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Background: Ventricular arrhythmias (VAs) are a common cause of death in patients with acute myocardial infarction (AMI). Studies have shown sex differences in the incidence, presentation, and outcomes of AMI. However, less is known about sex differences in patients with AMI who develop VAs. Objectives: The authors assessed sex differences in incidence and in-hospital outcomes of patients with AMI and VAs. Methods: Using the National Inpatient Sample 2016 to 2020, we conducted a retrospective analysis of patients admitted for AMI with a secondary diagnosis of VAs. Multivariable logistic regression was performed to estimate the sex-specific differences in the rates and in-hospital outcomes of VAs post-AMI. Results: We identified 1,543,140 patients admitted with AMI. Of these, (11.3%) 174,565 patients had VAs after AMI. The odds of VAs after AMI were higher among men (12.6% vs 8.8% adjusted odds ratio [AOR]: 1.72; CI: 1.67-1.78; P < 0.001). Women had significantly higher odds of in-hospital mortality (AOR: 1.32; CI: 1.21-1.42; P < 0.001), cardiogenic shock (AOR: 1.08; CI: 1.01-1.15; P < 0.022), and cardiac arrest (AOR: 1.11; CI: 1.03-1.18; P < 0.002). Women were less likely to receive an implantable cardioverter-defibrillator (ICD) (AOR: 0.57; CI: 0.47-0.68; P < 0.001) or undergo catheter ablation (AOR: 0.51; CI: 0.27-0.98; P < 0.001) during the index admission. Conclusions: We found important sex differences in the incidence and outcomes of VAs among patients with AMI. Women had lower odds of VAs but worse hospital outcomes overall. In addition, women were less likely to receive ICD. Further studies to address these sex disparities are needed.
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Negro ou Afro-Americano , Tomada de Decisão Clínica , Desfibriladores Implantáveis , Cardioversão Elétrica , Confiança , Humanos , Negro ou Afro-Americano/psicologia , Cardioversão Elétrica/instrumentação , Cardioversão Elétrica/efeitos adversos , Conhecimentos, Atitudes e Prática em Saúde/etnologia , Disparidades em Assistência à Saúde/etnologia , Relações Médico-Paciente , Medição de Risco , Fatores de Risco , Estados UnidosRESUMO
The global prevalence of atrial fibrillation is rapidly increasing, in large part due to the aging of the population. Atrial fibrillation is known to increase the risk of thromboembolic stroke by 5 times, but it has been evident for decades that well-managed anticoagulation therapy can greatly attenuate this risk. Despite advances in pharmacology (such as the shift from vitamin K antagonists to direct oral anticoagulants) that have increased the safety and convenience of chronic oral anticoagulation in atrial fibrillation, a preponderance of recent observational data indicates that protection from stroke is poorly achieved on a population basis. This outcomes deficit is multifactorial in origin, stemming from a combination of underprescribing of anticoagulants (often as a result of bleeding concerns by prescribers), limitations of the drugs themselves (drug-drug interactions, bioaccumulation in renal insufficiency, short half-lives that result in lapses in therapeutic effect, etc), and suboptimal patient adherence that results from lack of understanding/education, polypharmacy, fear of bleeding, forgetfulness, and socioeconomic barriers, among other obstacles. Often this adherence is not reported to treating clinicians, further subverting efforts to optimize care. A multidisciplinary, interprofessional panel of clinicians met during the 2023 International Society of Thrombosis and Haemostasis Congress to discuss these gaps in therapy, how they can be more readily recognized, and the potential for factor XI-directed anticoagulants to improve the safety and efficacy of stroke prevention. A full appreciation of this potential requires a reevaluation of traditional teaching about the "coagulation cascade" and decoupling the processes that result in (physiologic) hemostasis and (pathologic) thrombosis. The panel discussion is summarized and presented here.
