Beta-blockers for the treatment of arrhythmias: Bisoprolol - a systematic review.

OBJECTIVES: Beta-blockers have long been successfully used for the treatment of both supraventricular and ventricular arrhythmias. However, differences exist between their chemical structure, pharmacokinetic and pharmacodynamic properties (absorption, bioavailability, metabolism, hydrophilic or lipophilic character, selective or non-selective nature, the presence or absence of intrinsic sympathomimetic activity), which may confer different antiarrhythmic properties to different beta-blockers. The aim of this study was to analyze the current existing evidence for bisoprolol for the treatment of both supraventricular and ventricular arrhythmias. MATERIAL AND METHODS: Using the keywords "bisoprolol" and "arrhythmias" or "atrial fibrillation" or "ventricular tachycardia" or "premature ventricular complexes" or "ventricular fibrillation", the Medline database was searched for articles in English or French until April 2020 assessing the role of bisoprolol in the treatment of arrhythmias. Data was then analyzed according to the type of arrhythmia treated and the quality of evidence using the GRADE approach. RESULTS: A total of 325 studies were identified, of which 28 were considered relevant to the current topic. Among these studies, 19 assessed the role of bisoprolol for the treatment of supraventricular arrhythmias, 8 its role in treating ventricular arrhythmias and 1 its role in supraventricular and ventricular arrhythmias. The quality of evidence varied from low (7 studies) to high (5 studies). CONCLUSION: Current evidence exists supporting the use of bisoprolol for the treatment of supraventricular arrhythmias, especially for rate control during atrial fibrillation. Evidence also exists for its efficacy in the treatment of ventricular arrhythmias, both in primary and in secondary prevention.

THE ROLE OF NT PRO-BNP IN THE EVALUATION OF DIABETIC PATIENTS WITH HEART FAILURE.

CONTEXT: The prevalence of patients with concomitant heart failure (HF) and diabetes mellitus (DM) is high. OBJECTIVE: To analyze the role of NT-pro-BNP levels in the evaluation of diabetic patients with heart failure. DESIGN: Retrospective comparative cohort study. SUBJECTS AND METHODS: A total of 174 patients admitted to our Cardiology Department, previously diagnosed with HF, were enrolled. Among these patients, 47.7% had DM. HF was defined according to the 2016 ESC criteria. The NT-pro BNP levels above 126 pg/mL indicate a high probability of heart failure. RESULTS: In diabetic patients there were significant correlations between NT-pro-BNP values and the following parameters: hemoglobin (rho=-0.28, p=0.01), hematocrit (rho= -0.27, p=0.014), total cholesterol (rho= -0.21, p=0.048), triglycerides (rho= -0.283, p=0.01), ejection fraction (rho= -0.465, p<0.0001), end-diastolic volume (rho= 0.253, p= 0.026), end-systolic volume (rho= 0.29 p=0.01). Only the following 3 parameters: ejection fraction (p= 0.0009), hemoglobin (p= 0.0092) and triglycerides (p= 0.0380) were independent predictive factors for elevated NT-pro-BNP values. CONCLUSION: In diabetic heart failure patients, the value of NT-pro-BNP holds a pivotal role in the evaluation of their overall status, facilitating the establishment of correct management and follow-up.

Cardiovascular profiles of scleroderma patients with arrhythmias and conduction disorders.

