Mina K. Chung

2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction

Jeffrey L. Anderson, MD, FACC, FAHA, Chair; Alice K. Jacobs, MD, FACC, FAHA, Immediate Past Chair; Jonathan L. Halperin, MD, FACC, FAHA, Chair-Elect; Nancy M. Albert, PhD, CCNS, CCRN, FAHA; Ralph G. Brindis, MD, MPH, MACC; Mark A. Creager, MD, FACC, FAHA; David DeMets, PhD; Robert A. Guyton, MD,

2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: Executive Summary: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines

Jeffrey L. Anderson, MD, FACC, FAHA, Chair; Alice K. Jacobs, MD, FACC, FAHA, Immediate Past Chair; Jonathan L. Halperin, MD, FACC, FAHA, Chair-Elect; Nancy M. Albert, PhD, CCNS, CCRN, FAHA; Ralph G. Brindis, MD, MPH, MACC; Mark A. Creager, MD, FACC, FAHA; David DeMets, PhD; Robert A. Guyton, MD,

Complication Rates Associated With Pacemaker or Implantable Cardioverter-Defibrillator Generator Replacements and Upgrade Procedures Results From the REPLACE Registry

Background— Prospective studies defining the risk associated with pacemaker or implantable cardioverter-defibrillator replacement surgeries do not exist. These procedures are generally considered low risk despite results from recent retrospective series reporting higher rates. Methods and Results— We prospectively assessed predefined procedure-related complication rates associated with elective pacemaker or implantable cardioverter-defibrillator generator replacements over 6 months of follow-up. Two groups were studied: those without (cohort 1) and those with (cohort 2) a planned transvenous lead addition for replacement or upgrade to a device capable of additional therapies. Complications were adjudicated by an independent events committee. Seventy-two US academic and private practice centers participated. Major complications occurred in 4.0% (95% confidence interval, 2.9 to 5.4) of 1031 cohort 1 patients and 15.3% (95% confidence interval, 12.7 to 18.1) of 713 cohort 2 patients. In both cohorts, major complications were higher with implantable cardioverter-defibrillator compared with pacemaker generator replacements. Complications were highest in patients who had an upgrade to or a revised cardiac resynchronization therapy device (18.7%; 95% confidence interval, 15.1 to 22.6). No periprocedural deaths occurred in either cohort, although 8 later procedure-related deaths occurred in cohort 2. The 6-month infection rates were 1.4% (95% confidence interval, 0.7 to 2.3) and 1.1% (95% confidence interval, 0.5 to 2.2) for cohorts 1 and 2, respectively. Conclusions— Pacemaker and implantable cardioverter-defibrillator generator replacements are associated with a notable complication risk, particularly those with lead additions. These data support careful decision making before device replacement, when managing device advisories, and when considering upgrades to more complex systems. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT00395447.

Common variants in KCNN3 are associated with lone atrial fibrillation

Atrial fibrillation (AF) is the most common sustained arrhythmia. Previous studies have identified several genetic loci associated with typical AF. We sought to identify common genetic variants underlying lone AF. This condition affects a subset of individuals without overt heart disease and with an increased heritability of AF. We report a meta-analysis of genome-wide association studies conducted using 1,335 individuals with lone AF (cases) and 12,844 unaffected individuals (referents). Cases were obtained from the German AF Network, Heart and Vascular Health Study, the Atherosclerosis Risk in Communities Study, the Cleveland Clinic and Massachusetts General Hospital. We identified an association on chromosome 1q21 to lone AF (rs13376333, adjusted odds ratio = 1.56; P = 6.3 × 10−12), and we replicated this association in two independent cohorts with lone AF (overall combined odds ratio = 1.52, 95% CI 1.40–1.64; P = 1.83 × 10−21). rs13376333 is intronic to KCNN3, which encodes a potassium channel protein involved in atrial repolarization.

Meta-analysis identifies six new susceptibility loci for atrial fibrillation

Atrial fibrillation is a highly prevalent arrhythmia and a major risk factor for stroke, heart failure and death. We conducted a genome-wide association study (GWAS) in individuals of European ancestry, including 6,707 with and 52,426 without atrial fibrillation. Six new atrial fibrillation susceptibility loci were identified and replicated in an additional sample of individuals of European ancestry, including 5,381 subjects with and 10,030 subjects without atrial fibrillation (P < 5 × 10−8). Four of the loci identified in Europeans were further replicated in silico in a GWAS of Japanese individuals, including 843 individuals with and 3,350 individuals without atrial fibrillation. The identified loci implicate candidate genes that encode transcription factors related to cardiopulmonary development, cardiac-expressed ion channels and cell signaling molecules.

