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Affiliation(s)
- James A Reiffel
- Professor Emeritus of Medicine and Special Lecturer, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY
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Kowey PR, Naccarelli GV. Antiarrhythmic Drug Therapy: Where Do We Go From Here? Circulation 2024; 149:801-803. [PMID: 38466788 DOI: 10.1161/circulationaha.123.066989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/13/2024]
Affiliation(s)
- Peter R Kowey
- Thomas Jefferson University, Philadelphia, PA (P.R.K.)
- Lankenau Hearth Institute, Wynnewood, PA (P.R.K.)
| | - Gerald V Naccarelli
- Penn State Health, Penn State Heart and Vascular Institute, The Milton S. Hershey Medical Center, Hershey, PA (G.V.N.)
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Ray L, Geier C, DeWitt KM. Pathophysiology and treatment of adults with arrhythmias in the emergency department, part 1: Atrial arrhythmias. Am J Health Syst Pharm 2023; 80:1039-1055. [PMID: 37227130 DOI: 10.1093/ajhp/zxad108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Indexed: 05/26/2023] Open
Abstract
PURPOSE This article, the first in a 2-part review, aims to reinforce current literature on the pathophysiology of cardiac arrhythmias and various evidence-based treatment approaches and clinical considerations in the acute care setting. Part 1 of this series focuses on atrial arrhythmias. SUMMARY Arrhythmias are prevalent throughout the world and a common presenting condition in the emergency department (ED) setting. Atrial fibrillation (AF) is the most common arrhythmia worldwide and expected to increase in prevalence. Treatment approaches have evolved over time with advances in catheter-directed ablation. Based on historic trials, heart rate control has been the long-standing accepted outpatient treatment modality for AF, but the use of antiarrhythmics is often still indicated for AF in the acute setting, and ED pharmacists should be prepared and poised to help in AF management. Other atrial arrhythmias include atrial flutter (AFL), atrioventricular nodal reentry tachycardia (AVNRT), and atrioventricular reentrant tachycardia (AVRT), which warrant distinction due to their unique pathophysiology and because each requires a different approach to utilization of antiarrhythmics. Atrial arrhythmias are typically associated with greater hemodynamic stability than ventricular arrhythmias but still require nuanced management according to patient subset and risk factors. Since antiarrhythmics can also be proarrhythmic, they may destabilize the patient due to adverse effects, many of which are the focus of black-box label warnings that can be overreaching and limit treatment options. Electrical cardioversion for atrial arrhythmias is generally successful and, depending on the setting and/or hemodynamics, often indicated. CONCLUSION Atrial arrhythmias arise from a variety of mechanisms, and appropriate treatment depends on various factors. A firm understanding of physiological and pharmacological concepts serves as a foundation for exploring evidence supporting agents, indications, and adverse effects in order to provide appropriate care for patients.
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Affiliation(s)
- Lance Ray
- Denver Health and Hospital Authority, Denver, CO
- Department of Emergency Medicine, University of Colorado, Aurora, CO, USA
| | - Curtis Geier
- San Francisco General Hospital, San Francisco, CA, USA
| | - Kyle M DeWitt
- University of Vermont Medical Center, Burlington, VT, USA
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Hwang J, Oh YS, Park HS, Choi JI, Lee YS, Choi EK, Shin DG, On YK, Kim TH, Park HW, Cho MS, Bae MH, Han S. Comparing the Efficacy of Carvedilol and Flecainide on the Treatment of Idiopathic Premature Ventricular Complexes from Ventricular Outflow Tract: A Multicenter, Randomized, Open-Label Pilot Study. J Clin Med 2023; 12:jcm12082887. [PMID: 37109225 PMCID: PMC10144596 DOI: 10.3390/jcm12082887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 04/10/2023] [Accepted: 04/14/2023] [Indexed: 04/29/2023] Open
Abstract
The mechanism of premature ventricular complexes (PVC) occurring in the ventricular outflow tract (OT) is related to an intracellular calcium overload and delayed afterdepolarizations that lead to triggered activity. The guidelines recommend using beta-blockers and flecainide for idiopathic PVCs, but they also acknowledge the limited evidence supporting this recommendation. We conducted a multicenter, randomized, open-label pilot study comparing the effect of carvedilol and flecainide on OT PVC, which are widely used to treat this arrhythmia. Patients with a 24 h Holter recording a PVC burden ≥ 5%, which showed positive R waves in leads II, III, and aVF, and without structural heart disease were enrolled. They were randomly assigned to the carvedilol or flecainide group, and the maximum tolerated dose was administered for 12 weeks. A total of 103 participants completed the protocol: 51 with carvedilol and 52 with flecainide. After 12 weeks of treatment, the mean PVC burden significantly decreased in both groups: 20.3 ± 11.5 to 14.6 ± 10.8% with carvedilol (p < 0.0001) and 17.1 ± 9.9 to 6.6 ± 9.9% with flecainide (p < 0.0001). Both carvedilol and flecainide effectively suppressed OT PVCs in patients without structural heart disease, with flecainide showing a superior efficacy compared to carvedilol.
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Affiliation(s)
- Jongmin Hwang
- Cardiovascular Center, Keimyung University Dongsan Hospital, Daegu 42601, Republic of Korea
| | - Yong-Seog Oh
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Hyoung-Seob Park
- Cardiovascular Center, Keimyung University Dongsan Hospital, Daegu 42601, Republic of Korea
| | - Jong-Il Choi
- Arrhythmia Center, Korea University Medical Center Anam Hospital, Seoul 02841, Republic of Korea
| | - Young Soo Lee
- Department of Cardiology, Catholic University of Daegu, Daegu 42472, Republic of Korea
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Dong-Gu Shin
- Division of Cardiology, Department of Internal Medicine, Yeungnam University Medical Center, Yeungnam University College of Medicine, Daegu 42415, Republic of Korea
| | - Young Keun On
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - Tae-Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Hyung Wook Park
- Department of Cardiology, Chonnam National University Hospital, Gwangju 61469, Republic of Korea
| | - Min Soo Cho
- Department of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Republic of Korea
| | - Myung Hwan Bae
- Division of Cardiology, Department of Internal Medicine, Kyungpook National University Hospital, Daegu 41944, Republic of Korea
| | - Seongwook Han
- Cardiovascular Center, Keimyung University Dongsan Hospital, Daegu 42601, Republic of Korea
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Bray JJH, Warraich M, Whitfield MG, Peter CU, Baral R, Ahmad M, Ahmad S, Abraham GR, Kirresh A, Sahibzada MS, Muzaffar A, Tomson J, Lambiase PD, Captur G, Banerjee A, Providencia R. Oral Class I and III antiarrhythmic drugs for maintaining sinus rhythm after catheter ablation of atrial fibrillation. Cochrane Database Syst Rev 2023; 3:CD013765. [PMID: 36915032 PMCID: PMC10014144 DOI: 10.1002/14651858.cd013765.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
BACKGROUND Recurrence of atrial tachyarrhythmias (ATa) following catheter ablation for atrial fibrillation (AF) is a common problem. Antiarrhythmic drugs have been used shortly after ablation in an attempt to maintain sinus rhythm, particularly Class I and III agents. However, it still needs to be established if the use of Class I or III antiarrhythmic medications, or both, reduce the risk of recurrence of ATa. OBJECTIVES To assess the effects of oral Class I and III antiarrhythmic drugs versus control (standard medical therapy without Class I or III antiarrhythmics, or placebo) for maintaining sinus rhythm in people undergoing catheter ablation for AF. SEARCH METHODS We systematically searched CENTRAL, MEDLINE, Embase, Web of Science Core Collection, and two clinical trial registers without restrictions on language or date to 5 August 2022. SELECTION CRITERIA We sought published, unpublished, and ongoing parallel-design, randomised controlled trials (RCTs) involving adult participants undergoing ablation for AF, with subsequent comparison of Class I and/or III antiarrhythmic use versus control (standard medical therapy or non-Class I and/or III antiarrhythmic use). DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane and performed meta-analyses with risk ratios (RR) and Peto odds ratios (Peto OR). Our primary outcomes were recurrence of atrial tachyarrhythmias; adverse events: thromboembolic events; adverse events: myocardial infarction; adverse events: new diagnosis of heart failure; and adverse events: requirement for one or more hospitalisations for atrial tachyarrhythmia. Our secondary outcomes were: all-cause mortality; and requirement for one or more repeat ablations. Where possible, we performed comparison analysis by Class I and/or III antiarrhythmic and divided follow-up periods for our primary outcome. We performed comprehensive assessments of risk of bias and certainty of evidence applying the GRADE methodology. MAIN RESULTS We included nine RCTs involving a total of 3269 participants. Participants were on average 59.3 years old; 71.0% were male; and 72.9% and 27.4% had paroxysmal and persistent AF, respectively. Class I and/or III antiarrhythmics may reduce recurrence of ATa at 0 to 3 months postablation (risk ratio (RR) 0.74, 95% confidence interval (CI) 0.59 to 0.94, 8 trials, 3046 participants, low-certainty evidence) and likely reduce recurrence at > 3 to 6 months, our a priori primary time point (RR 0.85, 95% CI 0.78 to 0.93, 5 trials, 2591 participants, moderate-certainty evidence). Beyond six months the evidence is very uncertain, and the benefit of antiarrhythmics may not persist (RR 1.14, 95% CI 0.84 to 1.55, 4 trials, 2244 participants, very low-certainty evidence). The evidence suggests that Class I and/or III antiarrhythmics may not increase the risk of thromboembolic events, myocardial infarction, all-cause mortality, or requirement for repeat ablation, at 0 to 3, > 3 to 6, and > 6 months (where data were available; low- to very low-certainty evidence). The use of Class I and/or III antiarrhythmics postablation likely reduces hospitalisations for ATa by approximately 57% at 0 to 3 months (RR 0.43, 95% CI 0.28 to 0.64, moderate-certainty evidence). No data were available beyond three months. No data were available on new diagnoses of heart failure. Fewer data were available for Class I and III antiarrhythmics individually. Based on only one and two trials (n = 125 to 309), Class I antiarrhythmics may have little effect on recurrence of ATa at 0 to 3, > 3 to 6, and > 6 months (RR 0.88, 95% CI 0.64 to 1.20, 2 trials, 309 participants; RR 0.54, 95% CI 0.25 to 1.19, 1 trial, 125 participants; RR 0.87, 95% CI 0.57 to 1.32, 1 trial, 125 participants; low-certainty evidence throughout); requirement for hospitalisation for ATa at 0 to 3 months (low-certainty evidence); or requirement for repeat ablation at 0 to 3 months (low-certainty evidence). No data were available for thromboembolic events, myocardial infarction, new diagnosis of heart failure, or all-cause mortality at any time points, or hospitalisation or repeat ablation beyond three months. Class III antiarrhythmics may have little effect on recurrence of ATa at up to 3 months and at > 3 to 6 months (RR 0.76, 95% CI 0.50 to 1.16, 4 trials, 599 participants, low-certainty evidence; RR 0.82, 95% CI 0.62 to 1.09, 2 trials, 318 participants, low-certainty evidence), and beyond 6 months one trial reported a possible increase in recurrence of ATa (RR 1.95, 95% CI 1.29 to 2.94, 1 trial, 112 participants, low-certainty evidence). Class III antiarrhythmics likely reduce hospitalisations for ATa at 0 to 3 months (RR 0.40, 95% CI 0.26 to 0.63, moderate-certainty evidence), and may have little effect on all-cause mortality (low- to very low-certainty evidence). The effect of Class III antiarrhythmics on thromboembolic events and requirement for repeat ablation was uncertain (very low-certainty evidence for both outcomes). No data were available for myocardial infarction or new diagnosis of heart failure at any time point, outcomes other than recurrence beyond 6 months, or for hospitalisation and repeat ablation > 3 to 6 months. We assessed the majority of included trials as at low or unclear risk of bias. One trial reported an error in the randomisation process, raising the potential risk of selection bias; most of the included trials were non-blinded; and two trials were at high risk of attrition bias. AUTHORS' CONCLUSIONS We found evidence to suggest that the use of Class I and/or III antiarrhythmics up to 3 months after ablation is associated with a reduced recurrence of ATa 0 to 6 months after ablation, which may not persist beyond 6 months, and an immediate reduction in hospitalisation for ATa 0 to 3 months after ablation. The evidence suggests there is no difference in rates of all-cause mortality, thromboembolic events, or myocardial infarction between Class I and/or III antiarrhythmics versus control.
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Affiliation(s)
- Jonathan JH Bray
- Oxford Heart Centre, Oxford University Hospitals Trust, John Radcliffe Hospital, Headley Way, Headington, Oxford, UK
| | - Mazhar Warraich
- Department of Cardiology, Walsall Healthcare NHS Trust, Walsall, UK
| | - Michael G Whitfield
- Institute of Health Informatics Research, University College London, London, UK
- National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - Christina Udani Peter
- Department of Cardiology, Addenbrookes Hospital (Cambridge University Hospitals), Cambridge, UK
| | | | - Mahmood Ahmad
- Department of Cardiology, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Shazaib Ahmad
- Department of Anaesthesia, St Helier Hospital, London, UK
| | | | - Ali Kirresh
- Department of Cardiology, Royal Free Hospital, London, UK
| | | | - Adnan Muzaffar
- Department of Acute Medicine, Scunthrope General Hospital, Scunthorpe, UK
| | - Joseph Tomson
- Department of Cardiology, Royal Free Hospital, London, UK
| | - Pier D Lambiase
- Centre for Cardiology in the Young, The Heart Hospital, University College London Hospitals, London, UK
| | - Gabriella Captur
- Royal Free Hospital, London, UK
- MRC Unit of Lifelong Health and Ageing, University College London, London, UK
| | - Amitava Banerjee
- Institute of Health Informatics Research, University College London, London, UK
| | - Rui Providencia
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
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Yang E, Calkins H. Who Benefits Most From Early Rhythm Control in Newly Diagnosed Atrial Fibrillation? Circulation 2022; 146:848-850. [PMID: 36095065 DOI: 10.1161/circulationaha.122.060945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
- Eunice Yang
- Division of Cardiology, Inova Heart and Vascular Institute, Falls Church, VA (E.Y.)
| | - Hugh Calkins
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD (E.Y., H.C.)
