Prevalence of gastroesophageal reflux disorder in arrhythmic patients and adjunctive effects of proton pump inhibitors on comorbid atrial fibrillation

Background: Although the coexistence of atrial fibrillation (AF) and gastroesophageal reflux disorder (GERD) has been reported, the prevalence of GERD in arrhythmic patients remains unknown. This study aimed to investigate the relationship between GERD and several kinds of arrhythmia, and the therapeutic effects of proton pump inhibitors (PPI) on AF.Methods: In Study 1, patients with various kinds of arrhythmia (n=147) including AF (n=98) were administered a GERD-specific questionnaire (F-scale). In Study 2, patients with AF and GERD (n=27) responded to an AF-specific questionnaire (AFQLQ) before and after the additive PPI therapy to explore the effects of PPI on comorbid AF. In Study 3, device memory was assessed as it is related to PPI administration in pacemaker patients with GERD and AF (n=5) to study the effects of PPI on device-documented AF.Results: Left atrial (LA) size and F-scale scores in AF patients were the largest among the arrhythmic patients in Study 1. Logistic regression analysis showed no independent determinants of GERD. F-scale scores and AFQLQ scores showed temporal and partial correlations and significant improvement after starting PPI in Study 2. However, device interrogation confirmed limited AF improvement by starting PPI in Study 3.Conclusions: GERD is prevalent in AF patients. LA size is not an independent determinant of GERD. Symptoms of AF were improved, whereas device-documented paroxysms of AF were not ameliorated by PPI administration. A large-scale prospective study is required to conclude the efficacy of PPI on the comorbid AF

Intracoronary acetylcholine application as a possible probe inducing J waves in patients with early repolarization syndrome

Acetylcholine is widely used for a diagnostic provocation test of coronary spasm in patients with vasospastic angina. Acetylcholine usually induces coronary vasodilatation mediated by muscarinic receptor activation, but sometimes it evokes vasoconstriction of coronary arteries where the endothelium is damaged. Early repolarization syndrome is characterized by a J wave observed at the end of the QRS complex in a surface electrocardiogram. The J wave is attributed to the transmural voltage gradient at the early repolarization phase across the ventricular wall, which stems mainly from prominent transient outward current in the epicardium, but not in the endocardium. Transient high-dose application of acetylcholine into the epicardial coronary arteries provides a unique opportunity to augment net outward current, selectively, in the ventricular epicardium and unmask the J wave, irrespective of the cardiac ischemia based on coronary spasm. Acetylcholine augments cardiac membrane potassium conductance by enhancing acetylcholine-activated potassium current directly and by activating adenosine triphosphate-sensitive potassium current, in addition to the reduced sodium and calcium currents in the setting of severe ischemia due to vasospasm. However, the role of acetylcholine as an arrhythmogenic probe of the J wave induction in patients with suspected early repolarization syndrome warrants future prospective study

Complex regional pain syndrome induced by pacemaker implantation for sick sinus syndrome

A 53-year-old woman reported burning pain, muscle weakness, and dysesthesia of the left arm 2 months after permanent pacemaker insertion in the ipsilateral side for the treatment of sick sinus syndrome. Complex regional pain syndrome (CRPS) induced by pacemaker implantation was diagnosed. In 2017, her pulse generator became exhausted and was exchanged carefully to avoid exacerbation of CRPS, under the application of local anesthesia and premedication. Six months later, the patient's grip strength in her left hand remained lower relative to that in her right hand. Although rare, the presence of CRPS following device implantation should be remembered. Keywords: Complex regional pain syndrome, Pain control, Permanent pacemaker implantatio

Effect of renin–angiotensin system inhibitors in patients with cancer treated with anti-VEGF therapy

Background Cancer treatment with vascular endothelial growth factor signalling pathway (VSP) inhibitors frequently causes hypertension. Although previous reports suggested that the antihypertensive drug renin–angiotensin system inhibitor (RASI) may have a positive synergistic effect with VSP inhibitors, the actual impact on clinical outcomes is unknown.Objectives The study aims to clarify whether RASIs exhibit clinical benefits for patients with cancer with hypertension.Method From the Longevity Improvement and Fair Evidence Study database, comprising Japanese claims data between 2016 and 2020, we reviewed 2380 patients treated with VSP inhibitors who received antihypertensive treatment during cancer therapy. The patients were classified into two groups: with-RASI (n=883) and without-RASI (n=1497). In addition, 1803 of these patients treated for hypertension with RASI-only (n=707) or calcium channel blocker-only (n=1096) were also reviewed. The time-to-treatment failure (TTF), the interval from initiation of chemotherapy to its discontinuation, was applied as the primary endpoint.Results The median TTFs were 167 (60–382) days in the with-RASI group and 161 (63–377) days in the without-RASI group (p=0.587). All models, including Cox proportional hazard models and multiple propensity score models, did not reveal the superiority of with-RASI treatment. In the propensity score matching model, the HR for treatment with-RASI compared with that for without-RASI was 0.96 (95% CI 0.86 to 1.06, p=0.386). In addition, the TTFs of RASI-only were not superior to calcium channel blocker-only (p=0.584).Conclusions RASIs for hypertension do not benefit clinical outcomes during cancer therapy with VSP inhibitors. In addition, RASIs and calcium channel blockers have comparable clinical efficacy as first-line antihypertensive