Genome-wide association study of PR interval

The electrocardiographic PR interval (or PQ interval) reflects atrial and atrioventricular nodal conduction, disturbances of which increase risk of atrial fibrillation. We report a meta-analysis of genome-wide association studies for PR interval from seven population-based European studies in the CHARGE Consortium: AGES, ARIC, CHS, FHS, KORA, Rotterdam Study, and SardiNIA (N = 28,517). We identified nine loci associated with PR interval at P < 5 × 10−8. At the 3p22.2 locus, we observed two independent associations in voltage-gated sodium channel genes, SCN10A and SCN5A. Six of the loci were near cardiac developmental genes, including CAV1-CAV2, NKX2-5 (CSX1), SOX5, WNT11, MEIS1, and TBX5-TBX3, providing pathophysiologically interesting candidate genes. Five of the loci, SCN5A, SCN10A, NKX2-5, CAV1-CAV2, and SOX5, were also associated with atrial fibrillation (N = 5,741 cases, P < 0.0056). This suggests a role for common variation in ion channel and developmental genes in atrial and atrioventricular conduction as well as in susceptibility to atrial fibrillation.

2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the American College of Emergency Physicians and Society for Cardiovascular Angiography and Interventions.

WRITING COMMITTEE MEMBERS* Patrick T. O’Gara, MD, FACC, FAHA, Chair†; Frederick G. Kushner, MD, FACC, FAHA, FSCAI, Vice Chair*†; Deborah D. Ascheim, MD, FACC†; Donald E. Casey, Jr, MD, MPH, MBA, FACP, FAHA‡; Mina K. Chung, MD, FACC, FAHA*†; James A. de Lemos, MD, FACC*†; Steven M. Ettinger, MD, FACC*§; James C. Fang, MD, FACC, FAHA*†; Francis M. Fesmire, MD, FACEP* ¶; Barry A. Franklin, PHD, FAHA†; Christopher B. Granger, MD, FACC, FAHA*†; Harlan M. Krumholz, MD, SM, FACC, FAHA†; Jane A. Linderbaum, MS, CNP-BC†; David A. Morrow, MD, MPH, FACC, FAHA*†; L. Kristin Newby, MD, MHS, FACC, FAHA*†; Joseph P. Ornato, MD, FACC, FAHA, FACP, FACEP†; Narith Ou, PharmD†; Martha J. Radford, MD, FACC, FAHA†; Jacqueline E. Tamis-Holland, MD, FACC†; Carl L. Tommaso, MD, FACC, FAHA, FSCAI#; Cynthia M. Tracy, MD, FACC, FAHA†; Y. Joseph Woo, MD, FACC, FAHA†; David X. Zhao, MD, FACC*†

2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction: An Update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention and the 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction

Jonathan L. Halperin, MD, FACC, FAHA, Chair Glenn N. Levine, MD, FACC, FAHA, Chair-Elect Jeffrey L. Anderson, MD, FACC, FAHA, Immediate Past Chair [∗∗][1] Nancy M. Albert, PhD, RN, FAHA[∗∗][1] Sana M. Al-Khatib, MD, MHS, FACC, FAHA Kim K. Birtcher, PharmD, MS, AACC Biykem Bozkurt, MD

Cardioversion guided by transesophageal echocardiography: The ACUTE Pilot Study : A Randomized, controlled trial

