AIM: To compare the utility of the partners-heart failure(HF) algorithm with the care alert strategy for remote monitoring,in guiding clinical actions oriented to treat impending HF.METHODS: ...Consecutive cardiac resynchronizationdefibrillator recipients were followed with biweekly automatic transmissions. After every transmission,patients received a phone contact in order to check their health status,eventually followed by clinical actions,classified as "no-action","non-active" and "active". Active clinical actions were oriented to treat impending HF. The sensitivity,specificity,positive and negative predictive values and diagnostic accuracy of the partners-HF algorithm vs care alert in determining active clinical actions oriented to treat pre-HF status and to prevent an acute decompensation,were also calculated.RESULTS: The study population included 70 patients with moderate to advanced systolic HF and QRS duration longer than 120 ms. During a mean follow-up of 8 ± 2 mo,665 transmissions were collected. No deaths or HF hospitalizations occurred. The sensitivity and specificity of the partners-HF algorithm for active clinical actions oriented to treat impending HF were 96.9%(95%CI: 0.96-0.98) and 92.5%(95%CI: 0.90-0.94) respectively. The positive and negative predictive values were 84.6%(95%CI: 0.82-0.87) and 98.6%(95%CI: 0.98-0.99) respectively. The partners-HF algorithm had an accuracy of 93.8%(95%CI: 0.92-0.96) in determining active clinical actions. With regard to active clinical actions,care alert had a sensitivity and specificity of 11.05%(95%CI: 0.09-0.13) and 93.6% respectively(95%CI: 0.92-0.95). The positive predictive value was 42.3%(95%CI: 0.38-0.46); the negative predictive value was 71.1%(95%CI: 0.68-0.74). Care alert had an accuracy of 68.9%(95%CI: 0.65-0.72) in determining active clinical actions.CONCLUSION: The partners-HF algorithm proved higher accuracy and sensitivity than care alert in determining active clinical actions oriented to treat impending HF. Future studies in larger populations should evaluate partners-HF ability to improve HF-related clinical outcomes.
Atrial fibrillation-related stroke prevention with anticoagulant drugs is currently evolving towards the introduction into clinical practice of the new oral anticoagulants, including rivaroxaban. Our ...aim was to evaluate in a real-life setting the characteristics and management of patients with nonvalvular atrial fibrillation to whom Italian doctors decided to prescribe rivaroxaban.
Between January and February 2014, a group of 95 physicians collected aggregate retrospective data, through an online questionnaire, on 1127 patients with nonvalvular atrial fibrillation receiving rivaroxaban. Descriptive statistics were performed based on the data collected.
Mean age of patients was 76 years; 20% of patients suffered a previous transient ischemic attack and 16% a previous stroke; 16% was anemic or at risk of bleeding. Over 40% of patients was unable to have a good control of the previous antithrombotic therapy, 22% was also taking antiplatelet drugs or nonsteroidal anti-inflammatory drugs, and 85% had been on a previous stroke prevention therapy; among the latter the main causes for switching to rivaroxaban were patient choice (30%), problems in maintaining the prothromin time-international normalized ratio (PT-INR) within the therapeutic range (27%), and logistic problems in attending the PT-INR follow-up visits (20%). Rivaroxaban was prescribed at a dosage of 15 mg in 37.8% of patients and 20 mg in 62.2%; the 15 mg dose was prescribed to 264 of 354 patients with creatinine clearance <50 ml/h (74.6%) and in older patients with more comorbidities.
In this real-life analysis, patient characteristics were similar to those of patients enrolled in large randomized trials, whereas differences in dose prescriptions were observed.
At discharge from the hospital after an acute coronary syndrome, 81 consecutive patients with end-stage coronary artery disease were randomized to either conventional medical therapy or conventional ...treatment plus atorvastatin 80 mg/day. During the follow-up period, atorvastatin treatment was associated with a lower incidence of ischemic recurrences, suggesting that early aggressive lipid-lowering therapy may reduce cardiac events in patients with end-stage coronary artery disease.
Внешние эксперты: Haruhiko Abe (Япония), David G. Benditt (США), Wyatt W. Decker (США), Blair P. Grubb (США), Horacio Kaufmann9 (США), Carlos Morillo (Канада), Brian Olshansky (США), Steve W. Parry ...(Великобритания), Robert Sheldon (Канада), Win K. Shen (США)Члены Комитета Европейского общества кардиологов по практическим рекомендациям (ESC Committee for Practice Guidelines: CPG): Alec Vahanian (Председатель) (Франция), Angelo Auricchio (Швейцария),Jeroen Bax (Нидерланды), Claudio Ceconi (Италия), Veronica Dean (Франция), Gerasimos Filippatos (Греция), Christian Funck-Brentano (Франция), Richard Hobbs (Великобритания), Peter Kearney (Ирландия), Theresa McDonagh (Великобритания), Keith McGregor (Франция), Bogdan A. Popescu (Румыния), Zeljko Reiner (Хорватия), Udo Sechtem (Германия), Per Anton Sirnes (Норвегия), Michal Tendera (Польша), Panos Vardas (Греция), Petr Widimsky (Чехия)Рецензенты: Angelo Auricchio (Координатор от CPG) (Швейцария), Esmeray Acarturk (Турция), Felicita Andreotti (Италия), Riccardo Asteggiano (Италия), Urs Bauersfeld (Швейцария), Abdelouahab Bellou4 (Франция), Athanase Benetos6 (Франция), Johan Brandt (Швеция), Mina K. Chung3 (США), Pietro Cortelli 8 (Италия), Antoine Da Costa (Франция), Fabrice Extramiana (Франция), Jose´ Ferro7 (Португалия), Bulent Gorenek (Турция), Antti Hedman (Финляндия), Rafael Hirsch (Израиль), Gabriela Kaliska (Словакия), Rose Anne Kenny6 (Ирландия), Keld Per Kjeldsen (Дания), Rachel Lampert 3 (USA), Henning Mølgard (Denmark), Rain Paju (Эстония), Aras Puodziukynas (Литва), Antonio Raviele (Италия), Pilar Roman5 (Испания), Martin Scherer (Германия), Ronald Schondorf 9 (Канада), Rosa Sicari (Италия), Peter Vanbrabant 4 (Бельгия), Christian Wolpert1 (Германия), Jose Luis Zamorano (Испания).
