The dilemma of providing cardioverter/defibrillator back-up for all patients with heart failure eligible for cardiac resynchronization therapy

Cardiac resynchronization therapy (CRT) achieved by biventricular pacing (CRT-P) has been proved to improve symptoms and prognosis of patients with refractory heart failure. Sudden cardiac death is quite common among patients with symptomatic heart failure and implantable cardioverter-defibrillator (ICD) therapy has been proved to effectively reduce sudden deaths in heart failure patients. Given the results of the recently published primary prevention trials and the high incidence of sudden cardiac death among CRT-P recipients, CRT combined with backup defibrillator therapy (CRT-D) seems a logical therapeutic option in patients eligible for CRT. However, the apparent beneficial effects of such an appealing combination do not alleviate the skepticism about the unselected use of CRT-D therapy. This skepticism is largely related to the high cost of this method, to the limited availability of human and financial resources and to our inability to appropriately define the selection criteria for CRT candidates, which are expected to influence the clinicians??? decisions when confronted with the dilemma of providing CRT-D therapy for all patients eligible for CRT

Classical and Non-Classical Indications for Cardiac Resynchronization Therapy

Heart failure (HF) is a medical problem of huge socioeconomic importance, mainly due to the increasing life expectancy in our societies and the strides in the treatment of ischemic heart disease which resulted in improved prognosis of our patients. These medical and socioeconomic issues may explain why HF poses a significant financial burden on our health care systems. It is estimated that acute decompensated HF accounts for 2.9% of all emergency room visits, its prevalence is steadily increasing in epidemic proportions and in age-dependent manner, reaching an incidence of almost 10% in patients aged >65 years

Percutaneous Closure of a Large Atrial Septal Defect: A Simplified Approach

A 44-year-old female patient presented with easy fatigability, dyspnea on exertion and frequent episodes of migraine. Echocardiography revealed a large atrial septal defect (ASD) of the secundum type. This was further visualized with transesophageal echocardiography (TEE) (Figure, Panel A, arrow).The diameter of the ASD at TEE was measured at 1.93 cm. Pulmonary to systematic flow ratio (Qp/Qs) was calculated at 3.3:1, indicating a significant left-to-right shunt across the ASD. Percutaneous closure of the defect was subsequently undertaken. The diameter of the defect was measured intra-procedurally using an intracardiac balloon and it was found to be 2.6 cm (Panel B).An Amplatzer 9-ASD-032 occluder was successfully implanted percutaneously via the right femoral vein (Panel C, arrow). TEE 48 hours after implantation showed that the closure device was in proper place (Panel D, arrows) and the left-to-right shunt was abolished

Individualized Tailoring of Hypolipidemic Pharmacological Treatment

The validation of the lipid hypothesis, which pertains to the relationship between dyslipidemia and atherogenesis, has established the central role of hypolipidemic treatment in the frontline of primary and secondary prevention of coronary artery disease. However, the complexity of the lipoprotein disorders, which are usually associated with more than one biochemical abnormalities, and the availability of several hypolipidemic agents in the existing therapeutic armamentarium with combined beneficial effects of variable intensity on several lipoproteins, have stressed the need for the development and implementation of easily applicable therapeutic algorithms which will enable the individualized tailoring of hypolipidemic management with maximal efficiency and safety. One such algorithm of individualized tailoring of hypolipidemic therapy is being proposed in this brief overview

The Relation of Migraine Headaches and Interatrial Shunts

Foramen ovale plays a very important role in fetal circulation by bypassing the lungs and diverting circulation from the right to the left heart. With birth it is usually sealed; however, probe patent or incompletely sealed foramen ovale remains in approximately 25% of adults. Patent foramen ovale (PFO) acquires significance in various congenital heart diseases or other particular settings leading to a right to left shunt, and thus to paradoxical embolism. PFO has been associated with transient ischemic attacks or cryptogenic strokes and also a host of other problems, including migraine. The recognition of an association between migraine syndrome with aura and PFO appears to have come ???full circle??? over the past two decades. Epidemiologic studies have suggested a notably increased PFO prevalence in persons suffering from migraine.The prevalence of migraine headache is higher in cryptogenic stroke patients with PFO than in the general population. Studies have suggested that closure of the PFO may reduce migrainous symptoms. The relation between this association and the recognition of migraine as a risk factor for ischemic stroke in the young is unclear, though right to left passage of circulating factors has been postulated in both syndromes. Despite case series and uncontrolled studies documenting beneficial effects of PFO closure in patients with migraine, particularly those also afflicted by cryptogenic stroke, the recommendation for PFO closure in patients with migraine alone will need to await the results of ongoing randomized trials

Association of the 894G>T polymorphism in the endothelial nitric oxide synthase gene with risk of acute myocardial infarction

Background: This study was designed to investigate the association of the 894G>T polymorphism in the eNOS gene with risk of acute myocardial infarction (AMI), extent of coronary artery disease (CAD) on coronary angiography, and in-hospital mortality after AMI. Methods: We studied 1602 consecutive patients who were enrolled in the GEMIG study. The control group was comprised by 727 individuals, who were randomly selected from the general adult population. Results: The prevalence of the Asp298 variant of eNOS was not found to be significantly and independently associated with risk of AMI (RR = 1.08, 95%CI = 0.77–1.51, P = 0.663), extent of CAD on angiography (OR = 1.18, 95%CI = 0.63–2.23, P = 0.605) and in-hospital mortality (RR = 1.08, 95%CI = 0.29–4.04, P = 0.908). Conclusion: In contrast to previous reports, homozygosity for the Asp298 variant of the 894G>T polymorphism in the eNOS gene was not found to be associated with risk of AMI, extent of CAD and in-hospital mortality after AM

