Atrial Flutter: Diagnosis and Management strategies

Atrial flutter (AFL) is a regular, macro reentrant arrhythmia traditionally defined as a supraventricular tachycardia with an atrial rate of 240–320 beats per minute (bpm). Pathophysiology of atrial flutter and atrial fibrillation (AF) is closely related to the similar risk of stroke and they coexist clinically. Atrial flutter is classified to cavotricuspid isthmus (CTI) dependent (or typical) and non-isthmus dependent (atypical). Isthmus is a distinct structure in the right atrium (RA) through which atrial flutter passes and makes a good target for ablation therapy. Ablation is the primary therapy in atrial flutter, particularly in CTI dependent group, with regard to its safety profile and high success rate of approximately 90%. Three-dimensional electroanatomic mapping is progressively being used to ablate atypical forms of atrial flutter

Comparison of periodic face-to-face visits and use of smartphone application during COVID-19 pandemic in clinical follow-up of range of motion in patients with distal humeral fracture

Objective: As the prevalence of the coronavirus increases, there is now more emphasis on reducing "face-to-face" patient visits. Therefore, the use of smartphones and their special medical applications can play an important role in following up patients. The aim of this study was to evaluate the use of smartphone in evaluating clinical outcomes and range of motion of patients after elbow operation. Materials and Methods: Forty patients were randomly selected from patients undergoing elbow operation. Patients were divided into two groups, so that in the first group, the patients were visited and then were followed-up for 2,6, and 12 weeks as well as 6 months after first visit by smartphone connection and delivering the pictures and videos of involved organ to the physician as well as having the physical examination him. In the second group, all assessments were performed by clinical visiting at the same time points. Results: The two groups were similar in baseline characteristics including demographics; the side of involved elbow, type of fracture, surgical approach, operation time, and mean Mepi score. Assessing the postoperative complications and also patients' satisfaction was also similar in both groups. There was no difference in different range of elbow motion degrees between the case and control groups at different times of following-up as well as the progress in motion of elbow after surgery in two groups. Moreover, there was no significant difference between the range of motion evaluated by smartphone and physical examination. Conclusion: The use of the smartphone has a high degree of accuracy and sensitivity in assessing the status of elbow range of motion after surgical treatment, both in the short and long term after surgery

The effect of preoperative aspirin use on postoperative bleeding and perioperative myocardial infarction in patients undergoing coronary artery bypass surgery

Background: We tried to evaluate the clinical outcomes (mortality, postoperative bleeding and perioperative myocardial infarction) of patients who underwent first elective coronary artery bypass grafting and received aspirin during the preoperative period. Methods: The study was a prospective, randomized and single-blinded clinical trial. Two hundred patients were included and divided into two groups. One group received aspirin 80-160 mg, while in the other aspirin was stopped at least seven days before surgery. The primary end-points of the study were in-hospital mortality and hemorrhage-related complications (postoperative blood loss in the intensive care unit, re-exploration for bleeding and red blood cell and non-red blood cell requirements). The secondary end-point was perioperative myocardial infarction. Results: There were no differences in patient characteristics between the aspirin users and non-aspirin users. We found a significant difference between postoperative blood loss (608 ± 359.7 ml vs. 483 ± 251.5 ml; p = 0.005) and red blood cell product requirements (1.32 ± 0.97 unit packed cell vs. 0.94 ± 1.02 unit packed cell; p = 0.008). There was no significant difference between the two groups regarding platelet requirement and the rate of in-hospital mortality and re-exploration for bleeding. Similarly, we found no significant difference in the incidence of definite and probable perioperative myocardial infarction (p = 0.24 and p = 0.56 respectively) or in-hospital mortality between the two groups. Conclusion: Preoperative aspirin administration increased postoperative bleeding and red blood cell requirements with no effect on mortality, re-exploration rate and perioperative myocardial infarction. We recommend withdrawal of aspirin seven days prior to surgery. (Cardiol J 2007; 14: 453-457

Early septal activation, successful lateral ablation

The coronary sinus activation pattern is an important clue for the detection of arrhythmia mechanisms and/or localization of accessory pathways. Any change in this pattern during radiofrequency ablation should be evaluated carefully to recognize the presence of another accessory pathway or innocence of the accessory pathway during arrhythmia. Intra-atrial conduction block can change the coronary sinus activation pattern. Negligence regarding this phenomenon can cause irreversible complications. Here we describe a case with left lateral accessory pathway conduction in which intra-atrial conduction block completely reversed the coronary sinus activation pattern. (Cardiol J 2008; 15: 181-185

A patient with sick sinus syndrome, atrial flutter and bidirectional ventricular tachycardia: Coincident or concomitant presentations?

