Antiarrhythmic potential of aldosterone antagonists in atrial fibrillation

Upstream therapy is the promising issue in the treatment of atrial fibrillation (AF) especially in patients with arterial hypertension and heart failure. The possible beneficial effects of renin– –angiotensin–aldosterone system blockade with ACE-inhibitors and angiotensin receptor antagonists in AF prevention have been demonstrated in experimental and clinical studies. There is growing mass of evidence, from both theoretical and experimental research studies, to suggest that upstream therapy using spironolactone or eplerenone may reduce the deleterious effect of excess aldosterone secretion and further modify the environment of AF including inhibition of atrial muscle fibrosis. It refers to patients with different forms of AF, including chronic AF. Aldosterone antagonists treatment may be a simple and valuable additional option in low-risk, hypertensive and heart failure patients in primary and secondary prevention of refractory paroxysmal and persistent AF

Searching for the optimal strategy for the diagnosis of stable coronary artery disease. Cost-effectiveness of the new algorithm

Background: Coronary arteriography is still widely accepted as a gold standard for the diagnosis of coronary artery disease (CAD), despite emerging methods such as multi-slice computed tomography. None of the presently available non-invasive diagnostic tests is perfect. The aim of the article was to make a comparison of the value and limitations of history, resting electrocardiography, exercise electrocardiography and dobutamine stress echocardiography in the diagnosis of CAD, and to create a simple algorithm for non-invasive diagnosis of CAD to optimize indications for coronarography. Methods: Prospective, multicentre trial. The collection of clinical data, resting electrocardiography, exercise treadmill electrocardiography, dobutamine stress echocardiography and catheterization data was performed on 600 patients with chest pain regarded as angina pectoris and no previous history of myocardial infarction. CAD was defined as &#8805; 50% narrowing of at least one major vessel. Final results were obtained in 551 patients, 65% male. The studied population was divided into three groups on the basis of pre-test likelihood of CAD: 1. high (> 70%), 2. intermediate (10-70%) and 3. low (< 10%). Results: Sensitivity and specificity of resting electrocardiography, exercise treadmill electrocardiography, dobutamine stress echocardiography and created algorithm were calculated: 23%, 87% and 93%, 21% and 85%, 69% and 96%, 44%, respectively. The prevalence of CAD in the studied population was 61%. Conclusions: The diagnostic value of resting electrocardiography in stable CAD is low. Dobutamine echocardiography has comparable sensitivity but significantly higher specificity than exercise treadmill test. Our algorithm is simple, reasonably cost-effective and may be useful in decision making. When the probability of CAD is high, non-invasive testing is not indicated before coronary angiography; when it is intermediate or low, a first choice test should be different in female (stress echocardiography) and male (exercise electrocardiography). (Cardiol J 2007; 14: 544-551)

The right ventricle in patients with chronic heart failure and atrial fibrillation

Under normal conditions function of the right ventricle (RV) is determined by the heart rhythm, RV filling time, RV systolic synchrony and interdependence between both ventricles. Failure ofthe left ventricle (LV) can lead to RV failure. Impaired function of the RV significantly worsensthe prognosis in patients after myocardial infarction and with LV failure. Permanent atrialfibrillation (AF) is one of the most common arrhythmia in patients with depressed RV function. Frequent coexistence of chronic heart failure (CHF) and AF causes overlapping of the arrhythmiaand RV dysfunction in the setting of CHF. They may lead to hemodynamic compromiseand worsen prognosis in patients with chronic RV failure of various etiologies. RV structureand function can be assessed in 2D, 3D echocardiography, cardiac magnetic resonance imagingand computed tomography

High defibrillation threshold in patients with implantable cardioverter-defibrillator. How to solve the problem, single-center experience

Standard implantable cardioverter-defibrillator with transvenous leads systems have proven to be effective in terminating ventricular tachyarrhythmias in most patients (more then 90%) with sufficient safety margin, i.e. difference between maximal output energy of the ICD and defibrillation threshold. However in some clinical situation it is not possible, energy requirement is higher than normal, it is called high defibrillation threshold. We report clinical data of 3 patients with high defibrillation threshold among 415 ICD&#8217;s implanted in our institution (cases of ischaemic cardiomyopathy, dilated cardiomyopathy and hypertrophic cardiomyopathy are presented). We summarize our experience, therapeutic options and literature review investigating factors which influence defibrillation threshold: related to underlying cardiac disease, therapy (drugs interactions) and ICD system( lead and pulse generator type)