Introduction Arrhythmias and conduction disorders are common among patients with scleroderma. Their early identification is important, since scleroderma patients with arrhythmias have a higher mortality risk compared with scleroderma patients without arrhythmias. The aim of this study was to characterize the cardiovascular profiles of scleroderma patients with different types of arrhythmias and conduction disorders. Methods One hundred and ten consecutive patients with a diagnosis of systemic sclerosis according to the ACR criteria were included in the study. Patients underwent a 12-lead ECG and a 24-hour Holter ECG monitoring for arrhythmias and conduction disorders identification. Blood sample testing, echocardiography, spirometry, chest X-ray and, when considered appropriate, high resolution chest CT were also performed. A subgroup of 21 patients underwent NT-pro BNP level measurements. Patients' clinical and para-clinical characteristics were compared according to the presence or absence of arrhythmias and conduction disorders. Results The prevalence of arrhythmia and conduction disturbances was 60.9%. Patients with such disorders were older (54.4 ± 13.3 vs. 49.7 ± 10.1 years, p=0.05), had a higher prevalence of pulmonary hypertension (p=0.008), valve disease (p < 0.001), especially mitral and tricuspid regurgitation, chamber enlargement on echocardiography (left atrial and right ventricular, p = 0.012 and 0.005, respectively) as well as higher NT-pro BNP levels: 265.5 ± 399.7 vs. 163 ± 264.3 pg/ml, p=0.04. Conclusion Arrhythmias and conduction disorders are common in patients with scleroderma. Patients with such disorders are older, have a higher prevalence of pulmonary hypertension, more severe mitral and tricuspid regurgitation, left atrial and right ventricular dilation on echocardiography.

Cyclophosphamide in combination with glucocorticoids for severe neuropsychiatric systemic lupus erythematosus: a retrospective, observational two-centre study.

Cyclophosphamide (CYC) is used in severe neuropsychiatric systemic lupus erythematosus (NPSLE), but long-term data regarding its efficacy and safety are lacking. We identified NPSLE cases who received CYC from two centres during the period 1999-2013 and had regular follow-up. General and neuropsychiatric outcome at last follow-up visit were determined, and major complications were documented. CYC was administered in 50 neuropsychiatric events. Median age was 45.0 years and 46% of patients were positive for antiphospholipid antibodies. Most frequent indications were psychosis (11 cases), polyneuropathy (six cases), and cerebrovascular disease, seizure disorder and cranial neuropathy (five cases). CYC was mainly administered as monthly pulses (median number: 8.0 (range 3-26), median cumulative dose: 7.2 g (range 2.4-33.8)). Cases were followed for a median of 46.5 months (range 5-408). At last follow-up, partial or complete response of NPSLE was observed in 84% of events; 10% had stable disease, whereas the remaining 6% failed to improve or worsened and were rescued with rituximab. In events that responded to CYC, maintenance therapy consisted of azathioprine in 31 events (65.9%), bimonthly or quarterly pulses of intravenous CYC in nine (19.1%), and mycophenolate mofetil in five (10.6%). Relapses were observed in six events (12%) at median eight months after initial response. No malignancies were observed, yet there were three cases of severe infections. Amenorrhea was recorded in three patients, who had not received gonadal protection. In conclusion, cyclophosphamide was efficacious and led to sustained response of severe NPSLE in a cohort with long follow-up.

Correlations between the surface ECG and the intracavitary electrocardiogram in typical atrial flutter.

UNLABELLED: Typical atrial flutter (cavo-tricuspid isthmus-dependent) has as an electrophysiological substrate a macro-reentry circuit localized in the right atrium. Depending on the right atrial depolarization sequence, the rotation of the macro-reentry circuit can be counterclockwise (with an inferior to superior activation of the right atrium free wall and superior to inferior activation of the interatrial septum), characterized by negative F waves in inferior leads (DII, DIII, aVF) and V6, and positive in V1 on the surface electrogram (ECG), or clockwise (with a superior to inferior activation of the right atrium free wall and inferior to superior activation of the interatrial septum) characterized by positive F waves in inferior leads (DII, DIII, aVF) and V6, and negative in V1. Nevertheless, it is considered that for the diagnosis of the typical or atypical nature of this arrhythmia, the surface ECG has limited value. The purpose of this study was to compare the relationship between the flutter rotation sequence determined by the intracavitary electrogram and the morphology of the F waves on the surface ECG. METHODS: The study included 387 patients admitted to the Cardiology - Rehabilitation Hospital from Cluj-Napoca between January 2007 and May 2010, diagnosed with typical atrial flutter during an electrophysiological study. Using the intracavitary electrograms the flutter rotation sequence was determined (clockwise or counterclockwise). The F waves' aspect on the surface ECG in leads DII, DIII, aVF, aVL, V1 and V6 was then analyzed. RESULTS: One hundred and fifty two patients (39.3%) were diagnosed with clockwise atrial flutter and 235 patients (60.7%) with counterclockwise atrial flutter. The positive predictive value (PPV) of negative F waves in inferior leads and positive in V1 was, in the case of counterclockwise atrial flutter 98%; the negative predictive value (NPV) was 79%; sensitivity (Se) was 83% and specificity (Sp) was 97%. For typical clockwise atrial flutter, the PPV of the positive F waves in the inferior leads and negative in V1 was 94% (p < 0.001); the NPV was 85%; Se was 73% and Sp was 97%. CONCLUSION: The surface ECG has a high value in determining the macroreentry circuit rotation sequence in the case of typical atrial flutter.

