Cardiac electrophysiology review最新文献

{"title":"Detection of atrial fibrillation by permanent pacemakers: observations from the STOP AF trial.","authors":"C J Plummer,&nbsp;J M McComb","doi":"10.1023/B:CEPR.0000023133.43829.9a","DOIUrl":"https://doi.org/10.1023/B:CEPR.0000023133.43829.9a","url":null,"abstract":"<p><p>Pacemaker telemetry is increasingly being used to infer the presence or absence of arrhythmias in clinical practice. To evaluate the reliability of these data in patients with sick-sinus syndrome, a sub-study of eighteen consecutive patients in the Systematic Trial of Pacing to prevent Atrial Fibrillation (STOP AF) implanted with dual-chamber pacemakers had simultaneous 24-hour Holter recordings and pacemaker telemetry down-loaded. Whilst heart rate data were very similar, telemetry data achieved only 57% sensitivity with 64% specificity for the presence of atrial fibrillation on Holter recording over 24 hours. False-positive results were due to far-field sensing while false-negatives were seen with very short episodes of atrial fibrillation. The pacemaker's anti-tachycardia responses were not specific for the detection of atrial fibrillation. There are very few published reports correlating pacemaker diagnostic data and stored electrograms with external Holter monitoring. We believe that more validation studies of are needed before pacemaker diagnostic data can be used with confidence in clinical practice. It is unlikely that current devices with sophisticated detection algorithms will fail to detect prolonged episodes of arrhythmia and their capacity to confirm events with stored electrograms, intervals and markers reduces the possibility of false-positives, but care must be taken in the interpretation of stored data from devices without these capabilities. Equally, it cannot be assumed that if intracardiac electrograms from one episode confirm the presence of an arrhythmia, that all recorded events have been similarly correctly interpreted. We have shown in a sub-study of STOP-AF that simple mathematical models using heart rate bin analysis are not reliable for detection of arrhythmias with short durations. Despite these limitations, the potential of implanted pacemakers to record cardiac rhythm and trends, such as heart-rate variability, over time remains an exciting prospect, particularly in guiding individual patient therapy.</p>","PeriodicalId":80888,"journal":{"name":"Cardiac electrophysiology review","volume":"7 4","pages":"333-40"},"PeriodicalIF":0.0,"publicationDate":"2003-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1023/B:CEPR.0000023133.43829.9a","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"24457685","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"DEFibrillators In Non-Ischemic Cardiomyopathy Treatment Evaluation (DEFINITE).","authors":"Andi Schaechter,&nbsp;Alan H Kadish","doi":"10.1023/B:CEPR.0000023162.45506.c4","DOIUrl":"https://doi.org/10.1023/B:CEPR.0000023162.45506.c4","url":null,"abstract":"<p><p>The DEFibrillators In Non-Ischemic Cardiomyopathy Treatment Evaluation (DEFINITE) was a multi-center, randomized, investigator-initiated trial. Patients enrolled in the trial had non-ischemic cardiomyopathy (LVEF <or=35%), a history of symptomatic heart failure and spontaneous arrhythmia (>10 PVCs/hr or non-sustained ventricular tachycardia defined as 3 to 15 beats at a rate of >120 bpm) on Holter monitor or telemetry within the past 6 months. All patients received standard oral medical therapy for heart failure including angiotensin converting enzyme inhibitors and beta-blockers. Patients were randomized to implantable cardioverter defibrillator (ICD) versus no ICD. Patients were followed for 2 to 3 years. The primary endpoint was total mortality. Quality of life and pharmacoeconomics analysis was also performed. A registry tracked patients who met basic inclusion criteria but were not randomized. We estimated an annual total mortality of 15% at 2 years in the treatment arm that did not receive an ICD. The ICD was expected to reduce mortality by 50%. Approximately 229 patients were required in each treatment group. Forty-five centers were included in this trial that was designed to last an estimated 4 years. Enrollment was projected to occur over 2 1/2 years with a post enrollment follow-up of 1 1/2 years.</p>","PeriodicalId":80888,"journal":{"name":"Cardiac electrophysiology review","volume":"7 4","pages":"457-62"},"PeriodicalIF":0.0,"publicationDate":"2003-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1023/B:CEPR.0000023162.45506.c4","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"24458080","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Clinical significance of device-related complications in clinical trials and implications for future trials: insights from the Antiarrhytmics Versus Implantable Defibrillators (AVID) trial.","authors":"Jack Kron","doi":"10.1023/B:CEPR.0000023163.67758.b1","DOIUrl":"https://doi.org/10.1023/B:CEPR.0000023163.67758.b1","url":null,"abstract":"<p><strong>Background: </strong>Implantation of transvenous implantable