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Rillig A, Borof K, Breithardt G, Camm AJ, Crijns HJGM, Goette A, Kuck KH, Metzner A, Vardas P, Vettorazzi E, Wegscheider K, Zapf A, Kirchhof P. Early Rhythm Control in Patients With Atrial Fibrillation and High Comorbidity Burden. Circulation 2022; 146:836-847. [PMID: 35968706 DOI: 10.1161/circulationaha.122.060274] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 07/12/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND The randomized EAST-AFNET4 (Early Treatment of Atrial Fibrillation for Stroke Prevention Trial-Atrial Fibrillation Network) demonstrated that early rhythm control (ERC) reduces adverse cardiovascular outcomes in patients with recently diagnosed atrial fibrillation and stroke risk factors. The effectiveness and safety of ERC in patients with multiple cardiovascular comorbidities is not known. METHODS These prespecified subanalyses of EAST-AFNET4 compared the effectiveness and safety of ERC with usual care (UC) stratified into patients with higher (CHA2DS2-VASc score ≥4) and lower comorbidity burden. Sensitivity analyses ignored sex (CHA2DS2-VA score). RESULTS EAST-AFNET4 randomized 1093 patients with CHA2DS2-VASc score ≥4 (74.8±6.8 years, 61% female) and 1696 with CHA2DS2-VASc score <4 (67.4±8.0 years, 37% female). ERC reduced the composite primary efficacy outcome of cardiovascular death, stroke, or hospitalization for worsening of heart failure or for acute coronary syndrome in patients with CHA2DS2-VASc score ≥4 (ERC, 127/549 patients with events; UC, 183/544 patients with events; hazard ratio [HR], 0.64 [0.51-0.81]; P < 0.001) but not in patients with CHA2DS2-VASc score <4 (ERC, 122/846 patients with events; UC, 133/850 patients with events; HR, 0.93 [0.73-1.19]; P=0.56, Pinteraction=0.037). The primary safety outcome (death, stroke, or serious adverse events of rhythm control therapy) was not different between study groups in patients with CHA2DS2-VASc score ≥4 (ERC, 112/549 patients with events; UC, 132/544 patients with events; HR, 0.84 [0.65, 1.08]; P=0.175), but occurred more often in patients with CHA2DS2-VASc scores <4 randomized to ERC (ERC, 119/846 patients with events; UC, 91/850 patients with events; HR, 1.39 [1.05-1.82]; P=0.019, Pinteraction=0.008). Life-threatening events or death were not different between groups (CHA2DS2-VASc score ≥4, ERC, 84/549 patients with event, UC, 96/544 patients with event; CHA2DS2-VASc scores <4, ERC, 75/846 patients with event, UC, 73/850 patients with event). When female sex was ignored for the creation of higher and lower risk groups (CHA2DS2-VA score), the Pinteraction was not significant for the primary efficacy outcome (P=0.25), but remained significant (P=0.044) for the primary safety outcome. CONCLUSIONS Patients with recently diagnosed atrial fibrillation and CHA2DS2-VASc score ≥4 should be considered for ERC to reduce cardiovascular outcomes, whereas those with fewer comorbidities may have less favorable outcomes with ERC. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT01288352. URL: https://www.clinicaltrialsregister.eu; Unique identifier: 2010-021258-20. URL: https://www.isrctn.com/; Unique identifier: ISRCTN04708680.
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Affiliation(s)
- Andreas Rillig
- Department of Cardiology, University Heart and Vascular Center (A.R., K.B., A.M., P.K.), University Medical Center Hamburg-Eppendorf, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Luebeck/Kiel, Germany (A.R., K.-H.K., A.M., K.W., P.K.)
| | - Katrin Borof
- Department of Cardiology, University Heart and Vascular Center (A.R., K.B., A.M., P.K.), University Medical Center Hamburg-Eppendorf, Germany
| | - Günter Breithardt
- Atrial Fibrillation Network (AFNET), Münster, Germany (G.B., A.G., K.-H.K., K.W., P.K.)
- Department of Cardiology II (Electrophysiology), University Hospital Münster, Germany (G.B.)
| | - A John Camm
- Cardiology Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St George's University of London, UK (A.J.C.)
| | - Harry J G M Crijns
- Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute, The Netherlands (H.J.G.M.C.)
| | - Andreas Goette
- Atrial Fibrillation Network (AFNET), Münster, Germany (G.B., A.G., K.-H.K., K.W., P.K.)
- St Vincenz Hospital, Paderborn, Germany (A.G.)
- Working Group of Molecular Electrophysiology, University Hospital Magdeburg, Germany (A.G.)
| | - Karl-Heinz Kuck
- German Center for Cardiovascular Research, Partner Site Hamburg/Luebeck/Kiel, Germany (A.R., K.-H.K., A.M., K.W., P.K.)
- Atrial Fibrillation Network (AFNET), Münster, Germany (G.B., A.G., K.-H.K., K.W., P.K.)
- LANS Cardio, Hamburg, Germany (K.-H.K.)
| | - Andreas Metzner
- Department of Cardiology, University Heart and Vascular Center (A.R., K.B., A.M., P.K.), University Medical Center Hamburg-Eppendorf, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Luebeck/Kiel, Germany (A.R., K.-H.K., A.M., K.W., P.K.)
| | - Panos Vardas
- Heart Sector, Hygeia Hospitals Group, Athens, Greece (P.V.)
| | - Eik Vettorazzi
- Institute of Medical Biometry and Epidemiology (E.V., K.W., A.Z.), University Medical Center Hamburg-Eppendorf, Germany
| | - Karl Wegscheider
- Institute of Medical Biometry and Epidemiology (E.V., K.W., A.Z.), University Medical Center Hamburg-Eppendorf, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Luebeck/Kiel, Germany (A.R., K.-H.K., A.M., K.W., P.K.)
- Atrial Fibrillation Network (AFNET), Münster, Germany (G.B., A.G., K.-H.K., K.W., P.K.)
| | - Antonia Zapf
- Institute of Medical Biometry and Epidemiology (E.V., K.W., A.Z.), University Medical Center Hamburg-Eppendorf, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center (A.R., K.B., A.M., P.K.), University Medical Center Hamburg-Eppendorf, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Luebeck/Kiel, Germany (A.R., K.-H.K., A.M., K.W., P.K.)
- Atrial Fibrillation Network (AFNET), Münster, Germany (G.B., A.G., K.-H.K., K.W., P.K.)
- Institute of Cardiovascular Sciences, University of Birmingham, UK (P.K.)
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Chew DS, Li Y, Cowper PA, Anstrom KJ, Piccini JP, Poole JE, Daniels MR, Monahan KH, Davidson-Ray L, Bahnson TD, Al-Khalidi HR, Lee KL, Packer DL, Mark DB. Cost-Effectiveness of Catheter Ablation Versus Antiarrhythmic Drug Therapy in Atrial Fibrillation: The CABANA Randomized Clinical Trial. Circulation 2022; 146:535-547. [PMID: 35726631 PMCID: PMC9378541 DOI: 10.1161/circulationaha.122.058575] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND In the CABANA trial (Catheter Ablation vs Antiarrhythmic Drug Therapy for Atrial Fibrillation), catheter ablation did not significantly reduce the primary end point of death, disabling stroke, serious bleeding, or cardiac arrest compared with drug therapy by intention-to-treat, but did improve the quality of life and freedom from atrial fibrillation recurrence. In the heart failure subgroup, ablation improved both survival and quality of life. Cost-effectiveness was a prespecified CABANA secondary end point. METHODS Medical resource use data were collected for all CABANA patients (N=2204). Costs for hospital-based care were assigned using prospectively collected bills from US patients (n=1171); physician and medication costs were assigned using the Medicare Fee Schedule and National Average Drug Acquisition Costs, respectively. Extrapolated life expectancies were estimated using age-based survival models. Quality-of-life adjustments were based on EQ-5D-based utilities measured during the trial. The primary outcome was the incremental cost-effectiveness ratio, comparing ablation with drug therapy on the basis of intention-to-treat, and assessed from the US health care sector perspective. RESULTS Costs in the first 3 months averaged $20 794±SD 1069 higher with ablation compared with drug therapy. The cumulative within-trial 5-year cost difference was $19 245 (95% CI, $11 360-$27 170) and the lifetime mean cost difference was $15 516 (95% CI, -$2963 to $35,512) higher with ablation than with drug therapy. The drug therapy arm accrued an average of 12.5 life-years (LYs) and 10.7 quality-adjusted life-years (QALYs). For the ablation arm, the corresponding estimates were 12.6 LYs and 11.0 QALYs. The incremental cost-effectiveness ratio was $57 893 per QALY gained, with 75% of bootstrap replications yielding an incremental cost-effectiveness ratio <$100 000 per QALY gained. With no quality-of-life/utility adjustments, the incremental cost-effectiveness ratio was $183 318 per LY gained. CONCLUSIONS Catheter ablation of atrial fibrillation was economically attractive compared with drug therapy in the CABANA Trial overall at present benchmarks for health care value in the United States on the basis of projected incremental QALYs but not LYs alone.
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Affiliation(s)
- Derek S Chew
- Duke Clinical Research Institute (D.S.C., Y.L., P.A.C., K.J.A., J.P.P., M.R.D., L.D.-R., T.D.B., H.R.A.-K., K.L.L., D.B.M.), Duke University, Durham, NC
- Department of Cardiac Sciences, Libin Cardiovascular Institute, University of Calgary, Alberta, Canada (D.S.C.)
| | - Yanhong Li
- Duke Clinical Research Institute (D.S.C., Y.L., P.A.C., K.J.A., J.P.P., M.R.D., L.D.-R., T.D.B., H.R.A.-K., K.L.L., D.B.M.), Duke University, Durham, NC
| | - Patricia A Cowper
- Duke Clinical Research Institute (D.S.C., Y.L., P.A.C., K.J.A., J.P.P., M.R.D., L.D.-R., T.D.B., H.R.A.-K., K.L.L., D.B.M.), Duke University, Durham, NC
| | - Kevin J Anstrom
- Duke Clinical Research Institute (D.S.C., Y.L., P.A.C., K.J.A., J.P.P., M.R.D., L.D.-R., T.D.B., H.R.A.-K., K.L.L., D.B.M.), Duke University, Durham, NC
- Department of Biostatistics and Bioinformatics (K.J.A., H.R.A.-K., K.L.L.), Duke University, Durham, NC
- Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC (K.J.A.)
| | - Jonathan P Piccini
- Duke Clinical Research Institute (D.S.C., Y.L., P.A.C., K.J.A., J.P.P., M.R.D., L.D.-R., T.D.B., H.R.A.-K., K.L.L., D.B.M.), Duke University, Durham, NC
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC (J.P.P., T.D.B., D.B.M.)
| | - Jeanne E Poole
- University of Washington Medical Center, Seattle (J.E.P.)
| | - Melanie R Daniels
- Duke Clinical Research Institute (D.S.C., Y.L., P.A.C., K.J.A., J.P.P., M.R.D., L.D.-R., T.D.B., H.R.A.-K., K.L.L., D.B.M.), Duke University, Durham, NC
| | | | - Linda Davidson-Ray
- Duke Clinical Research Institute (D.S.C., Y.L., P.A.C., K.J.A., J.P.P., M.R.D., L.D.-R., T.D.B., H.R.A.-K., K.L.L., D.B.M.), Duke University, Durham, NC
| | - Tristram D Bahnson
- Duke Clinical Research Institute (D.S.C., Y.L., P.A.C., K.J.A., J.P.P., M.R.D., L.D.-R., T.D.B., H.R.A.-K., K.L.L., D.B.M.), Duke University, Durham, NC
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC (J.P.P., T.D.B., D.B.M.)
| | - Hussein R Al-Khalidi
- Duke Clinical Research Institute (D.S.C., Y.L., P.A.C., K.J.A., J.P.P., M.R.D., L.D.-R., T.D.B., H.R.A.-K., K.L.L., D.B.M.), Duke University, Durham, NC
- Department of Biostatistics and Bioinformatics (K.J.A., H.R.A.-K., K.L.L.), Duke University, Durham, NC
| | - Kerry L Lee
- Duke Clinical Research Institute (D.S.C., Y.L., P.A.C., K.J.A., J.P.P., M.R.D., L.D.-R., T.D.B., H.R.A.-K., K.L.L., D.B.M.), Duke University, Durham, NC
- Department of Biostatistics and Bioinformatics (K.J.A., H.R.A.-K., K.L.L.), Duke University, Durham, NC
| | | | - Daniel B Mark
- Duke Clinical Research Institute (D.S.C., Y.L., P.A.C., K.J.A., J.P.P., M.R.D., L.D.-R., T.D.B., H.R.A.-K., K.L.L., D.B.M.), Duke University, Durham, NC
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC (J.P.P., T.D.B., D.B.M.)
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9
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Lim YT, Kim YH, Kwon JE. Effective Control of Supraventricular Tachycardia in Neonates May Requires Combination Pharmacologic Therapy. J Clin Med 2022; 11:3279. [PMID: 35743350 DOI: 10.3390/jcm11123279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 06/01/2022] [Accepted: 06/06/2022] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Supraventricular tachycardia (SVT) is one of the arrhythmias that can occur in newborns. Most SVT incidents in the neonatal period are spontaneously resolved around the first year of life, but since tachycardia can frequently occur before complete resolution, appropriate medication use is required. However, no clear guidelines or consensus on the treatment of neonatal SVT have been established yet. METHODS From January 2011 to December 2021, demographic data and antiarrhythmic medications used were retrospectively analyzed for 18 newborns diagnosed with SVT at a single center. RESULTS A total of four medications (propranolol, amiodarone, flecainide, and atenolol) were used as maintenance therapy to prevent tachycardia recurrence, and propranolol was the most used, followed by amiodarone. Thirty-nine percent of the patients were controlled with monotherapy, but the remainder required two or more medications. The median period from medication initiation after diagnosis to the last tachycardia event was 15.5 days, and the median total duration of medication use was 362 days. None of the patients experienced any side effects of antiarrhythmic medications. The total duration of medication use was statistically significant according to the mechanism of SVT, and the usage time of the increased automaticity group was shorter than that of the re-entry group. CONCLUSION Since most neonatal SVT resolves within 1 year, it is significant to provide prophylactic medication to prevent tachycardia recurrence at least until 1 year of age, and depending on the patient, the appropriate combination of medications should be identified.
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10
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Mar PL, Horbal P, Chung MK, Dukes JW, Ezekowitz M, Lakkireddy D, Lip GYH, Miletello M, Noseworthy PA, Reiffel JA, Tisdale JE, Olshansky B, Gopinathannair R. Drug Interactions Affecting Antiarrhythmic Drug Use. Circ Arrhythm Electrophysiol 2022; 15:e007955. [PMID: 35491871 DOI: 10.1161/circep.121.007955] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Antiarrhythmic drugs (AAD) play an important role in the management of arrhythmias. Drug interactions involving AAD are common in clinical practice. As AADs have a narrow therapeutic window, both pharmacokinetic as well as pharmacodynamic interactions involving AAD can result in serious adverse drug reactions ranging from arrhythmia recurrence, failure of device-based therapy, and heart failure, to death. Pharmacokinetic drug interactions frequently involve the inhibition of key metabolic pathways, resulting in accumulation of a substrate drug. Additionally, over the past 2 decades, the P-gp (permeability glycoprotein) has been increasingly cited as a significant source of drug interactions. Pharmacodynamic drug interactions involving AADs commonly involve additive QT prolongation. Amiodarone, quinidine, and dofetilide are AADs with numerous and clinically significant drug interactions. Recent studies have also demonstrated increased morbidity and mortality with the use of digoxin and other AAD which interact with P-gp. QT prolongation is an important pharmacodynamic interaction involving mainly Vaughan-Williams class III AAD as many commonly used drug classes, such as macrolide antibiotics, fluoroquinolone antibiotics, antipsychotics, and antiemetics prolong the QT interval. Whenever possible, serious drug-drug interactions involving AAD should be avoided. If unavoidable, patients will require closer monitoring and the concomitant use of interacting agents should be minimized. Increasing awareness of drug interactions among clinicians will significantly improve patient safety for patients with arrhythmias.
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Affiliation(s)
- Philip L Mar
- Department of Medicine, Division of Cardiology, St. Louis University, St. Louis, MO (P.L.M., P.H.)
| | - Piotr Horbal
- Department of Medicine, Division of Cardiology, St. Louis University, St. Louis, MO (P.L.M., P.H.)
| | - Mina K Chung
- Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute (M.K.C.), Cleveland Clinic, OH
| | | | - Michael Ezekowitz
- Lankenau Heart Institute, Bryn Mawr Hospital & Sidney Kimmel Medical College (M.E.)
| | | | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart & Chest Hospital, Liverpool, United Kingdom (G.Y.H.L.).,Department of Clinical Medicine, Aalborg, Denmark (G.Y.H.L.)
| | | | - Peter A Noseworthy
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (P.A.N.)
| | - James A Reiffel
- Division of Cardiology, Department of Medicine, Columbia University, New York, NY (J.A.R.)
| | - James E Tisdale
- College of Pharmacy, Purdue University (J.E.T.).,School of Medicine, Indiana University, Indianapolis (J.E.T.)
| | - Brian Olshansky
- Division of Cardiology, Department of Medicine, University of Iowa, Iowa City (B.O.)