Assessment of the correlation between two defining criteria for bidirectional isthmic block in the ablation of typical atrial flutter.

BACKGROUND: A complete, bidirectional conduction block in the cavotricuspid isthmus (CTI) represents the end-point of the typical atrial flutter ablation. We investigated the correlation between two criteria for successful ablation, one based on the atrial bipolar electrogram morphology before and after complete CTI conduction block, compared to the standard criteria of differential pacing and reversal in the right atrial depolarization sequence during coronary sinus (CS) pacing. METHOD: We conducted a retrospective study in 111 patients (81 males, average age 62±10 years) who underwent an atrial flutter ablation during September 2007 - July 2009 in the Cardiology - Rehabilitation Hospital, UMF Cluj-Napoca. We assessed the presence of a bidirectional block at the end of the procedure using the standard criteria. We then analyzed the morphology of the bipolar atrial electrograms adjacent to the ablation line, before and after CTI conduction block. RESULTS: A change from a qRs morphology to a rSr' morphology when pacing from the coronary sinus and from a rsr' morphology to a QRS morphology when pacing from the low-lateral right atrium was associated with a CTI conduction block. Sensitivity (Se), specificity(Sp), positive predictive value (PPV), negative predictive value (NPV) were 96%, 89%, 99% and 67% respectively. CONCLUSION: Our study suggests that the analysis of the atrial bipolar electrogram next to the ablation line before and after CTI ablation may be used as a reliable criterion to validate CTI conduction block due to its high sensitivity, specificity and positive predictive value.

The role of radiofrequency ablation as a first line therapy in the treatment of atrial flutter.

UNLABELLED: Cavo-tricuspid isthmus radiofrequency (RF) ablation is an efficient option in the treatment of atrial flutter. In the case of a well-tolerated, first episode of atrial flutter, it has a class II indication, level of evidence B, the current first-line therapeutic option being electrical cardioversion, pharmacological cardioversion or atrial overdrive pacing followed by long-term antiarrhythmic therapy. The purpose of this study was to evaluate, in a prospective manner, the recurrence rate of these two different therapeutic options after the treatment of a first episode of atrial flutter. MATERIAL AND METHODS: Between January 2007 and May 2009, for 99 patients admitted to the hospital for a first episode of atrial flutter, cardioversion was attempted either by RF ablation (group 1-42 patients), or by electrical cardioversion, pharmacological cardioversion or atrial overdrive pacing followed by long-term Amiodarone therapy (group 21-57 patients). We compared the recurrence rate of atrial flutter in the 2 groups after a follow-up period of one year. RESULTS: In group 1, sinus rhythm was achieved in all patients, with bidirectional isthmic block being obtained for 37 patients (88.1%). In group 2, conversion to sinus rhythm was obtained in all cases. The recurrence rate was 6 times higher in group 2 vs group 1 (57.9% = 33 patients vs 9.5% = 4 patients) (p = 0.01). CONCLUSION: RF ablation should be considered as a therapeutic option in the treatment of the first episode of atrial flutter, due to its significant efficiency in maintaining sinus rhythm and to its low recurrence rate.