Long-term outcomes with abandoning versus extracting sterile leads: A 10-year population-based study

BACKGROUND

Long-term outcomes of sterile lead management strategies of lead abandonment (LA) or transvenous lead extraction (TLE) remain unclear.

METHODS

We performed a retrospective study of a population residing in southeastern Minnesota with follow-up at the Mayo Clinic and its health systems. Patients who underwent LA or TLE of sterile leads from January 1, 2000, to January 1, 2011, and had follow-up for at least 10 years or until their death were included.

RESULTS

A total of 172 patients were included in the study with 153 patients who underwent LA and 19 who underwent TLE for sterile leads. Indications for subsequent lead extraction arose in 9.1% (n = 14) of patients with initial LA and 5.3% (n = 1) in patients with initial TLE, after an average of 7 years. Moreover, 28.6% of patients in the LA cohort who required subsequent extraction did not proceed with the extraction, and among those who proceeded, 60% had clinical success and 40% had a clinical failure. Subsequent device upgrades or revisions were performed in 18.3% of patients in the LA group and 31.6% in the TLE group, with no significant differences in procedural challenges (5.2% vs. 5.3%). There was no difference in 10-year survival probability among the LA group and the TLE group (p = .64).

CONCLUSION

An initial lead abandonment strategy was associated with more complicated subsequent extraction procedures compared to patients with an initial transvenous lead extraction strategy. However, there was no difference in 10-year survival probability between both lead management approaches.

Predicting Major Adverse Events in Patients Undergoing Transcatheter Left Atrial Appendage Occlusion

BACKGROUND

The National Cardiovascular Data Registry Left Atrial Appendage Occlusion Registry (LAAO) includes the vast majority of transcatheter LAAO procedures performed in the United States. The objective of this study was to develop a model predicting adverse events among patients undergoing LAAO with Watchman FLX.

METHODS

Data from 41 001 LAAO procedures with Watchman FLX from July 2020 to September 2021 were used to develop and validate a model predicting in-hospital major adverse events. Randomly selected development (70%, n=28 530) and validation (30%, n=12 471) cohorts were analyzed with 1000 bootstrapped samples, using forward stepwise logistic regression to create the final model. A simplified bedside risk score was also developed using this model.

RESULTS

Increased age, female sex, low preprocedure hemoglobin, no prior attempt at atrial fibrillation termination, and increased fall risk most strongly predicted in-hospital major adverse events and were included in the final model along with other clinically relevant variables. The median in-hospital risk-standardized adverse event rate was 1.50% (range, 1.03%-2.84%; interquartile range, 1.42%-1.64%). The model demonstrated moderate discrimination (development C-index, 0.67 [95% CI, 0.65-0.70] and validation C-index, 0.66 [95% CI, 0.62-0.70]) with good calibration. The simplified risk score was well calibrated with risk of in-hospital major adverse events ranging from 0.26% to 3.90% for a score of 0 to 8, respectively.

CONCLUSIONS

A transcatheter LAAO risk model using National Cardiovascular Data Registry and LAAO Registry data can predict in-hospital major adverse events, demonstrated consistency across hospitals and can be used for quality improvement efforts. A simple bedside risk score was similarly predictive and may inform shared decision-making.

Analysis of Closed Claims Among All Medical Specialties: Importance of Communication and Other Non-Clinical Contributing Factors

Objective

Medical malpractice claims represent patient dissatisfaction of care delivered by their healthcare provider. Evaluation of contributing factors (CFs) associated with claims provides important information to optimize the patient-provider relationship.

Study Design

A total of 21,101 closed claims with 54,479 CFs (2.2 contributing factors per claim) from a large medical professional liability coverage provider were analyzed from 2010 to 2019.

Results

Four clinical CFs (technical performance, management of therapy, patient assessment, and patient factors) and four nonclinical CFs (communication between providers and patient, communication among providers, failure or delay in obtaining a consult, and insufficient documentation) were identified >1,500 times. Nonclinical CFs increased as a percentage from 50% in the first part of the study period to 54% in the second part of the study period (p < 0.01), and were more frequent in cases associated with indemnity when compared to clinical CFs (Nonclinical: 57% vs 43%; p < 0.001). Poor communication as a CF increased steadily during the study period (3-year average; 2010-2012: 777 CF/year vs 2017-2019: 1207 CF/year; p < 0.001). In claims associated with high severity injury, poor communication among providers was more significant than poor communication between the provider and patient (63% vs 29%; p < 0.001), mainly due to failure to convey the severity of the patient's condition. For non-surgical specialties except psychiatry, communication was the highest CF and the second or third CF for psychiatry or surgical specialties.

