Algorithm for the management of patients with ventricular arrhythmias recorded during wakefulness

Aim. To study the clinical and electrocardiographic characteristics of exerciseinduced arrhythmias and develop an algorithm for managing patients with exerciseinduced ventricular arrhythmias (VA).Material and methods. For the period from 2015 to 2019 203 patients with VA during periods of wakefulness were selected from the database of patients who performed Holter monitoring; 167 of them were selected, who underwent a treadmill test (TT) according to the standard Bruce protocol. During TT, the qualitative and quantitative characteristics of VA were assessed. Further examination and treatment were carried out according to the proposed algorithm.Results. In 80 patients (48% of all those who underwent TT), regardless of VA presence in the pretest, arrhythmias had an exercise nature and appeared and/or progressed during exercise. These patients were included in the present study to assess the causal relationship of VA with any disease. Following the algorithm, coronary artery disease was verified in 15 people, stage I-II hypertension — in 25, and minor heart defects — in 21. Of the remaining 19 patients without association of exercise-induced VA with any disease during the initial examination, 5 patients were diagnosed with arrhythmogenic cardiomyopathy/right ventricular dysplasia during prospective follow-up. In the remaining 14, VAs were considered idiopathic.Conclusion. The presented algorithm can accelerate both the search for the causes of exercise-induced VA and the choice of personalized treatment

A Case of Successful Medical Treatment of Ventricular Tachycardia in a Patient With Ischemic Heart Disease and Heart Failure

The pathogenetic mechanisms of arrhythmias, including  high-grade ventricular  arrhythmias (including non-sustained ventricular  tachycardia),  in patients with coronary  heart disease may be different. Therefore, the characteristics  of ventricular arrhythmias must be considered  based on the totality of data, taking  into account all the available features. The importance  of a personalized approach  to the management of a patient with coronary  heart disease who had extensive myocardial  infarction 18.5 years ago,  followed  by mammary  coronary  artery bypass  grafting, aneurysmectomy and the development of heart failure with a low ejection fraction, in whom ventricular arrhythmias occurred against the background of a stable course of coronary disease , but after emotional stress, is reflected in this work. An extended examination, as well as a detailed study of the nature of ventricular arrhythmias, made it possible  to determine  the main provoking factor and select an individualized pathogenetic treatment with a good  antiarrhythmic result that persists for several years of observation.  Conducting mental tests and psychological questioning can be recommended for patients with coronary  heart disease  and  chronic  heart failure as an additional  examination to assess  the contribution  of the psycho-emotional factor  to arrhythmogenesis after excluding the ischemic and sympathetic  nature of ventricular ectopia. It is incorrect to consider that all ventricular arrhythmias  in patients with coronary heart disease are ischemic in nature, and in some clinical situations this statement is even erroneous

Cause of Death and Predictors of All-Cause Mortality in Anticoagulated Patients With Nonvalvular Atrial Fibrillation : Data From ROCKET AF

M. Kaste on työryhmän ROCKET AF Steering Comm jäsen.Background-Atrial fibrillation is associated with higher mortality. Identification of causes of death and contemporary risk factors for all-cause mortality may guide interventions. Methods and Results-In the Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF) study, patients with nonvalvular atrial fibrillation were randomized to rivaroxaban or dose-adjusted warfarin. Cox proportional hazards regression with backward elimination identified factors at randomization that were independently associated with all-cause mortality in the 14 171 participants in the intention-to-treat population. The median age was 73 years, and the mean CHADS(2) score was 3.5. Over 1.9 years of median follow-up, 1214 (8.6%) patients died. Kaplan-Meier mortality rates were 4.2% at 1 year and 8.9% at 2 years. The majority of classified deaths (1081) were cardiovascular (72%), whereas only 6% were nonhemorrhagic stroke or systemic embolism. No significant difference in all-cause mortality was observed between the rivaroxaban and warfarin arms (P=0.15). Heart failure (hazard ratio 1.51, 95% CI 1.33-1.70, P= 75 years (hazard ratio 1.69, 95% CI 1.51-1.90, P Conclusions-In a large population of patients anticoagulated for nonvalvular atrial fibrillation, approximate to 7 in 10 deaths were cardiovascular, whereasPeer reviewe

