Neil Sulke

Central arteriovenous anastomosis for the treatment of patients with uncontrolled hypertension (the ROX CONTROL HTN study): a randomised controlled trial

BACKGROUNDnHypertension contributes to cardiovascular morbidity and mortality. We assessed the safety and efficacy of a central iliac arteriovenous anastomosis to alter the mechanical arterial properties and reduce blood pressure in patients with uncontrolled hypertension.nnnMETHODSnWe enrolled patients in this open-label, multicentre, prospective, randomised, controlled trial between October, 2012, and April, 2014. Eligible patients had baseline office systolic blood pressure of 140 mm Hg or higher and average daytime ambulatory blood pressure of 135 mm Hg or higher systolic and 85 mm Hg or higher diastolic despite antihypertensive treatment. Patients were randomly allocated in a 1:1 ratio to undergo implantation of an arteriovenous coupler device plus current pharmaceutical treatment or to maintain current treatment alone (control). The primary endpoint was mean change from baseline in office and 24 h ambulatory systolic blood pressure at 6 months. Analysis was by modified intention to treat (all patients remaining in follow-up at 6 months). This trial is registered with ClinicalTrials.gov, number NCT01642498.nnnFINDINGSn83 (43%) of 195 patients screened were assigned arteriovenous coupler therapy (n=44) or normal care (n=39). Mean office systolic blood pressure reduced by 26·9 (SD 23·9) mm Hg in the arteriovenous coupler group (p<0·0001) and by 3·7 (21·2) mm Hg in the control group (p=0·31). Mean systolic 24 h ambulatory blood pressure reduced by 13·5 (18·8) mm Hg (p<0·0001) in arteriovenous coupler recipients and by 0·5 (15·8) mm Hg (p=0·86) in controls. Implantation of the arteriovenous coupler was associated with late ipsilateral venous stenosis in 12 (29%) of 42 patients and was treatable with venoplasty or stenting.nnnINTERPRETATIONnArteriovenous anastomosis was associated with significantly reduced blood pressure and hypertensive complications. This approach might be a useful adjunctive therapy for patients with uncontrolled hypertension.nnnFUNDINGnROX Medical.

How do we diagnose syncope

Diagnosis of Syncope. Introduction: The Eastbourne Syncope Assessment Study aims to increase diagnostic yield in unexplained syncope while reducing investigational costs. The initial study phase was a retrospective analysis of every presentation to the Eastbourne General Hospital (a busy nontertiary center in the United Kingdom serving a population of 250,000; 24% are older than 65 years) with syncope for the year 1998.

Relationship of Indices of Inflammation and Thrombogenesis to Arrhythmia Burden in Paroxysmal Atrial Fibrillation

BACKGROUNDnAtrial fibrillation (AF) is associated with a high risk of stroke. The contribution of arrhythmia to events is clear in sustained forms of AF, but in paroxysmal AF, presently available data have yet to identify what proportion of time spent in AF (ie, arrhythmia burden [AFB]) is of clinical relevance. We aimed to assess this relationship using surrogate blood markers for the hypercoagulable state associated with AF.nnnMETHODSnOne hundred twenty-one consecutive outpatients (mean age 74.7 +/- 7.8 years; 73 [60.3%] men) with pacemakers capable of arrhythmia detection were recruited. AFB was assessed over a 1-month period and classified as AFB = 0%, 0.1% to 10%, 10.1% to 50%, or > 50%.nnnRESULTSnBaseline characteristics and comorbidities were comparable between groups. There were no significant differences in levels of soluble E-selectin (sE-selectin), von Willebrand factor (vWf), high-sensitivity C-reactive protein, interleukin-6, soluble P-selectin (sP-selectin), or tissue factor (TF) across the four patient groups. Levels of plasma brain natriuretic peptide (BNP) were approximately twofold greater in the group with the highest AFB (P < .001). Following a stepwise multiple linear regression analysis, age was a significant predictor of vWf (P = .010), sP-selectin (P = .042), and BNP (P = .012). Left ventricular fractional shortening was predictive of BNP (P = .001) and sE-selectin (P = .012). Anticoagulation was a predictor of vWf levels (P = .005), and hypertension was predictive of TF (P < .001).nnnCONCLUSIONnGiven no appreciable difference in levels of prothrombotic markers in relation to AFB in this study, it is plausible that these abnormalities do, in fact, relate to underlying risk factors, and that such patients should be anticoagulated if risk factors dictate. Thus, AFB per se should probably not influence the decision to anticoagulate, but rather the presence of AF combined with clinical risk scoring should remain the predominant tool for stroke risk assessment.

