Global disparities in arrhythmia care: Mind the gap

Bridging the Gaps in Atrial Fibrillation Management in the Emergency Department

Atrial fibrillation (AF) frequently presents in emergency departments (EDs), contributing significantly to adverse cardiovascular outcomes. Despite established guidelines, ED management of AF often varies, revealing important gaps in care. This review addresses specific challenges in AF management for patients in the ED, including the nuances of rate versus rhythm control, the timing of anticoagulation initiation, and patient disposition. The updated 2024 European Society of Cardiology (ESC) guidelines advocate early rhythm control for select patients while recommending rate control for others; however, uncertainties persist, particularly regarding these strategies' long-term impact on outcomes. Stroke prevention through timely anticoagulation remains crucial, though the ideal timing, especially for new-onset AF, needs further research. Additionally, ED discharge protocols and follow-up care for AF patients are often inconsistent, leaving many without proper long-term management. Integration of emerging therapies, including direct oral anticoagulants and advanced antiarrhythmic drugs, shows potential but remains uneven across EDs. Innovative multidisciplinary models, such as "AF Heart Teams" and observation units, could enhance care but face practical challenges in implementation. This review underscores the need for targeted research to refine AF management, optimize discharge protocols, and incorporate novel therapies effectively. Standardizing ED care for AF could significantly reduce stroke risk, lower readmission rates, and improve overall patient outcomes.

Global Health Inequities in Electrophysiology Care: A State-of-the-Art Review

This state-of-the-art review examines disparities in the diagnosis, management, and outcomes of cardiac arrhythmias globally. These arrhythmias include atrial fibrillation, ventricular tachyarrhythmias underlying sudden cardiac death, and bradyarrhythmias associated with sinus node and atrioventricular node disease. Arrhythmias in low- and middle-income countries often result in higher mortality rates due to complex and poorly documented risk factors, lack of clinical expertise among health care personnel, lack of sufficient infrastructure, and challenges in access to care. Innovative approaches like repurposing pacemakers, mobile clinics, use of digital technology, and training initiatives are being explored to address these issues. This article highlights the importance of diagnosis of arrhythmias in varying resource settings, access to care in those settings, and ongoing efforts to expand access to care.

Psychopathology associated with cardiac pacing in Tanzania: A case series

Emotional disarray linked to interventional procedures may potentially aggravate previous psychiatric conditions or even precipitate new psychopathologies. Despite of the well-known deleterious impact of mental health disorders on cardiac outcomes, psychological disturbances are relatively understudied yet of vital importance to the overall health of post-pacing patients. In this case series we present a spectrum of mental illnesses observed in a cohort of patients who underwent permanent pacemaker implantation in Tanzania's national referral cardiac centre. Five individuals of African origin aged between 58 and 81 years presented to Jakaya Kikwete Cardiac Institute with clinical conditions warranting permanent pacemaker implantation. All five denied prior history of mental illness, however, after thorough psychiatric reviews; organic brain syndrome, panic disorder, brief psychotic disorder, adjustment disorder and major depressive disorder diagnoses were reached. All five were successfully channeled for medical psychotherapy. To conclude, this case series illustrates variable consequences of poor psychological adaptation to implantable cardiac devices, and it underscores the importance of continued psychological evaluation to such patients.