CLINICAL AND ELECTROCARDIOGRAPHIC ANALYSIS OF ACCELERATED IDIOVENTRICULAR RHYTHMS

The aim of the work was to analyze 209 cases of accelerated idioventricular rhythms, after that we concluded with 4 types of an “interaction” of sinus node and ectopic pacemaker. The article is illustrated with 11 ECGs, among those rare phenomenon following the arrhythmia, and specifics of differential diagnosis

Ventricular arrhythmia: A 10-year path to diagnosis

Establishing the cause of newly diagnosed ventricular arrhythmia remains an urgent task that requires an individual strategy for the diagnosis and prevention of serious complications. The article describes the stages and difficulties of establishing a differential diagnosis in the detection of ventricular arrhythmia in a patient who has been observed for 20 years

SEARCH OF THE STRESS INDUSED VENTRICULAR TACHICARDIA REASONS — THE METABOLIC THERAPY OPPORTUNITIES

A clinical case of a 56-year-old man is presented in which only ventricular tachycardia without clinical and ECG criteria of myocardial ischemia is recorded on the exercise test. The ventricular tachycardia was the only reason for stopping the test. This clinical case demonstrates all the difficulties in determining the genesis of ventricular arrhythmias induced by exercise. The purpose of the work was to show all the difficulties in determining the genesis of exercise-induced ventricular arrhythmia. The literature references related to the exercise-induced ventricular arrhythmia differentiation is rather poor. It is only known that if a patient develops and progresses ventricular arrhythmia, a tredmill test is considered questionable. Exerciseinduced ventricular arrhythmias especially ventricular tachycardia, are the most dangerous. Therefore, additional diagnostic methods were used to reveal the main disease as the background of ventricular tachycardia. Results of pharmacological test with nitroglycerine were the indication of the ischemic origin of ventricular tachycardia. Coronary angiography did not reveal coronary artery stenoses. Positron emission tomography revealed coronary microcirculation disturbance after which a decision about metabolic therapy with Mexicor was made. The correct choice of the drug (Mеxisor) was confirmed by the results of control studies — improvement of metabolism and antiarrhythmic effect. The article concludes that the choice of the treatment exercise-induced ventricular arrhythmia in patients with stable coronary artery disease should be individual and pathogenetic

ACCELERATED IDIOVENTRICULAR RHYTHM: HISTORY OF RESEARCH

Accelerated idioventricular rhythm is a ventricular rhythm consisting of three or more consequent mono- or polymorphic complexes. It might be registered in patients with structural heart diseases, rarer in completely normal heart, might be found in sportsmen and children. Idioventricular rhythm might be seen in myocardial infarction, in reperfusion and under medications influence.The article focuses on the literature data that led to identification of this important ventricular arrhythmia

Choice of ventricular arrhythmia therapy in coronary artery disease

Aim. To study trigger factors of ventricular arrhythmias (VA) in patients with stable coronary artery disease (CAD) and evaluate the effectiveness of individualized treatment.Material and methods. The study included 155 patients with CAD aged 36 to 83 years (61,5±9,8 years); 73,5% were men with frequent single and coupled ventricular ectopic complexes (VEC) and the left ventricle ejection fraction (LVEF) of 56,4±8,5%. Exclusion criteria were class IV angina, acute coronary syndrome, LV aneurysm, LVEF ≤45%. Treatment and examination of patients was carried out according to the algorithm we proposed in 2017 for managing patients with CAD and high-grade VA.Results. Depending on association between ventricular ectopy and transient myocardial ischemia (TMI) during an exercise tolerance test, patients were divided into 2 groups. Group I included 84 patients (54,2%) with ischemic VA. According to noninvasive topical diagnostics, the arrhythmogenic focus in all patients with ischemic VA was located in the left ventricle. Group II consisted of 71 (45,8%) patients with nonischemic VA, and two subgroups were distinguished depending on presence/absence of TMI: 2A and 2B. During the exercise test, several types of VA were identified.Myocardial revascularization (MR) was indicated in 84,5% of cases in both groups. Six months after MR in group I, the antiarrhythmic effect (AAE) was observed in 55 (77,5%) patients. In group IIA, AAE was significantly lower at 61,7% (p=0,048). We also revealed anxiety in 15 patients of group II. Anxiolytic therapy showed AAE in 75% of group IIA patients and in 63,6% of group IIB patients. Nine patients of group II were referred to radiofrequency ablation of VA with a positive effect of 55,5%. Antiarrhythmic drugs (amiodarone, sotalol) were taken by 5 people of group I.Conclusion. The search for trigger factors and their elimination provides a high AAE for VA therapy in patients with CAD

