Slower heart rate and altered rate dependence of ventricular repolarization in patients with lone atrial fibrillation.

BACKGROUND: Electrophysiological alterations in atrial fibrillation (AF) may be genetically based and may lead to changes in ventricular repolarization. Short QT syndrome is a rare channelopathy with abbreviated ventricular repolarization and a propensity for AF. AIMS: To determine if minor unrecognized forms of short QT syndrome can explain some cases of lone AF. METHODS: We prospectively compared QT intervals in 66 patients with idiopathic lone AF and 132 age- and sex-matched controls. QT intervals were measured during sinus rhythm in each of the 12 surface electrocardiogram leads and corrected using Bazett's formula (QTc). QT intervals were also corrected using other formulae. Uncorrected QT and heart rate regression lines were compared between AF patients and controls. RESULTS: AF patients presented with a slower resting heart rate (64 ± 10 beats per minute [bpm] vs 69 ± 9 bpm; P=0.0006). QTc intervals were shorter in AF patients in 11/12 electrocardiogram leads (significant in 7/12, borderline in 2/12; mean QTc 381 ± 21 ms vs 388 ± 22 ms; P=0.02). QTc intervals were also shorter in AF patients, significantly or not, using other correction formulae. For similar heart rates, uncorrected QT intervals were shorter in patients when heart rates were greater than 70 bpm and longer when heart rates were less than 60 bpm. AF patients displayed steeper QT/heart rate regression line slopes than controls (P=0.009). CONCLUSION: Heart rate is significantly slower and the rate dependence of ventricular repolarization is significantly altered in patients with lone AF compared with controls. Further study is warranted to determine if AF induces subsequent ventricular repolarization changes or if these modifications are caused by an underlying primary electrical disease.

Gender disparity in 48-hour mortality is limited to emergency percutaneous coronary intervention for ST-elevation myocardial infarction.

BACKGROUND: Previous studies indicate that mortality from acute coronary syndromes is higher in women than in men, especially in case of interventional strategy. AIM: To assess whether the in-hospital mortality rate differs between genders during the first 48h after emergency percutaneous coronary intervention for ST-elevation myocardial infarction (emergency PCI-STEMI) or after non-emergency PCI. METHODS: All patients treated with PCI between January 2005 and June 2008 were included. The primary endpoint was frequency of death within 48h after the PCI procedure; secondary endpoints included frequency of recurrent myocardial infarction, new PCI or coronary artery bypass graft surgery, stroke, and major vascular or renal complications. Data were analysed via logistic regression with and without propensity-score matching. RESULTS: More than 9000 patients underwent PCI. In the emergency PCI-STEMI group (n=1753), 48-hour mortality occurred in 2.2% of men and 4.9% of women (p=0.004). However, gender disparity occurred only in elderly patients; the rate was significantly (p=0.02) higher in women (8.1%) than in men (3.3%) aged > or =75 years. There was no evidence of gender disparity in the non-emergency PCI group (n=7336) or in secondary endpoints for either PCI group. Similar results were obtained in pair analyses of men and women with matching propensity scores. CONCLUSIONS: Elderly women have a disproportionately high in-hospital mortality rate during the first 48h after emergency PCI for treatment of STEMI; however, there is no gender discrepancy in younger patients or patients of any age who receive non-emergency procedures.

Relationship between time of day, day of the week and in-hospital mortality in patients undergoing emergency percutaneous coronary intervention.

BACKGROUND: Previous studies have reported circadian variation in the rate of post-percutaneous coronary intervention (PCI) complications and mortality. AIM: To assess whether in-hospital outcomes during the first 48h after admission are related to the time or the day when PCI is performed. METHODS: Emergency PCIs (2266 total; 1396 during regular hours and 870 during off hours) performed consecutively during a 3.5-year-period (2005-2008) were evaluated. The primary endpoint was death and the secondary endpoint was a composite score based on cardiovascular complications. The association between PCI start time and in-hospital outcome was assessed using multivariable logistic regression and propensity score analysis. RESULTS: The patients' mean age was 64.8 years and 77.3% were men. The highest death rate was for night-time PCI (3.6%), with a 5.1% occurrence rate for PCI performed between 00:00 and 03:59, and a 3.0% occurrence rate for weekend daytime PCI compared with 1.5% for weekday daytime (regular-hours) PCI. The frequency of occurrence of other clinical events did not vary significantly throughout the day. Compared with weekday daytime PCI, the odds ratio for mortality was 2.95 for night-time PCI (95% confidence interval [CI] 1.58-6.01; p=0.0007) and 2.42 for weekend daytime PCI (95% CI 0.97-6.01; p=0.06). CONCLUSION: Our study shows a significant time-dependent effect on in-hospital deaths in patients treated with emergency PCI. Healthcare organization and circadian variation of ischaemic processes could explain this variation in mortality.

Improvement of Young and Elderly Patient's Knowledge of Heart Failure After an Educational Session.

BACKGROUND: Interest in the role of patient education sessions for optimizing the management of heart failure (HF) is increasing. We determined whether improvements in young and elderly patients' knowledge of HF and self-care behavior could be analyzed by administering a knowledge test before and after an educational session. METHODS: Stable heart failure patients (n = 115) were enrolled in a prospective cohort study from our Heart Failure educational centre in a university hospital. Patient knowledge of six major HF-related topics was assessed via a questionnaire distributed once before an educational session and twice afterward. Each answer was assigned a numerical value and the final score for each topic could range from 0 to 20. Scores >/= 15/20 were considered representative of a good level of knowledge. RESULTS: The level of knowledge was low (9.7/20) before the educational session but was significantly higher (16.3/20) during the 1st quarter after the session, and this benefit was maintained for up to 12 months (16.6/20). Knowledge levels increased in both younger and elderly patients, and the number of patients who had a good level of knowledge also increased after the educational session. CONCLUSION: This study confirms that an HF knowledge test is feasible and that educational sessions improve the knowledge and self-management of both younger and elderly patients.

