Similar Incidence of Stroke in Paroxysmal Versus Sustained Atrial Fibrillation?/ Performance Measures for Atrial Fibrillation

No clear evidence exists regarding the effect of atrial fibrillation (AF) duration and frequency on the occurrence of stroke. Some studies have suggested a lower stroke risk in paroxysmal than in persistent AF. In contrast, other studies have reported a comparable stroke risk of paroxysmal to permanent AF. Upcoming trials such as the TRENDS and the ASSERT studies will provide further insight into the direct relation of AF duration and systemic embolism in a large group of patients with an implantable device. Recently, an ACC/AHA physician consortium provided clinical performance measures for adults with nonvalvular atrial fibrillation or atrial flutter

Catheter ablation of atrial fibrillation in patients with left ventricular dysfunction

There is a complex interplay between atrial fibrillation and congestive heart failure. These two clinical entities often coexist, resulting in significant morbidity, affecting prognosis and rendering their management even more challenging. New nonpharmacologic therapies are emerging and may alter the management of these patients. Among them, catheter ablation of atrial fibrillation seems to be a promising therapeutic approach as it leads to improvement of cardiac function, symptoms, exercise capacity, and quality of life. This article reviews the role of catheter ablation in contemporary management of atrial fibrillation among patients with left ventricular dysfunction

Stress echocardiography in elderly patients with coronary artery disease Applicability, safety and prognostic value of dobutamine and adenosine echocardiography in elderly patients

AbstractObjectives. Our aim was to determine the applicability, safety and prognostic value of adenosine and dobutamine stress echocardiography in patients ≥70 years old.Background. These tests are sometimes mandatory because of difficulties and inaccuracies in interpreting traditional electrocardiographic stress tests. Furthermore, if these tests could be used to avoid coronary arteriography and cardiac catheterization, they would become essential in the care of the elderly, whose numbers are increasing.Methods. We performed coronary arteriography and dobutamine and adenosine stress echocardiographic tests in 120 patients (72 men) ≥70 years old who entered the hospital because of chest pain and had known or suspected coronary artery disease. The stress tests were performed on separate days, within 2 weeks of coronary arteriography. Both the arteriograms and the echocardiograms were analyzed by two experts who had no knowledge of the patients' other data or the other interpreter's report. Tests were judged to have positive or negative results, and the patients were followed up for the development of cardiac events. Univariate and multivariate analyses and other statistical modalities were applied for comparisons.Results. Documented coronary artery disease was found in 89 patients. During the 14 ± 7 months of follow-up, cardiac events developed in 50 patients, including 3 (7.9%) of 38 patients with negative dobutamine and 12 (20.7%) of 58 patients with negative adenosine test results. Demonstration of any abnormality on stress echocardiography was an independent factor for cardiac events, both for dobutamine (relative risk 7.3) and for adenosine (relative risk 3.0). Both cessation of dobutamine or adenosine tests and diagnosis of disease in two or more coronary vessels were also independent predictors. ST segment depression ≥1 mm was related to future events only with the dobutamine test.Conclusions. These echocardiographic stress tests proved safe and well tolerated. They successfully stratified this cohort of elderly patients with coronary artery disease to low or high risk subgroups for subsequent cardiac events

Real-time heart rate entropy predicts the need for lifesaving interventions in trauma activation patients

Heart rate complexity (HRC), commonly described as a "new vital sign," has shown promise in predicting injury severity, but its use in clinical practice has been precluded by the absence of real-time data. This study was conducted to evaluate the utility of real-time, automated, instantaneous, hand-held heart rate entropy analysis in predicting the need for lifesaving interventions (LSIs). We hypothesized that real-time HRC would predict LSIs. Prospective enrollment of patients who met criteria for trauma team activation was conducted at a Level I trauma center (September 2011 to February 2012). A novel, hand-held, portable device was used to measure HRC (by sample entropy) and time-domain heart rate variability continuously in real time for 2 hours after the moment of presentation. Electric impedance cardiography was used to determine cardiac output. Patients who received an LSI were compared with patients without any intervention (non-LSI). Multivariable analysis was performed to control for differences between the groups. Of 82 patients enrolled, 21 (26%) received 67 LSIs within 24 hours of hospital arrival. Initial systolic blood pressure was similar in both groups. LSI patients had a lower Glasgow Coma Scale (GCS) score (9.2 [5.1] vs. 14.9 [0.2], p < 0.0001). The mean (SD) HRC value on presentation was 0.8 (0.6) in the LSI group compared with 1.5 (0.6) in the non-LSI group (p < 0.0001). With the use of logistic regression, initial HRC was the only significant predictor of LSI. A cutoff value for HRC of 1.1 yields sensitivity, specificity, negative predictive value, and positive predictive value of 86%, 74%, 94%, and 53%, respectively, with an accuracy of 77% for predicting an LSI. Decreased HRC on hospital arrival is an independent predictor of the need for LSI in trauma activation patients. Real-time HRC may be a useful adjunct to standard vital signs monitoring and predicts LSIs. Prognostic and diagnostic study, level III