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11
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Bahnson TD, Giczewska A, Mark DB, Russo AM, Monahan KH, Al-Khalidi HR, Silverstein AP, Poole JE, Lee KL, Packer DL. Association Between Age and Outcomes of Catheter Ablation Versus Medical Therapy for Atrial Fibrillation: Results From the CABANA Trial. Circulation 2022; 145:796-804. [PMID: 34933570 PMCID: PMC9003625 DOI: 10.1161/circulationaha.121.055297] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Observational data suggest that catheter ablation may be safe and effective to treat younger and older patients with atrial fibrillation. No large, randomized trial has examined this issue. This report describes outcomes according to age at entry in the CABANA trial (Catheter Ablation versus Antiarrhythmic Drug Therapy for Atrial Fibrillation). METHODS Patients with atrial fibrillation ≥65 years of age, or <65 with ≥1 risk factor for stroke, were randomly assigned to catheter ablation versus drug therapy. The primary outcome was a composite of death, disabling stroke, serious bleeding, or cardiac arrest. Secondary outcomes included all-cause mortality, the composite of mortality or cardiovascular hospitalization, and recurrence of atrial fibrillation. Treatment effect estimates were adjusted for baseline covariables using proportional hazards regression models. RESULTS Of 2204 patients randomly assigned in CABANA, 766 (34.8%) were <65 years of age, 1130 (51.3%) were 65 to 74 years of age, and 308 (14.0%) were ≥75 years of age. Catheter ablation was associated with a 43% reduction in the primary outcome for patients <65 years of age (adjusted hazard ratio [aHR], 0.57 [95% CI, 0.30-1.09]), a 21% reduction for 65 to 74 years of age (aHR, 0.79 [95% CI, 0.54-1.16]), and an indeterminate effect for age ≥75 years of age (aHR, 1.39 [95% CI, 0.75-2.58]). Four-year event rates for ablation versus drug therapy across age groups, respectively, were 3.2% versus 7.8%, 7.8% versus 9.6%, and 14.8% versus 9.0%. For every 10-year increase in age, the primary outcome aHR increased (ie, less favorable to ablation) an average of 27% (interaction P value=0.215). A similar pattern was seen with all-cause mortality: for every 10-year increase in age, the aHR increased an average of 46% (interaction P value=0.111). Atrial fibrillation recurrence rates were lower with ablation than with drug therapy across age subgroups (aHR 0.47, 0.58, and 0.49, respectively). Treatment-related complications were infrequent for both arms (<3%) regardless of age. CONCLUSIONS We found age-based variations in clinical outcomes for catheter ablation compared with drug therapy, with the largest relative and absolute benefits of catheter ablation in younger patients. No prognostic benefits for ablation were seen in the oldest patients. No differences were found by age in treatment-related complications or in the relative effectiveness of catheter ablation in preventing recurrent atrial arrhythmias. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT00911508.
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Affiliation(s)
- Tristram D Bahnson
- Duke Clinical Research Institute, Duke University, Durham, NC (T.D.B., A.G., D.B.M., H.R.A.-K., A.P.S., K.L.L.).,Duke Center for Atrial Fibrillation, Duke Health System, Durham, NC (T.D.B.)
| | - Anna Giczewska
- Duke Clinical Research Institute, Duke University, Durham, NC (T.D.B., A.G., D.B.M., H.R.A.-K., A.P.S., K.L.L.)
| | - Daniel B Mark
- Duke Clinical Research Institute, Duke University, Durham, NC (T.D.B., A.G., D.B.M., H.R.A.-K., A.P.S., K.L.L.)
| | - Andrea M Russo
- Duke Clinical Research Institute, Duke University, Durham, NC (T.D.B., A.G., D.B.M., H.R.A.-K., A.P.S., K.L.L.).,Cooper University Health System, Camden, NJ (A.M.R.)
| | | | - Hussein R Al-Khalidi
- Duke Clinical Research Institute, Duke University, Durham, NC (T.D.B., A.G., D.B.M., H.R.A.-K., A.P.S., K.L.L.)
| | - Adam P Silverstein
- Duke Clinical Research Institute, Duke University, Durham, NC (T.D.B., A.G., D.B.M., H.R.A.-K., A.P.S., K.L.L.)
| | - Jeanne E Poole
- University of Washington Medical Center, Seattle (J.E.P.)
| | - Kerry L Lee
- Duke Clinical Research Institute, Duke University, Durham, NC (T.D.B., A.G., D.B.M., H.R.A.-K., A.P.S., K.L.L.)
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12
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Medina-Morales DA, Machado-Duque ME, Gaviria-Mendoza A, Carvajal-Varón AF, Machado-Alba JE. Clinical characteristics and stratification of the cerebrovascular accident risk among patients with atrial fibrillation in Colombia, 2011-2016. Expert Rev Cardiovasc Ther 2021; 19:181-187. [PMID: 33430660 DOI: 10.1080/14779072.2021.1873766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Background: Atrial fibrillation (AF) is the most common type of cardiac arrhythmia worldwide. This study aimed to determine the sociodemographic and clinical features of AF in a Colombian population.Methods: An observational, retrospective study was conducted using a sample of patients diagnosed with AF. Electronic medical records were reviewed to determine specific sociodemographic, clinical, risk stratification, outcome, and pharmacological variables.Results: A total of 357 patients with a mean age of 69.4 ± 13.3 years were included; 52.4% (n = 187) were women. Most patients (84.0%; n = 300) had an elevated risk of thromboembolism and an indication for anticoagulation, but 72 (24.0%) of these patients did not receive such treatment. Among the patients, 23.2% had HAS-BLED scores ≥3. During the study period, 76 patients (21.3%) had 121 adverse events, of which 75.2% (n = 91) were any bleeding events (major, minor, etc.) and 24.8% (n = 30) were thrombosis events (i.e., stroke). At the end of the follow-up period, the number of prescriptions for direct anticoagulants had increased, and warfarin decreased.Conclusions: AF primarily affects Colombian adults >65 years old. A high burden of comorbidities and a risk of thromboembolism were found in most patients; however, lack of treatment was evident in a large percentage of cases.
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Affiliation(s)
- Diego Alejandro Medina-Morales
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A., Pereira, Colombia.,Grupo de Investigación en Medicina Interna. Facultad Ciencias de la Salud, Universidad Tecnológica de Pereira, Pereira, Colombia
| | - Manuel Enrique Machado-Duque
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A., Pereira, Colombia.,Grupo Biomedicina, Fundación Universitaria Autonoma de las Américas, Pereira, Colombia
| | - Andrés Gaviria-Mendoza
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A., Pereira, Colombia.,Grupo Biomedicina, Fundación Universitaria Autonoma de las Américas, Pereira, Colombia
| | - Andrés Felipe Carvajal-Varón
- Grupo de Investigación en Medicina Interna. Facultad Ciencias de la Salud, Universidad Tecnológica de Pereira, Pereira, Colombia
| | - Jorge Enrique Machado-Alba
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A., Pereira, Colombia.,Grupo Biomedicina, Fundación Universitaria Autonoma de las Américas, Pereira, Colombia
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13
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Kowey PR, Robinson VM. The Relentless Pursuit of New Drugs to Treat Cardiac Arrhythmias. Circulation 2020; 141:1507-1509. [PMID: 32392105 DOI: 10.1161/circulationaha.119.045149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Peter R Kowey
- The Lankenau Institute for Medical Research, Wynnewood, PA (P.R.K., V.M.R.)
- Thomas Jefferson University, Philadelphia, PA (P.R.K.)
| | - Victoria M Robinson
- The Lankenau Institute for Medical Research, Wynnewood, PA (P.R.K., V.M.R.)
- The University of Manchester, UK (V.M.R.)
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14
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Wassner C, Cheng SH. Low-dose oral propranolol for treatment of thyrotoxic periodic paralysis with hypokalaemia in the emergency department: A case report. J Clin Pharm Ther 2020; 46:208-211. [PMID: 31913531 DOI: 10.1111/jcpt.13108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 12/03/2019] [Accepted: 12/17/2019] [Indexed: 11/26/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Thyrotoxic periodic paralysis (TPP) with hypokalaemia is a rare acute phenomenon. Reports of the use of high-dose non-selective β-blockers describe symptom resolution, but often administration does not occur promptly enough in the treatment course and patients may experience overcorrection and hyperkalaemia. CASE DESCRIPTION A 37-year-old Hispanic male developed TPP. Patient was successfully treated with low-dose oral propranolol and potassium supplementation with no overcorrection. WHAT IS NEW AND CONCLUSION Delay in the administration of non-selective β-blockers may lead to overcorrection of potassium with exogenous supplementation. Low-dose propranolol administered in the Emergency Department was successful in preventing overcorrection of potassium.
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Affiliation(s)
- Chanie Wassner
- Department of Pharmacy, NYU Langone Hospital-Brooklyn, Brooklyn, New York
| | - Susan H Cheng
- Ronald O. Perelman Department of Emergency Medicine, NYU Langone Hospital-Brooklyn, Brooklyn, New York
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15
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Sattler SM, Skibsbye L, Linz D, Lubberding AF, Tfelt-Hansen J, Jespersen T. Ventricular Arrhythmias in First Acute Myocardial Infarction: Epidemiology, Mechanisms, and Interventions in Large Animal Models. Front Cardiovasc Med 2019; 6:158. [PMID: 31750317 PMCID: PMC6848060 DOI: 10.3389/fcvm.2019.00158] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Accepted: 10/18/2019] [Indexed: 12/22/2022] Open
Abstract
Ventricular arrhythmia and subsequent sudden cardiac death (SCD) due to acute myocardial infarction (AMI) is one of the most frequent causes of death in humans. Lethal ventricular arrhythmias like ventricular fibrillation (VF) prior to hospitalization have been reported to occur in more than 10% of all AMI cases and survival in these patients is poor. Identification of risk factors and mechanisms for VF following AMI as well as implementing new risk stratification models and therapeutic approaches is therefore an important step to reduce mortality in people with high cardiovascular risk. Studying spontaneous VF following AMI in humans is challenging as it often occurs unexpectedly in a low risk subgroup. Large animal models of AMI can help to bridge this knowledge gap and are utilized to investigate occurrence of arrhythmias, involved mechanisms and therapeutic options. Comparable anatomy and physiology allow for this translational approach. Through experimental focus, using state-of-the-art technologies, including refined electrical mapping equipment and novel pharmacological investigations, valuable insights into arrhythmia mechanisms and possible interventions for arrhythmia-induced SCD during the early phase of AMI are now beginning to emerge. This review describes large experimental animal models of AMI with focus on first AMI-associated ventricular arrhythmias. In this context, epidemiology of first AMI, arrhythmogenic mechanisms and various potential therapeutic pharmacological targets will be discussed.
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Affiliation(s)
- Stefan Michael Sattler
- Department of Cardiology, Heart Centre, Copenhagen University Hospital, Copenhagen, Denmark.,Medical Department I, University Hospital Grosshadern, LMU Munich, Munich, Germany
| | - Lasse Skibsbye
- Department of Exploratory Toxicology, H. Lundbeck A/S, Copenhagen, Denmark
| | - Dominik Linz
- Medical Department III, Universitätsklinikum des Saarlandes, Homburg, Germany.,Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, Royal Adelaide Hospital, University of Adelaide, Adelaide, SA, Australia
| | - Anniek Frederike Lubberding
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jacob Tfelt-Hansen
- Department of Cardiology, Heart Centre, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Forensic Medicine, Faculty of Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Jespersen
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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16
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Soar J, Donnino MW, Maconochie I, Aickin R, Atkins DL, Andersen LW, Berg KM, Bingham R, Böttiger BW, Callaway CW, Couper K, Couto TB, de Caen AR, Deakin CD, Drennan IR, Guerguerian AM, Lavonas EJ, Meaney PA, Nadkarni VM, Neumar RW, Ng KC, Nicholson TC, Nuthall GA, Ohshimo S, O'Neil BJ, Ong GYK, Paiva EF, Parr MJ, Reis AG, Reynolds JC, Ristagno G, Sandroni C, Schexnayder SM, Scholefield BR, Shimizu N, Tijssen JA, Van de Voorde P, Wang TL, Welsford M, Hazinski MF, Nolan JP, Morley PT. 2018 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Summary. Circulation 2019; 138:e714-e730. [PMID: 30571263 DOI: 10.1161/cir.0000000000000611] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The International Liaison Committee on Resuscitation has initiated a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation science. This is the second annual summary of International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations that includes the most recent cardiopulmonary resuscitation science reviewed by the International Liaison Committee on Resuscitation. This summary addresses the role of antiarrhythmic drugs in adults and children and includes the Advanced Life Support Task Force and Pediatric Task Force consensus statements, which summarize the most recent published evidence and an assessment of the quality of the evidence based on Grading of Recommendations, Assessment, Development, and Evaluation criteria. The statements include consensus treatment recommendations approved by members of the relevant task forces. Insights into the deliberations of each task force are provided in the Values and Preferences and Task Force Insights sections. Finally, the task force members have listed the top knowledge gaps for further research.
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Panchal AR, Berg KM, Kudenchuk PJ, Del Rios M, Hirsch KG, Link MS, Kurz MC, Chan PS, Cabañas JG, Morley PT, Hazinski MF, Donnino MW. 2018 American Heart Association Focused Update on Advanced Cardiovascular Life Support Use of Antiarrhythmic Drugs During and Immediately After Cardiac Arrest: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2019; 138:e740-e749. [PMID: 30571262 DOI: 10.1161/cir.0000000000000613] [Citation(s) in RCA: 103] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Antiarrhythmic medications are commonly administered during and immediately after a ventricular fibrillation/pulseless ventricular tachycardia cardiac arrest. However, it is unclear whether these medications improve patient outcomes. This 2018 American Heart Association focused update on advanced cardiovascular life support guidelines summarizes the most recent published evidence for and recommendations on the use of antiarrhythmic drugs during and immediately after shock-refractory ventricular fibrillation/pulseless ventricular tachycardia cardiac arrest. This article includes the revised recommendation that providers may consider either amiodarone or lidocaine to treat shock-refractory ventricular fibrillation/pulseless ventricular tachycardia cardiac arrest.