Factors predictive for in-hospital mortality following percutaneous coronary intervention.

BACKGROUND: Despite advances in procedures for percutaneous coronary intervention (PCI) and enhancement of materials and adjunctive therapy, postprocedural mortality remains a possible adverse outcome after PCI. AIMS: To assess factors independently associated with in-hospital mortality in patients referred for PCI. METHODS: Between January 2004 and December 2005, 4074 PCI were performed in our University Hospital, with 70 deaths registered either during the procedure or during the in-hospital stay. The 70 patients who died were age- and sex-matched with 70 controls in a case-control design study. Clinical and angiographic characteristics at hospital admission were collected from the patients' medical files. RESULTS: The cumulative incidence rate for in-hospital mortality was 1.72%. Variables positively and significantly associated with in-hospital mortality were severe renal failure (55.7% in cases versus 12.9% in controls, p<0.0001), cardiac failure (26.1% versus 10.1%, p=0.01), ST-segment elevation myocardial infarction (STEMI) (70.6% versus 31.4%, p<0.0001), proximal coronary lesion (72.9% versus 40.0%, p<0.0001) and angiographically visible thrombus (14.3% versus 4.3%, p=0.04). Conversely, history of coronary heart disease, smoking and dyslipidemia were less frequent among cases. In multivariable analysis, the adjusted odds ratios (OR) for in-hospital death were 4.89 (95% confidence interval [CI] 1.96-12.2, p<0.001) in STEMI versus non-STEMI, 4.28 (95% CI 1.73-10.6, p<0.01) in those with a proximal coronary lesion, and 9.77 (95% CI 3.42-27.9, p<0.0001) in patients with severe renal failure. CONCLUSION: STEMI, proximal coronary lesion, and renal failure at admission are identified as particular settings associated with a higher probability of in-hospital mortality after PCI.

Radio-frequency ablation of atrial flutter: long-term results and predictive value of cavo-tricuspid isthmus bidirectional block as determined by a simplified technique.

OBJECTIVES: Complete bidirectional cavo-tricuspid isthmus (CTI) block is mandatory for radio-frequency (RF) ablation of typical atrial flutter (AF). CTI block can be assessed by a simplified method using two catheters and the technique of differential pacing, but long-term results in large series are poorly known. METHODS: CTI RF ablation was performed in 255 consecutive patients with typical AF, using one quadripolar catheter, and the ablation catheter, in association with the technique of differential pacing. RESULTS: Procedural success, as defined by documentation of complete bidirectional CTI block using limited activation mapping, positive differential pacing together with termination of ongoing AF, was achieved in 80% of patients. AF recurred in 37 patients (14%) over a mean follow-up period of 15 +/- 9 months. Two hundred and forty-one patients (94%) were finally cured, with 1.1 procedures/patient. The recurrence rate was related to the achievement of complete CTI bidirectional block (12% vs. 29%, p = 0.01). CONCLUSIONS: Long-term results of CTI ablation, employing a simplified method using the differential pacing technique, are similar to those for the standard methods using multipolar catheters. Therefore, this technique compares favorably to other established methods for such common RF procedures, especially due to its lower cost.

Risk factors for stent thrombosis after implantation of sirolimus-eluting stents in diabetic and nondiabetic patients: the EVASTENT Matched-Cohort Registry.

OBJECTIVES: We sought to assess the frequency and causes of stent thrombosis in diabetic and nondiabetic patients after implantation of sirolimus-eluting stents. BACKGROUND: Safety concerns about late stent thrombosis have been raised, particularly when drug-eluting stents are used in less highly selected patients than in randomized trials. METHODS: The EVASTENT study is a matched multicenter cohort registry of 1,731 patients undergoing revascularization exclusively with sirolimus stents; for each diabetic patient included (stratified as single- or multiple-vessel disease), a nondiabetic patient was subsequently included. Patients were treated with aspirin + clopidogrel for at least 3 months and were followed for 465 (range 0 to 1,062) days (1-year follow-up in 98.5%). The primary end point was a composite of stent thrombosis (according to Academic Research Consortium definitions), cardiovascular death, and nonfatal myocardial infarction (major adverse cardiac events [MACE]). RESULTS: During follow-up, MACE occurred in 78 patients (4.5%), cardiac death in 35 (2.1%), and stent thrombosis in 45 (2.6%): 30 definite, 23 subacute, and 22 late, including 9 at >6 months. In univariate analysis, the 1-year stent thrombosis rate was 1.8 times higher in diabetic than in nondiabetic patients (3.2% vs. 1.7%; log rank p = 0.03), with diabetic patients with multiple-vessel disease experiencing the highest rate and nondiabetic single-vessel disease patients the lowest (4.3% vs. 0.8%; p < 0.001). In multivariate analysis, in addition to the interruption of antithrombotic treatment, independent stent thrombosis predictors were previous stroke, renal failure, lower ejection fraction, calcified lesion, length stented, and insulin-requiring diabetes. CONCLUSIONS: The risk of sirolimus stent thrombosis is higher for multiple-vessel disease diabetic patients.

Left-circumflex coronary artery to right atrium fistula with saccular aneurysm and its endovascular treatment.

The combination of coronary artery aneurysm and coronary artery fistula is infrequent. A saccular aneurysm of a branch of the left-circumflex coronary artery associated with multiple fistulae to the right atrium was observed on a coronary angiogram performed in a 47-year-old female. Multidetector computed tomography coronary angiography detailed the anatomy of the abnormal coronary artery. An embolization with a microcoil was performed and the aneurysm sac was excluded.