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Journal of the American College of... Feb 2022Hypertrophic cardiomyopathy (HCM), a relatively common, globally distributed, and often inherited primary cardiac disease, has now transformed into a contemporary highly...
Hypertrophic cardiomyopathy (HCM), a relatively common, globally distributed, and often inherited primary cardiac disease, has now transformed into a contemporary highly treatable condition with effective options that alter natural history along specific personalized adverse pathways at all ages. HCM patients with disease-related complications benefit from: matured risk stratification in which major markers reliably select patients for prophylactic defibrillators and prevention of arrhythmic sudden death; low risk to high benefit surgical myectomy (with percutaneous alcohol ablation a selective alternative) that reverses progressive heart failure caused by outflow obstruction; anticoagulation prophylaxis that prevents atrial fibrillation-related embolic stroke and ablation techniques that decrease the frequency of paroxysmal episodes; and occasionally, heart transplant for end-stage nonobstructive patients. Those innovations have substantially improved outcomes by significantly reducing morbidity and HCM-related mortality to 0.5%/y. Palliative pharmacological strategies with currently available negative inotropic drugs can control symptoms over the short-term in some patients, but generally do not alter long-term clinical course. Notably, a substantial proportion of HCM patients (largely those identified without outflow obstruction) experience a stable/benign course without major interventions. The expert panel has critically appraised all available data and presented management insights and recommendations with concise principles for clinical decision-making.
Topics: Cardiomyopathy, Hypertrophic; Death, Sudden, Cardiac; Humans
PubMed: 35086661
DOI: 10.1016/j.jacc.2021.11.021 -
Circulation Oct 2020
Topics: Advanced Cardiac Life Support; American Heart Association; Cardiology; Cardiology Service, Hospital; Cardiopulmonary Resuscitation; Consensus; Emergencies; Emergency Service, Hospital; Evidence-Based Medicine; Heart Arrest; Humans; Risk Factors; Treatment Outcome; United States
PubMed: 33081529
DOI: 10.1161/CIR.0000000000000916 -
Circulation Oct 2020
Topics: Advanced Cardiac Life Support; American Heart Association; Cardiology; Cardiology Service, Hospital; Cardiopulmonary Resuscitation; Consensus; Emergencies; Emergency Service, Hospital; Evidence-Based Medicine; Heart Arrest; Humans; Risk Factors; Treatment Outcome; United States
PubMed: 33081530
DOI: 10.1161/CIR.0000000000000918 -
Circulation Oct 2020
Topics: Adolescent; Advanced Cardiac Life Support; Age Factors; American Heart Association; Cardiology; Cardiology Service, Hospital; Cardiopulmonary Resuscitation; Child; Child, Preschool; Consensus; Emergencies; Emergency Service, Hospital; Evidence-Based Medicine; Heart Arrest; Humans; Infant; Pediatrics; Risk Factors; Treatment Outcome; United States
PubMed: 33081526
DOI: 10.1161/CIR.0000000000000901 -
The Cochrane Database of Systematic... Sep 2019Atrial fibrillation is the most frequent sustained arrhythmia. Atrial fibrillation often recurs after restoration of normal sinus rhythm. Antiarrhythmic drugs have been...
BACKGROUND
Atrial fibrillation is the most frequent sustained arrhythmia. Atrial fibrillation often recurs after restoration of normal sinus rhythm. Antiarrhythmic drugs have been widely used to prevent recurrence. This is an update of a review previously published in 2006, 2012 and 2015.
OBJECTIVES
To determine the effects of long-term treatment with antiarrhythmic drugs on death, stroke, drug adverse effects and recurrence of atrial fibrillation in people who had recovered sinus rhythm after having atrial fibrillation.
SEARCH METHODS
We updated the searches of CENTRAL, MEDLINE and Embase in January 2019, and ClinicalTrials.gov and WHO ICTRP in February 2019. We checked the reference lists of retrieved articles, recent reviews and meta-analyses.
SELECTION CRITERIA
Two authors independently selected randomised controlled trials (RCTs) comparing any antiarrhythmic drug with a control (no treatment, placebo, drugs for rate control) or with another antiarrhythmic drug in adults who had atrial fibrillation and in whom sinus rhythm was restored, spontaneously or by any intervention. We excluded postoperative atrial fibrillation.