Discussion

Clinical and nonclinical CFs are equally important for malpractice claims. Communications issues are particularly important regardless of specialty. While focusing on clinical quality is important, implementing strategies that account for nonclinical issues, with a particular focus on communication, would have significant benefits particularly in an environment of increased consolidation of healthcare delivery systems.

Pulmonary vein capture is a predictor for long-term success of stand-alone pulmonary vein isolation with cryoballoon ablation in patients with persistent atrial fibrillation

Background

The mechanisms of AF development and progression are still not completely understood. Despite the relative efficacy of ablation, the risk of AF recurrence is substantial, particularly in patients with persistent AF (perAF). At present we do not have any reliable intra-procedural electrophysiologic predictors of long-term success of AF ablation other than pulmonary vein isolation. We evaluated selected intraprocedural pulmonary vein characteristics that may be helpful in future guidance of persistent AF ablation.

Methods

390 consecutive procedures using cryoballoon for initial AF ablation were divided by clinical presentation (paroxysmal or persistent AF), and by pulmonary vein (PV) response to pacing after completion of ablation (discrete electrogram elicited with pacing-"PV capture" or not-"Control"). Patients were followed (median 20 months) for recurrent atrial arrhythmias as the primary end point of the study.

Results

PV capture was identified in 20.3% and 17.1% and patients with paroxysmal and persistent AF respectively (ns). In patients with persistent AF presence of PV capture was associated with significantly better outcomes compared to patients without PV capture (p < 0.001). In the group "persistent AF and PV capture", an initial strategy of PV isolation and reisolation of the PVs (without additional lesions) for patients with recurrent atrial arrhythmias resulted in 20/23 (87%) patients in sinus rhythm off antiarrhythmic medications at study completion. In patients with paroxysmal AF, PV capture was not associated with outcome benefits. Specific electrophysiologic characteristics of PV (PV capture cycle length: PVCCL) did not have an impact on AF recurrence, although 25% shortening of PVCCL was observed after 60 s periods of pacing at short cycle lengths. No background demographic patient characteristic differences were identified between patients with vs. without PV capture.

Conclusion

The presence of PV capture was associated with better outcomes in patients with persistent AF. PV capture may identify those patients with persistent AF in whom cryoballoon PV isolation alone is sufficient as an initial ablation procedure and as the primary ablation strategy for recurrent AF.

Atrial Fibrillation: One Size Fits All?

Patients with atrial fibrillation not associated with other cardiac conditions require different individualized treatment strategies. However, in all patients it is critical to address modifiable risk factors, assess stroke risk, minimize atrial fibrillation burden, and identify the patient's individual goals of care.

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation.

METHODS

A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.

STRUCTURE

Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation.

METHODS

A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.

STRUCTURE

Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

Impact of Professional Society Guideline Publications in Medicine Subspecialties From 2012 to 2022: Implications for Clinical Care and Health Policy

Clinical guidelines have become an integral part of clinical care. We assessed professional society-based clinical guidelines from 2012 to 2022 to elucidate the trends in numbers of documents, recommendations, and classes of recommendations. Our results found that 40% of the guidelines do not follow all recommendations made by the Institute of Medicine for trustworthy documents. There has been a significant increase in documents in cardiology, gastroenterology, and hematology/oncology. In addition, of more than 20,000 recommendations, there was significant variability in recommendations made by different professional societies within a specialty. In documents from 11 of the 14 professional societies, more than 50% of the recommendations are supported with the lowest levels of evidence. In cardiology, in addition to the guideline documents, 140 nonguideline documents provide 1812 recommendations using the guideline verbiage, and 74% of the recommendations are supported by the lowest level of evidence. These data have important implications for health care because guidelines and guideline-like documents can be used for health policy issues such as assessment of quality of care, medical liability, education, and payment.