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18
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Parkash R, Nault I, Rivard L, Gula L, Essebag V, Nery P, Tung S, Raymond JM, Sterns L, Doucette S, Wells G, Tang ASL, Stevenson WG, Sapp JL. Effect of Baseline Antiarrhythmic Drug on Outcomes With Ablation in Ischemic Ventricular Tachycardia: A VANISH Substudy (Ventricular Tachycardia Ablation Versus Escalated Antiarrhythmic Drug Therapy in Ischemic Heart Disease). Circ Arrhythm Electrophysiol 2019; 11:e005663. [PMID: 29305400 DOI: 10.1161/circep.117.005663] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 11/25/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND The VANISH trial (Ventricular Tachycardia Ablation Versus Escalated Antiarrhythmic Drug Therapy in Ischemic Heart Disease) compared the effectiveness of escalated antiarrhythmic drug therapy to catheter ablation in patients with prior myocardial infarction, an implanted defibrillator, and ventricular tachycardia (VT). The effectiveness of these interventions in patients on sotalol versus amiodarone was compared. METHODS AND RESULTS Analysis was conducted based on whether patients had recurrent VT, despite amiodarone (amio-refractory) or nonamiodarone drugs (sotalol-refractory). Outcomes included death, VT storm, appropriate implantable cardioverter defibrillator shock, and any ventricular arrhythmia. At baseline, 169 (65.2%) were amio-refractory, and 90 (34.7%) were sotalol-refractory (1 patient on procainamide rather than sotalol). Amio-refractory patients had more renal insufficiency (23.7% versus 10%; P=0.0008), worse New York Heart Association class (82.3% II/III versus 65.5%; P=0.0003), and lower ejection fraction (29±9.7% versus 35.2±11%; P<0.0001). Within the amio-refractory group, ablation resulted in reduction of any ventricular arrhythmia compared with escalated drug therapy (hazard ratio, 0.53; 95% confidence interval, 0.31-0.9), P=0.020). Sotalol-refractory patients had trends toward higher mortality and VT storm with ablation, with no effect on implantable cardioverter defibrillator shocks. Within the escalated drug therapy arm, amio-refractory patients had a higher rate of the composite outcome (hazard ratio, 1.94; 95% confidence interval, 1.14-3.29; P=0.0144) and a trend to higher mortality (hazard ratio, 2.40; 95% confidence interval, 0.93-6.22; P=0.07), whereas mortality was not different between amio- and sotalol-refractory patients within the ablation treatment group. CONCLUSIONS Patients with amio-refractory VT have a higher rate of ventricular arrhythmia and mortality than those with sotalol-refractory VT and derive greater benefit of catheter ablation than for patients with sotalol-refractory VT who are switched to amiodarone. CLINICAL TRIAL REGISTRATION URL: https://clinicaltrials.gov. Unique identifier: NCT00905853.
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Affiliation(s)
- Ratika Parkash
- From the QEII Health Sciences Centre, Halifax, Nova Scotia, Canada (R.P., J.L.S.); Dalhousie University, Halifax, Nova Scotia, Canada (R.P., J.L.S.); Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Quebec City, Canada (I.N.); Montreal Heart Institute, Quebec, Canada (L.R.); University of Western Ontario, London, Canada (L.G., A.S.L.T.); McGill University Health Center, Montreal, Quebec, Canada (V.E.); Hôpital Sacré-Coeur de Montréal, Quebec, Canada (V.E.); University of Ottawa Heart Institute, Ontario, Canada (P.N., G.W.); Royal Columbian Hospital, Vancouver, British Columbia, Canada (S.T.); Centre Hospitalier de L'Universite de Montreal, Quebec, Canada (J.-M.R.); Royal Jubilee Hospital, Victoria, British Columbia, Canada (L.S.); Research Methods Unit, Dalhousie University, Halifax, Nova Scotia, Canada (S.D.); and Brigham and Women's Hospital, Boston, MA (W.G.S.).
| | - Isabelle Nault
- From the QEII Health Sciences Centre, Halifax, Nova Scotia, Canada (R.P., J.L.S.); Dalhousie University, Halifax, Nova Scotia, Canada (R.P., J.L.S.); Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Quebec City, Canada (I.N.); Montreal Heart Institute, Quebec, Canada (L.R.); University of Western Ontario, London, Canada (L.G., A.S.L.T.); McGill University Health Center, Montreal, Quebec, Canada (V.E.); Hôpital Sacré-Coeur de Montréal, Quebec, Canada (V.E.); University of Ottawa Heart Institute, Ontario, Canada (P.N., G.W.); Royal Columbian Hospital, Vancouver, British Columbia, Canada (S.T.); Centre Hospitalier de L'Universite de Montreal, Quebec, Canada (J.-M.R.); Royal Jubilee Hospital, Victoria, British Columbia, Canada (L.S.); Research Methods Unit, Dalhousie University, Halifax, Nova Scotia, Canada (S.D.); and Brigham and Women's Hospital, Boston, MA (W.G.S.)
| | - Lena Rivard
- From the QEII Health Sciences Centre, Halifax, Nova Scotia, Canada (R.P., J.L.S.); Dalhousie University, Halifax, Nova Scotia, Canada (R.P., J.L.S.); Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Quebec City, Canada (I.N.); Montreal Heart Institute, Quebec, Canada (L.R.); University of Western Ontario, London, Canada (L.G., A.S.L.T.); McGill University Health Center, Montreal, Quebec, Canada (V.E.); Hôpital Sacré-Coeur de Montréal, Quebec, Canada (V.E.); University of Ottawa Heart Institute, Ontario, Canada (P.N., G.W.); Royal Columbian Hospital, Vancouver, British Columbia, Canada (S.T.); Centre Hospitalier de L'Universite de Montreal, Quebec, Canada (J.-M.R.); Royal Jubilee Hospital, Victoria, British Columbia, Canada (L.S.); Research Methods Unit, Dalhousie University, Halifax, Nova Scotia, Canada (S.D.); and Brigham and Women's Hospital, Boston, MA (W.G.S.)
| | - Lorne Gula
- From the QEII Health Sciences Centre, Halifax, Nova Scotia, Canada (R.P., J.L.S.); Dalhousie University, Halifax, Nova Scotia, Canada (R.P., J.L.S.); Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Quebec City, Canada (I.N.); Montreal Heart Institute, Quebec, Canada (L.R.); University of Western Ontario, London, Canada (L.G., A.S.L.T.); McGill University Health Center, Montreal, Quebec, Canada (V.E.); Hôpital Sacré-Coeur de Montréal, Quebec, Canada (V.E.); University of Ottawa Heart Institute, Ontario, Canada (P.N., G.W.); Royal Columbian Hospital, Vancouver, British Columbia, Canada (S.T.); Centre Hospitalier de L'Universite de Montreal, Quebec, Canada (J.-M.R.); Royal Jubilee Hospital, Victoria, British Columbia, Canada (L.S.); Research Methods Unit, Dalhousie University, Halifax, Nova Scotia, Canada (S.D.); and Brigham and Women's Hospital, Boston, MA (W.G.S.)
| | - Vidal Essebag
- From the QEII Health Sciences Centre, Halifax, Nova Scotia, Canada (R.P., J.L.S.); Dalhousie University, Halifax, Nova Scotia, Canada (R.P., J.L.S.); Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Quebec City, Canada (I.N.); Montreal Heart Institute, Quebec, Canada (L.R.); University of Western Ontario, London, Canada (L.G., A.S.L.T.); McGill University Health Center, Montreal, Quebec, Canada (V.E.); Hôpital Sacré-Coeur de Montréal, Quebec, Canada (V.E.); University of Ottawa Heart Institute, Ontario, Canada (P.N., G.W.); Royal Columbian Hospital, Vancouver, British Columbia, Canada (S.T.); Centre Hospitalier de L'Universite de Montreal, Quebec, Canada (J.-M.R.); Royal Jubilee Hospital, Victoria, British Columbia, Canada (L.S.); Research Methods Unit, Dalhousie University, Halifax, Nova Scotia, Canada (S.D.); and Brigham and Women's Hospital, Boston, MA (W.G.S.)
| | - Pablo Nery
- From the QEII Health Sciences Centre, Halifax, Nova Scotia, Canada (R.P., J.L.S.); Dalhousie University, Halifax, Nova Scotia, Canada (R.P., J.L.S.); Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Quebec City, Canada (I.N.); Montreal Heart Institute, Quebec, Canada (L.R.); University of Western Ontario, London, Canada (L.G., A.S.L.T.); McGill University Health Center, Montreal, Quebec, Canada (V.E.); Hôpital Sacré-Coeur de Montréal, Quebec, Canada (V.E.); University of Ottawa Heart Institute, Ontario, Canada (P.N., G.W.); Royal Columbian Hospital, Vancouver, British Columbia, Canada (S.T.); Centre Hospitalier de L'Universite de Montreal, Quebec, Canada (J.-M.R.); Royal Jubilee Hospital, Victoria, British Columbia, Canada (L.S.); Research Methods Unit, Dalhousie University, Halifax, Nova Scotia, Canada (S.D.); and Brigham and Women's Hospital, Boston, MA (W.G.S.)
| | - Stanley Tung
- From the QEII Health Sciences Centre, Halifax, Nova Scotia, Canada (R.P., J.L.S.); Dalhousie University, Halifax, Nova Scotia, Canada (R.P., J.L.S.); Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Quebec City, Canada (I.N.); Montreal Heart Institute, Quebec, Canada (L.R.); University of Western Ontario, London, Canada (L.G., A.S.L.T.); McGill University Health Center, Montreal, Quebec, Canada (V.E.); Hôpital Sacré-Coeur de Montréal, Quebec, Canada (V.E.); University of Ottawa Heart Institute, Ontario, Canada (P.N., G.W.); Royal Columbian Hospital, Vancouver, British Columbia, Canada (S.T.); Centre Hospitalier de L'Universite de Montreal, Quebec, Canada (J.-M.R.); Royal Jubilee Hospital, Victoria, British Columbia, Canada (L.S.); Research Methods Unit, Dalhousie University, Halifax, Nova Scotia, Canada (S.D.); and Brigham and Women's Hospital, Boston, MA (W.G.S.)
| | - Jean-Marc Raymond
- From the QEII Health Sciences Centre, Halifax, Nova Scotia, Canada (R.P., J.L.S.); Dalhousie University, Halifax, Nova Scotia, Canada (R.P., J.L.S.); Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Quebec City, Canada (I.N.); Montreal Heart Institute, Quebec, Canada (L.R.); University of Western Ontario, London, Canada (L.G., A.S.L.T.); McGill University Health Center, Montreal, Quebec, Canada (V.E.); Hôpital Sacré-Coeur de Montréal, Quebec, Canada (V.E.); University of Ottawa Heart Institute, Ontario, Canada (P.N., G.W.); Royal Columbian Hospital, Vancouver, British Columbia, Canada (S.T.); Centre Hospitalier de L'Universite de Montreal, Quebec, Canada (J.-M.R.); Royal Jubilee Hospital, Victoria, British Columbia, Canada (L.S.); Research Methods Unit, Dalhousie University, Halifax, Nova Scotia, Canada (S.D.); and Brigham and Women's Hospital, Boston, MA (W.G.S.)
| | - Laurence Sterns
- From the QEII Health Sciences Centre, Halifax, Nova Scotia, Canada (R.P., J.L.S.); Dalhousie University, Halifax, Nova Scotia, Canada (R.P., J.L.S.); Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Quebec City, Canada (I.N.); Montreal Heart Institute, Quebec, Canada (L.R.); University of Western Ontario, London, Canada (L.G., A.S.L.T.); McGill University Health Center, Montreal, Quebec, Canada (V.E.); Hôpital Sacré-Coeur de Montréal, Quebec, Canada (V.E.); University of Ottawa Heart Institute, Ontario, Canada (P.N., G.W.); Royal Columbian Hospital, Vancouver, British Columbia, Canada (S.T.); Centre Hospitalier de L'Universite de Montreal, Quebec, Canada (J.-M.R.); Royal Jubilee Hospital, Victoria, British Columbia, Canada (L.S.); Research Methods Unit, Dalhousie University, Halifax, Nova Scotia, Canada (S.D.); and Brigham and Women's Hospital, Boston, MA (W.G.S.)
| | - Steve Doucette
- From the QEII Health Sciences Centre, Halifax, Nova Scotia, Canada (R.P., J.L.S.); Dalhousie University, Halifax, Nova Scotia, Canada (R.P., J.L.S.); Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Quebec City, Canada (I.N.); Montreal Heart Institute, Quebec, Canada (L.R.); University of Western Ontario, London, Canada (L.G., A.S.L.T.); McGill University Health Center, Montreal, Quebec, Canada (V.E.); Hôpital Sacré-Coeur de Montréal, Quebec, Canada (V.E.); University of Ottawa Heart Institute, Ontario, Canada (P.N., G.W.); Royal Columbian Hospital, Vancouver, British Columbia, Canada (S.T.); Centre Hospitalier de L'Universite de Montreal, Quebec, Canada (J.-M.R.); Royal Jubilee Hospital, Victoria, British Columbia, Canada (L.S.); Research Methods Unit, Dalhousie University, Halifax, Nova Scotia, Canada (S.D.); and Brigham and Women's Hospital, Boston, MA (W.G.S.)
| | - George Wells
- From the QEII Health Sciences Centre, Halifax, Nova Scotia, Canada (R.P., J.L.S.); Dalhousie University, Halifax, Nova Scotia, Canada (R.P., J.L.S.); Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Quebec City, Canada (I.N.); Montreal Heart Institute, Quebec, Canada (L.R.); University of Western Ontario, London, Canada (L.G., A.S.L.T.); McGill University Health Center, Montreal, Quebec, Canada (V.E.); Hôpital Sacré-Coeur de Montréal, Quebec, Canada (V.E.); University of Ottawa Heart Institute, Ontario, Canada (P.N., G.W.); Royal Columbian Hospital, Vancouver, British Columbia, Canada (S.T.); Centre Hospitalier de L'Universite de Montreal, Quebec, Canada (J.-M.R.); Royal Jubilee Hospital, Victoria, British Columbia, Canada (L.S.); Research Methods Unit, Dalhousie University, Halifax, Nova Scotia, Canada (S.D.); and Brigham and Women's Hospital, Boston, MA (W.G.S.)
| | - Anthony S L Tang
- From the QEII Health Sciences Centre, Halifax, Nova Scotia, Canada (R.P., J.L.S.); Dalhousie University, Halifax, Nova Scotia, Canada (R.P., J.L.S.); Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Quebec City, Canada (I.N.); Montreal Heart Institute, Quebec, Canada (L.R.); University of Western Ontario, London, Canada (L.G., A.S.L.T.); McGill University Health Center, Montreal, Quebec, Canada (V.E.); Hôpital Sacré-Coeur de Montréal, Quebec, Canada (V.E.); University of Ottawa Heart Institute, Ontario, Canada (P.N., G.W.); Royal Columbian Hospital, Vancouver, British Columbia, Canada (S.T.); Centre Hospitalier de L'Universite de Montreal, Quebec, Canada (J.-M.R.); Royal Jubilee Hospital, Victoria, British Columbia, Canada (L.S.); Research Methods Unit, Dalhousie University, Halifax, Nova Scotia, Canada (S.D.); and Brigham and Women's Hospital, Boston, MA (W.G.S.)
| | - William G Stevenson
- From the QEII Health Sciences Centre, Halifax, Nova Scotia, Canada (R.P., J.L.S.); Dalhousie University, Halifax, Nova Scotia, Canada (R.P., J.L.S.); Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Quebec City, Canada (I.N.); Montreal Heart Institute, Quebec, Canada (L.R.); University of Western Ontario, London, Canada (L.G., A.S.L.T.); McGill University Health Center, Montreal, Quebec, Canada (V.E.); Hôpital Sacré-Coeur de Montréal, Quebec, Canada (V.E.); University of Ottawa Heart Institute, Ontario, Canada (P.N., G.W.); Royal Columbian Hospital, Vancouver, British Columbia, Canada (S.T.); Centre Hospitalier de L'Universite de Montreal, Quebec, Canada (J.-M.R.); Royal Jubilee Hospital, Victoria, British Columbia, Canada (L.S.); Research Methods Unit, Dalhousie University, Halifax, Nova Scotia, Canada (S.D.); and Brigham and Women's Hospital, Boston, MA (W.G.S.)
| | - John L Sapp
- From the QEII Health Sciences Centre, Halifax, Nova Scotia, Canada (R.P., J.L.S.); Dalhousie University, Halifax, Nova Scotia, Canada (R.P., J.L.S.); Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Quebec City, Canada (I.N.); Montreal Heart Institute, Quebec, Canada (L.R.); University of Western Ontario, London, Canada (L.G., A.S.L.T.); McGill University Health Center, Montreal, Quebec, Canada (V.E.); Hôpital Sacré-Coeur de Montréal, Quebec, Canada (V.E.); University of Ottawa Heart Institute, Ontario, Canada (P.N., G.W.); Royal Columbian Hospital, Vancouver, British Columbia, Canada (S.T.); Centre Hospitalier de L'Universite de Montreal, Quebec, Canada (J.-M.R.); Royal Jubilee Hospital, Victoria, British Columbia, Canada (L.S.); Research Methods Unit, Dalhousie University, Halifax, Nova Scotia, Canada (S.D.); and Brigham and Women's Hospital, Boston, MA (W.G.S.)