ACE inhibitor therapy: Possible effective prevention of new-onset atrial fibrillation following cardiac surgery

Background: Atrial fibrillation (AF) is a common complication after coronary artery bypass grafting (CABG). The aims of the study were to assess possible predictors and identify modes of prevention of new-onset AF following coronary surgery. Methods: Retrospective clinical and statistical analysis was made of the medical records of 217 patients who had undergone coronary surgery. Results: AF occurred in 28% (61/217) of the patients. In univariate analysis the age of the patients with AF was higher (p = 0.0033), they had a longer history of coronary disease (p = 0.0417) and more had > 3 grafts (p < 0.05). Low ejection fraction (< 40%) was also a risk factor of arrhythmia (p < 0.0001). In multivariate regression analysis two independent predictors of AF were identified: no ACE inhibitor treatment before surgery (p = 0.0005) and age > 60 years (p < 0.01). Patients with AF had a higher mean heart rate after the procedure: 115 &#177; 34 vs. 78 &#177; 21/min (p < 0.0005). Patients treated with ACE inhibitors before and after surgery had a lower incidence of AF than non-treated patients: 8% vs. 48% (p < 0.0001) and 4% vs. 61%, p < 0.0001) respectively. Beta-blocker treatment before and after surgery resulted in a lower incidence of AF: at 23% vs. 75% (p < 0.001) and 19% vs. 96% (p < 0.0001), respectively. Conclusions: No ACE inhibitor therapy before surgery, advanced age, low ejection fraction, high post-procedure heart rate, duration of coronary disease and the number of grafts (corresponding to the length of the procedure) were found to be strong probable predictors of AF following cardiac surgery. ACE inhibitor therapy may be effective in the prevention of newonset AF. Treatment based on individual variables is crucial for proper treatment and to diminish the risk of arrhythmia. (Cardiol J 2007; 14: 274-280

The use of 1.5T magnetic resonance imaging for therapeutic decisions in patients with cardiac implantable electronic devices and significant neurological, neurosurgical and neuro-oncology diagnostic indications

Between September 2009 and May 2014 the classification of 36 patients with cardiac implantable electronic devices (CIEDs) in terms of the feasibility of MRI scanning due to strong clinical indications was carried out. Finally MRI examinations were performed in 20 patients, of whom 27 studies were conducted and a total number of 35 anatomical regions were scanned. Neurological, neurosurgical and neuro-oncology indications for MRI were reported in 19 patients (95%) in whom 26 MRI studies (96.3%) were performed, and 34 anatomical regions (97.1%) were scanned. One patient had indications for MRI in the field of cardiology. Medical information obtained from 27 MRI studies allowed decisions to be made regarding the treatment in all patients. After 8 studies (29.6%), patients were classified into 9 different neurosurgical procedures. In the case of the remaining 19 studies (70.4%), there were no indications for surgical treatment and the decisions to implement conservative treatment were made. There were no complications related to the implanted CIEDs observed: neither immediate nor in the follow-up. Conclusions (1)Magnetic resonance imaging studies in patients with non-MRI-conditional CIEDs in the vast majority are performed because of significant neurological, neurosurgical and neuro-oncology clinical indications.(2)Careful determination of the indications for MRI in each case allows the data necessary to be obtained to make definitive treatment decisions.(3)The adherence to examination protocol and device controlling procedures after MRI allows a very high safety profile of the method to be achieved

Arrhythmogenic focus localization in patients with right outflow tract ventricular arrhythmias

