Heart rate variability in hypertensive pregnancy disorders: A systematic review.

BACKGROUND: Hypertensive pregnancy disorders (HPD) are associated with dysfunction of the autonomic nervous system. Cardiac autonomic functions can be assessed by heart rate variability (HRV) measurements. OBJECTIVE: To study whether HRV detects differences in the function of the autonomic nervous system between pregnant women with HPD compared to normotensive pregnant women and between women with a history of a pregnancy complicated by HPD compared to women with a history of an uncomplicated pregnancy. METHODS: A systematic search was performed in Medline, EMBASE, and CENTRAL to identify studies comparing HRV between pregnant women with HPD or women with a history of HPD to women with (a history of) normotensive pregnancies. RESULTS: The search identified 523 articles of which 24 were included in this review, including 850 women with (a history of) HPD and 1205 normotensive controls. The included studies showed a large heterogenicity. A decrease in overall HRV was found in preeclampsia (PE), compared to normotensive pregnant controls. A trend is seen towards increased low frequency/high frequency-ratio in women with PE compared to normotensive pregnant controls. CONCLUSION: Our systematic review supports the hypothesis a sympathetic overdrive is found in HPD which is associated with a parasympathetic withdrawal. However, the included studies in our review showed a large diversity in the methods applied and their results.

Review on Factors Influencing Physician Guideline Adherence in Cardiology.

Cardiovascular disease is the most common cause of death in Western countries. Physician adherence to guidelines is often suboptimal, resulting in impaired patient outcome and prognosis. Multiple studies have been conducted to evaluate patterns and the influencing factors of patient adherence, but little is known about factors influencing physician guideline adherence. This review aims to identify factors influencing physician guideline adherence relevant to cardiology and to provide insights and suggestions for future improvement. Physician adherence was measured as adherence to standard local medical practice and applicable guidelines. Female gender and older age had a negative effect on physician guideline adherence. In addition, independent of the type of heart disease, physicians without cardiologic specialization were linked to physician noncompliance. Also, guideline adherence in primary care centers was at a lower level compared with secondary or tertiary care centers. The importance of guideline adherence increases as patients age, and complex diseases and comorbidity arise. Appropriate resources and interventions, taking important factors for nonadherence in account, are necessary to improve guideline adoption and adherence in every level of the chain. This in turn should improve patient outcome.

Cardiac structure and function before and after bariatric surgery: a clinical overview.

Obesity, defined as a body mass index of ≥30 kg/m2 , is the most common chronic metabolic disease worldwide and its prevalence has been strongly increasing. Obesity has deleterious effects on cardiac function. The purpose of this review is to evaluate the effects of obesity and excessive weight loss due to bariatric surgery on cardiac function, structural changes and haemodynamic responses of both the left and right ventricle.

Catheter ablation of symptomatic idiopathic ventricular arrhythmias : A five-year single-centre experience.

AIMS: This study was designed to gain insight into the patient characteristics, results and possible complications of ablation procedures for symptomatic idiopathic premature ventricular complexes (PVC) and idiopathic ventricular tachycardia (VT). METHODS: Data were collected from all patients who underwent radiofrequency catheter ablation for symptomatic PVCs and idiopathic VT in the Catharina Hospital between 1 January 2011 and 31 December 2015. The procedural endpoint was elimination or non-inducibility of the clinical arrhythmia. Successful sustained ablation was defined as the persistent elimination of at least 80% of the PVCs or the absence of VTs at follow-up. In case of suspected PVC-induced cardiomyopathy, the systolic left ventricular function was reassessed 3 months post procedure. RESULTS: Our cohort consisted of 131 patients who underwent one or more ablation procedures; 99 because of symptomatic premature ventricular complexes, 32 because of idiopathic VT. In total 147 procedures were performed. The procedural ablation success rate was 89%. Successful sustained ablation rate was 82%. Eighteen (13.2%) patients had suspected PVC-induced cardiomyopathy. In 15 of them (83%), successful sustained ablation was achieved and the left ventricular ejection fraction improved from a mean of 39% (±8.8) to 55.4% (±8.1). Most arrhythmias originated from the right ventricular outflow tract (60%) or aortic cusps (13%). Complications included three tamponades. CONCLUSION: Catheter ablation therapy for idiopathic ventricular arrhythmias is very effective with a sustained success rate of 82%. In patients with PVC-induced cardiomyopathy, it leads to improvement of systolic left ventricular function. However, risk for complications is not negligible, even in experienced hands.