Diazepam or midazolam for external DC cardioversion (The DORM Study)

AIMSnTo compare the clinical efficacy and tolerability of two intravenous sedatives for physician-led DC cardioversion of atrial arrhythmias.nnnMETHODS AND RESULTSnOne hundred and forty-one patients attending for elective DC cardioversion of atrial arrhythmias were randomized to intravenous midazolam or diazepam. Sedation was administered using titration protocols. Procedure times, operator satisfaction scores and adverse events were documented. The patients immediate, 24- and 48-h recall and awareness of after-effects were obtained from questionnaires. Seventy-one patients received midazolam (mean 12.5 mg) and 70 patients received diazepam (mean 28.1 mg). There were 16 minor adverse events with midazolam (20% hypotension, 3% oxygen desaturation) and nine with diazepam (7% hypotension, 6% required additional analgesia), P = 0.14. There were no major adverse events. Sedation time was 5.0 +/- 3.4 min for midazolam and 6.5 +/- 3.4 min for diazepam (P = 0.0016). Patients awoke 77 +/- 46 min post-sedation with midazolam and 39 +/- 24 min with diazepam (P < 0.0001). There was no recall of the procedure at 48 h and no difference in awareness of after-effects between the two groups at 24 or 48 h, P = ns.nnnCONCLUSIONnPhysician-led cardioversion of atrial arrhythmias using intravenous sedation is effective and well tolerated. Sedation with diazepam was associated with fewer minor adverse events and a quicker recovery time than midazolam.

Effect of atrial antitachycardia pacing treatments in patients with an atrial defibrillator: randomised study comparing subthreshold and nominal pacing outputs.

Objective: To assess the true efficacy of antitachycardia pacing on spontaneous persistent atrial fibrillation in patients with an implanted atrial defibrillator, by comparing the effects of nominal pacing treatment with subthreshold pacing treatment. Design: The effects of antitachycardia pacing and burst 50 Hz atrial pacing on spontaneous atrial arrhythmias were evaluated six months after implantation of a Medtronic Jewel AF® atrial defibrillator. Setting: Cardiology department in a district general hospital. Patients: 15 patients with persistent atrial fibrillation. Interventions: Patients were randomised to either “nominal” output pacing treatment or surface ECG and endocardial electrogram proven subthreshold “sham” pacing treatment for three months, and then crossed over to the alternative treatment for a further three months. Results: During the nominal output phase, 31 episodes of atrial fibrillation were treated with 53 bursts of 50 Hz pacing, 98 sequences of ramp atrial pacing, and 61 sequences of burst atrial pacing. Atrial fibrillation was not pace terminated during any episode. Thirty one episodes of atrial tachycardia were treated with 19 bursts of 50 Hz atrial pacing, 103 sequences of ramp atrial pacing, and 38 sequences of burst atrial pacing. Termination of atrial tachycardia was observed in 17 episodes. During the “sham” pacing period, no episodes were terminated by any pacing treatment. Conclusion: Atrial antitachycardia pacing treatments are ineffective at terminating persistent atrial fibrillation but may be useful in terminating episodes of atrial tachycardia or flutter, thus reducing the burden of arrhythmia.

