ABSTRACT
The use of nondihydropyridine calcium channel blockers (NDCCBs) to achieve rate control in atrial fibrillation with the rapid ventricular rate (AF RVR) is not recommended in patients with comorbid heart failure with reduced ejection fraction (HFrEF) due to the concern for further blunting of contractility. However, these recommendations are extrapolated from data examining chronic NDCCB use in HFrEF patients, and comorbid AF was not analyzed. These recommendations also do not cite the hemodynamic effects or clinical outcomes of NDCCBs for acute rate control in HFrEF patients with AF RVR. It is our goal to open the discussion concerning the hemodynamic effects and safety profile of NDCCBs for acute rate control in this specific patient population. In the acute setting of AF RVR and HFrEF, there is a paucity of low-quality data on the safety and hemodynamic effects of NDCCBs, with mixed results. There has not been a clear signal toward adverse outcomes with NDCCBs, particularly for diltiazem. Data in this scenario is similarly limited for beta blockers, which provide the additional hemodynamic effect of the neurohormonal blockade, which provides a long-term mortality benefit to HFrEF patients. We support the cautious use of beta blockers as first-line therapy in clinical settings where an acute rate control strategy for AF RVR is warranted. We also support diltiazem as a reasonable second-line option, though the relative paucity of data calls for further research to validate this conclusion. Verapamil in this setting should be avoided until more data are available.
ABSTRACT
BACKGROUND: Predictors of in-hospital mortality after myocardial infarction (MI) have been reported dichotomously: survival vs death. Predictors of time from admission to death have not been reported. METHODS: A total of 7335 patients were enrolled in a prospective multicentre registry of acute MI. In-hospital mortality was classified by time from admission as acute (≤ 2 days), subacute (3 to 7 days), late (8 to 14 days), and very late (≥ 15 days) to identify factors associated with time to death in patients who died before discharge. Patient and MI characteristics, in-hospital interventions, and electrocardiographic findings were screened for differences in time to in-hospital death. RESULTS: In-hospital death affected 351 patients (4.8%). Mean age was 72.0 ± 12.4 years, and 40.5% were female patients. Median survival was 5 days (interquartile range: 2-12), and 41% of in-hospital deaths occurred after 1 week. Cardiac biomarkers and ejection fraction were not related to time to in-hospital death. Previous MI, systolic blood pressure, pharmacologic therapy, and interventional treatments were different among the 4 groups. The factors associated with late in-hospital death were coronary artery bypass graft surgery (CABG), new-onset atrial fibrillation or flutter, heart failure or pulmonary edema, bleeding, and lung disease. Acute and subacute in-hospital death was associated with ST-elevation MI, lower systolic blood pressure, and cardiac arrest on admission. CABG was performed in 12% of post-MI patients who died in hospital. CONCLUSIONS: Clinical risk factors for in-hospital mortality evolve over time immediately after acute MI. Understanding the time-dependent risk factors may allow for the development of new approaches to curtail the "later" in-hospital mortality.
Subject(s)
Myocardial Infarction , Humans , Female , Middle Aged , Aged , Aged, 80 and over , Male , Hospital Mortality , Prospective Studies , Coronary Artery Bypass/adverse effects , RegistriesABSTRACT
Although fractured coronary wires are a rare occurrence, failure to retrieve them successfully puts patients at undue risk. We offer a technique that can be used when traditional retrieval with a Microsnare system is unsuccessful.