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Abstract
BACKGROUND Among his major cardiac electrophysiological contributions, Miles Vaughan Williams (1918-2016) provided a classification of antiarrhythmic drugs that remains central to their clinical use. METHODS We survey implications of subsequent discoveries concerning sarcolemmal, sarcoplasmic reticular, and cytosolic biomolecules, developing an expanded but pragmatic classification that encompasses approved and potential antiarrhythmic drugs on this centenary of his birth. RESULTS We first consider the range of pharmacological targets, tracking these through to cellular electrophysiological effects. We retain the original Vaughan Williams Classes I through IV but subcategorize these divisions in light of more recent developments, including the existence of Na+ current components (for Class I), advances in autonomic (often G protein-mediated) signaling (for Class II), K+ channel subspecies (for Class III), and novel molecular targets related to Ca2+ homeostasis (for Class IV). We introduce new classes based on additional targets, including channels involved in automaticity, mechanically sensitive ion channels, connexins controlling electrotonic cell coupling, and molecules underlying longer-term signaling processes affecting structural remodeling. Inclusion of this widened range of targets and their physiological sequelae provides a framework for a modernized classification of established antiarrhythmic drugs based on their pharmacological targets. The revised classification allows for the existence of multiple drug targets/actions and for adverse, sometimes actually proarrhythmic, effects. The new scheme also aids classification of novel drugs under investigation. CONCLUSIONS We emerge with a modernized classification preserving the simplicity of the original Vaughan Williams framework while aiding our understanding and clinical management of cardiac arrhythmic events and facilitating future developments in this area.
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Affiliation(s)
- Ming Lei
- Department of Pharmacology, University of Oxford, United Kingdom (M.L., D.A.T.)
- Key Laboratory of Medical Electrophysiology of the Ministry of Education and Institute of Cardiovascular Research, Southwest Medical University, Luzhou, China (M.L., L.W.)
| | - Lin Wu
- Department of Cardiology, Peking University First Hospital, Beijing, China (L.W.)
- Key Laboratory of Medical Electrophysiology of the Ministry of Education and Institute of Cardiovascular Research, Southwest Medical University, Luzhou, China (M.L., L.W.)
| | - Derek A Terrar
- Department of Pharmacology, University of Oxford, United Kingdom (M.L., D.A.T.)
| | - Christopher L-H Huang
- Physiological Laboratory (C.L.-H.H.), University of Cambridge, United Kingdom
- Department of Biochemistry (C.L.-H.H.). University of Cambridge, United Kingdom
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20
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Barnett AS, Kim S, Fonarow GC, Thomas LE, Reiffel JA, Allen LA, Freeman JV, Naccarelli G, Mahaffey KW, Go AS, Kowey PR, Ansell JE, Gersh BJ, Hylek EM, Peterson ED, Piccini JP. Treatment of Atrial Fibrillation and Concordance With the American Heart Association/American College of Cardiology/Heart Rhythm Society Guidelines: Findings From ORBIT-AF (Outcomes Registry for Better Informed Treatment of Atrial Fibrillation). Circ Arrhythm Electrophysiol 2017; 10:CIRCEP.117.005051. [PMID: 29141842 DOI: 10.1161/circep.117.005051] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Accepted: 09/05/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND It is unclear how frequently patients with atrial fibrillation receive guideline-concordant (GC) care and whether guideline concordance is associated with improved outcomes. METHODS AND RESULTS Using data from ORBIT-AF (Outcomes Registry for Better Informed Treatment of Atrial Fibrillation), we determined how frequently patients received care that was concordant with 11 recommendations from the 2014 American Heart Association/American College of Cardiology/Heart Rhythm Society atrial fibrillation guidelines pertaining to antithrombotic therapy, rate control, and antiarrhythmic medications. We also analyzed the association between GC care and clinical outcomes at both the patient level and center level. A total of 9570 patients were included. The median age was 75 years (interquartile range, 67-82), and the median CHA2DS2-VASc score was 4 (interquartile range, 3-5). A total of 5977 patients (62.5%) received care that was concordant with all guideline recommendations for which they were eligible. Rates of GC care were higher in patients treated by providers with greater specialization in arrhythmias (60.0%, 62.4%, and 67.0% for primary care physicians, cardiologists, and electrophysiologists, respectively; P<0.001). During a median of 30 months of follow-up, patients treated with GC care had a higher risk of bleeding hospitalization (hazard ratio=1.21; P=0.021) but a similar risk of death, stroke, major bleeding, and all-cause hospitalization. CONCLUSIONS Over a third of patients with atrial fibrillation in this large outpatient registry received care that differed in some respect from guideline recommendations. There was no apparent association between GC care and improved risk-adjusted outcomes.
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Affiliation(s)
- Adam S Barnett
- From the Duke Center for Atrial Fibrillation, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (A.S.B., S.K., L.E.T., E.D.P., J.P.P.); Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan-UCLA Medical Center (G.C.F.); Columbia University College of Physicians and Surgeons, New York, NY (J.A.R.); University of Colorado School of Medicine, Aurora (L.A.A.); Yale University School of Medicine, New Haven, CT (J.V.F.); Penn State Hershey Heart and Vascular Institute (G.N.); Stanford University School of Medicine, CA (K.W.M.); Kaiser Permanente Division of Research, Oakland, CA (A.S.G.); Lankenau Institute for Medical Research and Jefferson Medical College, Philadelphia, PA (P.R.K.); Hofstra Northwell School of Medicine, New York, NY (J.E.A.); Mayo Clinic and Mayo Clinic College of Medicine, Rochester, MN (B.J.G.); and Boston University Medical Center, MA (E.M.H.)
| | - Sunghee Kim
- From the Duke Center for Atrial Fibrillation, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (A.S.B., S.K., L.E.T., E.D.P., J.P.P.); Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan-UCLA Medical Center (G.C.F.); Columbia University College of Physicians and Surgeons, New York, NY (J.A.R.); University of Colorado School of Medicine, Aurora (L.A.A.); Yale University School of Medicine, New Haven, CT (J.V.F.); Penn State Hershey Heart and Vascular Institute (G.N.); Stanford University School of Medicine, CA (K.W.M.); Kaiser Permanente Division of Research, Oakland, CA (A.S.G.); Lankenau Institute for Medical Research and Jefferson Medical College, Philadelphia, PA (P.R.K.); Hofstra Northwell School of Medicine, New York, NY (J.E.A.); Mayo Clinic and Mayo Clinic College of Medicine, Rochester, MN (B.J.G.); and Boston University Medical Center, MA (E.M.H.)
| | - Gregg C Fonarow
- From the Duke Center for Atrial Fibrillation, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (A.S.B., S.K., L.E.T., E.D.P., J.P.P.); Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan-UCLA Medical Center (G.C.F.); Columbia University College of Physicians and Surgeons, New York, NY (J.A.R.); University of Colorado School of Medicine, Aurora (L.A.A.); Yale University School of Medicine, New Haven, CT (J.V.F.); Penn State Hershey Heart and Vascular Institute (G.N.); Stanford University School of Medicine, CA (K.W.M.); Kaiser Permanente Division of Research, Oakland, CA (A.S.G.); Lankenau Institute for Medical Research and Jefferson Medical College, Philadelphia, PA (P.R.K.); Hofstra Northwell School of Medicine, New York, NY (J.E.A.); Mayo Clinic and Mayo Clinic College of Medicine, Rochester, MN (B.J.G.); and Boston University Medical Center, MA (E.M.H.)
| | - Laine E Thomas
- From the Duke Center for Atrial Fibrillation, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (A.S.B., S.K., L.E.T., E.D.P., J.P.P.); Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan-UCLA Medical Center (G.C.F.); Columbia University College of Physicians and Surgeons, New York, NY (J.A.R.); University of Colorado School of Medicine, Aurora (L.A.A.); Yale University School of Medicine, New Haven, CT (J.V.F.); Penn State Hershey Heart and Vascular Institute (G.N.); Stanford University School of Medicine, CA (K.W.M.); Kaiser Permanente Division of Research, Oakland, CA (A.S.G.); Lankenau Institute for Medical Research and Jefferson Medical College, Philadelphia, PA (P.R.K.); Hofstra Northwell School of Medicine, New York, NY (J.E.A.); Mayo Clinic and Mayo Clinic College of Medicine, Rochester, MN (B.J.G.); and Boston University Medical Center, MA (E.M.H.)
| | - James A Reiffel
- From the Duke Center for Atrial Fibrillation, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (A.S.B., S.K., L.E.T., E.D.P., J.P.P.); Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan-UCLA Medical Center (G.C.F.); Columbia University College of Physicians and Surgeons, New York, NY (J.A.R.); University of Colorado School of Medicine, Aurora (L.A.A.); Yale University School of Medicine, New Haven, CT (J.V.F.); Penn State Hershey Heart and Vascular Institute (G.N.); Stanford University School of Medicine, CA (K.W.M.); Kaiser Permanente Division of Research, Oakland, CA (A.S.G.); Lankenau Institute for Medical Research and Jefferson Medical College, Philadelphia, PA (P.R.K.); Hofstra Northwell School of Medicine, New York, NY (J.E.A.); Mayo Clinic and Mayo Clinic College of Medicine, Rochester, MN (B.J.G.); and Boston University Medical Center, MA (E.M.H.)
| | - Larry A Allen
- From the Duke Center for Atrial Fibrillation, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (A.S.B., S.K., L.E.T., E.D.P., J.P.P.); Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan-UCLA Medical Center (G.C.F.); Columbia University College of Physicians and Surgeons, New York, NY (J.A.R.); University of Colorado School of Medicine, Aurora (L.A.A.); Yale University School of Medicine, New Haven, CT (J.V.F.); Penn State Hershey Heart and Vascular Institute (G.N.); Stanford University School of Medicine, CA (K.W.M.); Kaiser Permanente Division of Research, Oakland, CA (A.S.G.); Lankenau Institute for Medical Research and Jefferson Medical College, Philadelphia, PA (P.R.K.); Hofstra Northwell School of Medicine, New York, NY (J.E.A.); Mayo Clinic and Mayo Clinic College of Medicine, Rochester, MN (B.J.G.); and Boston University Medical Center, MA (E.M.H.)
| | - James V Freeman
- From the Duke Center for Atrial Fibrillation, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (A.S.B., S.K., L.E.T., E.D.P., J.P.P.); Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan-UCLA Medical Center (G.C.F.); Columbia University College of Physicians and Surgeons, New York, NY (J.A.R.); University of Colorado School of Medicine, Aurora (L.A.A.); Yale University School of Medicine, New Haven, CT (J.V.F.); Penn State Hershey Heart and Vascular Institute (G.N.); Stanford University School of Medicine, CA (K.W.M.); Kaiser Permanente Division of Research, Oakland, CA (A.S.G.); Lankenau Institute for Medical Research and Jefferson Medical College, Philadelphia, PA (P.R.K.); Hofstra Northwell School of Medicine, New York, NY (J.E.A.); Mayo Clinic and Mayo Clinic College of Medicine, Rochester, MN (B.J.G.); and Boston University Medical Center, MA (E.M.H.)
| | - Gerald Naccarelli
- From the Duke Center for Atrial Fibrillation, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (A.S.B., S.K., L.E.T., E.D.P., J.P.P.); Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan-UCLA Medical Center (G.C.F.); Columbia University College of Physicians and Surgeons, New York, NY (J.A.R.); University of Colorado School of Medicine, Aurora (L.A.A.); Yale University School of Medicine, New Haven, CT (J.V.F.); Penn State Hershey Heart and Vascular Institute (G.N.); Stanford University School of Medicine, CA (K.W.M.); Kaiser Permanente Division of Research, Oakland, CA (A.S.G.); Lankenau Institute for Medical Research and Jefferson Medical College, Philadelphia, PA (P.R.K.); Hofstra Northwell School of Medicine, New York, NY (J.E.A.); Mayo Clinic and Mayo Clinic College of Medicine, Rochester, MN (B.J.G.); and Boston University Medical Center, MA (E.M.H.)
| | - Kenneth W Mahaffey
- From the Duke Center for Atrial Fibrillation, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (A.S.B., S.K., L.E.T., E.D.P., J.P.P.); Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan-UCLA Medical Center (G.C.F.); Columbia University College of Physicians and Surgeons, New York, NY (J.A.R.); University of Colorado School of Medicine, Aurora (L.A.A.); Yale University School of Medicine, New Haven, CT (J.V.F.); Penn State Hershey Heart and Vascular Institute (G.N.); Stanford University School of Medicine, CA (K.W.M.); Kaiser Permanente Division of Research, Oakland, CA (A.S.G.); Lankenau Institute for Medical Research and Jefferson Medical College, Philadelphia, PA (P.R.K.); Hofstra Northwell School of Medicine, New York, NY (J.E.A.); Mayo Clinic and Mayo Clinic College of Medicine, Rochester, MN (B.J.G.); and Boston University Medical Center, MA (E.M.H.)
| | - Alan S Go
- From the Duke Center for Atrial Fibrillation, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (A.S.B., S.K., L.E.T., E.D.P., J.P.P.); Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan-UCLA Medical Center (G.C.F.); Columbia University College of Physicians and Surgeons, New York, NY (J.A.R.); University of Colorado School of Medicine, Aurora (L.A.A.); Yale University School of Medicine, New Haven, CT (J.V.F.); Penn State Hershey Heart and Vascular Institute (G.N.); Stanford University School of Medicine, CA (K.W.M.); Kaiser Permanente Division of Research, Oakland, CA (A.S.G.); Lankenau Institute for Medical Research and Jefferson Medical College, Philadelphia, PA (P.R.K.); Hofstra Northwell School of Medicine, New York, NY (J.E.A.); Mayo Clinic and Mayo Clinic College of Medicine, Rochester, MN (B.J.G.); and Boston University Medical Center, MA (E.M.H.)
| | - Peter R Kowey
- From the Duke Center for Atrial Fibrillation, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (A.S.B., S.K., L.E.T., E.D.P., J.P.P.); Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan-UCLA Medical Center (G.C.F.); Columbia University College of Physicians and Surgeons, New York, NY (J.A.R.); University of Colorado School of Medicine, Aurora (L.A.A.); Yale University School of Medicine, New Haven, CT (J.V.F.); Penn State Hershey Heart and Vascular Institute (G.N.); Stanford University School of Medicine, CA (K.W.M.); Kaiser Permanente Division of Research, Oakland, CA (A.S.G.); Lankenau Institute for Medical Research and Jefferson Medical College, Philadelphia, PA (P.R.K.); Hofstra Northwell School of Medicine, New York, NY (J.E.A.); Mayo Clinic and Mayo Clinic College of Medicine, Rochester, MN (B.J.G.); and Boston University Medical Center, MA (E.M.H.)
| | - Jack E Ansell
- From the Duke Center for Atrial Fibrillation, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (A.S.B., S.K., L.E.T., E.D.P., J.P.P.); Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan-UCLA Medical Center (G.C.F.); Columbia University College of Physicians and Surgeons, New York, NY (J.A.R.); University of Colorado School of Medicine, Aurora (L.A.A.); Yale University School of Medicine, New Haven, CT (J.V.F.); Penn State Hershey Heart and Vascular Institute (G.N.); Stanford University School of Medicine, CA (K.W.M.); Kaiser Permanente Division of Research, Oakland, CA (A.S.G.); Lankenau Institute for Medical Research and Jefferson Medical College, Philadelphia, PA (P.R.K.); Hofstra Northwell School of Medicine, New York, NY (J.E.A.); Mayo Clinic and Mayo Clinic College of Medicine, Rochester, MN (B.J.G.); and Boston University Medical Center, MA (E.M.H.)
