Do Elderly Patients with Heart Failure and Reduced Ejection Fraction Benefit from Pharmacological Strategies for Prevention of Arrhythmic Events?

Background Heart failure constitutes one of the leading causes of morbidity and mortality in Western countries, in which it is also the leading cause of hospitalization in elderly patients. The pharmacological therapy of patients with heart failure with reduced ejection fraction (HFrEF) has greatly improved during the last years. Summary The quadruple therapy (sacubitril/valsartan, beta-blockers, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter 2 inhibitors) is nowadays the cornerstone of medical treatment since it associates lower risk of heart failure hospitalizations and mortality (also of arrhythmic origin). Cardiac arrhythmias, including sudden cardiac death, are common in patients with HFrEF, entailing worse prognosis. Previous studies addressing the role of blocking the renin-angiotensin-aldosterone system and beta-adrenergic receptors in HFrEF have suggested different beneficial effects on arrhythmia mechanisms. Therefore, the lower mortality associated with the use of the four pillars of HFrEF therapy depends, in part, on lower sudden (mostly arrhythmic) cardiac death. Key Messages In this review, we highlight and assess the role of the four pharmacological groups that constitute the central axis of the medical treatment of patients with HFrEF in clinical prognosis and prevention of arrhythmic events, with special focus on the elderly patient, since evidence supports most benefits provided are irrespective of age, but elderly HF patients receive less frequently guideline recommended medical treatment.12 página

Structural remodeling and rotational activity in persistent/long-lasting atrial fibrillation: gender-effect differences and impact on post-ablation outcome

Background: Structural and post-ablation gender differences are reported in atrial fibrillation (AF). We analyzed the gender differences in structural remodeling and AF mechanisms in patients with persistent/long-lasting AF who underwent wide area circumferential pulmonary vein isolation (WACPVI). Materials and Methods: Ultra-high-density mapping was used to study atrial remodeling and AF drivers in 85 consecutive patients. Focal and rotational activity (RAc) were identified with the CartoFinder system and activation sequence analysis. The impact of RAc location on post-ablation outcomes was analyzed. Results: This study included 64 men and 21 women. RAc was detected in 73.4% of men and 38.1% of women (p = 0.003). RAc patients had higher left atrium (LA) voltage (0.64 ± 0.3 vs. 0.50 ± 0.2 mV; p = 0.01), RAc sites had higher voltage than non-RAc sites 0.77 ± 0.46 vs. 0.53 ± 0.37 mV (p < 0.001). Women had lower LA voltage than men (0.42 vs. 0.64 mV; p < 0.001), including pulmonary vein (PV) antra (0.16 vs. 0.30 mV; p < 0.001) and posterior wall (0.34 vs. 0.51 mV; p < 0.001). RAc in the posterior atrium was recorded in few women (23.8 vs. 54.7% in men; p = 0.014). AF recurrence rate was higher in patients with RAc outside WACPVI than those with all RAc inside WACPVI or no RAc (63.4 vs. 11.1 and 31.0%; p = 0.008 and p = 0.01). Comparison of selected patients using propensity score matching confirmed lower atrial voltage (0.4 ± 0.2 vs. 0.7 ± 0.3 mV; p = 0.007) and less RAc (38 vs. 75%; p = 0.02) in women. Conclusion: Women have shown more advanced structural remodeling at ablation, which is associated with a lower incidence of RAc (usually located outside the WACPVI). These findings could explain post-ablation gender differences.This study was supported by the Instituto de Salud Carlos III, Madrid, Spain (PI18/01895 and DTS21/00064), Red de Terapia Celular from the Instituto de Salud Carlos III, Madrid, Spain (RD16/0011/0029), Ricors "Red de Investigación Cooperativa Orientada a Resultados en Salud" RICORS TERAV (RD21/0017/0002), and the Sección del Ritmo de la Sociedad Española de Cardiología (Grant: Beca de la Asociacion del Ritmo para formación en investigacion post-residencia en centros españoles de la Sección del Ritmo de la Sociedad Española de Cardiología), Madrid, Spain

Clinical impact of defibrillation testing at the time of implantable cardioverter-defibrillator insertion