cardioverter-defibrillators (ICDs) utilizing a non-thoracotomy approach has become routine therapy for survivors of life-threatening tachyarrhythmias. In the Antiarrhythmics versus Implantable Defibrillator (AVID) Trial, we sought to identify and prospectively characterize the frequency of lead and ICD-related complications. Between June 1, 1993, and April 7, 1997, 539 patients received non-thoracotomy ICDs. A total of 62 first complications occurred. The subclavian route of insertion resulted in more complications than the cephalic vein route, 46 of 339 (14%) versus 6 of 135 (4%), p =.005 as did the abdominal versus pectoral generator site; 31 of 238 (13%) versus 17 of 291 (6%), p <.02. Most dislodgements and system infections tended to occur in the 3 months following implantation, whereas lead fractures continued to occur throughout follow-up. Failure to use peri-operative antibiotics was a predictor of system infection (p =.001). These data suggest that cephalic vein access and pectoral generator site may result in fewer complications. Although implantation techniques and generator technology continue to evolve, the continued occurrence of lead fractures and the need for premature system revision supports the practice of close routine ICD system surveillance.</p>","PeriodicalId":80888,"journal":{"name":"Cardiac electrophysiology review","volume":"7 4","pages":"473-8"},"PeriodicalIF":0.0,"publicationDate":"2003-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1023/B:CEPR.0000023163.67758.b1","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"24458083","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"AFFIRM and RACE trials: implications for the management of atrial fibrillation.","authors":"Joseph L Blackshear,&nbsp;Robert E Safford","doi":"10.1023/B:CEPR.0000023140.38226.75","DOIUrl":"https://doi.org/10.1023/B:CEPR.0000023140.38226.75","url":null,"abstract":"<p><p>The Atrial Fibrillation (AF) Follow-up Investigation of Rhythm Management (AFFIRM) and Rate Control versus Electrical Cardioversion for Persistent Atrial Fibrillation Study (RACE) Trials evaluated strategies of rate control or rhythm control in atrial fibrillation. AFFIRM enrolled patients with recent onset AF, and at entry over half of all patients were in sinus rhythm. At any point in the trial, the achieved difference in cardiac rhythm was likely only about 30%. In RACE all patients were entered in AF, and at the end of the study, sinus rhythm was present in 10% vs 39%. The strategy of rate control was non-inferior to the rhythm control strategy in both trials, and permits consideration of rate control as primary therapy. However, the actual differences in rhythm were relatively small, and do not allow the conclusion that maintenance of sinus rhythm is inferior to non-maintenance. Current guidelines recommend that patients with paroxysmal AF receive warfarin if they have risk factors for stroke. This is supported by data from AFFIRM. Most strokes in AFFIRM occurred either during subtherapeutic INR, or after cessation of warfarin. Since more patients in the rhythm control arm of AFFIRM discontinued warfarin, it is possible that asymptomatic recurrences of paroxysmal AF fostered clot development and embolization. We cannot answer from the data available whether or not it is safe to discontinue anticoagulation if all episodes of AF are suppressed. Among the reasons that AF is associated with increased mortality may be that it encourages development of congestive heart failure or progressive left ventricular dysfunction. Congestive heart failure occurrence was monitored in both trials, and occurred at a rate of 2-5% without significant differences between rate and rhythm arms. In patients with heart failure at entry, a mortality trend in AFFIRM favored the rhythm control arm. The issue of survivorship and rhythm control in AF in congestive heart failure is undergoing further testing.</p>","PeriodicalId":80888,"journal":{"name":"Cardiac electrophysiology review","volume":"7 4","pages":"366-9"},"PeriodicalIF":0.0,"publicationDate":"2003-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1023/B:CEPR.0000023140.38226.75","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"24457028","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Low molecular weight heparin in atrial fibrillation management: facts, fiction, future.","authors":"Michael H Kim,&nbsp;Richard G Trohman,&nbsp;Kim A Eagle","doi":"10.1023/B:CEPR.0000023148.24324.6b","DOIUrl":"https://doi.org/10.1023/B:CEPR.0000023148.24324.6b","url":null,"abstract":"<p><strong>Background: </strong>Atrial fibrillation (AF) is the most common sustained arrhythmia and various AF disease management strategies can be utilized.</p><p><strong>Methods: </strong>A prospective, randomized pilot study of two AF disease management strategies was conducted at a single university hospital in patients newly diagnosed with AF. The impact of low molecular weight heparin (LMWH) on AF management strategies is discussed with respect to the current guidelines for AF management, existing data on LMWH for AF, and recent investigations pertaining to AF.