DATA COLLECTION AND ANALYSIS
Two authors independently assessed quality and extracted data. We pooled studies, if appropriate, using Mantel-Haenszel risk ratios (RR), with 95% confidence intervals (CI). All results were calculated at one year of follow-up or the nearest time point.
MAIN RESULTS
This update included one new study (100 participants) and excluded one previously included study because of double publication. Finally, we included 59 RCTs comprising 20,981 participants studying quinidine, disopyramide, propafenone, flecainide, metoprolol, amiodarone, dofetilide, dronedarone and sotalol. Overall, mean follow-up was 10.2 months.All-cause mortalityHigh-certainty evidence from five RCTs indicated that treatment with sotalol was associated with a higher all-cause mortality rate compared with placebo or no treatment (RR 2.23, 95% CI 1.03 to 4.81; participants = 1882). The number need to treat for an additional harmful outcome (NNTH) for sotalol was 102 participants treated for one year to have one additional death. Low-certainty evidence from six RCTs suggested that risk of mortality may be higher in people taking quinidine (RR 2.01, 95% CI 0.84 to 4.77; participants = 1646). Moderate-certainty evidence showed increased RR for mortality but with very wide CIs for metoprolol (RR 2.02, 95% CI 0.37 to 11.05, 2 RCTs, participants = 562) and amiodarone (RR 1.66, 95% CI 0.55 to 4.99, 2 RCTs, participants = 444), compared with placebo.We found little or no difference in mortality with dofetilide (RR 0.98, 95% CI 0.76 to 1.27; moderate-certainty evidence) or dronedarone (RR 0.86, 95% CI 0.68 to 1.09; high-certainty evidence) compared to placebo/no treatment. There were few data on mortality for disopyramide, flecainide and propafenone, making impossible a reliable estimation for those drugs.Withdrawals due to adverse eventsAll analysed drugs increased withdrawals due to adverse effects compared to placebo or no treatment (quinidine: RR 1.56, 95% CI 0.87 to 2.78; disopyramide: RR 3.68, 95% CI 0.95 to 14.24; propafenone: RR 1.62, 95% CI 1.07 to 2.46; flecainide: RR 15.41, 95% CI 0.91 to 260.19; metoprolol: RR 3.47, 95% CI 1.48 to 8.15; amiodarone: RR 6.70, 95% CI 1.91 to 23.45; dofetilide: RR 1.77, 95% CI 0.75 to 4.18; dronedarone: RR 1.58, 95% CI 1.34 to 1.85; sotalol: RR 1.95, 95% CI 1.23 to 3.11). Certainty of the evidence for this outcome was low for disopyramide, amiodarone, dofetilide and flecainide; moderate to high for the remaining drugs.ProarrhythmiaVirtually all studied antiarrhythmics showed increased proarrhythmic effects (counting both tachyarrhythmias and bradyarrhythmias attributable to treatment) (quinidine: RR 2.05, 95% CI 0.95 to 4.41; disopyramide: no data; flecainide: RR 4.80, 95% CI 1.30 to 17.77; metoprolol: RR 18.14, 95% CI 2.42 to 135.66; amiodarone: RR 2.22, 95% CI 0.71 to 6.96; dofetilide: RR 5.50, 95% CI 1.33 to 22.76; dronedarone: RR 1.95, 95% CI 0.77 to 4.98; sotalol: RR 3.55, 95% CI 2.16 to 5.83); with the exception of propafenone (RR 1.32, 95% CI 0.39 to 4.47) for which the certainty of evidence was very low and we were uncertain about the effect. Certainty of the evidence for this outcome for the other drugs was moderate to high.StrokeEleven studies reported stroke outcomes with quinidine, disopyramide, flecainide, amiodarone, dronedarone and sotalol. High-certainty evidence from two RCTs suggested that dronedarone may be associated with reduced risk of stroke (RR 0.66, 95% CI 0.47 to 0.95; participants = 5872). This result is attributed to one study dominating the meta-analysis and has yet to be reproduced in other studies. There was no apparent effect on stroke rates with the other antiarrhythmics.Recurrence of atrial fibrillationModerate- to high-certainty evidence, with the exception of disopyramide which was low-certainty evidence, showed that all analysed drugs, including metoprolol, reduced recurrence of atrial fibrillation (quinidine: RR 0.83, 95% CI 0.78 to 0.88; disopyramide: RR 0.77, 95% CI 0.59 to 1.01; propafenone: RR 0.67, 95% CI 0.61 to 0.74; flecainide: RR 0.65, 95% CI 0.55 to 0.77; metoprolol: RR 0.83 95% CI 0.68 to 1.02; amiodarone: RR 0.52, 95% CI 0.46 to 0.58; dofetilide: RR 0.72, 95% CI 0.61 to 0.85; dronedarone: RR 0.85, 95% CI 0.80 to 0.91; sotalol: RR 0.83, 95% CI 0.80 to 0.87). Despite this reduction, atrial fibrillation still recurred in 43% to 67% of people treated with antiarrhythmics.
