When Cardioversion May Be Complicated.

BACKGROUND: In recent years cardioversion of atrial fibrillation has become a routine procedure, enabling symptomatic functional improvement in most cases. However, some patients develop complications after cardioversion. Identifying these individuals is an important step toward improving patient outcome. OBJECTIVES: To characterize those patients who may not benefit from cardioversion or who may develop complications following cardioversion. METHODS: We retrospectively analyzed 186 episodes of cardioversion in 163 patients with atrial fibrillation who were admitted to our cardiology department between 2008 and 2013 based on their clinical and echocardiographic data. Patients were divided into two groups: those with uncomplicated cardioversion, and those who developed complications after cardioversion. RESULTS: Of the 186 episodes, cardioversion was done in 112 men (60%) and 74 women (40%), P < 0.00001. Complications after cardioversion occurred in 25 patients (13%). These patients were generally older (72 vs. 65 years, P < 0.01), were more often diabetic (52% vs. 27%, P = 0.005), had undergone emergency cardioversion (64% vs. 40%, P = 0.01), had left ventricular hypertrophy (left ventricular mass 260 vs. 218 g, P = 0.01), had larger left atrium (left atrial volume 128 vs. 102 ml, P < 0.009), and more often died from complications of cardioversion (48% vs. 16%). They had significant mitral regurgitation (20% vs. 4%, P = 0.03) and higher pulmonary artery pressure (50 vs. 42 mm Hg, P < 0.02). CONCLUSIONS: People with complications after cardioversion tend to be older, are more often diabetic and more often have severe mitral regurgitation. In these patients, the decision to perform cardioversion should consider the possibility of complications.

Acute myocardial infarction with spontaneous reperfusion: clinical characteristics and optimal timing for revascularization.

BACKGROUND: Spontaneous coronary reperfusion occurs in 7-27% of patients with ST elevation myocardial infarction, and is an independent predictor of myocardial salvage, percutaneous coronary intervention success, and improved outcome. OBJECTIVES: To determine the optimal PCI time for patients admitted to the hospital due to STEMI with SCR. METHODS: We performed a retrospective analysis of all patients admitted to the coronary care unit between July 2002 and November 2004 with a diagnosis of STEMI with SCR. RESULTS: The study group comprised 86 patients. There was not a single reinfarction episode during an observation period of 6579 patient hours. Cardiac catheterization was executed early (< 24 hours from pain onset) in 26 patients and late (> 24 hours) in 55. Pre-PCI angiographic TIMI flow 2-3 was seen in > 95% in both groups. PCI was performed more frequently in the "early" group (P = 0.024), while multi-vessel coronary artery disease (P = 0.094) requiring coronary bypass surgery (P = 0.056) was observed more frequently in the "late catheterization" group. Myocardial infarction and angina pectoris at 30 days occurred more frequently in the early catheterization group (P = 0.039), however no difference in any major adverse cardiac events was detected during long-term follow-up (491 +/- 245 days). CONCLUSIONS: Reinfarction after STEMI with SCR is a rare event. Early PCI in patients with STEMI and SCR, even when executed with aggressive antiplatelet therapy, seems to result in an excess of early MACE without any long-term advantage. Prospective randomized trials should determine the optimal PCI timing for these patients.

The benefits and safety of external counterpulsation in symptomatic heart failure.

BACKGROUND: External counterpulsation is a safe and effective method of alleviating angina pectoris, but the mechanism of benefit is not understood. OBJECTIVES: To evaluate the safety and efficacy of external counterpulsation therapy in heart failure patients. METHODS: Fifteen symptomatic heart failure patients (subsequent to optimal medical and device therapy) underwent 35 hourly sessions of ECPT over a 7 week period. Before and after each ECPT session we performed pro-B-type natriuretic peptide and brachial artery function studies, administered a quality of life questionnaire, and assessed exercise tolerance and functional class. RESULTS: Baseline left ventricular ejection fraction was 28.1+/-5.8%. ECPT was safe and well tolerated and resulted in a reduction in pro-BNP levels (from 2,245+/- 2,149 pcg/ml to 1,558+/-1206 pcg/ml, P= 0.022). Exercise duration (Naughton protocol) improved (from 720+/-389 to 893+/-436 seconds, P= 0.0001), along with functional class (2.63+/-0.6 vs. 1.93+/-0.7, P= 0.023) and quality of life scores (54+/-22 vs. 67+/-23, P= 0.001). Nitroglycerine-mediated brachial vasodilatation increased (11.5+/-7.3% vs. 15.6+/-5.2%, P=0.049), as did brachial flow-mediated dilation (8.35+/-6.0% vs. 11.37+/-4.9%, P= 0.09). CONCLUSIONS: ECPT is safe for symptomatic heart failure patients and is associated with functional and neurohormonal improvement. Larger long-term randomized studies with a control arm are needed to confirm these initial encouraging observations.