Background: Ventricular fibrillation is routinely induced during implantable cardioverter- -defibrillator insertion to assess defibrillator performance, but this strategy is experiencing a progressive decline. We aimed to assess the efficacy of defibrillator therapies and long-term outcome in a cohort of patients that underwent defibrillator implantation with and without defibrillation testing. Methods: Retrospective observational series of consecutive patients undergoing initial defibrillator insertion or generator replacement. We registered spontaneous ventricular arrhythmias incidence and therapy efficacy, and mortality. Results: A total of 545 patients underwent defibrillator implantation (111 with and 434 without defibrillation testing). After 19 (range 9–31) months of follow-up, the death rate per observation year (4% vs. 4%; p = 0.91) and the rate of patients with defibrillator-treated ventricular arrhythmic events per observation year (with test: 10% vs. without test: 12%; p = 0.46) were similar. The generalized estimating equations-adjusted first shock probability of success in patients with test (95%; CI 88–100%) vs. without test (98%; CI 96–100%; p = 0.42) and the proportion of successful antitachycardia therapies (with test: 87% vs. without test: 80%; p = 0.35) were similar between groups. There was no difference in the annualized rate of failed first shock per patient and per shocked patient between groups (5% vs. 4%; p = 0.94). Conclusions: In this observational study, that included an unselected population of patients with a defibrillator, no difference was found in overall mortality, first shock efficacy and rate of failed shocks regardless of whether defibrillation testing was performed or not.Hadid, C.; Atienza, F.; Strasberg, B.; Arenal, Á.; Codner, P.; González-Torrecilla, E.; Datino, T.... (2015). Clinical impact of defibrillation testing at the time of implantable cardioverter-defibrillator insertion. Cardiology Journal. 22(3):253-259. doi:10.5603/Cj.a2014.0062S25325922

Personalized Evaluation of Atrial Complexity of Patients Undergoing Atrial Fibrillation Ablation: A Clinical Computational Study

Current clinical guidelines establish Pulmonary Vein (PV) isolation as the indicated treatment for Atrial Fibrillation (AF). However, AF can also be triggered or sustained due to atrial drivers located elsewhere in the atria. We designed a new simulation workflow based on personalized computer simulations to characterize AF complexity of patients undergoing PV ablation, validated with non-invasive electrocardiographic imaging and evaluated at one year after ablation. We included 30 patients using atrial anatomies segmented from MRI and simulated an automata model for the electrical modelling, consisting of three states (resting, excited and refractory). In total, 100 different scenarios were simulated per anatomy varying rotor number and location. The 3 states were calibrated with Koivumaki action potential, entropy maps were obtained from the electrograms and compared with ECGi for each patient to analyze PV isolation outcome. The completion of the workflow indicated that successful AF ablation occurred in patients with rotors mainly located at the PV antrum, while unsuccessful procedures presented greater number of driving sites outside the PV area. The number of rotors attached to the PV was significantly higher in patients with favorable long-term ablation outcome (1-year freedom from AF: 1.61 ± 0.21 vs. AF recurrence: 1.40 ± 0.20; p-value = 0.018). The presented workflow could improve patient stratification for PV ablation by screening the complexity of the atria

Magnetic resonance imaging based signal intensity mapping predicts appropriate therapies after prophylactic ventricular tachycardia substrate ablation in patients with previous myocardial infarction and secondary prevention implantable cardioverter-defibrillator implantation

The aim of this study was to determine the capability of ceMRI based signal intensity (SI) mapping to predict appropriate ICD therapies after PVTSA

Infarto agudo de miocardio con elevación del segmento ST en pacientes con 89 o más años: Descripción de una serie de 96 casos

Caracterizar la presentación y manejo del infarto agudo de miocardio (IAM) en pacientes muy ancianos y determinar cuál es su pro-nóstico y los factores que lo condicionan

Atrial Fibrillation Ablation Translating Basic Mechanistic Insights to the Patient

AbstractAtrial fibrillation (AF) ablation is widely performed and is progressively supplanting drug therapy. Catheter-based AF ablation modalities have evolved progressively in parallel to our understanding of underlying mechanisms. Initial attempts to mimic the surgical maze procedure, which were based on the multiple wavelet model, failed because of adverse outcomes and insufficient effectiveness. A major advance was the targeting of pulmonary veins, which is highly effective for paroxysmal AF. Active research on the underlying mechanisms continues. The main challenge is reconnection, but procedures to minimize this are being developed. Ablation procedures for persistent AF are presently limited by suboptimal success rates and long-term disease progression that causes recurrences. Basic research into the underlying mechanisms has led to promising driver mechanism-directed clinical approaches along with pathways toward the prevention of atrial remodeling. Here, we review the role of basic research in the development of presently used AF-ablation procedures and look toward future contributions in improving outcomes

Ergonovine provocative test in Caucasian patients with left ventricular apical ballooning syndrome

Of a series of 346 consecutive patients with chest pain and no significantcoronary stenosis studied whithergonovine provocative test EPT), 18 fulfilled diagnostic criteria for left ventricular apical ballooning syndrome(LVABS). EPT was negative in all these patients. On the other 328 patients, EPT was positive in 69 (21%). LVABS patients were more frequently women (94 vs. 30%), had a lower left ventricular ejection fraction (0.41 ± 0.11 vs. 0.55 ± 0.09), more troponin T level increments (83 vs. 23%), and a higher prevalence of stress situations (72 vs. 3%) than patients EPT positive.6.802 JCR (2010) Q1, 6/114 Cardiac & cardiovascular system