Background: Vast majority of ventricular arrhythmias in patients (pts) without structural heart disease (NHVA) originate from the right ventricular outflow tract (RVOT). Premature ventricular contractions (PVC) and ventricular tachycardia (VT) ECG morphology are proposed to localize the site of radiofrequency ablation (RFA). An ECG algorithm to localize the arrhythmogenic focus in RVOT was designed and verified in a prospective study. Methods: Analysis of ECG morphology of spontaneous PVC and VT was performed in 30 pts (25 women), mean age 42 &plusmn; 10, after successful RFA of arrhythmogenic focus (AFo) in RVOT (PVC in 11 pts, VT in 5 pts, PVC + VT in 14 pts). In the first step ECG data and fluoroscopic RVOT sites of successful RFA were combined to gain the characteristic QRS morphology patterns for exact sites of successful ablation (first 16 pts). This own algorithm was used to recognize AFo in the following 14 pts. Results: First step: RVOT in RAO 30° view was divided into 9 zones: 3 vertical (1, 2, 3) and 3 horizontal (superior, intermediate and inferior). Q, R and S waves < 0.5 mV in 12-lead ECG were coded as q, r, s and waves &#8805; 0.5 mV as Q, R, S. Vertical zones: zone 1 (RVOT postero-lateral part): r in lead I; zone 3 (RVOT anterior wall): QS/qs in lead I. Other QRS morphologies in lead I: zone 2. Horizontal zones: superior - transition from QS wave or r < S in V1 into R > s in lead V4, intermediate - R = S or r = s in V4, inferior - transition from qs/QS or r < S in V1&#8211;V4 into r, R in V6. Second step. Concordant ECG locations were predicted by two independent cardiologists in 14 pts. Concordant AFo locations (ECG and fluoroscopic) were achieved: in all 14 pts in horizontal zones and in 13 pts in vertical zones. Overall (30 pts) no AFo discordances were noted in horizontal zones. In vertical zones AFo location was concordant in 28 pts (93.3%). Conclusions: Our data show that simple ECG algorithm based on spontaneous arrhythmia morphology precisely localizes the arrhythmogenic focus in RVOT. This analysis applied before RFA may shorten and simplify ablation procedure in patients with RVOT arrhythmia

Post-procedural TIMI flow grade 2 is not associated with improved prognosis in patients with non-ST-segment elevation myocardial infarction undergoing percutaneous coronary revascularization (PL-ACS registry)

Background: The impact of final Thrombolysis in Myocardial Infarction (TIMI) flow in the infarct-related artery (IRA) on outcomes in non-ST-segment elevation myocardial infarc­tion (NSTEMI) patients treated with percutaneous coronary intervention (PCI) is unknown. This study aimed to evaluate the impact of post-procedural TIMI flow in IRA on outcomes in NSTEMI patients undergoing percutaneous coronary revascularization. Methods: We analyzed 2,767 patients with first NSTEMI from the Polish Registry of Acute Coronary Syndromes (PL-ACS) who underwent PCI. The patients were divided according to post-procedural culprit vessel TIMI (0–1: 90, 3.26%; 2: 61, 2.20%; 3: 2,616, 94.54%). Results: The following mortality values were obtained in TIMI 0–1, 2, and 3 groups, respec­tively: in-hospital, 12.22%, 13.11%, 1.72% (p &lt; 0.0001); 1-month, 13.33%, 13.11%, 3.44% (p &lt; 0.0001); 12-month, 15.56%, 16.39%, 6.50% (p &lt; 0.0001); 36-month, 25.56%, 21.31%, 13.91% (p = 0.0007). Mortality rates in patients with final TIMI 0–1 and 2 were not signifi­cantly different. Optimal TIMI 3 was independently associated with baseline TIMI 2–3 (OR ± ± 95% CI: 7.070 [4.35–11.82]), p &lt; 0.0001; higher ejection fraction (1.30 [1.03–1.63]), p = 0.0038; and family history of coronary artery disease (2.83 [1.17–8.11]), p = 0.0294. Type C lesion, previous heart failure, and PCI without stenting independently predicted suboptimal TIMI 0–2. Conclusions: Only achieving final TIMI 3 in IRA improves outcomes in NSTEMI patients treated with percutaneous coronary revascularization. The mortality rate of near-normal TIMI 2 is comparable to that of TIMI 0–1 after PCI.