| | - Bernard J Gersh
- From the Duke Center for Atrial Fibrillation, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (A.S.B., S.K., L.E.T., E.D.P., J.P.P.); Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan-UCLA Medical Center (G.C.F.); Columbia University College of Physicians and Surgeons, New York, NY (J.A.R.); University of Colorado School of Medicine, Aurora (L.A.A.); Yale University School of Medicine, New Haven, CT (J.V.F.); Penn State Hershey Heart and Vascular Institute (G.N.); Stanford University School of Medicine, CA (K.W.M.); Kaiser Permanente Division of Research, Oakland, CA (A.S.G.); Lankenau Institute for Medical Research and Jefferson Medical College, Philadelphia, PA (P.R.K.); Hofstra Northwell School of Medicine, New York, NY (J.E.A.); Mayo Clinic and Mayo Clinic College of Medicine, Rochester, MN (B.J.G.); and Boston University Medical Center, MA (E.M.H.)
| | - Elaine M Hylek
- From the Duke Center for Atrial Fibrillation, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (A.S.B., S.K., L.E.T., E.D.P., J.P.P.); Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan-UCLA Medical Center (G.C.F.); Columbia University College of Physicians and Surgeons, New York, NY (J.A.R.); University of Colorado School of Medicine, Aurora (L.A.A.); Yale University School of Medicine, New Haven, CT (J.V.F.); Penn State Hershey Heart and Vascular Institute (G.N.); Stanford University School of Medicine, CA (K.W.M.); Kaiser Permanente Division of Research, Oakland, CA (A.S.G.); Lankenau Institute for Medical Research and Jefferson Medical College, Philadelphia, PA (P.R.K.); Hofstra Northwell School of Medicine, New York, NY (J.E.A.); Mayo Clinic and Mayo Clinic College of Medicine, Rochester, MN (B.J.G.); and Boston University Medical Center, MA (E.M.H.)
| | - Eric D Peterson
- From the Duke Center for Atrial Fibrillation, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (A.S.B., S.K., L.E.T., E.D.P., J.P.P.); Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan-UCLA Medical Center (G.C.F.); Columbia University College of Physicians and Surgeons, New York, NY (J.A.R.); University of Colorado School of Medicine, Aurora (L.A.A.); Yale University School of Medicine, New Haven, CT (J.V.F.); Penn State Hershey Heart and Vascular Institute (G.N.); Stanford University School of Medicine, CA (K.W.M.); Kaiser Permanente Division of Research, Oakland, CA (A.S.G.); Lankenau Institute for Medical Research and Jefferson Medical College, Philadelphia, PA (P.R.K.); Hofstra Northwell School of Medicine, New York, NY (J.E.A.); Mayo Clinic and Mayo Clinic College of Medicine, Rochester, MN (B.J.G.); and Boston University Medical Center, MA (E.M.H.)
| | - Jonathan P Piccini
- From the Duke Center for Atrial Fibrillation, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (A.S.B., S.K., L.E.T., E.D.P., J.P.P.); Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan-UCLA Medical Center (G.C.F.); Columbia University College of Physicians and Surgeons, New York, NY (J.A.R.); University of Colorado School of Medicine, Aurora (L.A.A.); Yale University School of Medicine, New Haven, CT (J.V.F.); Penn State Hershey Heart and Vascular Institute (G.N.); Stanford University School of Medicine, CA (K.W.M.); Kaiser Permanente Division of Research, Oakland, CA (A.S.G.); Lankenau Institute for Medical Research and Jefferson Medical College, Philadelphia, PA (P.R.K.); Hofstra Northwell School of Medicine, New York, NY (J.E.A.); Mayo Clinic and Mayo Clinic College of Medicine, Rochester, MN (B.J.G.); and Boston University Medical Center, MA (E.M.H.).
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Affiliation(s)
- Anson M Lee
- From the Department of Cardiothoracic Surgery, Stanford University, CA.
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Lane JD, Tinker A. Have the Findings from Clinical Risk Prediction and Trials Any Key Messages for Safety Pharmacology? Front Physiol 2017; 8:890. [PMID: 29163223 PMCID: PMC5681497 DOI: 10.3389/fphys.2017.00890] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 10/20/2017] [Indexed: 01/28/2023] Open
Abstract
Anti-arrhythmic drugs are a mainstay in the management of symptoms related to arrhythmias, and are adjuncts in prevention and treatment of life-threatening ventricular arrhythmias. However, they also have the potential for pro-arrhythmia and thus the prediction of arrhythmia predisposition and drug response are critical issues. Clinical trials are the latter stages in the safety testing and efficacy process prior to market release, and as such serve as a critical safeguard. In this review, we look at some of the lessons to be learned from approaches to arrhythmia prediction in patients, clinical trials of drugs used in the treatment of arrhythmias, and the implications for the design of pre-clinical safety pharmacology testing.
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Affiliation(s)
- Jem D Lane
- William Harvey Heart Centre, Barts and The London School of Medicine and Dentistry, London, United Kingdom.,Department of Cardiac Electrophysiology, Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom
| | - Andrew Tinker
- William Harvey Heart Centre, Barts and The London School of Medicine and Dentistry, London, United Kingdom
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Abstract
Atrial fibrillation (AF) and heart failure with reduced ejection fraction (HFrEF) frequently coexist, and each complicates the course and treatment of the other. Recent population-based studies have demonstrated that the 2 conditions together increase the risk of stroke, heart failure hospitalization, and all-cause mortality, especially soon after the clinical onset of AF. Guideline-directed pharmacological therapy for HFrEF is important; however, although there are various treatment modalities for AF, there is no clear consensus on how best to treat AF with concomitant HFrEF. This in-depth review discusses the available data for the treatment of AF in the setting of HFrEF, focuses on areas where more investigation is necessary, examines the clinical implications of randomized and observational clinical trials, and presents suggestions for individualized treatment strategies for specific patient groups.
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Affiliation(s)
- Atul Verma
- From Department of Medicine and Surgery, Division of Cardiology, Southlake Regional Health Centre, University of Toronto, Canada (A.V.); Department of Medicine, Division of Cardiology, Royal Melbourne Hospital, University of Melbourne, Australia (J.M.K.); and Department of Medicine, Division of Cardiovascular Diseases, Perelman School of Medicine, University of Pennsylvania, Philadelphia (D.J.C.)
| | - Jonathan M Kalman
- From Department of Medicine and Surgery, Division of Cardiology, Southlake Regional Health Centre, University of Toronto, Canada (A.V.); Department of Medicine, Division of Cardiology, Royal Melbourne Hospital, University of Melbourne, Australia (J.M.K.); and Department of Medicine, Division of Cardiovascular Diseases, Perelman School of Medicine, University of Pennsylvania, Philadelphia (D.J.C.)
| | - David J Callans
- From Department of Medicine and Surgery, Division of Cardiology, Southlake Regional Health Centre, University of Toronto, Canada (A.V.); Department of Medicine, Division of Cardiology, Royal Melbourne Hospital, University of Melbourne, Australia (J.M.K.); and Department of Medicine, Division of Cardiovascular Diseases, Perelman School of Medicine, University of Pennsylvania, Philadelphia (D.J.C.).
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24
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Strauss DG, Vicente J, Johannesen L, Blinova K, Mason JW, Weeke P, Behr ER, Roden DM, Woosley R, Kosova G, Rosenberg MA, Newton-Cheh C. Common Genetic Variant Risk Score Is Associated With Drug-Induced QT Prolongation and Torsade de Pointes Risk: A Pilot Study. Circulation 2017; 135:1300-1310. [PMID: 28213480 DOI: 10.1161/circulationaha.116.023980] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 01/26/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Drug-induced QT interval prolongation, a risk factor for life-threatening ventricular arrhythmias, is a potential side effect of many marketed and withdrawn medications. The contribution of common genetic variants previously associated with baseline QT interval to drug-induced QT prolongation and arrhythmias is not known. METHODS We tested the hypothesis that a weighted combination of common genetic variants contributing to QT interval at baseline, identified through genome-wide association studies, can predict individual response to multiple QT-prolonging drugs. Genetic analysis of 22 subjects was performed in a secondary analysis of a randomized, double-blind, placebo-controlled, crossover trial of 3 QT-prolonging drugs with 15 time-matched QT and plasma drug concentration measurements. Subjects received single doses of dofetilide, quinidine, ranolazine, and placebo. The outcome was the correlation between a genetic QT score comprising 61 common genetic variants and the slope of an individual subject's drug-induced increase in heart rate-corrected QT (QTc) versus drug concentration. RESULTS The genetic QT score was correlated with drug-induced QTc prolongation. Among white subjects, genetic QT score explained 30% of the variability in response to dofetilide (r=0.55; 95% confidence interval, 0.09-0.81; P=0.02), 23% in response to quinidine (r=0.48; 95% confidence interval, -0.03 to 0.79; P=0.06), and 27% in response to ranolazine (r=0.52; 95% confidence interval, 0.05-0.80; P=0.03). Furthermore, the genetic QT score was a significant predictor of drug-induced torsade de pointes in an independent sample of 216 cases compared with 771 controls (r2=12%, P=1×10-7). CONCLUSIONS We demonstrate that a genetic QT score comprising 61 common genetic variants explains a significant proportion of the variability in drug-induced QT prolongation and is a significant predictor of drug-induced torsade de pointes. These findings highlight an opportunity for recent genetic discoveries to improve individualized risk-benefit assessment for pharmacological therapies. Replication of these findings in larger samples is needed to more precisely estimate variance explained and to establish the individual variants that drive these effects. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01873950.
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Affiliation(s)
- David G Strauss
- From Office of Clinical Pharmacology, Center for Drug Evaluation and Research (D.G.S., J.V., L.J.) and Office of Science and Engineering Laboratories, Center for Devices and Radiological Health (D.G.S., J.V., L.J., K.B.), US Food and Drug Administration, Silver Spring, MD; BSICoS Group, Aragón Institute for Engineering Research (I3A), IIS Aragón, University of Zaragoza, Spain (J.V.); Department of Clinical Physiology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden (L.J.); Division of Cardiology, University of Utah, Salt Lake City (J.W.M.); Spaulding Clinical Research, West Bend, WI (J.W.M.); Departments of Medicine (P.W., D.R.), Pharmacology (D.R.), and Biomedical Informatics (D.R.), Vanderbilt University Medical Center, Nashville, TN; Department of Cardiology, Copenhagen University Hospital, Gentofte, Denmark (P.W.); Cardiology Clinical Academic Group, St. George's University of London, London, UK (E.R.B.); AZCERT, Inc, Oro Valley, AZ (R.W.); Center for Genomic Medicine and Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA (G.K., M.A.R., C.N.-C.); Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge (G.K., M.A.R., C.N.-C.); and Division of Cardiac Electrophysiology, Veterans Administration Hospital System of Boston, Harvard Medical School, West Roxbury, MA (M.A.R.).
| | - Jose Vicente
- From Office of Clinical Pharmacology, Center for Drug Evaluation and Research (D.G.S., J.V., L.J.) and Office of Science and Engineering Laboratories, Center for Devices and Radiological Health (D.G.S., J.V., L.J., K.B.), US Food and Drug Administration, Silver Spring, MD; BSICoS Group, Aragón Institute for Engineering Research (I3A), IIS Aragón, University of Zaragoza, Spain (J.V.); Department of Clinical Physiology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden (L.J.); Division of Cardiology, University of Utah, Salt Lake City (J.W.M.); Spaulding Clinical Research, West Bend, WI (J.W.M.); Departments of Medicine (P.W., D.R.), Pharmacology (D.R.), and Biomedical Informatics (D.R.), Vanderbilt University Medical Center, Nashville, TN; Department of Cardiology, Copenhagen University Hospital, Gentofte, Denmark (P.W.); Cardiology Clinical Academic Group, St. George's University of London, London, UK (E.R.B.); AZCERT, Inc, Oro Valley, AZ (R.W.); Center for Genomic Medicine and Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA (G.K., M.A.R., C.N.-C.); Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge (G.K., M.A.R., C.N.-C.); and Division of Cardiac Electrophysiology, Veterans Administration Hospital System of Boston, Harvard Medical School, West Roxbury, MA (M.A.R.)
| | - Lars Johannesen
- From Office of Clinical Pharmacology, Center for Drug Evaluation and Research (D.G.S., J.V., L.J.) and Office of Science and Engineering Laboratories, Center for Devices and Radiological Health (D.G.S., J.V., L.J., K.B.), US Food and Drug Administration, Silver Spring, MD; BSICoS Group, Aragón Institute for Engineering Research (I3A), IIS Aragón, University of Zaragoza, Spain (J.V.); Department of Clinical Physiology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden (L.J.); Division of Cardiology, University of Utah, Salt Lake City (J.W.M.); Spaulding Clinical Research, West Bend, WI (J.W.M.); Departments of Medicine (P.W., D.R.), Pharmacology (D.R.), and Biomedical Informatics (D.R.), Vanderbilt University Medical Center, Nashville, TN; Department of Cardiology, Copenhagen University Hospital, Gentofte, Denmark (P.W.); Cardiology Clinical Academic Group, St. George's University of London, London, UK (E.R.B.); AZCERT, Inc, Oro Valley, AZ (R.W.); Center for Genomic Medicine and Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA (G.K., M.A.R., C.N.-C.); Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge (G.K., M.A.R., C.N.-C.); and Division of Cardiac Electrophysiology, Veterans Administration Hospital System of Boston, Harvard Medical School, West Roxbury, MA (M.A.R.)
| | - Ksenia Blinova
- From Office of Clinical Pharmacology, Center for Drug Evaluation and Research (D.G.S., J.V., L.J.) and Office of Science and Engineering Laboratories, Center for Devices and Radiological Health (D.G.S., J.V., L.J., K.B.), US Food and Drug Administration, Silver Spring, MD; BSICoS Group, Aragón Institute for Engineering Research (I3A), IIS Aragón, University of Zaragoza, Spain (J.V.); Department of Clinical Physiology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden (L.J.); Division of Cardiology, University of Utah, Salt Lake City (J.W.M.); Spaulding Clinical Research, West Bend, WI (J.W.M.); Departments of Medicine (P.W., D.R.), Pharmacology (D.R.), and Biomedical Informatics (D.R.), Vanderbilt University Medical Center, Nashville, TN; Department of Cardiology, Copenhagen University Hospital, Gentofte, Denmark (P.W.); Cardiology Clinical Academic Group, St. George's University of London, London, UK (E.R.B.); AZCERT, Inc, Oro Valley, AZ (R.W.); Center for Genomic Medicine and Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA (G.K., M.A.R., C.N.-C.); Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge (G.K., M.A.R., C.N.-C.); and Division of Cardiac Electrophysiology, Veterans Administration Hospital System of Boston, Harvard Medical School, West Roxbury, MA (M.A.R.)
| | - Jay W Mason
- From Office of Clinical Pharmacology, Center for Drug Evaluation and Research (D.G.S., J.V., L.J.) and Office of Science and Engineering Laboratories, Center for Devices and Radiological Health (D.G.S., J.V., L.J., K.B.), US Food and Drug Administration, Silver Spring, MD; BSICoS Group, Aragón Institute for Engineering Research (I3A), IIS Aragón, University of Zaragoza, Spain (J.V.); Department of Clinical Physiology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden (L.J.); Division of Cardiology, University of Utah, Salt Lake City (J.W.M.); Spaulding Clinical Research, West Bend, WI (J.W.M.); Departments of Medicine (P.W., D.R.), Pharmacology (D.R.), and Biomedical Informatics (D.R.), Vanderbilt University Medical Center, Nashville, TN; Department of Cardiology, Copenhagen University Hospital, Gentofte, Denmark (P.W.); Cardiology Clinical Academic Group, St. George's University of London, London, UK (E.R.B.); AZCERT, Inc, Oro Valley, AZ (R.W.); Center for Genomic Medicine and Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA (G.K., M.A.R., C.N.-C.); Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge (G.K., M.A.R., C.N.-C.); and Division of Cardiac Electrophysiology, Veterans Administration Hospital System of Boston, Harvard Medical School, West Roxbury, MA (M.A.R.)