Impact of Pulmonary Hypertension Hemodynamic Phenotype on Incident Atrial Fibrillation

INTRODUCTION

Atrial fibrillation/flutter (AF) is common among patients with pulmonary hypertension (PH) and is associated with poor clinical outcomes. AF has been shown to occur more commonly among patients with postcapillary PH, although AF also occurs among patients with precapillary PH. The goal of this study was to evaluate the independent impact of PH hemodynamic phenotype on incident AF among patients with PH.

METHODS

We retrospectively identified 262 consecutive patients, without a prior diagnosis of atrial arrhythmias, seen at the PH clinic at Mayo Clinic, Florida, between 1997 and 2017, who had right heart catheterization and echocardiography performed, with follow-up for outcomes through 2021. Kaplan-Meier analysis and Cox-proportional hazards regression modeling were used to evaluate the independent effect of PH hemodynamic phenotype on incident AF.

RESULTS

Our study population was classified into two broad PH hemodynamic groups: precapillary (64.9%) and postcapillary (35.1%). The median age was 59.5 years (Q1: 48.4, Q3: 68.4), and 72% were female. In crude models, postcapillary PH was significantly associated with incident AF (HR 2.17, 95% CI: 1.26-3.74, p = 0.005). This association was lost following multivariable adjustment, whereas left atrial volume index remained independently associated with incident AF (aHR 1.30, 95% CI: 1.09-1.54, p = 0.003).

CONCLUSION

We found PH hemodynamic phenotype was not significantly associated with incident AF in our patient sample; however, echocardiographic evidence of left atrial remodeling appeared to have a greater impact on AF development. Larger studies are needed to validate these findings and identify potential modifiable risk factors for AF in this population.

Subcutaneous implantable cardioverter-defibrillator noise following left ventricular assist device implantation

Background

The incidence and impact of noise in a subcutaneous implantable cardioverter defibrillator (S-ICD) after left ventricular assist device (LVAD) implantation is not well established.

Methods

We performed a retrospective study of patients implanted with LVAD and with a pre-existing S-ICD between January 2005 and December 2020 at the three Mayo Clinic centers (Minnesota, Arizona, and Florida).

Results

Of the 908 LVAD patients, a pre-existing S-ICD was present in 9 patients (mean age 49.1 ± 13.7 years, 66.7% males), 100% with Boston Scientific third-generation EMBLEM MRI S-ICD, 11% with HeartMate II (HM II), 44% with HeartMate 3 (HM 3), and 44% with HeartWare (HW) LVAD. The incidence of noise from LVAD-related electromagnetic interference (EMI) was 33% and was only seen with HM 3 LVAD. Multiple measures attempted to resolve noise, including using alternative S-ICD sensing vector, adjusting S-ICD time zone, and increasing LVAD pump speed, were unsuccessful, necessitating S-ICD device therapies to be turned off permanently.

Conclusions

The incidence of LVAD-related S-ICD noise is high in patients with concomitant LVAD and S-ICD with significant impact on device function. As conservative management failed to resolve the EMI, the S-ICDs had to be programmed off to avoid inappropriate shocks. This study highlights the importance of awareness of LVAD-SICD device interference and the need to improve S-ICD detection algorithms to eliminate noise.

Palpitations and Shortness of Breath-Just a "Bump in the Road" or Something More?

A previously healthy person in their 60s with progressive shortness of breath and fatigue for the past 6 months presented to the emergency department with palpitations and shortness of breath. What is your diagnosis?

Electrophysiology and arrhythmia care in Romania

Interventional electrophysiological procedures such as catheter ablation and cardiac implantable electronic device (CIED) implantation have become important treatment options for patients with arrhythmia, but delivering state-of-the-art care can be challenging in developing countries. Romania has 19 million people. Throughout Romania, there are 28 centers that can implant CIEDs and 16 centers that can perform catheter ablation, but they are concentrated in the capital of Bucharest. Interventional arrhythmia procedures are performed less frequently than in other European countries (pacemaker: 301/million; implantable cardioverter-defibrillator: 44/million; cardiac resynchronization therapy: 13/million; catheter ablation: 0.8/million). Cardiologists with expertise in arrhythmia care have increased over the past decade and have formed an active organization that has instituted a national registry for interventional arrhythmia procedures and have been active in research and international arrhythmia organizations. Although significant work remains, our electrophysiology community is energized and is working to develop access to the best arrhythmia care for all Romanians.