A trial fibrillation is characterized by a lack of organized electrical and mechanical atrial activity that results in an irregular heartbeat and increased risks for congestive heart failure, thromboembolism, and death [1-3]. Since 1962, direct-current cardioversion has been used to restore sinus rhythm in patients with atrial fibrillation [4]. However, successful cardioversion, with the sudden resumption of sinus rhythm, is itself associated with an increased risk for embolic stroke, which can result when thrombi in the left atrial appendage are dislodged [5-12]. Transesophageal echocardiography (TEE) is an excellent method with which to detect thrombi in the left atrial appendage [13-19]. Its use has therefore been proposed as a way to allow cardioversion to be done earlier and more safely than would be possible with conventional therapy, which consists of a total of 7 weeks of treatment with warfarin [14-23]. Recent studies [15-19] indicate that TEE-guided cardioversion with short-term anticoagulation therapy may have several advantages over the conventional approach. These advantages include a decreased risk for embolism, which results from the avoidance of cardioversion in patients who have thrombi in the left atrial appendage [15]; a decreased risk for bleeding, which occurs because anticoagulation therapy can be briefer [19]; greater initial conversion to and long-term maintenance of sinus rhythm, which result from doing cardioversion earlier [18, 19]; and greater cost-effectiveness, which results from the decreased incidence of embolic stroke [17]. The ACUTE (Assessment of Cardioversion Using Transesophageal Echocardiography) Pilot Study was a multicenter, randomized clinical trial designed to compare TEE-guided cardioversion with conventional management of cardioversion in patients with atrial fibrillation who have cardioversion [19]. The study had two objectives: to assess the general feasibility of a TEE-guided approach to cardioversion and to determine the general safety of the TEE-guided approach by comparing its clinical outcome with those of conventional management. Methods Patient Selection Patients who were candidates for electrical cardioversion were eligible for inclusion if they had atrial fibrillation, or atrial flutter with a history of atrial fibrillation, lasting longer than 2 days. Patients were excluded if they had received anticoagulant therapy for more than 7 days, had required urgent cardioversion as a result of hemodynamic instability, had had a cardioembolic event within the previous month, had contraindications to TEE or warfarin, were women with childbearing potential in whom pregnancy could not be excluded, were unable to give informed consent, or were unable to return for a follow-up visit. Our study protocol was approved by the institutional review boards at all clinical sites, and all patients provided written informed consent in advance. Study Protocol Patients who met the inclusion criteria were randomly assigned to receive either a conventional or a TEE-guided approach to cardioversion. Randomization was done using presealed, opaque envelopes that were computer generated and distributed to each clinical site (Figure 1). Random assignments were stratified by site and were generated in blocks of six. Figure 1. The ACUTE (Assessment of Cardioversion Using Transesophageal Echocardiography) study protocol. The conventional approach to cardioversion was that recommended by the American College of Chest Physicians: 3 weeks of therapeutic warfarin therapy, then cardioversion, then 4 weeks of warfarin therapy, and then a follow-up examination at the end of the 4 weeks [23]. Prothrombin times were monitored regularly, and the target international normalized ratio (INR) was 2 to 3. If assigned to the TEE group, patients began receiving anticoagulation therapy at their initial visit. The goal was to have patients therapeutically anticoagulated (therapeutic anticoagulation was defined as a partial thromboplastin time 1.5 to 2.5 times control values or an INR of 2.0 to 3.0) at the time of and after the planned cardioversion, for a total of 4 weeks of therapy. The initial choice of antithrombotic agent was determined by whether the patient was an inpatient or an outpatient at the time of randomization: Heparin was used for inpatients; warfarin was administered to outpatients. Transesophageal echocardiography, with subsequent cardioversion within 24 hours, was then scheduled as soon as stable therapeutic anticoagulation was assured. For example, if a patient was hospitalized and intravenous heparin therapy was administered, TEE was done as soon as a stable therapeutic partial thromboplastin time could be documented (for 24 to 36 hours); subsequent cardioversion was done if the presence of a thrombus was excluded. A 4- to 5-day overlap of warfarin therapy and intravenous heparin therapy was often necessary to maintain adequate anticoagulation after cardioversion. If the patient was to