Heart rate increase after pulmonary vein isolation predicts freedom from atrial fibrillation at 1 year.

INTRODUCTION: Ablation of atrial vagal ganglia has been associated with improved pulmonary vein isolation (PVI) outcomes. Disruption of vagal reflexes results in heart rate (HR) increase. We investigated the association between HR change after PVI and freedom from atrial fibrillation (AF) at 1 year. METHODS AND RESULTS: Patients who underwent PVI for paroxysmal AF were identified from the Johns Hopkins Hospital AF registry. Electrocardiograms taken pre-PVI and post-PVI were used to determine the change in HR. Patients followed-up at 3, 6, and 12 months. Of 257 patients (66% male, age 59+/-11 years), 134 (52%) remained free from AF at 1 year. The average HR increased from 60.6 ± 11.3 beats per minute (bpm) pre-PVI to 70.7 ± 12.0 bpm post-PVI. Patients with recurrence of AF had lower post-PVI HR than those who remained free from AF (67.8 ± 0.2 vs 73.3 ± 13.0 bpm; P <.001). The probability of AF recurrence at 1-year decreased as the change in HR increased (estimated odds ratio [OR], 0.83; 95% confidence interval [CI, 0.74-0.93]; P = .002). HR increase more than 15 bpm was associated with the lowest odds of AF recurrence (estimated OR, 0.39; 95% [0.17-0.85]; P = .018) compared to HR decrease. CONCLUSIONS: Resting HR was found to increase after PVI. Increase in HR more than 15 bpm has a positive association with remaining free from atrial fibrillation at 1 year.

Preoperative Antibiotic Orders: Protocol-Initiated Pharmacist Order Entry.

OBJECTIVE: To evaluate the antibiotic selection of preoperative orders before and after a pharmacist order entry protocol for patients with methicillin-resistant Staphylococcus aureus (MRSA) colonization. METHODS: A retrospective chart review of orthopedic surgery procedures on patients with MRSA colonization at a free-standing, academic pediatric hospital, between February 2010 and February 2012. RESULTS: Procedures that were performed pre protocol (n = 27) implementation had a 63% rate of appropriate antibiotic selection compared to 81% in the postprotocol group (n = 32; p = 0.1155). The preprotocol group dose accuracy was 96% compared to 97% in the postprotocol group (p = 0.81). Two procedures, 1 in each group, were redosed appropriately for extended surgery duration. Correct timing of antibiotic administration occurred in 82% of cases pre protocol versus 68% post protocol (p = 0.42). CONCLUSIONS: Patients with MRSA colonization had a greater rate of appropriate drug selection after the implementation of a pharmacist-initiated preoperative protocol. Correct antibiotic dose and redose remained consistent between the study groups. Most of the orthopedic procedures performed included patients on antibiotic coverage at steady state for ongoing infections, which impacted the analysis of preoperative timing. Further studies should be conducted to assess whether the increase in the number of appropriate antibiotic selections decreases the rate of postoperative MRSA infections.