What can anatomy teach the electrophysiologist for diagnostic procedures?

Even for a basic study, the electrophysiologist needs to have a clear mental picture of cardiac anatomy when positioning the diagnostic catheters. This review highlights some of the features of the four cardiac chambers relevant for translating anatomic knowledge into an understanding of fluoroscopy images and electrograms. Integration of images from real cardiac anatomy into three-dimensional mapping based on electrograms and "virtual" anatomy is crucial for the success and safety of diagnostic and therapeutic electrophysiological procedures.

Electromagnetic interference from left ventricular assist device in patients with transvenous implantable cardioverter-defibrillator

BACKGROUND

Many advanced heart failure patients have both a left ventricular assist device (LVAD) and an implantable cardioverter-defibrillator (ICD). This study examines incidence, clinical impact, and management of LVAD-related EMI.

METHODS

We performed a three-center retrospective analysis of transvenous ICD implanted patients with LVAD implanted between January 1, 2005 and December 31, 2020. The primary outcome was EMI after LVAD implantation, categorized as LVAD-related noise or telemetry interference.

RESULTS

The rate of LVAD-related EMI among the 737 patients (mean age 58.6 ± 12.8 years) studied was 5.0%. Telemetry interference (1.5%) compromised ICD interrogation in all patients. This was resolved successfully with use of a metal shield, encased wand, radiofrequency tower, different ICD programmer or by increasing distance between ICD programmer and LVAD (n = 6). ICD replacement was required to reestablish successful communication in three patients. LVAD-related noise (3.5%) led to oversensing (n = 4), inappropriate mode switches (n = 4), noise reversion (n = 3), inhibition of pacing (n = 2), inappropriate detection as atrial fibrillation (AF) (n = 2) and inappropriate detection as ventricular tachycardia (VT) and/or ventricular fibrillation (VF) (n = 2). This noise interference persisted (n = 3), resolved spontaneously (n = 16), resolved with programming change (n = 6) or required lead revision (n = 1).

CONCLUSIONS

EMI from LVAD impacts ICD function, although, the incidence rate is low. Physicians implanting both, LVAD in patients with ICD (more common) or ICD in patients with LVAD, should be aware of possible interferences. Telemetry failure not resolved by metal shielding was overcome by ICD generator replacement to a different manufacturer. In most cases, LVAD-related noise resolves spontaneously.

Comparison of Incident Cardiovascular Event Rates Between Generic and Brand l-Thyroxine for the Treatment of Hypothyroidism

OBJECTIVE

To determine whether levothyroxine (L-T4) preparation (generic vs brand) affected hospitalization for cardiovascular events.

PATIENTS AND METHODS

We performed a retrospective analysis using a large administrative claims database, OptumLabs Data Warehouse, creating two 1-to-1 propensity score-matched cohorts initiating generic or brand L-T4. Patients were followed for a mean of 1.0±1.2 years (range, 0-9.3 years). We included 87,902 propensity score-matched patients (43,951 patients per cohort) initiating generic or brand L-T4. Variables included in matching were age, sex, race/ethnicity, residence region, selected comorbidities, and Charlson-Deyo comorbidity score. Patients with previous use of any thyroid preparation, amiodarone, or lithium were excluded. Primary outcomes were the event rates for hospitalizations for incident atrial fibrillation, myocardial infarction, congestive heart failure, or stroke.

RESULTS

In the generic L-T4 cohort, 35,242 (80.2%) were women and 7327 (16.7%) were 65 years of age or older; in the brand L-T4 cohort, 34,633 (78.8%) were women and 8092 (18.4%) were 65 years of age or older. We found no differences in event rates (events per 1000 person-years) for 4 outcomes comparing generic and brand L-T4 therapy: (1) atrial fibrillation (1.82 vs 2.19; hazard ratio [HR], 1.22; 95% CI, 0.90-1.65; P=.19); (2) myocardial infarction (2.12 vs 1.83; HR, 0.86; 95% CI, 0.64-1.17; P=.35); (3) congestive heart failure (2.27 vs 2.00; HR, 0.88; 95% CI, 0.66-1.18; P=.41); and (4) stroke (3.10 vs 2.38; HR, 0.77; 95% CI, 0.59-1.00; P=.05). Stratification by age group revealed no differences.