Channelopathies are among the major causes of syncope or sudden cardiac death in patients with structurally normal hearts. In these patients, the atrium, ventricle or both could be affected and reveal different presentations. In this case, we present a patient with an apparently structurally normal heart and recurrent syncope, presented as sick sinus syndrome with atrial flutter and bidirectional ventricular tachycardia. (Cardiol J 2007; 14: 585-588)

Relationship between QRS complex notch and ventricular dyssynchrony in patients with heart failure and prolonged QRS duration

Background: Cardiac resynchronization therapy (CRT) has been accepted as an established therapy for advanced systolic heart failure. Electrical and mechanical dyssynchrony are usually evaluated to increase the percentage of CRT responders. We postulated that QRS notch can increase mechanical LV dyssynchrony independently of other known predictors such as left ventricular ejection fraction and QRS duration. Methods: A total of 87 consecutive patients with advanced systolic heart failure and QRS duration more than 120 ms with an LBBB-like pattern in V1 were prospectively evaluated. Twelve-lead electrocardiogram was used for detection of QRS notch. Complete echocardiographic examination including tissue Doppler imaging, pulse wave Doppler and M-mode echocardiography were done for all patients. Results: Eighty-seven patients, 65 male (75%) and 22 female (25%), with mean (SD) age of 56.7 (12.3) years were enrolled the study. Ischemic cardiomyopathy was the underlying heart disease in 58% of the subjects, and in the others it was idiopathic. Patients had a mean (SD) QRS duration of 155.13 (23.34) ms. QRS notch was seen in 49.4% of the patients in any of two precordial or limb leads. Interventricular mechanical delay was the only mechanical dyssynchrony index that was significantly longer in the group of patients with QRS notch. Multivariate analysis revealed that the observed association was actually caused by the effect of QRS duration, rather than the presence of notch per se. Conclusions: QRS notch was not an independent predictor of higher mechanical dyssynchrony indices in patients with wide QRS complex and symptomatic systolic heart failure; however, there was a borderline association between QRS notch and interventricular delay

Wpływ przedoperacyjnego stosowania kwasu acetylosalicylowego na występowanie krwawienia pooperacyjnego i okołooperacyjnego zawału serca u osób poddawanych pomostowaniu aortalno-wieńcowemu

Wstęp: Podjęto próbę oceny wyników klinicznych (śmiertelność, występowanie krwawienia pooperacyjnego i okołooperacyjnego zawału serca) u pacjentów, których poddano pierwszej operacji pomostowania aortalno-wieńcowego, otrzymujących w okresie przedoperacyjnym kwas acetylosalicylowy. Metoda: Do prospektywnego, randomizowanego badania przeprowadzonego metodą ślepej próby włączono 200 pacjentów, których podzielono na dwie grupy. Osoby z jednej z nich otrzymywały kwas acetylosalicylowy w dawce 80–160 mg, natomiast chorzy z drugiej grupy przyjmowanie tego leku zakończyli przynajmniej 7 dni przed operacją. Pierwotnymi punktami końcowymi badania były: zgon w trakcie hospitalizacji i powikłania związane z krwawieniem (pooperacyjna utrata krwi na oddziale intensywnej opieki medycznej, reoperacja z powodu krwawienia oraz konieczność przetoczeń koncentratu krwinek czerwonych lub innych preparatów krwiopochodnych). Za wtórny punkt końcowy przyjęto występowanie okołooperacyjnego zawału serca. Wyniki: Pacjenci leczeni kwasem acetylosalicylowym nie różnili się w zakresie charakterystyki od osób, u których nie wdrożono tej formy terapii. Stwierdzono natomiast istotną różnicę w wielkości pooperacyjnej utraty krwi (608 ± 359,7 ml vs. 483 ± 251,5 ml; p = 0,005) i konieczności przetoczeń masy erytrocytarnej (1,32 ± 0,97 j. vs. 0,94 ± 1,02 j.; p = 0,008). Grupy nie różniły się w zakresie zapotrzebowania na płytki krwi i liczby zgonów szpitalnych oraz częstości reoperacji z powodu krwawienia. Nie wykazano również istotnych statystycznie różnic między grupami w występowaniu rzeczywistego i prawdopodobnego zawału serca (odpowiednio p = 0,24 i p = 0,56) oraz śmiertelności wewnątrzszpitalnej. Wnioski: Stosowanie kwasu acetylosalicylowego przed operacją zwiększało krwawienie pooperacyjne i konieczność przetoczeń masy erytrocytarnej, nie wpływając na liczbę zgonów, częstość reoperacji i występowanie okołooperacyjnego zawału serca. Zaleca się odstawienie kwasu acetylosalicylowego na 7 dni przed operacją (Folia Cardiologica Excerpta 2008; 3: 35–39

Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND Regular, detailed reporting on population health by underlying cause of death is fundamental for public health decision making. Cause-specific estimates of mortality and the subsequent effects on life expectancy worldwide are valuable metrics to gauge progress in reducing mortality rates. These estimates are particularly important following large-scale mortality spikes, such as the COVID-19 pandemic. When systematically analysed, mortality rates and life expectancy allow comparisons of the consequences of causes of death globally and over time, providing a nuanced understanding of the effect of these causes on global populations. METHODS The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 cause-of-death analysis estimated mortality and years of life lost (YLLs) from 288 causes of death by age-sex-location-year in 204 countries and territories and 811 subnational locations for each year from 1990 until 2021. The analysis used 56 604 data sources, including data from vital registration and verbal autopsy as well as surveys, censuses, surveillance systems, and cancer registries, among others. As with previous GBD rounds, cause-specific death rates for most causes were estimated using the Cause of Death Ensemble model-a modelling tool developed for GBD to assess the out-of-sample predictive validity of different statistical models and covariate permutations and combine those results to produce cause-specific mortality estimates-with alternative strategies adapted to model causes with insufficient data, substantial changes in reporting over the study period, or unusual epidemiology. YLLs were computed as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 1000-draw distribution for each metric. We decomposed life expectancy by cause of death, location, and year to show cause-specific effects on life expectancy from 1990 to 2021. We also used the coefficient of variation and the fraction of population affected by 90% of deaths to highlight concentrations of mortality. Findings are reported in counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2021 include the expansion of under-5-years age group to include four new age groups, enhanced methods to account for stochastic variation of sparse data, and the inclusion of COVID-19 and other pandemic-related mortality-which includes excess mortality associated with the pandemic, excluding COVID-19, lower respiratory infections, measles, malaria, and pertussis. For this analysis, 199 new country-years of vital registration cause-of-death data, 5 country-years of surveillance data, 21 country-years of verbal autopsy data, and 94 country-years of other data types were added to those used in previous GBD rounds. FINDINGS The leading causes of age-standardised deaths globally were the same in 2019 as they were in 1990; in descending order, these were, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and lower respiratory infections. In 2021, however, COVID-19 replaced stroke as the second-leading age-standardised cause of death, with 94·0 deaths (95% UI 89·2-100·0) per 100 000 population. The COVID-19 pandemic shifted the rankings of the leading five causes, lowering stroke to the third-leading and chronic obstructive pulmonary disease to the fourth-leading position. In 2021, the highest age-standardised death rates from COVID-19 occurred in sub-Saharan Africa (271·0 deaths [250·1-290·7] per 100 000 population) and Latin America and the Caribbean (195·4 deaths [182·1-211·4] per 100 000 population). The lowest age-standardised death rates from COVID-19 were in the high-income super-region (48·1 deaths [47·4-48·8] per 100 000 population) and southeast Asia, east Asia, and Oceania (23·2 deaths [16·3-37·2] per 100 000 population). Globally, life expectancy steadily improved between 1990 and 2019 for 18 of the 22 investigated causes. Decomposition of global and regional life expectancy showed the positive effect that reductions in deaths from enteric infections, lower respiratory infections, stroke, and neonatal deaths, among others have contributed to improved survival over the study period. However, a net reduction of 1·6 years occurred in global life expectancy between 2019 and 2021, primarily due to increased death rates from COVID-19 and other pandemic-related mortality. Life expectancy was highly variable between super-regions over the study period, with southeast Asia, east Asia, and Oceania gaining 8·3 years (6·7-9·9) overall, while having the smallest reduction in life expectancy due to COVID-19 (0·4 years). The largest reduction in life expectancy due to COVID-19 occurred in Latin America and the Caribbean (3·6 years). Additionally, 53 of the 288 causes of death were highly concentrated in locations with less than 50% of the global population as of 2021, and these causes of death became progressively more concentrated since 1990, when only 44 causes showed this pattern. The concentration phenomenon is discussed heuristically with respect to enteric and lower respiratory infections, malaria, HIV/AIDS, neonatal disorders, tuberculosis, and measles. INTERPRETATION Long-standing gains in life expectancy and reductions in many of the leading causes of death have been disrupted by the COVID-19 pandemic, the adverse effects of which were spread unevenly among populations. Despite the pandemic, there has been continued progress in combatting several notable causes of death, leading to improved global life expectancy over the study period. Each of the seven GBD super-regions showed an overall improvement from 1990 and 2021, obscuring the negative effect in the years of the pandemic. Additionally, our findings regarding regional variation in causes of death driving increases in life expectancy hold clear policy utility. Analyses of shifting mortality trends reveal that several causes, once widespread globally, are now increasingly concentrated geographically. These changes in mortality concentration, alongside further investigation of changing risks, interventions, and relevant policy, present an important opportunity to deepen our understanding of mortality-reduction strategies. Examining patterns in mortality concentration might reveal areas where successful public health interventions have been implemented. Translating these successes to locations where certain causes of death remain entrenched can inform policies that work to improve life expectancy for people everywhere. FUNDING Bill & Melinda Gates Foundation