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Anticoagulantes , Fibrilação Atrial , Fator XI , Acidente Vascular Cerebral , Humanos , Fibrilação Atrial/tratamento farmacológico , Fibrilação Atrial/complicações , Anticoagulantes/uso terapêutico , Acidente Vascular Cerebral/prevenção & controle , Fator XI/antagonistas & inibidores , Fator XI/metabolismo , Hemorragia/induzido quimicamente , Tromboembolia/prevenção & controleRESUMO
Racial and ethnic differences in treatment-cardiovascular and otherwise-have been documented in many aspects of the American health care system and can be seen in implantable cardioverter-defibrillator (ICD) patient selection, counseling, and management. ICDs have been demonstrated to be a powerful tool in the prevention of sudden cardiac death, yet uptake across all eligible patients has been modest. Although patients who do not identify as White are disproportionately eligible for ICDs in the United States, they are less likely to see specialists, be counseled on ICDs, and ultimately have an ICD implanted. This review explores racial and ethnic differences demonstrated in ICD patient selection, outcomes including shock effectiveness, and postimplantation monitoring for both primary and secondary prevention devices. It also highlights barriers for uptake at the health system, physician, and patient levels and suggests areas of further research needed to clarify the differences, illuminate the driving forces of these differences, and investigate strategies to address them.
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Fumar Maconha , Parada Sinusal Cardíaca , Síncope/etiologia , Eletrocardiografia , Feminino , Humanos , Adulto JovemRESUMO
BACKGROUND: The purpose of this study is to describe key elements, clinical outcomes, and potential uses of the Kaiser Permanente-Cardiac Device Registry. METHODS AND RESULTS: This is a cohort study of implantable cardioverter defibrillators (ICD), pacemakers (PM), and cardiac resynchronization therapy (CRT) devices implanted between January 1, 2007 and December 31, 2013 by ≈400 physicians in 6 US geographical regions. Registry data variables, including patient characteristics, comorbidities, indication for procedures, complications, and revisions, were captured using the healthcare system's electronic medical record. Outcomes were identified using electronic screening algorithms and adjudicated via chart review. There were 11 924 ICDs, 33 519 PMs, 4472 CRTs, and 66 067 leads registered. A higher proportion of devices were implanted in males: 75.1% (ICD), 55.0% (PM), and 66.7% (CRT), with mean patient age 63.2 years (ICD), 75.2 (PM), and 67.2 (CRT). The 30-day postoperative incidence of tamponade, hematoma, and pneumothorax were ≤0.3% (ICD), ≤0.6% (PM), and ≤0.4% (CRT). Device failures requiring revision occurred at a rate of 2.17% for ICDs, 0.85% for PMs, and 4.93% for CRTs, per 100 patient observation years. Superficial infection rates were <0.03% for all devices; deep infection rates were 0.6% (ICD), 0.5% (PM), and 1.0% (CRT). Results were used to monitor vendor-specific variations and were systematically shared with individual regions to address potential variations in outcomes, utilization, and to assist with the management of device recalls. CONCLUSIONS: The Kaiser Permanente-Cardiac Device Registry is a robust tool to monitor postprocedural patient outcomes and postmarket surveillance of implants and potentially change practice patterns.
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Arritmias Cardíacas/terapia , Dispositivos de Terapia de Ressincronização Cardíaca/estatística & dados numéricos , Serviços de Saúde Comunitária , Desfibriladores Implantáveis/estatística & dados numéricos , Marca-Passo Artificial/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Arritmias Cardíacas/diagnóstico , Arritmias Cardíacas/fisiopatologia , Dispositivos de Terapia de Ressincronização Cardíaca/efeitos adversos , Dispositivos de Terapia de Ressincronização Cardíaca/tendências , Desfibriladores Implantáveis/efeitos adversos , Desfibriladores Implantáveis/tendências , Remoção de Dispositivo , Feminino , Sistemas Pré-Pagos de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Marca-Passo Artificial/efeitos adversos , Marca-Passo Artificial/tendências , Vigilância de Produtos Comercializados , Desenho de Prótese , Falha de Prótese , Infecções Relacionadas à Prótese/microbiologia , Sistema de Registros , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados UnidosAssuntos