CONCLUSION

In patients with newly treated hypothyroidism, cardiovascular event rates were similar for generic and brand L-T4.

Updates in medical professional liability: a primer for electrophysiologists

Medical professional liability (MPL), traditionally known as medical malpractice, affects most electrophysiologists some point during their career, either directly through personal experience or indirectly by the experiences of colleagues. Despite this, most physicians struggle to accurately describe MPL in the context of clinical practice. Providers know little about the outcomes of malpractice claims as reporting of settled or litigated MPL cases is sparse in the medical literature. In the USA, individual patients can file a malpractice claim in a tort-based system, whereas in other parts of the world, no-fault malpractice systems are increasingly prevalent. Tort reform remains a topic of much debate as the economic costs of malpractice contribute to the ever-expanding costs of health care in the USA. This review provides a framework to define MPL, describes the tort and no-fault systems of malpractice, and details the economic impacts of MPL on health care and the practice of cardiology in the USA. Current policy trends towards MPL including tort reform are reviewed, and MPL as it relates to the practice of cardiac electrophysiology is detailed.

Frequency of in-hospital adverse outcomes and cost utilization associated with cardiac resynchronization therapy defibrillator implantation in the United States

BACKGROUND

The utilization of cardiac resynchronization therapy defibrillator (CRT-D) has increased significantly, since its initial approval for use in selected patients with heart failure. Limited data exist as for current trends in implant-related in-hospital complications and cost utilization. The aim of our study was to examine in-hospital complication rates associated with CRT-D and their trends over the last decade.

METHODS AND RESULTS

Using the Nationwide Inpatient Sample, we estimated 378 248 CRT-D procedures from 2003 to 2012. We investigated common complications, including mechanical, cardiovascular, pericardial complications (hemopericardium, cardiac tamponade, or pericardiocentesis), pneumothorax, stroke, vascular complications (consisting of hemorrhage/hematoma, incidents requiring surgical repair, and accidental arterial puncture), and in-hospital deaths described with CRT-D, defining them by the validated International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code. Mechanical complications (5.9%) were the commonest, followed by cardiovascular (3.6%), respiratory failure (2.4%), and pneumothorax (1.5%). Age (≥65 years), female gender (OR, 95% CI; P value) (1.08, 1.03-1.13; 0.001), and the Charlson score ≥3 (1.52, 1.45-1.60; <0.001) were significantly associated with increased mortality/complications.

CONCLUSIONS

The overall complication rate in patients undergoing CRT-D has been increasing in the last decade. Age (≥65), female sex, and the Charlson score ≥3 were associated with higher complications. In patients who underwent CRT-D implantation, postoperative complications were associated with significant increases in cost.

Arrhythmia care in Africa

Data on cardiovascular disease, including arrhythmias, in Africa is limited. However, the burden of cardiovascular disease appears to be on the rise. Recent global data suggests an increase in atrial fibrillation rates despite declining rates of rheumatic heart disease. Atrial fibrillation is also associated with increased mortality in Africa. Current management with medical therapy is sub-optimal and ablation procedures, inaccessible. Atrial fibrillation is also an independent risk factor for death in patients with rheumatic heart disease. Sudden cardiac deaths from ventricular arrhythmias are under-recognized and inadequately treated with very high rates out of hospital cardiac arrest due to poor education of the general public on cardiopulmonary resuscitation skills and lack of essential healthcare infrastructure. Use of cardiac devices such as implantable defibrillators and pacemakers is low with significant regional variations and is almost non-existent in sub-Saharan Africa. There is a great unmet need for arrhythmia diagnosis and management in Africa. Governments and healthcare stakeholders need to include cardiovascular disease as a healthcare priority given the rising burden of disease and associated mortality.

