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EP News: Clinical
EP News: Clinical N.A. Mark Estes III, MD, FHRS From the Tufts Medical Center, Boston, Massachusetts.
Radiofrequency catheter ablation of drivers vs circumferential pulmonary vein isolation Atienza et al (J Am Coll Cardiol 2014;64:2455, PMID 25500229) evaluated localized high-frequency source ablation (HFSA) compared with circumferential pulmonary vein isolation (CPVI) in 232 patients with atrial fibrillation (AF) in a multicenter trial. Patients with paroxysmal AF (n ¼ 115) were randomized to a CPVI or HFSA-only (noninferiority design) group. Patients with persistent AF (n ¼ 117) were randomized to CPVI or a combined ablation approach (CPVI þ HFSA; superiority design). The primary end point was freedom from AF at 6 months after the first ablation procedure. Secondary end points included freedom from atrial tachyarrhythmias at 6 and 12 months, periprocedural complications, overall adverse events, and quality of life. In paroxysmal AF, HFSA failed to achieve noninferiority at 6 months. Adverse events were significantly reduced in the HFSA group than in the CPVI group (P ¼ .02). There were no significant differences between treatment groups for primary and secondary end points. The authors conclude that in paroxysmal AF, HFSA failed to achieve noninferiority at 6 months. In persistent AF, CPVI þ HFSA offered no incremental value.
Antithrombotic therapy in patients with atrial fibrillation and chronic kidney disease Bonde et al (J Am Coll Cardiol 2014;64:2471, PMID 25500231) assessed the net clinical benefit of warfarin in patients with atrial fibrillation (AF) and chronic kidney disease (CKD). A total of 11,128 patients had non–end-stage CKD and 1728 were receiving renal replacement therapy. In all CHA2DS2-VASc risk groups, renal replacement therapy was independently associated with a higher risk of stroke/thromboembolism, from a 5.5-fold higher risk in patients with a CHA2DS2-VASc score of 0 to a 1.6-fold higher risk in patients with a CHA2DS2-VASc score of Z2. In patients receiving dialysis with a CHA2DS2-VASc score of Z2, warfarin was associated with a lower risk of all-cause death (hazard ratio [HR] 0.85). In patients with non–end-stage CKD and a CHA2DS2-VASc score of Z2, warfarin was associated with a lower risk of a composite outcome of fatal stroke/fatal bleeding (HR 0.71), a lower risk of cardiovascular death (HR 0.80), and a lower risk of all-cause death (HR 0.64). The authors conclude that CKD is associated with a higher risk of stroke/ thromboembolism across stroke-risk strata in patients with AF. Address reprint requests and correspondence: Dr N.A. Mark Estes III, Tufts Medical Center, 800 Washington St, Boston, MA 02111. E-mail address: [email protected].
1547-5271/$-see front matter
Patients with high-risk CKD (CHA2DS2-VASc Z2) with AF benefit from warfarin treatment for stroke prevention.
Epinephrine during cardiac arrest: Worse outcomes in resuscitated patients? Dumas et al (J Am Coll Cardiol 2014;64:236, PMID 25465423) investigated the relationship between prehospital use of epinephrine and functional survival in patients with out-of-hospital cardiac arrest who achieved successful return of spontaneous circulation from 2000 to 2012. Of the 1556 eligible patients, 1134 (73%) received epinephrine. One hundred ninety-four of 1134 patients (17%) had a good outcome as compared with 255 of 422 patients (63%) in the nontreated group (P o .001). This adverse association of epinephrine was observed regardless of length of resuscitation or inhospital interventions. Compared with patients who did not receive epinephrine, the adjusted odds ratio of intact survival was 0.48 for 1 mg, 0.30 for 2–5 mg, and 0.23 for 45 mg of epinephrine. The authors conclude that prehospital use of epinephrine was consistently associated with a lower chance of survival, an association that showed a dose effect and persisted despite postresuscitation interventions.
Ejection fraction normalization in cardiac resynchronization therapy: Ventricular arrhythmias and clinical outcomes Ruwald et al (Circulation 2014;130:2278, PMID 2530183) evaluated patients randomized to cardiac resynchronization therapy (CRT)-defibrillator in a multicenter trial who had paired echocardiograms at enrollment and at 12 months (n ¼ 752). Patients were evaluated by left ventricular ejection fraction (LVEF) recovery in 3 groups: r35%, 36%–50%, and 450%). A total of 7.3% achieved LVEF normalization (450%). The risk of ventricular tachyarrhythmias (VTA) was reduced in patients with LVEF 450% (hazard ration [HR] 0.24; P ¼ .023) and LVEF of 36%–50% (HR 0.44; P o .001). The risk of HF or death was reduced with improvements in LVEF (LVEF 450%: HR 0.29; P ¼ .045; and LVEF 36%–50%: HR 0.44; P o .001). A total of 6 factors were associated with LVEF normalization. Patients with all factors present (n ¼ 42) had no VTAs (positive predictive value 100%). The authors conclude that patients with LVEF normalization (450%) have very low absolute and relative risk of VTAs and a favorable clinical course. The risk of inappropriate implantable cardioveter-defibrillator therapy is still present, so these patients could be considered for downgrade from CRT-defibrillator to CRT-pacemaker at the time of battery depletion if no VTAs have occurred.