AUTHORS' CONCLUSIONS
There is high-certainty evidence of increased mortality associated with sotalol treatment, and low-certainty evidence suggesting increased mortality with quinidine, when used for maintaining sinus rhythm in people with atrial fibrillation. We found few data on mortality in people taking disopyramide, flecainide and propafenone, so it was not possible to make a reliable estimation of the mortality risk for these drugs. However, we did find moderate-certainty evidence of marked increases in proarrhythmia and adverse effects with flecainide.Overall, there is evidence showing that antiarrhythmic drugs increase adverse events, increase proarrhythmic events and some antiarrhythmics may increase mortality. Conversely, although they reduce recurrences of atrial fibrillation, there is no evidence of any benefit on other clinical outcomes, compared with placebo or no treatment.
Topics: Anti-Arrhythmia Agents; Atrial Fibrillation; Electric Countershock; Humans; Randomized Controlled Trials as Topic; Recurrence; Secondary Prevention
PubMed: 31483500
DOI: 10.1002/14651858.CD005049.pub5 -
Cureus Aug 2023Sudden cardiac death (SCD) is a condition that accounts for a high percentage of cardiovascular fatalities, with ventricular tachyarrhythmias being the most common... (Review)
Review
Sudden cardiac death (SCD) is a condition that accounts for a high percentage of cardiovascular fatalities, with ventricular tachyarrhythmias being the most common cause. There are signs and symptoms of SCD that occur spontaneously without any warning and are deadly. Despite preventative efforts focusing on the use of subcutaneous implanted cardioverter defibrillators (S-ICD) in the highest-risk population categories, a high number of SCDs occur in the normal population and in people who do not have a documented cardiac condition. Therefore, primary prevention for SCD should be a more viable strategy for the general population, considering measures in the form of preventive medicine such as knowing more about any genetic predisposition, family history of any fatal arrhythmia, continuous surveillance after any syncope with unknown causes, etc. However, little data about SCD risk factors are known in comparison with other well-known diseases like ischemic heart disease and stroke. In search of medical databases for relevant medical literature, we looked at PubMed/Medline, the Cochrane Library, and Google Scholar. Thirteen publications were discovered after the papers were located, assessed, and qualifying criteria were applied. The finished articles were done to give an overview of SCD. Some others have shown that the major predisposition for SCD is related to the male gender, which increases the incidence if they have a family history of SCD. We described the importance of obstructive sleep apnea (OSA) as a comorbid condition. Patients with S-ICD and young athletes with a history of ventricular arrhythmia showed us that the predisposition for SCD can be higher than in the normal population. Based on the above, we concluded that more study is required to establish the most important approach for each of the risk factors mentioned in this systematic review in order to apply them in daily practice and have more knowledge about how to apply preventive and therapeutic medicine to the population at risk and the ones that already develop the disease.