Granulomatose com Poliangiite/diagnóstico , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/etiologia , Vasculite/complicações , Vasculite/diagnóstico , Biópsia , Eletrocardiografia , Feminino , Granulomatose com Poliangiite/patologia , Granulomatose com Poliangiite/fisiopatologia , Humanos , Imageamento por Ressonância Magnética , Miocárdio/patologia , Taquicardia Ventricular/fisiopatologia , Vasculite/fisiopatologia , Adulto JovemRESUMO
INTRODUCTION: Extensive in vitro studies and clinical evidence (MERLIN trial) indicate an antiarrhythmic potential of ranolazine, a novel antianginal agent. Programmed electrophysiologic testing was performed to quantify ranolazine's effects on ventricular vulnerability and defibrillation thresholds and to gain insights into mechanisms. METHODS AND RESULTS: Effects of ranolazine (9.2 +/- 2.1 microM, plasma level) on surface ECG, right ventricular effective refractory period (ERP), and repetitive extrasystole (RE), ventricular fibrillation (VF), and defibrillation (DFT) thresholds were determined in 29 normal closed-chest anesthetized pigs. The single extrastimulus method was employed for ERP and for RE and VF thresholds. DFT(50) was determined using an up-down testing protocol with an implantable cardioverter-defibrillator. Ranolazine increased rate-corrected QT interval from 490 +/- 30 to 527 +/- 24 ms (P < 0.05) but did not alter T(peak)-T(end) interval (59 +/- 8 to 62 +/- 11, P = 0.65). ERP increased by 40 +/- 6 ms (P < 0.001). Compared with baseline, ranolazine raised RE threshold from 20 +/- 6 to 34 +/- 9 mA (P < 0.001) and VF threshold from 38 +/- 4 to 48 +/- 10 mA (P < 0.05). DFT(50) was unchanged (baseline: 14 +/- 2 J; ranolazine: 14 +/- 2 J; P = 0.6), whereas diastolic pacing threshold increased from baseline pulse width of 0.07 +/- 0.03 to 0.17 +/- 0.07 ms (P < 0.01) with 1V pulse amplitude. CONCLUSIONS: Ranolazine, at therapeutic concentrations, produces a mild increase in QT interval and a marked increase in both RE and VF thresholds. Thus, ranolazine does not augment and may improve dispersion of ventricular repolarization, suggesting a potential antiarrhythmic action. Ranolazine is unlikely to affect the margin of safety of defibrillation, given no significant effect on DFT, but could result in a mild increase in pacing threshold.
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Acetanilidas/administração & dosagem , Limiar Diferencial/fisiologia , Cardioversão Elétrica/métodos , Sistema de Condução Cardíaco/fisiologia , Piperazinas/administração & dosagem , Função Ventricular Esquerda/fisiologia , Animais , Limiar Diferencial/efeitos dos fármacos , Inibidores Enzimáticos/administração & dosagem , Sistema de Condução Cardíaco/efeitos dos fármacos , Ranolazina , Suínos , Função Ventricular Esquerda/efeitos dos fármacosRESUMO
Risk stratification for primary prevention of sudden cardiac death (SCD) remains a major challenge in cardiology. The utility of T-wave alternans (TWA) as a marker of risk of life-threatening ventricular tachycardia and fibrillation is supported by two decades of basic and clinical research. Both frequency- and time-domain methods have been developed, validated, and made available in clinical practice. A principal application of TWA testing has been to improve assessment of patients with depressed left ventricular ejection fraction (EF; = 40%) who are considered for implantable cardioverter-defibrillator (ICD) implantation for primary prevention of SCD. TWA has been most useful in identifying patients who are unlikely to benefit from ICD therapy. Although patients with low EF should remain an important focus, the absolute number of SCD events is far greater among post-myocardial infarction patients with relatively preserved EF, even though the incidence of SCD in this population is low. Recent studies suggest that TWA testing is predictive in this population as well. Absolute quantification of TWA rather than binary classification into "normal" or "abnormal" appears to be valuable in more finely stratifying the magnitude of arrhythmic risk. Longitudinal testing may be warranted in certain populations, although the optimum interval remains to be determined. Combining TWA with noninvasive markers of autonomic function, such as heart rate turbulence, may further increase predictive accuracy. Future development will likely expand the role of TWA testing with routine exercise and ambulatory electrocardiographic monitoring to screen lower-risk populations and to guide medical and device-based therapy.