http://dx.doi.org/10.1016/j.hrthm.2015.01.008
Radiofrequency catheter ablation of drivers vs circumferential pulmonary vein isolation Atienza et al (J Am Coll Cardiol 2014;64:2455, PMID 25500229) evaluated localized high-frequency source ablation (HFSA) compared with circumferential pulmonary vein isolation (CPVI) in 232 patients with atrial fibrillation (AF) in a multicenter trial. Patients with paroxysmal AF (n ¼ 115) were randomized to a CPVI or HFSA-only (noninferiority design) group. Patients with persistent AF (n ¼ 117) were randomized to CPVI or a combined ablation approach (CPVI þ HFSA; superiority design). The primary end point was freedom from AF at 6 months after the first ablation procedure. Secondary end points included freedom from atrial tachyarrhythmias at 6 and 12 months, periprocedural complications, overall adverse events, and quality of life. In paroxysmal AF, HFSA failed to achieve noninferiority at 6 months. Adverse events were significantly reduced in the HFSA group than in the CPVI group (P ¼ .02). There were no significant differences between treatment groups for primary and secondary end points. The authors conclude that in paroxysmal AF, HFSA failed to achieve noninferiority at 6 months. In persistent AF, CPVI þ HFSA offered no incremental value.
Antithrombotic therapy in patients with atrial fibrillation and chronic kidney disease Bonde et al (J Am Coll Cardiol 2014;64:2471, PMID 25500231) assessed the net clinical benefit of warfarin in patients with atrial fibrillation (AF) and chronic kidney disease (CKD). A total of 11,128 patients had non–end-stage CKD and 1728 were receiving renal replacement therapy. In all CHA2DS2-VASc risk groups, renal replacement therapy was independently associated with a higher risk of stroke/thromboembolism, from a 5.5-fold higher risk in patients with a CHA2DS2-VASc score of 0 to a 1.6-fold higher risk in patients with a CHA2DS2-VASc score of Z2. In patients receiving dialysis with a CHA2DS2-VASc score of Z2, warfarin was associated with a lower risk of all-cause death (hazard ratio [HR] 0.85). In patients with non–end-stage CKD and a CHA2DS2-VASc score of Z2, warfarin was associated with a lower risk of a composite outcome of fatal stroke/fatal bleeding (HR 0.71), a lower risk of cardiovascular death (HR 0.80), and a lower risk of all-cause death (HR 0.64). The authors conclude that CKD is associated with a higher risk of stroke/ thromboembolism across stroke-risk strata in patients with AF. Address reprint requests and correspondence: Dr N.A. Mark Estes III, Tufts Medical Center, 800 Washington St, Boston, MA 02111. E-mail address: [email protected].
1547-5271/$-see front matter
Patients with high-risk CKD (CHA2DS2-VASc Z2) with AF benefit from warfarin treatment for stroke prevention.
Epinephrine during cardiac arrest: Worse outcomes in resuscitated patients? Dumas et al (J Am Coll Cardiol 2014;64:236, PMID 25465423) investigated the relationship between prehospital use of epinephrine and functional survival in patients with out-of-hospital cardiac arrest who achieved successful return of spontaneous circulation from 2000 to 2012. Of the 1556 eligible patients, 1134 (73%) received epinephrine. One hundred ninety-four of 1134 patients (17%) had a good outcome as compared with 255 of 422 patients (63%) in the nontreated group (P o .001). This adverse association of epinephrine was observed regardless of length of resuscitation or inhospital interventions. Compared with patients who did not receive epinephrine, the adjusted odds ratio of intact survival was 0.48 for 1 mg, 0.30 for 2–5 mg, and 0.23 for 45 mg of epinephrine. The authors conclude that prehospital use of epinephrine was consistently associated with a lower chance of survival, an association that showed a dose effect and persisted despite postresuscitation interventions.
Ejection fraction normalization in cardiac resynchronization therapy: Ventricular arrhythmias and clinical outcomes Ruwald et al (Circulation 2014;130:2278, PMID 2530183) evaluated patients randomized to cardiac resynchronization therapy (CRT)-defibrillator in a multicenter trial who had paired echocardiograms at enrollment and at 12 months (n ¼ 752). Patients were evaluated by left ventricular ejection fraction (LVEF) recovery in 3 groups: r35%, 36%–50%, and 450%). A total of 7.3% achieved LVEF normalization (450%). The risk of ventricular tachyarrhythmias (VTA) was reduced in patients with LVEF 450% (hazard ration [HR] 0.24; P ¼ .023) and LVEF of 36%–50% (HR 0.44; P o .001). The risk of HF or death was reduced with improvements in LVEF (LVEF 450%: HR 0.29; P ¼ .045; and LVEF 36%–50%: HR 0.44; P o .001). A total of 6 factors were associated with LVEF normalization. Patients with all factors present (n ¼ 42) had no VTAs (positive predictive value 100%). The authors conclude that patients with LVEF normalization (450%) have very low absolute and relative risk of VTAs and a favorable clinical course. The risk of inappropriate implantable cardioveter-defibrillator therapy is still present, so these patients could be considered for downgrade from CRT-defibrillator to CRT-pacemaker at the time of battery depletion if no VTAs have occurred.
http://dx.doi.org/10.1016/j.hrthm.2015.01.008