PubMed: 37664320
DOI: 10.7759/cureus.42859 -
Journal of Clinical Medicine May 2023Subcutaneous implantable cardioverter defibrillators (S-ICDs) have emerged in recent years as a valid alternative to traditional transvenous ICDs (TV-ICDs). Therefore,... (Review)
Review
BACKGROUND AND PURPOSE
Subcutaneous implantable cardioverter defibrillators (S-ICDs) have emerged in recent years as a valid alternative to traditional transvenous ICDs (TV-ICDs). Therefore, the number of S-ICD implantations is rising, leading to a consequent increase in S-ICD-related complications sometimes requiring complete device removal. Thus, the aim of this systematic review is to gather all the available literature on S-ICD lead extraction (SLE), with particular reference to the type of indication, techniques, complications and success rate.
METHODS
Studies were identified by searching electronic databases (Medline via PubMed, Scopus and Web of Science) from inception to 21 November 2022. The search strategy adopted was developed using the following key words: subcutaneous, S-ICD, defibrillator, ICD, extraction, explantation. Studies were included if they met both of the following criteria: (1) inclusion of patients with S-ICD; (2) inclusion of patients who underwent SLE.
RESULTS
Our literature search identified 238 references. Based on the abstract evaluation, 38 of these citations were considered potentially eligible for inclusion, and their full texts were analyzed. We excluded 8 of these studies because no SLE was performed. Eventually, 30 studies were included, with 207 patients who underwent SLE. Overall, the majority of SLEs were performed for non-infective causes (59.90%). Infection of the device (affecting either the lead or the pocket) was the cause of SLE in 38.65% of cases. Indication data were not available in 3/207 cases. The mean dwelling time was 14 months. SLEs were performed using manual traction or with the aid of a tool designed for transvenous lead extraction (TLE), including either a rotational or non-powered mechanical dilator sheath.
CONCLUSIONS
SLE is performed mainly for non-infective causes. Techniques vary greatly across different studies. Dedicated tools for SLE might be developed in the future and standard approaches should be defined. In the meantime, authors are encouraged to share their experience and data to further refine the existing variegated approaches.
PubMed: 37297905
DOI: 10.3390/jcm12113710 -
Sensors (Basel, Switzerland) Apr 2022For cardiac defibrillator testing and design purposes, the range and limits of the human TTI is of high interest. Potential influencing factors regarding the electronic... (Review)
Review
For cardiac defibrillator testing and design purposes, the range and limits of the human TTI is of high interest. Potential influencing factors regarding the electronic configurations, the electrode/tissue interface and patient characteristics were identified and analyzed. A literature survey based on 71 selected articles was used to review and assess human TTI and the influencing factors found. The human TTI extended from 12 to 212 Ω in the literature selected. Excluding outliers and pediatric measurements, the mean TTI recordings ranged from 51 to 112 Ω with an average TTI of 76.7 Ω under normal distribution. The wide range of human impedance can be attributed to 12 different influencing factors, including shock waveforms and protocols, coupling devices, electrode size and pressure, electrode position, patient age, gender, body dimensions, respiration and lung volume, blood hemoglobin saturation and different pathologies. The coupling device, electrode size and electrode pressure have the greatest influence on TTI.
Topics: Cardiography, Impedance; Child; Electric Countershock; Electric Impedance; Electrodes; Heart; Humans
PubMed: 35408422
DOI: 10.3390/s22072808 -
The Journal of Innovations in Cardiac... May 2022Defibrillation threshold (DFT) testing is performed in individuals with higher predicted risks of defibrillation failure. Many strategies have been explored to overcome...