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BACKGROUND: Previous studies have demonstrated that alterations in myocardial structure, consistent with tissue and sarcomere disruption as well as myofibril dissociation, occur after myocardial ischemia and reperfusion. In this study we determine the onset of these structural changes and their contribution to electrical conduction. METHODS: Langendorff perfused rabbit hearts (n = 47) were subjected to 0, 5, 10, 15, 20, 25, and 30 minutes global ischemia, followed by 120 minutes reperfusion. Hemodynamics were recorded and tissue samples were collected for histochemical and immunohistochemical studies. Orthogonal epicardial conduction velocities were measured, with temperature controlled, in a separate group of 10 hearts subjected to 0 or 30 minutes of global ischemia, followed by 120 minutes of reperfusion. RESULTS: Histochemical and quantitative light microscopy spatial analysis showed significantly increased longitudinal and transverse interfibrillar separation after 15 minutes or more of ischemia (p < 0.05 versus control). Confocal immunohistochemistry and Western blot analysis demonstrated significant reductions (p < .05 versus control) of the intercellular adherens junction protein, N-cadherin, and the active phosphorylated isoform of the principal gap junction protein, connexin 43 at more than 15 minutes of ischemia. Cellular redistribution of connexin 43 was also evidenced on immunohistochemistry. No change in integrin-beta1, an extracellular matrix attachment protein, or in epicardial conduction velocity anisotropy was observed. CONCLUSIONS: These data indicate that there are significant alterations in the structural integrity of the myocardium as well as gap and adherens junction protein expression with increasing global ischemia time. The changes occur coincident with previously observed significant decreases in postischemic functional recovery, but are not associated with altered expression of matrix binding proteins or electrical anisotropic conduction.
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Junções Aderentes/fisiologia , Proteínas da Matriz Extracelular/fisiologia , Junções Comunicantes/fisiologia , Sistema de Condução Cardíaco/fisiopatologia , Traumatismo por Reperfusão Miocárdica/fisiopatologia , Proteínas , Junções Aderentes/patologia , Animais , Técnicas Eletrofisiológicas Cardíacas , Junções Comunicantes/patologia , CoelhosRESUMO
This study examined whether the antifibrillatory action of nitroglycerin (NTG) is attributable to reduction in calcium-induced heterogeneity of repolarization independent of autonomic and coronary vasodilatory influences. The effects of intrapericardial (IPC) NTG on coronary blood flow, contractility, repolarization, and arrhythmia susceptibility were measured in anesthetized pigs (N = 43). Autonomic influences were minimized by vagotomy and beta-adrenergic blockade (metoprolol, 1.25 mg/kg, intravenous). Electrophysiological parameters were tested at 30 min, a time when coronary hemodynamics had returned to baseline. Intracoronary calcium chloride (CaCl2, 50-mg bolus) injection augmented contractility (dP/dt(max), 1760 +/- 144 to 2769 +/- 274 mmHg/s, and following NTG, 1531 +/- 384 to 2138 +/- 242 mmHg/s, P < 0.0002), reflecting increased myocardial intracellular calcium. Calcium increased repolarization heterogeneity (interlead precordial T-wave heterogeneity, 95 +/- 15 to 264 +/- 33 microV, P < 0.006; T(peak)-T(end), an index of transmural dispersion of repolarization, 37 +/- 3 to 76 +/- 6 ms, P < 0.05) and lowered repetitive extrasystole threshold (RET; 24 +/- 2 to 13 +/- 1 mA, and following NTG, 32 +/- 4 to 18 +/- 1 mA, P < 0.0001). IPC NTG raised the RET from baseline by 33% and blunted calcium-induced contractility (dP/dt(max) by 23%, P < 0.05), repolarization changes (T-wave heterogeneity by 24%, P < 0.006; T(peak)-T(end) by 18%, P = 0.04), and arrhythmia vulnerability (RET by 39%, P < 0.003). Thus, the capacity of NTG to suppress calcium-induced repolarization heterogeneity is an important mechanism of its antiarrhythmic action, which is independent of autonomic and vasodilatory actions.
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Antiarrítmicos/farmacologia , Cálcio/antagonistas & inibidores , Eletrocardiografia/efeitos dos fármacos , Nitroglicerina/farmacologia , Animais , Pressão Sanguínea/efeitos dos fármacos , Circulação Coronária/efeitos dos fármacos , Feminino , Frequência Cardíaca/efeitos dos fármacos , Masculino , Contração Miocárdica/efeitos dos fármacos , SuínosRESUMO
This is a case of two siblings with the autosomal recessive Wolfram syndrome who both have documented atrioventricular nodal reentrant tachycardia (AVNRT). This is the first report to our knowledge that links AVNRT to a syndrome in which the putative gene has been identified.