be managed as an outpatient, warfarin therapy was initiated on the day of study enrollment, and TEE and subsequent possible cardioversion were scheduled for at least 5 to 7 days later. Again, cardioversion was done when the patient was therapeutically anticoagulated, and all patients received maintenance therapy with warfarin for 4 weeks after cardioversion [15]. In the TEE group, cardioversion was done immediately after or within 24 hours of TEE because of the potential for thrombus formation in the period between TEE and cardioversion. If thrombi were detected in the left or right atrial appendages or atrial cavities, cardioversion was postponed and the patient received warfarin therapy for 4 weeks. After 4 weeks, TEE was repeated and, if no thrombus was detected, cardioversion was done. If a thrombus was still present, another 4-week course of warfarin therapy was administered and cardioversion was not done [15]. Clinical Outcomes Our feasibility outcomes were frequency of cardioversion, frequency of cardioversion occurring as scheduled, time to cardioversion, and time to sinus rhythm. Our clinical safety outcomes were clinically apparent ischemic stroke, transient ischemic attack, systemic embolization, deaths related to cardioversion or episodes of bleeding, and detected episodes of clinical hemodynamic instability (worsening congestive heart failure or hypotension) that rendered the patient unable to complete the protocol. Other outcome variables were the prevalence of thrombi, the number of patients without thrombi who had early cardioversion, and the immediate and follow-up rhythms after cardioversion. These outcomes were assessed for as long as 4 weeks after cardioversion but for no longer than 8 weeks after randomization. In the patients who did not have cardioversion and who spontaneously reverted to sinus rhythm, the variables were assessed at 4 weeks after spontaneous reversion. Study Organization and Procedures The administrative organization of the pilot study is described in the Appendix. Echocardiographic Examination Conventional transthoracic echocardiography was done in both study groups using commercially available equipment. In the TEE group, TEE was done according to standard techniques using phased-array biplane or multiplane transducers [24-26]. Complete transesophageal echocardiographic examination was done, and special attention was paid to imaging the left and right atria and left and right atrial appendages to assess the presence or absence of thrombi and spontaneous echo contrast. Echocardiographic Data Analysis Two-dimensional directed M-mode transthoracic echocardiography was used to derive the left ventricular septal and posterior wall thicknesses and the end-diastolic, end-systolic, and left atrial dimensions. Ejection fraction was calculated using standard techniques [27, 28]. The maximal left atrial and right atrial areas were planimetered on-line, and the severity of mitral regurgitation was qualitatively graded from 0 to 4+ by using color-flow mapping [29]. A thrombus was considered to be present if a mass detected in the appendage or body of the atrium appeared to be distinct from the underlying endocardium, was not caused by pectinate muscles, and was detected in more than one imaging plane. The presence or absence of spontaneous echo contrast was analyzed and defined as dynamic intracavitary echoes with a characteristic swirling pattern distinct from artifact. The degree of spontaneous echo contrast was categorized independently as absent, mild, or severe [30, 31]. Quality Control Measures Standard definitions of echocardiographic measurements were available to all of the clinical centers as part of a pilot operations manual. Echocardiograms at each clinical center were interpreted locally by a single physician who was highly experienced in echocardiography. Videotapes that showed the results of the first five echocardiographic examinations and all videotapes that showed thrombi were forwarded from the clinical centers to a central laboratory and overread by three experienced reviewers for consensus [19]. Electrical Cardioversion Cardioversion was done by using the standard method of Lown and associates [4] with an initial energy of at least 40 J for atrial flutter and 200 J for atrial fibrillation. Statistical Analysis Summaries of clinical, echocardiographic, and outcome data are expressed as means or frequencies with 95% CIs. Data that were not normally distributed were log-transformed and presented as geometric means. Outcomes were compared for the TEE and conventional therapy groups, for patients with and without thrombus (in the TEE group only), and for patients in the TEE and conventional therapy groups who had cardioversion. These analyses were done using the t-test for independent groups for continuous variables and the Fisher exact test for categorical variables. StatXact (Cytel Software, Cambridge, Massachusetts) was used to compute binary CIs; SAS softwar

