Vladimir Khalameizer

Circadian Variation of the Efficacy of Thrombolytic Therapy in Acute Myocardial Infarction—Isn’t the Time Ripe for Cardiovascular Chronotherapy?:

This study was designed to assess the circadian variation of the efficacy of thrombolytic therapy (TT) in 163 patients with acute myocardial infarction. Statistical analysis of the results suggests the existence of circadian variation in the efficacy of thrombolytic therapy with marked early morning resistance and significantly better late daytime results. There is a strong relationship between the normal physiologic rhythms of biochemical, hemodynamic, and hematologic parameters, observed in patients with CAD and the circadian fluctuations of efficacy of TT. Obviously the efficacy of TT is influenced by more evident impact of chronorisk factors during the early morning hours.

Atrial fibrillation in the elderly: to ablate or not to ablate.

The reality that atrial fibrillation (AF) is the most frequently encountered arrhythmia in clinical practice, and that the incidence and prevalence of AF appears to be on the rise, is well known. This reality presents new challenges for cardiovascular practitioners and for the electrophysiology community. There is an increase in incidence of AF with age.1 The median age of patients with AF is 75 years, with prevalence of 2.3% and 5.9% in people older than 40 years and 65 years, respectively. Approximately 70% of individuals with AF are between 65 and 85 years of age.2 Beyond the sheer numbers of the elderly with AF, this population presents unique challenges to disease management. Elderly patients are more likely to have comorbid illnesses including hypertension, congestive heart failure, and left ventricular hypertrophy, placing them at increased risk for thromboembolic complications with AF and antithrombotic therapy complications.3 Age-related degenerative changes in the cardiac conduction system predispose the elderly to sick sinus syndrome and tachycardia–bradycardia syndrome.4 The age-related pharmacologic and pharmacodynamic changes in the antiarrhythmic drugs (AAD) increase the predilection for side effects and pro-arrhythmias.5-7 This makes pharmacologic rhythm control difficult to achieve in elderly patients with symptomatic paroxysmal and persistent AF. Until recently, there has been a paucity of data regarding the use of catheter ablation for maintenance of sinus rhythm in the elderly population (particularly those ≥ 70 years of age). Most AF ablation procedures have been performed in white male patients younger than 70 years of age.8 Probable reasons for this are comorbidities and fragility of elderly patients. Younger patients have fewer periprocedural complications, thus avoiding the age-related atrial substrate modification2 that leads to AF perpetuation and reduced chance of AF sinus rhythm maintenance. With increasing life expectancy, the elderly are the most rapidly expanding portion of our population, making AF an even more important public health concern. Given that elderly patients with symptomatic paroxysmal or persistent AF may be less tolerant of AAD than their

Morbidity and mortality with cardiac resynchronization therapy with pacing vs. with defibrillation in octogenarian patients in a real-world setting

Aims Cardiac resynchronization therapy (CRT) with a defibrillator (CRT-D) has downsides of high cost and inappropriate shocks compared to CRT without a defibrillator (CRT-P). Recent data suggest that the survival benefit of implantable cardioverter defibrillator (ICD) therapy is attenuated in the older age group. We hypothesized that, among octogenarians eligible for cardiac resynchronization therapy, CRT-P confers similar morbidity and mortality benefits as CRT-D. Methods and results We compared morbidity and mortality outcomes between consecutive octogenarian patients eligible for CRT therapy who underwent CRT-P implantation at Barzilai MC (n = 142) vs. those implanted with CRT-D for primary prevention indication who were prospectively enrolled in the Israeli ICD Registry (n = 104). Among the 246 study patients, mean age was 84 ± 3 years, 74% were males, and 66% had ischaemic cardiomyopathy. Kaplan-Meier survival analysis showed that at 5 years of follow-up the rate of all-cause mortality was 43% in CRT-P vs. 57% in the CRT-D group [log-rank P = 0.13; adjusted hazard ratio (HR) = 0.79, 95% CI 0.46-1.35, P = 0.37]. Kaplan-Meier analysis also showed no significant difference in the rates of the combined endpoint of heart failure or death (46 vs. 60%, respectively, log-rank P = 0.36; adjusted HR was 0.85, 95% CI 0.51-1.44, P = 0.55). A Cox proportional hazard with competing risk model showed that re-hospitalizations for cardiac cause were not different for the two groups (adjusted HR 1.35, 95% CI 0.7-2.6, P = 0.37). Conclusion Our data suggest that, in octogenarians with systolic heart failure, CRT-P therapy is associated with similar morbidity and mortality outcomes as CRT-D therapy.

Transient ventricular fibrillation. A clinical case report.

Self-terminating ventricular fibrillation (VF) was recorded in a 42-year-old woman without coronary artery or structural heart disease. Reviewing the scientific literature, we found that this type of VF had appeared in vivo in some animal models but was sparsely described in clinical practice. This most unusual case shows that potentially lethal arrhythmias may be self-terminating.

Developing a risk score to predict mortality in the first year after implantable cardioverter defibrillator implantation: Data from the Israeli ICD Registry: NEVZOROV et al.

Life expectancy of less than 1 year is usually a contraindication for implantable cardioverter defibrillator (ICD) implantation. The aim was to identify patients at risk of death during the first year after implantation.

Atrial infarction: a clinical and electrocardiographic case report.

A trial infarction is not commonly diagnosed because of its subt le and nonspecif ic elect rocard iographic f indings, which may be overshadowed by changes associated with concomitant ventr icular infarction. The prevalence of atrial infarction is unknown. A review of the English l i terature showed that the rarely repor ted ent i ty of atrial infarction occurs in 7% to 42% of autopsyp roved cases of myocardia l infarct ion. 1,2 This reflects the dif f iculty in antemortem diagnosis. The complicat ions of atrial infarction, which can be serious and may require urgent treatment, inc lude atrial ectopic arrhythmias, 3 a high prevalence of intramural thrombi (_<84% of autopsyproved cases of atrial infarction), and pulmonary embol ism (_<24%). 4 Some investigators I have pro~ posed anticoagulant t r e a t m e n t for pat ients who are thought to have atrial infarction. We report a case of acute infer ior myocardial infarction associated with suspected atrial infarct ion that was d iagnosed by electrocardiographic criteria.