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Irmãos , Taquicardia por Reentrada no Nó Atrioventricular/fisiopatologia , Síndrome de Wolfram/fisiopatologia , Adulto , Eletrocardiografia , Feminino , Humanos , Masculino , Taquicardia por Reentrada no Nó Atrioventricular/diagnóstico , Síndrome de Wolfram/diagnósticoRESUMO
In children, interruption of cardiac atrioventricular (AV) electrical conduction can result from congenital defects, surgical interventions, and maternal autoimmune diseases during pregnancy. Complete AV conduction block is typically treated by implanting an electronic pacemaker device, although long-term pacing therapy in pediatric patients has significant complications. As a first step toward developing a substitute treatment, we implanted engineered tissue constructs in rat hearts to create an alternative AV conduction pathway. We found that skeletal muscle-derived cells in the constructs exhibited sustained electrical coupling through persistent expression and function of gap junction proteins. Using fluorescence in situ hybridization and polymerase chain reaction analyses, myogenic cells in the constructs were shown to survive in the AV groove of implanted hearts for the duration of the animal's natural life. Perfusion of hearts with fluorescently labeled lec-tin demonstrated that implanted tissues became vascularized and immunostaining verified the presence of proteins important in electromechanical integration of myogenic cells with surrounding re-cipient rat cardiomyocytes. Finally, using optical mapping and electrophysiological analyses, we provide evidence of permanent AV conduction through the implant in one-third of recipient animals. Our experiments provide a proof-of-principle that engineered tissue constructs can function as an electrical conduit and, ultimately, may offer a substitute treatment to conventional pacing therapy.
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Sistema de Condução Cardíaco/fisiologia , Coração/fisiologia , Células Musculares/citologia , Células Musculares/transplante , Músculo Esquelético/citologia , Engenharia Tecidual , Animais , Nó Atrioventricular/fisiologia , Comunicação Celular/fisiologia , Diferenciação Celular/fisiologia , Transplante de Células , Conexinas , Immunoblotting , Imuno-Histoquímica , Hibridização in Situ Fluorescente , Microscopia Eletrônica de Transmissão , Músculo Esquelético/irrigação sanguínea , Músculo Esquelético/fisiologia , Reação em Cadeia da Polimerase , Ratos , Ratos Endogâmicos Lew , Células-Tronco/citologia , Células-Tronco/metabolismoRESUMO
Ethanol septal ablation has emerged as a less invasive alternative to surgical myomectomy for treatment of asymmetric hypertrophic obstructive cardiomyopathy (ASH). The procedure has very low mortality, but high-degree AV conduction block is a frequent complication. Prior studies have documented baseline left bundle branch block and high volume of ethanol injection (greater than 4 mL) as risk factors. Complete heart block is often preceded by postprocedure conduction abnormalities and generally develops within 48 hours after ethanol ablation. We present a unique case of a patient with symmetric hypertensive hypertrophic obstructive cardiomyopathy (SHOCM) who developed phase IV complete heart block >96 hours postprocedure without preceding conduction abnormalities or other classic risk factors.
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Cardiomiopatia Hipertrófica/tratamento farmacológico , Etanol/administração & dosagem , Bloqueio Cardíaco/induzido quimicamente , Eletrocardiografia , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de TempoAssuntos
Fibrilação Atrial/terapia , Transplante de Células/métodos , Animais , Nó Atrioventricular/fisiopatologia , Estimulação Cardíaca Artificial , Fibroblastos/citologia , Fibroblastos/efeitos dos fármacos , Fibroblastos/transplante , Humanos , Fator de Crescimento Transformador beta/farmacologia , Fator de Crescimento Transformador beta1RESUMO
AIMS: This study evaluates whether non-inducibility of atrial fibrillation (AF) after achieving bi-directional electrical pulmonary vein (PV) isolation is a useful predictor of freedom from AF recurrence. METHODS AND RESULTS: This study included 102 consecutive patients who underwent PV isolation for symptomatic paroxysmal (59%), persistent (32%), or permanent (9%) AF. Patients were followed for 16+/-10 months. Complete isolation of all four PVs was confirmed by demonstration of bi-directional block, defined by both loss of PV potentials and failure to capture the LA by pacing (at 10 mA) 10-14 bipolar pairs of electrodes on a circumferential catheter positioned at the entrance of the PV. Induction of AF by burst pacing on/off isoproterenol was attempted after PV isolation. Freedom from recurrent symptomatic or asymptomatic AF was present in 70% of patients at 6 months and 62% of patients at 12 months. In multi-variable analysis, non-inducibility post-PV isolation (OR=3.84, P=0.047) and paroxysmal AF (OR=4.80, P=0.012) predicted freedom from AF at 12 months. CONCLUSION: Non-inducibility of AF after bi-directional PV isolation predicts maintenance of sinus rhythm. This finding suggests that routine extensive left atrial ablation may be unnecessary.