The benefit of a remotely monitored implantable loop recorder as a first line investigation in unexplained syncope: the EaSyAS II trial

AIMSnThis prospective randomized controlled study evaluated the first-line use of a novel remotely monitored implantable loop recorder (ILR) in the initial investigation of unexplained syncope, and compared this to conventional therapy and a dedicated Syncope Clinic (SC).nnnMETHODS AND RESULTSnA total of 246 patients (mean age 70.3 years) were randomly allocated to conventional management, SC alone, ILR alone, or SC + ILR. Median follow-up was 20 months (IQR 15-25 months). Time to electrocardiogram (ECG) diagnosis was significantly shorter with ILR alone vs. conventional [hazard ratio (HR) 35.5, P = 0.0004] and with SC vs. conventional (HR 25.6, P = 0.002). Seventy-four per cent of first syncopal events documented in the SC groups occurred during provocative tilt testing. Twenty-two per cent of patients who received an ILR were found to have a bradycardia indication for permanent pacing, compared with 3% of patients who did not. Overall, more investigative tests were undertaken in the conventional group than in any other. Only patients who received an ILR had a significant increase in time to second syncope (P = 0.02), suggesting successful diagnosis and management of treatable causes of syncope.nnnCONCLUSIONSnImplantable loop recorder monitoring achieved a more rapid diagnosis in unexplained syncope than usual care. Conventional management of syncope failed to achieve an ECG diagnosis despite a large number of investigative tests. Syncope Clinic and provocative tilt testing delivered a rapid ECG diagnosis, but did not prevent recurrent syncope. Implantable loop recorders offered rapid diagnosis, increased the likelihood of syncope being reported, demonstrated a high rate of intermittent bradycardia requiring pacing, and reduced recurrent syncope.

Are implantable cardiac monitors the ‘gold standard’ for atrial fibrillation detection? A prospective randomized trial comparing atrial fibrillation monitoring using implantable cardiac monitors and DDDRP permanent pacemakers in post atrial fibrillation ablation patients

AIMSnImplantable devices are widely accepted, but not proven, to be the most reliable monitoring method to assess atrial fibrillation (AF) therapies. We compared REVEAL(®)XT implantable cardiac monitors (ICMs) and permanent pacemakers (PPMs).nnnMETHODS AND RESULTSnFifty patients with paroxysmal AF were randomized to ICM or PPM implant 6 weeks prior to pulmonary vein isolation. Permanent pacemakers were programmed to monitoring only (ODO). Device downloads were performed at 0, 3, 6, 9, and 12 months. All patients underwent 7-day external loop recorder. Device ECGs and EGMs were compared for AF burden. A total of 20 744 and 11 238 arrhythmia episodes were identified in the ICM and PPM groups, respectively. Correct identification of AF was significantly better in the PPM group (97 vs. 55% P < 0.001). In the ICM group, 26% of ECGs were un-interpretable. Sensitivity and specificity for each episode of AF was significantly better in the PPM group (100 vs. 79% and 98 vs. 66%, respectively, P < 0.001). The positive predictive value for the detection of any AF was significantly better in the PPM than the ICM (100 vs. 58%, P = 0.03). The negative predictive value for the absence of all AF was not significantly different between the PPM and ICM (100% vs. 92%, P = 0.76).nnnCONCLUSIONnPermanent pacemakers Holters are the most accurate method of evaluating arrhythmia burden and the therapeutic efficacy of novel AF therapies. ICM has a high degree of artefact, which reduces its specifity and sensitivity. Despite the deficiencies of ICM monitoring the negative predictive value of the ICM is satisfactory if zero AF burden is the aim of therapy.