</p><p><strong>Results: </strong>18 patients were enrolled. The accelerated emergency department based strategy utilizing LMWH resulted in a significant reduction in length of stay (2.1 +/- 2.3 versus <1 day) and a trend toward lower costs (1,706 +/- 1,512 dollars versus 879 +/- 394 dollars; p = 0.15) when compared to the more traditional strategy of hospital admission. Measured clinical outcomes were similar for both treatment strategies.</p><p><strong>Conclusions: </strong>The investigation showed that an outpatient, emergency department based disease management strategy for new, uncomplicated AF could result in clinically acceptable, cost-effective innovations in AF treatment strategies. LMWH is an example of an agent allowing innovations in disease management strategies.</p>","PeriodicalId":80888,"journal":{"name":"Cardiac electrophysiology review","volume":"7 4","pages":"397-400"},"PeriodicalIF":0.0,"publicationDate":"2003-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1023/B:CEPR.0000023148.24324.6b","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"24457576","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Selecting the appropriate pacing mode for patients with sick sinus syndrome: evidence from randomized clinical trials.","authors":"A E Albertsen,&nbsp;J C Nielsen","doi":"10.1023/B:CEPR.0000023156.58418.2a","DOIUrl":"https://doi.org/10.1023/B:CEPR.0000023156.58418.2a","url":null,"abstract":"<p><p>Several observational studies have indicated that selection of pacing mode may be important for the clinical outcome in patients with symptomatic bradycardia, affecting the development of atrial fibrillation (AF), thromboembolism, congestive heart failure, mortality and quality of life. In this paper we present and discuss the most recent data from six randomized trials on mode selection in patients with sick sinus syndrome (SSS). In pacing mode selection, VVI(R) pacing is the least attractive solution, increasing the incidence of AF and-as compared with AAI(R) pacing, also the incidence of heart failure, thromboembolism and death. VVI(R) pacing should not be used as the primary pacing mode in patients with SSS, who haven't chronic AF. AAIR pacing is superior to DDDR pacing, reducing AF and preserving left ventricular function. Single site right ventricular pacing-VVI(R) or DDD(R) mode-causes an abnormal ventricular activation and contraction (called ventricular desynchronization), which results in a reduced left ventricular function. Despite the risk of AV block, we consider AAIR pacing to be the optimal pacing mode for isolated SSS today and an algorithm to select patients for AAIR pacing is suggested. Trials on new pacemaker algorithms minimizing right ventricular pacing as well as trials testing alternative pacing sites and multisite pacing to reduce ventricular desynchronization can be expected within the next years.</p>","PeriodicalId":80888,"journal":{"name":"Cardiac electrophysiology review","volume":"7 4","pages":"406-10"},"PeriodicalIF":0.0,"publicationDate":"2003-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1023/B:CEPR.0000023156.58418.2a","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"24457578","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"MADIT-II: substudies and their implications.","authors":"Arthur J Moss","doi":"10.1023/B:CEPR.0000023155.60684.91","DOIUrl":"https://doi.org/10.1023/B:CEPR.0000023155.60684.91","url":null,"abstract":"<p><p>In MADIT-II, prophylactic ICD therapy was effective in improving survival in patients with prior myocardial infarction and an ejection fraction <or=0.30, and a host of prespecified secondary analyses indicate that life-saving effect of ICD therapy is consistent across all studied subgroups. We have not been able to identify any traditional risk factors that will permit selection of patients who will receive a significantly better effect from the ICD within any subgroup. The ICD provides appropriate therapy for life-threatening ventricular arrhythmias on at least one occasion in over a third of the patients during the first 4 years after device implantation. Computations from the MADIT-II database indicate that 9 patients need to be treated with an ICD to save one life during a 4-year period. The findings from MADIT-II have implications for patients, physicians, and society.