2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation

During the past three decades, catheter and surgical ablation of atrial fibrillation (AF) have evolved from investigational procedures to their current role as effective treatment options for patients with AF. Surgical ablation of AF, using either standard, minimally invasive, or hybrid techniques, is available in most major hospitals throughout the world. Catheter ablation of AF is even more widely available, and is now the most commonly performed catheter ablation procedure. In 2007, an initial Consensus Statement on Catheter and Surgical AF Ablation was developed as a joint effort of the Heart Rhythm Society (HRS), the European Heart Rhythm Association (EHRA), and the European Cardiac Arrhythmia Society (ECAS).1 The 2007 document was also developed in collaboration with the Society of Thoracic Surgeons (STS) and the American College of Cardiology (ACC). This Consensus Statement on Catheter and Surgical AF Ablation was rewritten in 2012 to reflect the many advances in AF ablation that had occurred in the interim.2 The rate of advancement in the tools, techniques, and outcomes of AF ablation continue to increase as enormous research efforts are focused on the mechanisms, outcomes, and treatment of AF. For this reason, the HRS initiated an effort to rewrite and update this Consensus Statement. Reflecting both the worldwide importance of AF, as well as the worldwide performance of AF ablation, this document is the result of a joint partnership between the HRS, EHRA, ECAS, the Asia Pacific Heart Rhythm Society (APHRS), and the Latin American Society of Cardiac Stimulation and Electrophysiology (Sociedad Latinoamericana de Estimulacion Cardiaca y Electrofisiologia [SOLAECE]). The purpose of this 2017 Consensus Statement is to provide a state-of-the-art review of the field of catheter and surgical ablation of AF and to report the findings of a writing group, convened by these five international societies. The writing group is charged with defining the indications, techniques, and outcomes of AF ablation procedures. Included within this document are recommendations pertinent to the design of clinical trials in the field of AF ablation and the reporting of outcomes, including definitions relevant to this topic. The writing group is composed of 60 experts representing 11 organizations: HRS, EHRA, ECAS, APHRS, SOLAECE, STS, ACC, American Heart Association (AHA), Canadian Heart Rhythm Society (CHRS), Japanese Heart Rhythm Society (JHRS), and Brazilian Society of Cardiac Arrhythmias (Sociedade Brasileira de Arritmias Cardiacas [SOBRAC]). All the members of the writing group, as well as peer reviewers of the document, have provided disclosure statements for all relationships that might be perceived as real or potential conflicts of interest. All author and peer reviewer disclosure information is provided in Appendix A and Appendix B. In writing a consensus document, it is recognized that consensus does not mean that there was complete agreement among all the writing group members. Surveys of the entire writing group were used to identify areas of consensus concerning performance of AF ablation procedures and to develop recommendations concerning the indications for catheter and surgical AF ablation. These recommendations were systematically balloted by the 60 writing group members and were approved by a minimum of 80% of these members. The recommendations were also subject to a 1-month public comment period. Each partnering and collaborating organization then officially reviewed, commented on, edited, and endorsed the final document and recommendations. The grading system for indication of class of evidence level was adapted based on that used by the ACC and the AHA.3,4 It is important to state, however, that this document is not a guideline. The indications for catheter and surgical ablation of AF, as well as recommendations for procedure performance, are presented with a Class and Level of Evidence (LOE) to be consistent with what the reader is familiar with seeing in guideline statements. A Class I recommendation means that the benefits of the AF ablation procedure markedly exceed the risks, and that AF ablation should be performed; a Class IIa recommendation means that the benefits of an AF ablation procedure exceed the risks, and that it is reasonable to perform AF ablation; a Class IIb recommendation means that the benefit of AF ablation is greater or equal to the risks, and that AF ablation may be considered; and a Class III recommendation means that AF ablation is of no proven benefit and is not recommended. The writing group reviewed and ranked evidence supporting current recommendations with the weight of evidence ranked as Level A if the data were derived from high-quality evidence from more than one randomized clinical trial, meta-analyses of high-quality randomized clinical trials, or one or more randomized clinical trials corroborated by high-quality registry studies. The writing group ranked available evidence as Level B-R when there was moderate-quality evidence from one or more randomized clinical trials, or meta-analyses of moderate-quality randomized clinical trials. Level B-NR was used to denote moderate-quality evidence from one or more well-designed, well-executed nonrandomized studies, observational studies, or registry studies. This designation was also used to denote moderate-quality evidence from meta-analyses of such studies. Evidence was ranked as Level C-LD when the primary source of the recommendation was randomized or nonrandomized observational or registry studies with limitations of design or execution, meta-analyses of such studies, or physiological or mechanistic studies of human subjects. Level C-EO was defined as expert opinion based on the clinical experience of the writing group. Despite a large number of authors, the participation of several societies and professional organizations, and the attempts of the group to reflect the current knowledge in the field adequately, this document is not intended as a guideline. Rather, the group would like to refer to the current guidelines on AF management for the purpose of guiding overall AF management strategies.5,6 This consensus document is specifically focused on catheter and surgical ablation of AF, and summarizes the opinion of the writing group members based on an extensive literature review as well as their own experience. It is directed to all health care professionals who are involved in the care of patients with AF, particularly those who are caring for patients who are undergoing, or are being considered for, catheter or surgical ablation procedures for AF, and those involved in research in the field of AF ablation. This statement is not intended to recommend or promote catheter or surgical ablation of AF. Rather, the ultimate judgment regarding care of a particular patient must be made by the health care provider and the patient in light of all the circumstances presented by that patient. The main objective of this document is to improve patient care by providing a foundation of knowledge for those involved with catheter ablation of AF. A second major objective is to provide recommendations for designing clinical trials and reporting outcomes of clinical trials of AF ablation. It is recognized that this field continues to evolve rapidly. As this document was being prepared, further clinical trials of catheter and surgical ablation of AF were under way.