Electrophysiological characteristics associated with symptoms in pacemaker patients with paroxysmal atrial fibrillation

PurposeThe purpose of this study is to identify the electrophysiological factors affecting symptoms in paroxysmal atrial fibrillation (PAF) using patients with paroxysmal atrial fibrillation and pacemakers with advanced atrial fibrillation (AF) diagnostics.MethodsSeventy-nine patients (age 71.0u2009±u20098.2, 54.4% male) with symptomatic PAF and AF burden of 1% to 50% with DDDRP pacemakers implanted were assessed for 6xa0months. Patients recorded symptom onset and duration and these were correlated with device-derived electrophysiological data.ResultsOf 2,638 AF episodes, 333 were symptomatic and 2,305 asymptomatic, with 194 non-atrial tachyarrhythmia symptomatic episodes giving a sensitivity of 12.6% and a positive predictive value of 63.2% for specific AF symptoms. Symptomatic AF episodes were 3.8 times more common diurnally than nocturnally (pu2009<u20090.001). Diurnally, symptomatic AF was significantly associated with a shorter AF cycle length (CL; pu2009=u20090.04), faster ventricular rate (pu2009=u20090.004), shorter PR interval (pu2009<u20090.001), faster preceding heart rate (pu2009=u20090.001) and increased early recurrence of AF (pu2009<u20090.04). Nocturnally, a significantly longer AF CL (pu2009=u20090.04) and PR interval (pu2009<u20090.001) prior to AF onset predicted symptomatic AF.ConclusionsSymptoms in PAF are predicted by changes in AF episode duration, ventricular rate during AF, preceding sinus heart rate, AV nodal conduction and AF cycle length but not ventricular irregularity. Excess diurnal sympathetic tone and excess nocturnal vagal tone predispose to symptomatic PAF. These findings may have relevance for therapies for symptom control of PAF.

Rhythm Control and Cardioversion

The three main aims of treatment for paroxysmal atrial fibrillation are: (1) to suppress paroxysms of atrial fibrillation and maintain long-term sinus rhythm; (2) to control heart rate during paroxysms of atrial fibrillation if they occur; and (3) to prevent the complications associated with paroxysmal atrial fibrillation—that is, stroke and tachycardia-induced cardiomyopathy.1nnMany patients with paroxysmal atrial fibrillation can be highly symptomatic, although asymptomatic paroxysms are common.2 However, the abolition of symptoms of paroxysmal atrial fibrillation does not necessarily mean abolition of the atrial fibrillation per se, as heart rate slowing may abolish symptoms but still allow asymptomatic episodes to continue.3 In some patients, it may be appropriate to document the frequency of arrhythmia by Holter monitoring or event recording. Of note, most pharmacological studies of paroxysmal atrial fibrillation have concentrated on the reduction of symptomatic recurrences of paroxysmal atrial fibrillation.nnIf attacks of paroxysmal atrial fibrillation are frequent, current clinical practice usually uses chronic prophylaxis with drugs to reduce the frequency of paroxysms after removal of precipitating factors such as caffeine, alcohol, stress, and adequate treatment of underlying diseases such as myocardial ischaemia, thyrotoxicosis, and heart failure.1nnIn the long term, few patients achieve complete suppression of paroxysms of atrial fibrillation. Drug treatment for paroxysmal atrial fibrillation may be administered as prophylaxis against recurrent atrial fibrillation, but in those patients who are asymptomatic or have rare paroxysms (eg, only a few paroxysms a year) may decide not to take routine medication or to use a “pill-in-the-pocket” strategy, and the patient’s views need to be considered.nnBased on the systematic review undertaken as part of this guideline development, propafenone appears to be at least as effective as sotalol in preventing the recurrence of atrial fibrillation for up to 12 months following administration,4,5 although for …

Situs inversus and acute coronary syndrome

Dextrocardia is a rare clinical phenomenon with a reported incidence of one in 10 000. Consequently, acute coronary syndromes in such patients are rare. When chest pain occurs in this setting, it is important to be aware of the unique problems that may occur if coronary intervention is contemplated. Previous case reports have shown successful attempts at reperfusing one coronary artery percutaneously. In this case, coronary stents were successfully deployed in two vessels of a man with situs inversus, which has not been reported before. Additionally, the angiographic results that followed from successful intervention did not produce the expected haemodynamic and electrocardiographic changes.