Mayo registry for telemetry efficacy in arrest study: An evaluation of the feasibility of the do not intubate code status

Introduction: Guidelines recommend discussing code status with patients on hospital admission. No study has evaluated the feasibility of a full code with do not intubate (DNI) status. Methods: A retrospective analysis of patients who experienced a cardiopulmonary arrest was performed between May 1, 2008 and June 20, 2014. A descriptive analysis was created based on whether patients required mechanical ventilatory support during the hospitalization and comparisons were made between both patient subsets. Results: A total of 239 patients were included. Almost all (n = 218, 91.2%) required intubation during the hospitalization. Over half (n = 117, 53.7%) were intubated on the same day as the cardiopulmonary arrest and 91 patients (41.7%) were intubated at the time of arrest. Comparisons between intubated and non-intubated patients showed little differences in clinical characteristics, except for a higher proportion of medical cardiac etiology for admission in patients who did not require intubation (n = 10, 47.6% versus n = 55, 25.2%; p = 0.18) and initial arrest rhythm of ventricular tachycardia/fibrillation (n = 8, 38.1% versus n = 50, 22.9%; p = 0.37). No differences in 24-hour and posthospital survivals were present. Conclusion: Mechanical ventilatory support is commonly utilized in patients who experience a cardiopulmonary arrest. The DNI status may not be a feasible code status option for most patients.

Revisiting propafenone toxicity

Propafenone is a Vaughan Williams class 1c antiarrhythmic medication widely used for treatment of arrhythmias. Although the long-term safety of propafenone use has not been established, it is commonly used for treatment of atrial fibrillation in patients with no structural heart disease. Propafenone is well known as pill-in-the-pocket treatment for its effect in terminating paroxysmal episodes of atrial fibrillation. Herein, we discuss an unusual adverse reaction to propafenone in a patient who presented with symptomatic bradycardia and hypotension. The aim of this article is to increase physician awareness for propafenone toxicity and its management, with a focused literature review on propafenone pharmacotherapy.

Heart Rhythm Society: expert consensus statements-part 2

One of the most important roles for professional societies in medicine is assembling multiple stakeholders and experts to develop documents that can help guide and define policies and strategies for best medical care. Each year the Heart Rhythm Society (HRS) develops several consensus documents that address critical clinical subjects that have been identified by input from HRS members and HRS committees. Over the past 5 years, HRS has produced documents with multiple professional societies from around the world, and although the topics chosen for exploration center around arrhythmia management, the reviews and recommendations made in the documents are important for clinical cardiologists and generalists who are not arrhythmia specialists. When an internist or other primary care provider identifies a patient who may be having symptoms from an arrhythmia, the referral first is made to the clinical cardiologist and only later, if necessary, does an arrhythmia specialist become involved. These expert consensus statements are developed for specific clinical questions regarding arrhythmia management where there is controversy or uncertainty, often with less data from randomized controlled trials to help guide recommendations, which must then be made by extrapolation of existing data, observational data, and expert opinion. In this 2-part review, the consensus statements developed by the HRS over the past 5 years that pertain to adults are discussed in part 1; part 2 focuses on consensus statements that HRS has developed in conjunction with the Pediatric and Congenital Electrophysiology Society that address arrhythmia issues in children and adults with congenital heart disease.

Heart Rhythm Society: expert consensus statements-part 1

One of the most important roles for professional societies in medicine is assembling multiple stakeholders and experts to develop documents that can help guide and define policies and strategies for best medical care. Each year the Heart Rhythm Society (HRS) develops several consensus documents that address critical clinical subjects that have been identified by input from HRS members and HRS committees. Over the past 5 years, HRS has produced documents with multiple professional societies from around the world, and although the topics chosen for exploration center around arrhythmia management, the reviews and recommendations made in the documents are important for clinical cardiologists and generalists who are not arrhythmia specialists. When an internist or other primary care provider identifies a patient who may be having symptoms from an arrhythmia, the referral first is made to the clinical cardiologist and only later, if necessary, does an arrhythmia specialist become involved. These expert consensus statements are developed for specific clinical questions regarding arrhythmia management where there is controversy or uncertainty, often with less data from randomized controlled trials to help guide recommendations, which must then be made by extrapolation of existing data, observational data, and expert opinion. In this 2-part review, the consensus statements developed by the HRS over the past 5 years that pertain to adults are discussed in part 1; part 2 focuses on consensus statements that HRS has developed in conjunction with the Pediatric and Congenital Electrophysiology Society that address arrhythmia issues in children and adults with congenital heart disease.