| | - Peter Weeke
- From Office of Clinical Pharmacology, Center for Drug Evaluation and Research (D.G.S., J.V., L.J.) and Office of Science and Engineering Laboratories, Center for Devices and Radiological Health (D.G.S., J.V., L.J., K.B.), US Food and Drug Administration, Silver Spring, MD; BSICoS Group, Aragón Institute for Engineering Research (I3A), IIS Aragón, University of Zaragoza, Spain (J.V.); Department of Clinical Physiology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden (L.J.); Division of Cardiology, University of Utah, Salt Lake City (J.W.M.); Spaulding Clinical Research, West Bend, WI (J.W.M.); Departments of Medicine (P.W., D.R.), Pharmacology (D.R.), and Biomedical Informatics (D.R.), Vanderbilt University Medical Center, Nashville, TN; Department of Cardiology, Copenhagen University Hospital, Gentofte, Denmark (P.W.); Cardiology Clinical Academic Group, St. George's University of London, London, UK (E.R.B.); AZCERT, Inc, Oro Valley, AZ (R.W.); Center for Genomic Medicine and Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA (G.K., M.A.R., C.N.-C.); Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge (G.K., M.A.R., C.N.-C.); and Division of Cardiac Electrophysiology, Veterans Administration Hospital System of Boston, Harvard Medical School, West Roxbury, MA (M.A.R.)
| | - Elijah R Behr
- From Office of Clinical Pharmacology, Center for Drug Evaluation and Research (D.G.S., J.V., L.J.) and Office of Science and Engineering Laboratories, Center for Devices and Radiological Health (D.G.S., J.V., L.J., K.B.), US Food and Drug Administration, Silver Spring, MD; BSICoS Group, Aragón Institute for Engineering Research (I3A), IIS Aragón, University of Zaragoza, Spain (J.V.); Department of Clinical Physiology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden (L.J.); Division of Cardiology, University of Utah, Salt Lake City (J.W.M.); Spaulding Clinical Research, West Bend, WI (J.W.M.); Departments of Medicine (P.W., D.R.), Pharmacology (D.R.), and Biomedical Informatics (D.R.), Vanderbilt University Medical Center, Nashville, TN; Department of Cardiology, Copenhagen University Hospital, Gentofte, Denmark (P.W.); Cardiology Clinical Academic Group, St. George's University of London, London, UK (E.R.B.); AZCERT, Inc, Oro Valley, AZ (R.W.); Center for Genomic Medicine and Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA (G.K., M.A.R., C.N.-C.); Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge (G.K., M.A.R., C.N.-C.); and Division of Cardiac Electrophysiology, Veterans Administration Hospital System of Boston, Harvard Medical School, West Roxbury, MA (M.A.R.)
| | - Dan M Roden
- From Office of Clinical Pharmacology, Center for Drug Evaluation and Research (D.G.S., J.V., L.J.) and Office of Science and Engineering Laboratories, Center for Devices and Radiological Health (D.G.S., J.V., L.J., K.B.), US Food and Drug Administration, Silver Spring, MD; BSICoS Group, Aragón Institute for Engineering Research (I3A), IIS Aragón, University of Zaragoza, Spain (J.V.); Department of Clinical Physiology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden (L.J.); Division of Cardiology, University of Utah, Salt Lake City (J.W.M.); Spaulding Clinical Research, West Bend, WI (J.W.M.); Departments of Medicine (P.W., D.R.), Pharmacology (D.R.), and Biomedical Informatics (D.R.), Vanderbilt University Medical Center, Nashville, TN; Department of Cardiology, Copenhagen University Hospital, Gentofte, Denmark (P.W.); Cardiology Clinical Academic Group, St. George's University of London, London, UK (E.R.B.); AZCERT, Inc, Oro Valley, AZ (R.W.); Center for Genomic Medicine and Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA (G.K., M.A.R., C.N.-C.); Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge (G.K., M.A.R., C.N.-C.); and Division of Cardiac Electrophysiology, Veterans Administration Hospital System of Boston, Harvard Medical School, West Roxbury, MA (M.A.R.)
| | - Ray Woosley
- From Office of Clinical Pharmacology, Center for Drug Evaluation and Research (D.G.S., J.V., L.J.) and Office of Science and Engineering Laboratories, Center for Devices and Radiological Health (D.G.S., J.V., L.J., K.B.), US Food and Drug Administration, Silver Spring, MD; BSICoS Group, Aragón Institute for Engineering Research (I3A), IIS Aragón, University of Zaragoza, Spain (J.V.); Department of Clinical Physiology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden (L.J.); Division of Cardiology, University of Utah, Salt Lake City (J.W.M.); Spaulding Clinical Research, West Bend, WI (J.W.M.); Departments of Medicine (P.W., D.R.), Pharmacology (D.R.), and Biomedical Informatics (D.R.), Vanderbilt University Medical Center, Nashville, TN; Department of Cardiology, Copenhagen University Hospital, Gentofte, Denmark (P.W.); Cardiology Clinical Academic Group, St. George's University of London, London, UK (E.R.B.); AZCERT, Inc, Oro Valley, AZ (R.W.); Center for Genomic Medicine and Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA (G.K., M.A.R., C.N.-C.); Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge (G.K., M.A.R., C.N.-C.); and Division of Cardiac Electrophysiology, Veterans Administration Hospital System of Boston, Harvard Medical School, West Roxbury, MA (M.A.R.)
| | - Gulum Kosova
- From Office of Clinical Pharmacology, Center for Drug Evaluation and Research (D.G.S., J.V., L.J.) and Office of Science and Engineering Laboratories, Center for Devices and Radiological Health (D.G.S., J.V., L.J., K.B.), US Food and Drug Administration, Silver Spring, MD; BSICoS Group, Aragón Institute for Engineering Research (I3A), IIS Aragón, University of Zaragoza, Spain (J.V.); Department of Clinical Physiology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden (L.J.); Division of Cardiology, University of Utah, Salt Lake City (J.W.M.); Spaulding Clinical Research, West Bend, WI (J.W.M.); Departments of Medicine (P.W., D.R.), Pharmacology (D.R.), and Biomedical Informatics (D.R.), Vanderbilt University Medical Center, Nashville, TN; Department of Cardiology, Copenhagen University Hospital, Gentofte, Denmark (P.W.); Cardiology Clinical Academic Group, St. George's University of London, London, UK (E.R.B.); AZCERT, Inc, Oro Valley, AZ (R.W.); Center for Genomic Medicine and Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA (G.K., M.A.R., C.N.-C.); Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge (G.K., M.A.R., C.N.-C.); and Division of Cardiac Electrophysiology, Veterans Administration Hospital System of Boston, Harvard Medical School, West Roxbury, MA (M.A.R.)
| | - Michael A Rosenberg
- From Office of Clinical Pharmacology, Center for Drug Evaluation and Research (D.G.S., J.V., L.J.) and Office of Science and Engineering Laboratories, Center for Devices and Radiological Health (D.G.S., J.V., L.J., K.B.), US Food and Drug Administration, Silver Spring, MD; BSICoS Group, Aragón Institute for Engineering Research (I3A), IIS Aragón, University of Zaragoza, Spain (J.V.); Department of Clinical Physiology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden (L.J.); Division of Cardiology, University of Utah, Salt Lake City (J.W.M.); Spaulding Clinical Research, West Bend, WI (J.W.M.); Departments of Medicine (P.W., D.R.), Pharmacology (D.R.), and Biomedical Informatics (D.R.), Vanderbilt University Medical Center, Nashville, TN; Department of Cardiology, Copenhagen University Hospital, Gentofte, Denmark (P.W.); Cardiology Clinical Academic Group, St. George's University of London, London, UK (E.R.B.); AZCERT, Inc, Oro Valley, AZ (R.W.); Center for Genomic Medicine and Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA (G.K., M.A.R., C.N.-C.); Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge (G.K., M.A.R., C.N.-C.); and Division of Cardiac Electrophysiology, Veterans Administration Hospital System of Boston, Harvard Medical School, West Roxbury, MA (M.A.R.)
| | - Christopher Newton-Cheh
- From Office of Clinical Pharmacology, Center for Drug Evaluation and Research (D.G.S., J.V., L.J.) and Office of Science and Engineering Laboratories, Center for Devices and Radiological Health (D.G.S., J.V., L.J., K.B.), US Food and Drug Administration, Silver Spring, MD; BSICoS Group, Aragón Institute for Engineering Research (I3A), IIS Aragón, University of Zaragoza, Spain (J.V.); Department of Clinical Physiology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden (L.J.); Division of Cardiology, University of Utah, Salt Lake City (J.W.M.); Spaulding Clinical Research, West Bend, WI (J.W.M.); Departments of Medicine (P.W., D.R.), Pharmacology (D.R.), and Biomedical Informatics (D.R.), Vanderbilt University Medical Center, Nashville, TN; Department of Cardiology, Copenhagen University Hospital, Gentofte, Denmark (P.W.); Cardiology Clinical Academic Group, St. George's University of London, London, UK (E.R.B.); AZCERT, Inc, Oro Valley, AZ (R.W.); Center for Genomic Medicine and Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA (G.K., M.A.R., C.N.-C.); Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge (G.K., M.A.R., C.N.-C.); and Division of Cardiac Electrophysiology, Veterans Administration Hospital System of Boston, Harvard Medical School, West Roxbury, MA (M.A.R.).
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Shojaee M, Feizi B, Miri R, Etemadi J, Feizi AH. Intravenous Amiodarone versus Digoxin in Atrial Fibrillation Rate Control; a Clinical Trial. Emerg (Tehran) 2017; 5:e29. [PMID: 28286836 PMCID: PMC5325898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Treatment of rapid ventricular response arterial fibrillation (rapid AF) varies depending on the decision of the in-charge physician, condition of the patient, availability of the drug, and the treatment protocol of the hospital. The present study was designed aiming to compare IV digoxin and amiodarone in controlling the heart rate of patients presenting to emergency department with rapid AF and relative contraindication for first line drug in this regard. METHOD In the present clinical trial, patients presented to the ED with rapid AF and relative contraindication for calcium channel blockers and beta-blockers were treated with either IV amiodarone or IV digoxin and compared regarding success rate and complication using SPSS version 22. P < 0.05 was considered as statistically significant. RESULTS 84 patients were randomly allocated to either amiodarone or digoxin treatment groups of 42 (53.6% male). The mean age of the studied patients was 61.8 ± 11.14 years (38 - 79). No significant difference was present regarding baseline characteristics. The rate of treatment failure was 21.4% (9 cases) in amiodarone and 59.5% (25 cases) in digoxin groups (p < 0.001). The mean onset of action was 56.66 ± 39.52 minutes (10 - 180) in amiodarone receivers and 135.38 ± 110.41 minutes (25 - 540) in digoxin group (p < 0.001). None of the patients showed any adverse outcomes of hypotension, bradycardia, and rhythm control. CONCLUSION Based on the findings of the present study, rapid AF patients with relative contraindication for calcium channel blockers or beta-blockers who had received amiodarone experienced both higher (about 2 times) treatment success and a more rapid (about 2.5 times) response compared to those who received IV digoxin.
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Affiliation(s)
- Majid Shojaee
- Emergency Department, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Bahareh Feizi
- Emergency Department, Bouali Hospital, Islamic Azad University, Tehran Medical Sciences Branch, Tehran, Iran
| | - Reza Miri
- Cardiology Department, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Jalil Etemadi
- Cardiology Department, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Amir Hossein Feizi
- Emergency Department, Bouali Hospital, Islamic Azad University, Tehran Medical Sciences Branch, Tehran, Iran
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Robinson VM, Kowey PR. Smoothing the Bumpy Road to Antiarrhythmic Drug Development. Circulation 2015; 132:2195-7. [PMID: 26499961 DOI: 10.1161/circulationaha.115.019463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Victoria M Robinson
- From the Manchester Royal Infirmary, Manchester, United Kingdom (V.M.R.); Lankenau Institute for Medical Research, Philadelphia, PA (V.M.R., P.R.K.); and Jefferson Medical College, Philadelphia, PA (P.R.K.)
| | - Peter R Kowey
- From the Manchester Royal Infirmary, Manchester, United Kingdom (V.M.R.); Lankenau Institute for Medical Research, Philadelphia, PA (V.M.R., P.R.K.); and Jefferson Medical College, Philadelphia, PA (P.R.K.).
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27
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Page RL, Joglar JA, Caldwell MA, Calkins H, Conti JB, Deal BJ, Estes NAM, Field ME, Goldberger ZD, Hammill SC, Indik JH, Lindsay BD, Olshansky B, Russo AM, Shen WK, Tracy CM, Al-Khatib SM. 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia: Executive summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Heart Rhythm 2015; 13:e92-135. [PMID: 26409097 DOI: 10.1016/j.hrthm.2015.09.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Indexed: 10/23/2022]
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28
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Page RL, Joglar JA, Caldwell MA, Calkins H, Conti JB, Deal BJ, Estes NAM, Field ME, Goldberger ZD, Hammill SC, Indik JH, Lindsay BD, Olshansky B, Russo AM, Shen WK, Tracy CM, Al-Khatib SM. 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2015; 67:e27-e115. [PMID: 26409259 DOI: 10.1016/j.jacc.2015.08.856] [Citation(s) in RCA: 239] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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29
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Pezhouman A, Singh N, Song Z, Nivala M, Eskandari A, Cao H, Bapat A, Ko CY, Nguyen T, Qu Z, Karagueuzian HS, Weiss JN. Molecular Basis of Hypokalemia-Induced Ventricular Fibrillation. Circulation 2015; 132:1528-1537. [PMID: 26269574 DOI: 10.1161/circulationaha.115.016217] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 08/05/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Hypokalemia is known to promote ventricular arrhythmias, especially in combination with class III antiarrhythmic drugs like dofetilide. Here, we evaluated the underlying molecular mechanisms. METHODS AND RESULTS Arrhythmias were recorded in isolated rabbit and rat hearts or patch-clamped ventricular myocytes exposed to hypokalemia (1.0-3.5 mmol/L) in the absence or presence of dofetilide (1 μmol/L). Spontaneous early afterdepolarizations (EADs) and ventricular tachycardia/fibrillation occurred in 50% of hearts at 2.7 mmol/L [K] in the absence of dofetilide and 3.3 mmol/L [K] in its presence. Pretreatment with the Ca-calmodulin kinase II (CaMKII) inhibitor KN-93, but not its inactive analogue KN-92, abolished EADs and hypokalemia-induced ventricular tachycardia/fibrillation, as did the selective late Na current (INa) blocker GS-967. In intact hearts, moderate hypokalemia (2.7 mmol/L) significantly increased tissue CaMKII activity. Computer modeling revealed that EAD generation by hypokalemia (with or without dofetilide) required Na-K pump inhibition to induce intracellular Na and Ca overload with consequent CaMKII activation enhancing late INa and the L-type Ca current. K current suppression by hypokalemia and dofetilide alone in the absence of CaMKII activation were ineffective at causing EADs. CONCLUSIONS We conclude that Na-K pump inhibition by even moderate hypokalemia plays a critical role in promoting EAD-mediated arrhythmias by inducing a positive feedback cycle activating CaMKII and enhancing late INa. Class III antiarrhythmic drugs like dofetilide sensitize the heart to this positive feedback loop.