Defibrillation threshold (DFT) testing is performed in individuals with higher predicted risks of defibrillation failure. Many strategies have been explored to overcome the challenge of high DFT, including an insertion of a defibrillator lead into the azygos vein. We performed a systematic review of the literature to evaluate the safety and efficacy of azygos vein implantable cardioverter-defibrillator insertion for high DFT combined with the analysis of a single-center experience of the procedure at our institution. The literature search was performed in PubMed and Embase from database inception to December 2020 to identify all case reports and case series related to azygos vein defibrillator lead insertion. Our search identified 291 records. After excluding duplicate studies and those without DFT thresholds and non-azygos vascular destinations, 12 studies (23 cases) were reviewed from the current database. We also conducted a retrospective analysis of 5 cases performed at our institution, and a total of 28 patients were included in our final analysis. The mean age of the pooled cohort was 47 years (range, 17-88 years). Men composed 92% of the total cases, and the average body mass index was 34 kg/m. The mean ejection fraction (EF) was 25%, with 78% having non-ischemic cardiomyopathy. The left axillary (36%) or subclavian (48%) vein was the common percutaneous access point. The mean duration of azygos vein access and lead delivery was 22 min (range, 13-60 min). The average DFT prior to azygos coil insertion was 35 J (range, 20-45 J). Fifty-seven percent of cases achieved substantial DFT improvement, whereas 18% achieved relative improvement compared to the pre-procedural threshold. No immediate or remote procedure-related complications were reported in 24 cases where data were available. During an average follow-up period of 18 months, 5 patients had ventricular arrhythmic events requiring device therapy and 4 had successful cardioversion from the device. One patient died from cardiac arrest with variable device therapies of both unsuccessful and successful events. In conclusion, azygos vein defibrillator lead insertion has a considerable rate of success, ease of vascular access with minimal procedural time, and lower risks and complications. Larger studies and longer follow-up periods are warranted to establish its efficacy and safety.
PubMed: 35655807
DOI: 10.19102/icrm.2022.130502 -
ESC Heart Failure Apr 2023This systematic review evaluated the clinical effectiveness and safety of subcutaneous implantable cardioverter-defibrillator (S-ICD) in patients at an increased risk of... (Review)
Review
This systematic review evaluated the clinical effectiveness and safety of subcutaneous implantable cardioverter-defibrillator (S-ICD) in patients at an increased risk of sudden cardiac death and with an ICD indication for primary or secondary prevention. A systematic literature search was conducted in four databases (Medline via Ovid, Embase, the Cochrane Library, and HTA-INAHTA). Randomized controlled trials (RCTs) and controlled observational studies with ≥100 S-ICD patients and a low to moderate risk of bias were eligible for inclusion. The studies' quality and the available evidence's strength were assessed using the Cochrane risk of bias tool, the ROBINS-I tool, and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. One RCT, a post hoc analysis of the RCT (n = 849) and four controlled observational studies (n = 7149) were included. The quality of the available evidence was graded as low to very low, except for the primary composite endpoint of the RCT, which was rated as moderate quality. After 4 years, the RCT showed that S-ICD was non-inferior to TV-ICD regarding the composite endpoint of inappropriate shocks and device-related complications (68 [15.1%] vs. 68 [15.7%], hazard ratio [HR] 0.99, 95% confidence interval [CI] [0.71, 1.39], non-inferiority margin 1.45, P = 0.001). The RCT and two observational studies reported statistically significantly fewer lead complications in S-ICD patients (after 4 years: 1.4% vs. 6.6%, HR 0.24, 95% CI [0.10, 0.54]; after 3 years: 0.3% vs. 2.3%, P = 0.03; and after 5 years: 0.8% vs. 11.5%, P = 0.03). Identified evidence about appropriate and inappropriate shocks was inconclusive: The RCT detected statistically significantly more appropriate shocks in patients with S-ICD (83 [19.2%] vs. 57 [11.5%], HR 1.52, 95% CI [1.08, 2.12], P = 0.02), whereas one observational study showed a statistically significantly lower rate in the S-ICD group (9.9%, 95% CI [7.0, 13.9], vs. 13.9%, 95% CI [10.8, 17.8], P = 0.003). Regarding inappropriate shocks, one observational study reported statistically significantly higher rates in the S-ICD cohort (11.9% vs. 7.5%, P = 0.007), whereas the RCT and two other observational studies did not detect a statistically significant difference between the treatment groups (P > 0.05). None of the included studies showed a statistically significant difference in overall mortality and shock efficacy between patients with S-ICD and TV-ICD (P > 0.05). The available evidence is insufficient to show the superiority of S-ICD compared with TV-ICD, hindering the widespread use of the technology. Results of the recently completed ATLAS trial are to be awaited, and the anticipated role of the S-ICD needs to be clearly formulated.
Topics: Humans; Defibrillators, Implantable; Death, Sudden, Cardiac; Treatment Outcome; Observational Studies as Topic
PubMed: 36444868
DOI: 10.1002/ehf2.14249