ANTIARRHYTHMIC ACTION OF CARDIOCYTOPROTECTORS IN TREATMENT OF ISCHEMIC HEART DISEASE WITH VENTRICULAR ARRHYTHMIAS

It is known that ventricular dysrhythmias in patients  with ischemic heart  diasease can be of various origin. Hence selection of antiarrhythmic tactics in such patients should be individual and pathogenetically proved.Aim. To check  antiarrhythmic  abilities of metabolic  therapy  for ischemic  heart disease  combined   with variety  of  ventricular  arrhythmias  of  III-IV  grades   (by Myerburg RJ).Material and methods. for 42 patients with ventricular arrhythmias of high grade and stable ischemic heart disease with saved ejection fraction of the left ventricle, before and after treatment were done the following: Holter monitoring, treadmill test, and  as  indicated  — coronary  arteriography,  radionuclide  methods  of perfusion assessment and metabolism  of myocardium, non-invasive topical diagnostics. To individually selected antianginal and antihypertension  therapy  for all patients  was added  ethylmethylhydroxypyridine succinate  (es) in daily dosage 300 mg, for 2 months.Results. During the study, according  to relationship of ventricular arrhythmia with transient ischemia, patients were selected to 2 groups. In the 1 group, with ischemic arrhythmias,  in 2 months  after  start  of es, there  was significant antiarrhythmic effect: number of single ventricular premature beats decreased by 55%, couplets — by 90%,  and  episodes of non-sustained ventricular tachicardia  — by 100%.  At control positrone-emisson tomography  in the areas  of myocardial ischemia  there was significant increase of 11C-buthirate  sodium excretion,  which witness on the increase of efficacy of energetic metabolism in zones of hypoxia. In the II group, with non-ischemic  ventricular arrhythmias — antiarrhythmic effect was not achieved. Conclusion. es should be regarded as pathogenetic chain in complex antiarrhythmic treatment of ventricular arrhythmias in patients with stable ischemic heart disease

THE ROLE OF CORONARY CIRCULATION RESTORATION AND CARDIOMYOCYTE METABOLISM OPTIMISATION IN THE MANAGEMENT OF HIGH-GRADE ISCHEMIC VENTRICULAR ARRHYTHMIA

This study was aimed at the assessment of antiarrhythmic (AA) effectiveness of myocardial revascularisation (MR), as well as the evaluation of the Mexicor (M) role in the complex management of coronary heart disease (CHD) patients with high-grade ischemic ventricular arrhythmia (VA). In total, 34 patients underwent MR, based on the clinical, instrumental, and angiographic indications. Another 20 patients, who refused MR, or did not have clinical and angiographic indications for it, received conservative treatment, with an addition of M (300 mg/d). AA effectiveness of MR and M was assessed during Holter ECG monitoring, stress tests, and radionuclide examination. MR effectiveness, regardless of the intervention type, was maximal in the early post-surgery period (79,4%) and decreased later, reaching 55,8% after 12 months. In patients who did not undergo MR, M therapy demonstrated good AA effectiveness (75-100%). Therefore, the restoration of coronary circulation and myocardial metabolism agrees with the principles of complex etiopathogenetic treatment of ischemic VA