Reduced number of cardiovascular events and increased cost-effectiveness by genotype-guided antiplatelet therapy in patients undergoing percutaneous coronary interventions in the Netherlands.

AIM: This study explores clinical outcome in cytochrome P450 2C19 (CYP2C19)-related poor metaboliser patients treated with either clopidogrel or prasugrel after percutaneous coronary intervention (PCI) and investigates whether this could be cost-effective. METHODS AND RESULTS: This single-centre, observational study included 3260 patients scheduled for elective PCI between October 2010 and June 2013 and followed for adverse cardiovascular events until October 2014. Post PCI, CYP2C19 poor metaboliser patients were treated with clopidogrel or prasugrel, in addition to aspirin. In total, 32 poor metabolisers were treated with clopidogrel and 41 with prasugrel. The number of adverse cardiovascular events, defined as death from cardiovascular cause, myocardial infarction, stent thrombosis, every second visit to the catheterisation room for re-PCI in the same artery, or stroke, within 1.5 years of PCI, was significantly higher in the CYP2C19 poor metaboliser group treated with clopidogrel (n = 10, 31 %) compared with the poor metaboliser group treated with prasugrel (n = 2, 5 %) (p = 0.003). Costs per gained quality-adjusted life years (QALY) were estimated, showing that genotype-guided post-PCI treatment with prasugrel could be cost-effective with less than € 10,000 per gained QALY. CONCLUSION: This study provides evidence that for CYP2C19-related poor metabolisers prasugrel may be more effective than clopidogrel to prevent major adverse cardiovascular events after PCI and this approach could be cost-effective.

Spatial distribution of electrical reconnection after pulmonary vein isolation in patients with recurrent paroxysmal atrial fibrillation.

INTRODUCTION: Recurrence of atrial fibrillation after pulmonary vein isolation (PVI) occurs frequently and may be associated with electrical reconnection of the pulmonary veins (PV). We investigated spatial distribution of electrical reconnection during re-do procedures in patients with paroxysmal atrial fibrillation who had previous successful acute electrical PVI with either single irrigated tip, antral ablation (s-RF; n = 38) or multi-electrode, duty-cycled ablation (PVAC; n = 48). METHODS AND RESULTS: EP navigator, mapping and irrigated tip ablation catheters were used in all re-do procedures. Sites of reconnection were assessed in a 12-segment model. Baseline clinical and demographic characteristics were similar in both groups. The number of PVs reconnected per patient was similar in both groups (2.9 ± 0.9 and 3.2 ± 0.7 (p = 0.193), s­RF and PVAC, respectively), and each PV was equally affected. However, the inferior quadrant of the right lower PV was significantly more vulnerable to reconnection after previous PVAC ablation, whereas the superior quadrant of the right upper PV showed significantly more reconnection in the s­RF group. CONCLUSION: The overall number of PVs reconnected was equally high in both groups, and each PV was affected equally. However, there were significant differences in the spatial distribution of electrical reconnection. Better understanding of predilection sites for reconnection might help to improve the long-term success rate of PVI.

Three-dimensional computed tomography overlay for pulmonary vein antrum isolation: Follow-up and clinical outcomes.