Primary Percutaneous Coronary Intervention in Acute ST-Elevation Myocardial Infarction: The Experience of "Evagelismos" General Hospital of Athens

BACKROUND: Primary percutaneous coronary intervention (PCI) has been shown to be a better reperfusion strategy in patients with ST-elevation myocardial infarction (STEMI) compared with thrombolysis, particularly when applied early. The objective of the present study was to report our experience from treating patients presenting to the emergency room of our hospital with STEMI with primary PCI. PATIENTS AND METHODS: The population of the study included 100 patients who presented to our hospital with STEMI and underwent primary PCI over a 12-month period. Patients’ clinical and angiographic data were retrospectively collected and patients were followed up for 9 months. Technical details of the primary PCI, including stent implantation, and use of drug eluting stents, thrombus aspiration catheter, or platelet glycoprotein IIb/ΙΙΙa inhibitors were recorded and correlated to clinical and angiographic patient data. RESULTS: Of 196 patients who presented o the emergency room with STEMI during the study period, 100 (51%) patients (85 men and 15 women) underwent primary PCI. PCI was successful with TIMI 3 flow of the infarct-related coronary artery in 79 (79%) patients. Six (6%) patients died during hospitalization and another 4 (4.3%) patients died during the 9-month follow up period. Twenty one (22%) patients required rehospitalization for acute coronary syndrome, of whom 17 needed a repeat PCI and 4 patients were submitted to coronary artery bypass grafting. Left ventricular ejection fraction (LVEF) was <50% in 54 (54%) patients. In 52 patients primary PCI was performed in less than 4 hours from onset of symptoms. In his cohort, 19 patients were thrombolyzed before arriving to the catheterization laboratory. Antithrombotic therapy with platelet glycoprotein IIb/IIIa inhibitors was used in 48 (48%) patients. Univariate analysis showed that the odds of achieving TIMI 3 flow were higher after using IIb/ΙΙΙa inhibitors (odds ratio-OR 6.4) or if the LVEF ≥50% (vs LVEF < 50%) at the beginning of the PCI (OR 6.4). If the time from the onset of symptoms to PCI was >4 hours, the odds of achieving TIMI 3 flow were reduced by 23.4% compared to time from symptoms to PCI <4 hours. The presence of TIMI 3 flow of the infarct-related artery reduced the odds of death by 10.2% compared to the absence of TIMI 3 flow of the infarct-related coronary artery. CONCLUSION: Our results are in keeping with those published by other groups performing primary PCI. We demonstrated the importance of time interval from onset of symptoms until PCI is started. We found that the use of GP IIb/IIIa inhibitors was beneficial and emphasized the predictive value of LVEF >50% and the importance of achieving TIMI 3 flow in the IRA at the end of the procedure

Longer and better lives for patients with atrial fibrillation:the 9th AFNET/EHRA consensus conference

Aims: Recent trial data demonstrate beneficial effects of active rhythm management in patients with atrial fibrillation (AF) and support the concept that a low arrhythmia burden is associated with a low risk of AF-related complications. The aim of this document is to summarize the key outcomes of the 9th AFNET/EHRA Consensus Conference of the Atrial Fibrillation NETwork (AFNET) and the European Heart Rhythm Association (EHRA). Methods and results: Eighty-three international experts met in Münster for 2 days in September 2023. Key findings are as follows: (i) Active rhythm management should be part of the default initial treatment for all suitable patients with AF. (ii) Patients with device-detected AF have a low burden of AF and a low risk of stroke. Anticoagulation prevents some strokes and also increases major but non-lethal bleeding. (iii) More research is needed to improve stroke risk prediction in patients with AF, especially in those with a low AF burden. Biomolecules, genetics, and imaging can support this. (iv) The presence of AF should trigger systematic workup and comprehensive treatment of concomitant cardiovascular conditions. (v) Machine learning algorithms have been used to improve detection or likely development of AF. Cooperation between clinicians and data scientists is needed to leverage the potential of data science applications for patients with AF. Conclusions: Patients with AF and a low arrhythmia burden have a lower risk of stroke and other cardiovascular events than those with a high arrhythmia burden. Combining active rhythm control, anticoagulation, rate control, and therapy of concomitant cardiovascular conditions can improve the lives of patients with AF

2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation: executive summary.

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Longer and better lives for patients with atrial fibrillation: the 9th AFNET/EHRA consensus conference.

AIMS: Recent trial data demonstrate beneficial effects of active rhythm management in patients with atrial fibrillation (AF) and support the concept that a low arrhythmia burden is associated with a low risk of AF-related complications. The aim of this document is to summarize the key outcomes of the 9th AFNET/EHRA Consensus Conference of the Atrial Fibrillation NETwork (AFNET) and the European Heart Rhythm Association (EHRA). METHODS AND RESULTS: Eighty-three international experts met in Münster for 2 days in September 2023. Key findings are as follows: (i) Active rhythm management should be part of the default initial treatment for all suitable patients with AF. (ii) Patients with device-detected AF have a low burden of AF and a low risk of stroke. Anticoagulation prevents some strokes and also increases major but non-lethal bleeding. (iii) More research is needed to improve stroke risk prediction in patients with AF, especially in those with a low AF burden. Biomolecules, genetics, and imaging can support this. (iv) The presence of AF should trigger systematic workup and comprehensive treatment of concomitant cardiovascular conditions. (v) Machine learning algorithms have been used to improve detection or likely development of AF. Cooperation between clinicians and data scientists is needed to leverage the potential of data science applications for patients with AF. CONCLUSIONS: Patients with AF and a low arrhythmia burden have a lower risk of stroke and other cardiovascular events than those with a high arrhythmia burden. Combining active rhythm control, anticoagulation, rate control, and therapy of concomitant cardiovascular conditions can improve the lives of patients with AF