction biventricular pacing [cardiac resynchronization (CRT)] pacing is superior to pharmacological rate-control therapy in reducing heart failure (HF) and hospitalization in patients with permanent atrial fibrillation (AF) and narrow QRS.nnnMethods and resultsnWe randomly assigned 102 patients (mean age 72u2009±u200910u2009years) with severely symptomatic permanent AF (>6u2009months), narrow QRS (≤110u2009ms), and at least one hospitalization for HF in the previous year to AV junction ablation and CRT (plus defibrillator according to guidelines) or to pharmacological rate-control therapy (plus defibrillator according to guidelines). After a median follow-up of 16u2009months, the primary composite outcome of death due to HF, or hospitalization due to HF, or worsening HF had occurred in 10 patients (20%) in the Ablation+CRT arm and in 20 patients (38%) in the Drug arm [hazard ratio (HR) 0.38; 95% confidence interval (CI) 0.18-0.81; Pu2009=u20090.013]. Significantly fewer patients in the Ablation+CRT arm died from any cause or underwent hospitalization for HF [6 (12%) vs. 17 (33%); HR 0.28; 95% CI 0.11-0.72; Pu2009=u20090.008], or were hospitalized for HF [5 (10%) vs. 13 (25%); HR 0.30; 95% CI 0.11-0.78; Pu2009=u20090.024]. In comparison with the Drug arm, Ablation+CRT patients showed a 36% decrease in the specific symptoms and physical limitations of AF at 1u2009year follow-up (Pu2009=u20090.004).nnnConclusionnAblation+CRT was superior to pharmacological therapy in reducing HF and hospitalization and improving quality of life in elderly patients with permanent AF and narrow QRS.nnnClinicalTrials.gov IdentifiernNCT02137187 (May 2018, date last accessed).

Current Practice in Italy of VF Testing at Implant: What Do We Know and Where Do We Go From Here?

The standardized requirements for cardioverter defibrillator (ICD) implantation, with or without cardiac resynchronization therapy (CRT), include defibrillation testing (DT), which consists of the induction and termination of ventricular fibrillation (VF). This procedure has been followed from the early days of ICD therapy in order to assess the reliability of an implanted ICD device and to measure the defibrillation threshold. Effective DT is considered mandatory in accordance with the rules of good clinical practice.

Performing Carotid Sinus Massage

Carotid sinus syndrome is a frequent cause of syncope, especially in the elderly. The initial evaluation for this condition consists of a patient history, physical examination, standard electrocardiogram (ECG) and systemic blood pressure measurement in the supine and upright positions. If the origin of syncope remains uncertain, carotid sinus massage (CSM) together with the tilt test becomes the method of choice to unmask neuromediated syncopes.

Severe Paroxysmal Atrial Fibrillation: Atrioventricular Junction Ablation and DDDR Mode-Switching Pacemaker Versus Pharmacological Treatment

Atrial fibrillation (AF) is by far the most frequent arrhythmia. It has been calculated that it accounts for 1.6–2% of the general population. It is particularly frequent in the elderly, in males and in patients with heart disease; the prevalence of AF is 9.1 in men and women with cardiovascular disease over 65 years of age1,2. Given this high incidence, even if catheter ablation therapy were prescribed for a minority of drug refractory patients3, the total number of potential candidates for this treatment would be very high. For example, we have calculated that in Europe about 396 000 patients (216 000 over 65 years) are affected by intolerable paroxysmal AF (Fig. 1).