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Affiliation(s)
- Arash Pezhouman
- UCLA Cardiovascular Research Laboratory, Departments of Medicine (Cardiology) and Physiology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Neha Singh
- UCLA Cardiovascular Research Laboratory, Departments of Medicine (Cardiology) and Physiology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Zhen Song
- UCLA Cardiovascular Research Laboratory, Departments of Medicine (Cardiology) and Physiology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Michael Nivala
- UCLA Cardiovascular Research Laboratory, Departments of Medicine (Cardiology) and Physiology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Anahita Eskandari
- UCLA Cardiovascular Research Laboratory, Departments of Medicine (Cardiology) and Physiology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Hong Cao
- UCLA Cardiovascular Research Laboratory, Departments of Medicine (Cardiology) and Physiology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Aneesh Bapat
- UCLA Cardiovascular Research Laboratory, Departments of Medicine (Cardiology) and Physiology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Christopher Y Ko
- UCLA Cardiovascular Research Laboratory, Departments of Medicine (Cardiology) and Physiology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Thao Nguyen
- UCLA Cardiovascular Research Laboratory, Departments of Medicine (Cardiology) and Physiology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Zhilin Qu
- UCLA Cardiovascular Research Laboratory, Departments of Medicine (Cardiology) and Physiology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Hrayr S Karagueuzian
- UCLA Cardiovascular Research Laboratory, Departments of Medicine (Cardiology) and Physiology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - James N Weiss
- UCLA Cardiovascular Research Laboratory, Departments of Medicine (Cardiology) and Physiology, David Geffen School of Medicine at UCLA, Los Angeles, CA
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Naruse Y, Sekiguchi Y, Nogami A, Okada H, Yamauchi Y, Machino T, Kuroki K, Ito Y, Yamasaki H, Igarashi M, Tada H, Nitta J, Xu D, Sato A, Aonuma K. Systematic treatment approach to ventricular tachycardia in cardiac sarcoidosis. Circ Arrhythm Electrophysiol 2014; 7:407-13. [PMID: 24837644 DOI: 10.1161/circep.113.000734] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Fatal arrhythmia is commonly observed in cardiac sarcoidosis, but clinical effects of a systematic treatment approach are still uncertain. This study sought to describe both clinical and electrophysiological characteristics and outcomes of systematic treatment approach to ventricular tachycardia (VT) associated with cardiac sarcoidosis. METHODS AND RESULTS We enrolled 37 consecutive patients (11 men; age, 56±11 years) with a diagnosis of sustained VT associated with cardiac sarcoidosis. Clinical effects of a systematic treatment approach including medical therapy (both steroid and antiarrhythmic agents), in association with radiofrequency catheter ablation, were evaluated. All patients received antiarrhythmic agents, and 34 received steroid therapy. During a 39-month follow-up, 23 (62%) patients were free from any VT episodes with medical therapy. Multivariable Cox regression analyses revealed that the absence of gallium-67 myocardial uptake was an independent predictor for VT recurrence (hazard ratio, 7.51; 95% confidence interval, 1.65-34.26; P<0.01). Fourteen patients who experienced VT recurrences even while on drug therapy underwent radiofrequency catheter ablation. Electrophysiological study revealed that the mechanisms of VTs could be classified into 2 subgroups: Purkinje-related or scar-related VT. The QRS duration of VT was narrower in Purkinje-related than in scar-related VTs (157±23 versus 183±22 ms; P<0.05). After a 33-month follow-up subsequent to the radiofrequency catheter ablation, 6 of 14 patients experienced VT recurrence. The number of VTs sustained during electrophysiological study was higher in the patients with VT recurrence than in those without (3.7±1.4 versus 1.9±0.8; P<0.01). CONCLUSIONS A systematic treatment approach to cardiac sarcoidosis with VT successfully suppressed VT recurrences in the majority of patients studied.
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Affiliation(s)
- Yoshihisa Naruse
- From the Cardiovascular Division, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan (Y.N., Y.S., A.N., T.M., K.K., Y.I., H.Y., M.I., H.T., D.X., A.S., K.A.); Cardiovascular Division, Musashino Red Cross Hospital, Musashino, Tokyo, Japan (H.O., Y.Y.); and Cardiovascular Division, Saitama Red Cross Hospital, Saitama, Saitama, Japan (J.N.)
| | - Yukio Sekiguchi
- From the Cardiovascular Division, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan (Y.N., Y.S., A.N., T.M., K.K., Y.I., H.Y., M.I., H.T., D.X., A.S., K.A.); Cardiovascular Division, Musashino Red Cross Hospital, Musashino, Tokyo, Japan (H.O., Y.Y.); and Cardiovascular Division, Saitama Red Cross Hospital, Saitama, Saitama, Japan (J.N.).
| | - Akihiko Nogami
- From the Cardiovascular Division, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan (Y.N., Y.S., A.N., T.M., K.K., Y.I., H.Y., M.I., H.T., D.X., A.S., K.A.); Cardiovascular Division, Musashino Red Cross Hospital, Musashino, Tokyo, Japan (H.O., Y.Y.); and Cardiovascular Division, Saitama Red Cross Hospital, Saitama, Saitama, Japan (J.N.)
| | - Hiroyuki Okada
- From the Cardiovascular Division, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan (Y.N., Y.S., A.N., T.M., K.K., Y.I., H.Y., M.I., H.T., D.X., A.S., K.A.); Cardiovascular Division, Musashino Red Cross Hospital, Musashino, Tokyo, Japan (H.O., Y.Y.); and Cardiovascular Division, Saitama Red Cross Hospital, Saitama, Saitama, Japan (J.N.)
| | - Yasuteru Yamauchi
- From the Cardiovascular Division, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan (Y.N., Y.S., A.N., T.M., K.K., Y.I., H.Y., M.I., H.T., D.X., A.S., K.A.); Cardiovascular Division, Musashino Red Cross Hospital, Musashino, Tokyo, Japan (H.O., Y.Y.); and Cardiovascular Division, Saitama Red Cross Hospital, Saitama, Saitama, Japan (J.N.)
| | - Takeshi Machino
- From the Cardiovascular Division, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan (Y.N., Y.S., A.N., T.M., K.K., Y.I., H.Y., M.I., H.T., D.X., A.S., K.A.); Cardiovascular Division, Musashino Red Cross Hospital, Musashino, Tokyo, Japan (H.O., Y.Y.); and Cardiovascular Division, Saitama Red Cross Hospital, Saitama, Saitama, Japan (J.N.)
| | - Kenji Kuroki
- From the Cardiovascular Division, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan (Y.N., Y.S., A.N., T.M., K.K., Y.I., H.Y., M.I., H.T., D.X., A.S., K.A.); Cardiovascular Division, Musashino Red Cross Hospital, Musashino, Tokyo, Japan (H.O., Y.Y.); and Cardiovascular Division, Saitama Red Cross Hospital, Saitama, Saitama, Japan (J.N.)
| | - Yoko Ito
- From the Cardiovascular Division, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan (Y.N., Y.S., A.N., T.M., K.K., Y.I., H.Y., M.I., H.T., D.X., A.S., K.A.); Cardiovascular Division, Musashino Red Cross Hospital, Musashino, Tokyo, Japan (H.O., Y.Y.); and Cardiovascular Division, Saitama Red Cross Hospital, Saitama, Saitama, Japan (J.N.)
| | - Hiro Yamasaki
- From the Cardiovascular Division, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan (Y.N., Y.S., A.N., T.M., K.K., Y.I., H.Y., M.I., H.T., D.X., A.S., K.A.); Cardiovascular Division, Musashino Red Cross Hospital, Musashino, Tokyo, Japan (H.O., Y.Y.); and Cardiovascular Division, Saitama Red Cross Hospital, Saitama, Saitama, Japan (J.N.)
| | - Miyako Igarashi
- From the Cardiovascular Division, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan (Y.N., Y.S., A.N., T.M., K.K., Y.I., H.Y., M.I., H.T., D.X., A.S., K.A.); Cardiovascular Division, Musashino Red Cross Hospital, Musashino, Tokyo, Japan (H.O., Y.Y.); and Cardiovascular Division, Saitama Red Cross Hospital, Saitama, Saitama, Japan (J.N.)
| | - Hiroshi Tada
- From the Cardiovascular Division, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan (Y.N., Y.S., A.N., T.M., K.K., Y.I., H.Y., M.I., H.T., D.X., A.S., K.A.); Cardiovascular Division, Musashino Red Cross Hospital, Musashino, Tokyo, Japan (H.O., Y.Y.); and Cardiovascular Division, Saitama Red Cross Hospital, Saitama, Saitama, Japan (J.N.)
| | - Junichi Nitta
- From the Cardiovascular Division, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan (Y.N., Y.S., A.N., T.M., K.K., Y.I., H.Y., M.I., H.T., D.X., A.S., K.A.); Cardiovascular Division, Musashino Red Cross Hospital, Musashino, Tokyo, Japan (H.O., Y.Y.); and Cardiovascular Division, Saitama Red Cross Hospital, Saitama, Saitama, Japan (J.N.)
| | - Dongzhu Xu
- From the Cardiovascular Division, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan (Y.N., Y.S., A.N., T.M., K.K., Y.I., H.Y., M.I., H.T., D.X., A.S., K.A.); Cardiovascular Division, Musashino Red Cross Hospital, Musashino, Tokyo, Japan (H.O., Y.Y.); and Cardiovascular Division, Saitama Red Cross Hospital, Saitama, Saitama, Japan (J.N.)
| | - Akira Sato
- From the Cardiovascular Division, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan (Y.N., Y.S., A.N., T.M., K.K., Y.I., H.Y., M.I., H.T., D.X., A.S., K.A.); Cardiovascular Division, Musashino Red Cross Hospital, Musashino, Tokyo, Japan (H.O., Y.Y.); and Cardiovascular Division, Saitama Red Cross Hospital, Saitama, Saitama, Japan (J.N.)
| | - Kazutaka Aonuma
- From the Cardiovascular Division, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan (Y.N., Y.S., A.N., T.M., K.K., Y.I., H.Y., M.I., H.T., D.X., A.S., K.A.); Cardiovascular Division, Musashino Red Cross Hospital, Musashino, Tokyo, Japan (H.O., Y.Y.); and Cardiovascular Division, Saitama Red Cross Hospital, Saitama, Saitama, Japan (J.N.)
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Burashnikov A, Di Diego JM, Barajas-Martínez H, Hu D, Zygmunt AC, Cordeiro JM, Moise NS, Kornreich BG, Belardinelli L, Antzelevitch C. Ranolazine effectively suppresses atrial fibrillation in the setting of heart failure. Circ Heart Fail 2014; 7:627-33. [PMID: 24874201 DOI: 10.1161/circheartfailure.114.001129] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND There is a critical need for safer and more effective pharmacological management of atrial fibrillation (AF) in the setting of heart failure (HF). METHODS AND RESULTS This study investigates the electrophysiological, antiarrhythmic, and proarrhythmic effects of a clinically relevant concentration of ranolazine (5 μmol/L) in coronary-perfused right atrial and left ventricular preparations isolated from the hearts of HF dogs. HF was induced by ventricular tachypacing (2-6 weeks at 200-240 beats per minute; n=17). Transmembrane action potentials were recorded using standard microelectrode techniques. In atria, ranolazine slightly prolonged action potential duration but significantly depressed sodium channel current-dependent parameters causing a reduction of maximum rate of rise of the action potential upstroke, a prolongation of the effective refractory period secondary to the development of postrepolarization refractoriness, and an increase in diastolic threshold of excitation and atrial conduction time. Ranolazine did not significantly alter these parameters or promote arrhythmias in the ventricles. Ranolazine produced greater inhibition of peak sodium channel current in atrial cells isolated from HF versus normal dogs. A single premature beat reproducibly induced self-terminating AF in 10 of 17 atria. Ranolazine (5 μmol/L) suppressed induction of AF in 7 of 10 (70%) atria. In the remaining 3 atria, ranolazine reduced frequency and duration of AF. CONCLUSIONS Our results demonstrate more potent suppression of AF by ranolazine in the setting of HF than previously demonstrated in nonfailing hearts and absence of ventricular proarrhythmia. The data suggest that ranolazine may be of benefit as an alternative to amiodarone and dofetilide in the management of AF in patients with HF.
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Affiliation(s)
- Alexander Burashnikov
- From the Masonic Medical Research Laboratory, Utica, NY (A.B., J.M.D.D., H.B.-M., D.H., A.C.Z., J.M.C., C.A.); Department of Clinical and Biological Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY (N.S.M., B.G.K.); and Gilead Sciences, Foster City, CA (L.B.).
| | - José M Di Diego
- From the Masonic Medical Research Laboratory, Utica, NY (A.B., J.M.D.D., H.B.-M., D.H., A.C.Z., J.M.C., C.A.); Department of Clinical and Biological Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY (N.S.M., B.G.K.); and Gilead Sciences, Foster City, CA (L.B.)
| | - Hector Barajas-Martínez
- From the Masonic Medical Research Laboratory, Utica, NY (A.B., J.M.D.D., H.B.-M., D.H., A.C.Z., J.M.C., C.A.); Department of Clinical and Biological Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY (N.S.M., B.G.K.); and Gilead Sciences, Foster City, CA (L.B.)
| | - Dan Hu
- From the Masonic Medical Research Laboratory, Utica, NY (A.B., J.M.D.D., H.B.-M., D.H., A.C.Z., J.M.C., C.A.); Department of Clinical and Biological Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY (N.S.M., B.G.K.); and Gilead Sciences, Foster City, CA (L.B.)
| | - Andrew C Zygmunt
- From the Masonic Medical Research Laboratory, Utica, NY (A.B., J.M.D.D., H.B.-M., D.H., A.C.Z., J.M.C., C.A.); Department of Clinical and Biological Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY (N.S.M., B.G.K.); and Gilead Sciences, Foster City, CA (L.B.)
| | - Jonathan M Cordeiro
- From the Masonic Medical Research Laboratory, Utica, NY (A.B., J.M.D.D., H.B.-M., D.H., A.C.Z., J.M.C., C.A.); Department of Clinical and Biological Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY (N.S.M., B.G.K.); and Gilead Sciences, Foster City, CA (L.B.)
| | - N Sydney Moise
- From the Masonic Medical Research Laboratory, Utica, NY (A.B., J.M.D.D., H.B.-M., D.H., A.C.Z., J.M.C., C.A.); Department of Clinical and Biological Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY (N.S.M., B.G.K.); and Gilead Sciences, Foster City, CA (L.B.)
| | - Bruce G Kornreich
- From the Masonic Medical Research Laboratory, Utica, NY (A.B., J.M.D.D., H.B.-M., D.H., A.C.Z., J.M.C., C.A.); Department of Clinical and Biological Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY (N.S.M., B.G.K.); and Gilead Sciences, Foster City, CA (L.B.)
| | - Luiz Belardinelli
- From the Masonic Medical Research Laboratory, Utica, NY (A.B., J.M.D.D., H.B.-M., D.H., A.C.Z., J.M.C., C.A.); Department of Clinical and Biological Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY (N.S.M., B.G.K.); and Gilead Sciences, Foster City, CA (L.B.)
| | - Charles Antzelevitch
- From the Masonic Medical Research Laboratory, Utica, NY (A.B., J.M.D.D., H.B.-M., D.H., A.C.Z., J.M.C., C.A.); Department of Clinical and Biological Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY (N.S.M., B.G.K.); and Gilead Sciences, Foster City, CA (L.B.).
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