</p>","PeriodicalId":80888,"journal":{"name":"Cardiac electrophysiology review","volume":"7 4","pages":"430-3"},"PeriodicalIF":0.0,"publicationDate":"2003-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1023/B:CEPR.0000023155.60684.91","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"24457582","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Cost-effectiveness of the implantable cardioverter defibrillator.","authors":"Mark A Hlatky,&nbsp;Gillian D Sanders,&nbsp;Douglas K Owens","doi":"10.1023/B:CEPR.0000023153.81976.3a","DOIUrl":"https://doi.org/10.1023/B:CEPR.0000023153.81976.3a","url":null,"abstract":"<p><p>Many clinicians and policymakers are concerned whether use of the implantable defibrillator (ICD) is justified in view of its high cost. Three randomized trials of the ICD have reported economic outcomes. Each trial found a large difference in cost between patients assigned to an ICD versus patients assigned to conventional therapy that persisted over three to six years of follow-up. Each trial also found better survival among ICD patients, and calculated ICD cost-effectiveness (CE) ratios between 27,000 dollars per life year added and 139,000 dollars per life year added. The variability in the cost-effectiveness ratios among trials is mainly due to variability in the years of life added by the ICD among the trials and, by extension, among patient subgroups. A rough rule of thumb is that the ICD will be economically attractive when it prolongs mean survival by six months or more, which is attainable in higher risk patient subgroups.</p>","PeriodicalId":80888,"journal":{"name":"Cardiac electrophysiology review","volume":"7 4","pages":"479-82"},"PeriodicalIF":0.0,"publicationDate":"2003-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1023/B:CEPR.0000023153.81976.3a","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"24457985","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Use of subcutaneous enoxaparin compared to intravenous heparin and oral phenprocoumon in the setting of cardioversion--the ACE study (Anticoagulation in Cardioversion using Enoxaparin).","authors":"Christoph Stellbrink,&nbsp;Uwe Nixdorff,&nbsp;Thomas Hofmann,&nbsp;Walter Lehmacher,&nbsp;Werner Günther Daniel,&nbsp;Peter Hanrath,&nbsp;Christoph Geller,&nbsp;Andreas Mügge,&nbsp;Walter Sehnert,&nbsp;Caroline Schmidt-Lucke,&nbsp;Jan-André Schmidt-Lucke","doi":"10.1023/B:CEPR.0000023145.54503.a2","DOIUrl":"https://doi.org/10.1023/B:CEPR.0000023145.54503.a2","url":null,"abstract":"<p><p>The mode and duration of anticoagulation in the setting of cardioversion of atrial fibrillation-either with or without guidance by transesophageal echocardiography (TEE)-is still an unresolved issue. Oral anticoagulation with warfarin or phenprocoumon is frequently used but may be associated with an increased risk of bleeding complications or, conversely, episodes of undercoagulation. Moreover, it takes several days to reach full anticoagulation with oral compounds. This phase may be covered with intravenous heparin but this requires prolonged hospitalization. Low-molecular weight heparin is an attractive alternative as it not only provides a safe and predictable level of anticoagulation with few side effects but can also be administered safely on an outpatient basis. In addition, anticoagulation monitoring is usually unnecessary. The ACE study (Anticoagulation in Cardioversion using Enoxaparin) compared the safety and efficacy of subcutaneous enoxaparin with intravenous heparin/oral phenprocoumon before and after cardioversion (stratified to TEE guidance or no TEE guidance). This article summarizes the study rationale and design. The results will be published shortly.</p>","PeriodicalId":80888,"journal":{"name":"Cardiac electrophysiology review","volume":"7 4","pages":"382-6"},"PeriodicalIF":0.0,"publicationDate":"2003-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1023/B:CEPR.0000023145.54503.a2","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"24457033","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Cardioversion related thromboembolism: value of transesophageal echocardiography to guide cardioversion in patients with atrial fibrillation.","authors":"Karlheinz Seidl,&nbsp;Jochen Senges","doi":"10.1023/B:CEPR.0000023147.52620.85","DOIUrl":"https://doi.org/10.1023/B:CEPR.0000023147.52620.85","url":null,"abstract":"<p><p>The aim of this article is to review two recent investigations of the value of transesophageal echocardiography to guide direct current cardioversion in different patient populations. In the Ludwigshafener Observational Cardioversion Study (LOCS) a TEE was performed prior to electrical cardioversion in patients with atrial fibrillation who had been receiving oral anticoagulation adjusted to an international normalized ratio of 2 to 3 for at least three weeks. In contrast, the ACUTE study investigated the value of transesophageal echocardiography in patients with atrial fibrillation in whom long-term oral anticoagulants had not been initiated in comparison to standard anticoagulation therapy. Furthermore, the following questions in respect to anticoagulation therapy are addressed: (1) how should patients be approached for pharmacological or spontaneous conversion; (2) how to treat emergency situations, (3) what is the importance of the postcardioversion period and long-term anticoagulation therapy; and (4) what is the role of low molecular weight heparin in the pericardioversion period.</p>","PeriodicalId":80888,"journal":{"name":"Cardiac electrophysiology review","volume":"7 4","pages":"392-6"},"PeriodicalIF":0.0,"publicationDate":"2003-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1023/B:CEPR.0000023147.52620.85","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"24457035","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}