BACKGROUND: To facilitate the creation of circumferential lines in pulmonary vein (PV) antrum isolation, three-dimensional (3D) navigation systems are used widely. Alternatively, 3D reconstructions of the left atrium (LA) can be superimposed directly on fluoroscopy to guide ablation catheters and to mark ablation sites. METHODS: In 71 atrial fibrillation patients circumferential PV ablation was performed. 3D reconstructions of the LA were derived from contrast cardiac-computed tomography and circumferential PV isolation was performed. In subsequent ablation procedures, veins were re-isolated, and defragmentation or linear lesions were performed if necessary. RESULTS: Adequate 3D reconstructions were formed and registered to fluoroscopy in all patients. All veins, except 2 in one single patient, could be isolated, resulting in freedom of AF in 45 patients (63 %). In 19 patients a second procedure was performed, in which 2.7 ± 1.1 PV per patient were re-isolated; in 3 patients a third procedure was performed. After follow-up of 15 ± 8 months, 51 (91 %) of patients with paroxysmal and 10 (67 %) with persistent AF were free of AF. CONCLUSIONS: The results of 3D overlay for circumferential PV isolation are good, although the reconduction rate and need for subsequent ablations remains high, and the outcomes of this technique appear to be equivalent to other mapping techniques.

Left ventricular endocardial pacing in cardiac resynchronisation therapy: Moving from bench to bedside.

In cardiac resynchronisation therapy, failure to implant a left ventricular lead in a coronary sinus branch has been reported in up to 10% of cases. Although surgical insertion of epicardial leads is considered the standard alternative, this is not without morbidity and technical limitations. Endocardial left ventricular pacing can be an alternative as it has been associated with a favourable acute haemodynamic response compared with epicardial pacing in both animal and human studies. In this paper, we discuss left ventricular endocardial pacing and compare it with epicardial surgical implantation. Ease of application and procedural complications and morbidity compare favourably with epicardial surgical techniques. However, with limited experience, the most important concern is the still unknown long-term risk of thromboembolic complications. Therefore, for now endovascular implants should remain reserved for severely symptomatic heart failure patients and patients at high surgical risk of failed coronary sinus implantation.

Primary prevention with the ICD in clinical practice: not as straightforward as the guidelines suggest?

At first sight, guidelines for implantation of an implantable cardioverter defibrillator (ICD) for primary prevention of sudden cardiac death in patients with left ventricular systolic dysfunction seem unambiguous. There are clear cut-off values for ejection fraction, and functional class. However, determination of the ejection fraction itself is not unambiguous, and other risk factors for sudden death that may have a profound effect on risk are not used for decision-making. Furthermore, to obtain a clinically significant impact on survival, expected longevity is important as it can greatly compromise the benefit in elderly patients but underestimate the long-term potential of ICD therapy in younger patients. (Neth Heart J 2009;17:107-10.).

[Differential diagnosis in patients with suspected anoxic-ischaemic coma]. / Differentiaaldiagnose bij patiënten bij wie een anoxisch-ischemisch coma wordt vermoed.

Three case studies illustrate that suspected anoxic-ischaemic coma often requires careful differential diagnosis to detect treatable conditions. A 47-year-old man underwent cardiopulmonary resuscitation for ventricular fibrillation caused by myocardial ischaemia. He exhibited rhythmic eyelid movements while in a coma. Epilepsy was suspected, and the patient regained consciousness after being treated with antiepileptic drugs. A 34-year-old man underwent cardiopulmonary resuscitation for multiple episodes of ventricular fibrillation. Treatment was directed toward myocardial ischaemia and included anticoagulants. The patient had bilateral, fixed dilated pupils. A CT of the brain showed traumatic contrecoup haemorrhage in the left temporal lobe with signs of transtentorial herniation. The patient died. A 74-year-old woman was found unconscious at home. An ECG performed by the paramedics showed ST segment elevation in the precordial leads. Anoxic-ischaemic coma following cardiac arrest was suspected. However, a coronary angiogram was normal and a CT of the brain revealed subarachnoid haemorrhage caused by a ruptured intracranial aneurysm. She recovered after cranial surgery.