The transition to value-based care

Delivery of medical care is evolving rapidly worldwide. Over the past several years in the USA, there has been a rapid shift in reimbursement from a simple fee-for-service model to more complex models that attempt to link payment to quality and value. Change in any large system can be difficult, but with medicine, the transition to a value-based system has been particularly hard to implement because both quality and cost are difficult to quantify. Professional societies and other medical groups are developing different programs in an attempt to define high value care. However, applying a national standard of value for any treatment is challenging, since value varies from person to person, and the individual benefit must remain the central tenet for delivering best patient-centered medical care. Regardless of the specific operational features of the rapidly changing healthcare environment, physicians must first and foremost always remain patient advocates.

Mayo Registry for Telemetry Efficacy in Arrest Study: An Assessment of the Utility of Telemetry in Predicting Clinical Decompensation

Introduction:

Our study assesses the utility of telemetry in identifying decompensation in patients with documented cardiopulmonary arrest.

Methods:

A retrospective review of inpatients who experienced a cardiopulmonary arrest from May 1, 2008, until June 30, 2014, was performed. Telemetry records 24 hours prior to and immediately preceding cardiopulmonary arrest were reviewed. Patient subanalyses based on clinical demographics were made as well as analyses of survival comparing patients with identifiable rhythm changes in telemetry to those without.

Results:

Of 242 patients included in the study, 75 (31.0%) and 110 (45.5%) experienced telemetry changes at the 24-hour and immediately preceding time periods, respectively. Of the telemetry changes, the majority were classified as nonmalignant (n = 50, 66.7% and n = 66, 55.5% at 24 hours prior and immediately preceding, respectively). There was no difference in telemetry changes between intensive care unit (ICU) and non-ICU patients and among patients stratified according to the American Heart Association telemetry indications. There was no difference in survival when comparing patients with telemetry changes immediately preceding and at 24 hours prior to an event (n = 30, 27.3% and n = 15, 20.0%) to those without telemetry changes during the same periods (n = 27, 20.5% and n = 42, 25.2%; P = .22 and .39).

Conclusion:

Telemetry has limited utility in predicting clinical decompensation in the inpatient setting.

Mayo registry for telemetry efficacy in arrest (MR TEA) study: An assessment of the effect of admission diagnosis on outcomes from in-hospital cardiopulmonary arrest

INTRODUCTION

Little data exists evaluating how different risk factors influence outcomes following in-hospital arrests.

METHODS

A retrospective review of patients that suffered a cardiopulmonary arrest between 1 May 2008 and 30 June 2014 was performed. Patients were stratified into subsets based on cardiac versus non-cardiac reasons for admission.

RESULTS

199 patients met inclusion criteria, of which 138 (69.3%) had a non-cardiac reason for admission and 61 (30.7%) a cardiac etiology. No difference in demographics and non-cardiac comorbidities were present. Cardiac-related comorbidities were more prevalent in the cardiac etiology subset. Arrests with a shockable rhythm were more common in the cardiac group (P < 0.0001), yet return of spontaneous circulation from the index event was similar (P = 0.254). More patients in the cardiac group were alive at 24-h post resuscitation (n = 34, 55.7% versus n = 49, 35.5%; P = 0.0085), discharge (n = 21, 34.4% versus n = 19, 13.8%; P = 0.0018), and at last follow-up (n = 13, 21.3% versus n = 14, 10.1%; P = 0.0434).

CONCLUSION

Although patients with cardiac and non-cardiac etiologies for admission have similar rates of return of spontaneous circulation, those with cardiac etiologies are more likely to survive to hospital discharge and outpatient follow-up.

Syncope

Syncope is common representing approximately 3% of ED visits and up to 6% of hospital admissions, with a cost close to 2 billion dollars per year. Diagnostic testing is often poorly sensitive and evaluations commonly lack a standardized approach. A mindful and systematic approach can increase sensitivity and improve diagnostic accuracy. A thorough history and physical exam is paramount, as conclusions drawn from the history and exam will guide further assessment. Developing a strategy for the first and, if necessary, subsequent tests will improve the accuracy of identifying the etiology of syncope and reduce cost. Although syncope has a favorable prognosis, identification of patients with structural heart disease is critical, as these patients are at greatest risk for mortality. Several risk scoring systems have been developed to help separate high risk from low risk patients.