In animal models, induced atrial fibrillation shortens the atrial effective refractory period (ERP) and reverses its physiological adaptation to rate. It is not clear whether this process, known as ..."electrical remodeling," occurs in humans.
We determined the ERPs, at 5 pacing cycle lengths (300 to 700 ms) and in 5 right atrial sites, after internal cardioversion of chronic atrial fibrillation in 25 patients (14 in pharmacological washout and 11 on amiodarone). The ERPs were 195.5+/-18.8 ms in the washout and 206.3+/-17.9 ms in the amiodarone patients (P<0.0001). ERPs were closely correlated with the stimulation rates (r=0.95 in the washout and r=0.94 in the amiodarone group), and slope values indicating a normal (>/=0.07) or nearly normal (0.05 to 0.06) adaptation of ERP to rate were found in 77% of the 84 paced sites. The mean ERP was shorter in the lateral wall (198.1+/-17.9 ms) than in the atrial roof (203.3+/-21.5 ms) and in the septum (210.5+/-20.0 ms) (P<0.03). After 4 weeks of sinus rhythm, the mean ERP, determined again in 8 patients (4 in wash-out and 4 on amiodarone), was significantly increased compared with the basal study (221. 4+/-21.4 versus 197.8+/-18.3 ms, P<0.0001).
After cardioversion of chronic atrial fibrillation, (1) atrial ERP adaptation to rate was normal or nearly normal in the majority of the cases, (2) a significant dispersion of refractoriness between different right atrial sites was present, and (3) ERPs were significantly increased after 4 weeks of sinus rhythm in both washout and amiodarone patients.
Background
The HeartLogic algorithm measures data from multiple implantable cardioverter‐defibrillator‐based sensors and combines them into a single index. The associated alert has proved to be a ...sensitive and timely predictor of impending heart failure (HF) decompensation.
Hypothesis
We describe a multicenter experience of remote HF management by means of HeartLogic and appraise the value of an alert‐based follow‐up strategy.
Methods
The alert was activated in 104 patients. All patients were followed up according to a standardized protocol that included remote data reviews and patient phone contacts every month and at the time of alerts. In‐office examinations were performed every 6 months or when deemed necessary.
Results
During a median follow‐up of 13 (10–16) months, the overall number of HF hospitalizations was 16 (rate 0.15 hospitalizations/patient‐year) and 100 alerts were reported in 53 patients. Sixty alerts were judged clinically meaningful, and were associated with multiple HF‐related conditions. In 48 of the 60 alerts, the clinician was not previously aware of the condition. Of these 48 alerts, 43 triggered clinical actions. The rate of alerts judged nonclinically meaningful was 0.37/patient‐year, and the rate of hospitalizations not associated with an alert was 0.05/patient‐year. Centers performed remote follow‐up assessments of 1113 scheduled monthly transmissions (10.3/patient‐year) and 100 alerts (0.93/patient‐year). Monthly remote data review allowed to detect 11 (1%) HF events requiring clinical actions (vs 43% actionable alerts, P < .001).
Conclusions
HeartLogic allowed relevant HF‐related clinical conditions to be identified remotely and enabled effective clinical actions to be taken; the rates of unexplained alerts and undetected HF events were low. An alert‐based management strategy seemed more efficient than a scheduled monthly remote follow‐up scheme.
This clinical investigation was performed to compare the effects of permanent dual-chamber cardiac pacing with pharmacological therapy in patients with recurrent vasovagal syncope.
Patients from 14 ...centers were randomized to receive either a DDD pacemaker provided with rate-drop response function or the beta-blocker atenolol at the dosage of 100 mg once a day. Inclusion criteria were age >35 years, >/=3 syncopal spells in the preceding 2 years, and positive response to tilt table testing with syncope occurring in association with relative bradycardia. The primary outcome was the first recurrence of syncope after randomization. Enrollment was started in December 1997, and the first formal interim analysis was performed on July 30, 2000. By that time, 93 patients (38 men and 55 women; mean age, 58.1+/-14.3 years) had been enrolled and randomized, although follow-up data were available for all patients (46 patients in the pacemaker arm, 47 patients in the pharmacological arm). The interim analysis showed a significant effect in favor of permanent cardiac pacing (recurrence of syncope in 2 patients 4.3% after a median of 390 days) compared with medical treatment (recurrence of syncope in 12 patients 25.5% after a median of 135 days; OR, 0.133; 95% CI, 0.028 to 0.632; P=0.004). Consequently, enrollment and follow-up were terminated.
DDD pacing with rate-drop response function is more effective than beta-blockade for the prevention of syncopal recurrences in highly symptomatic vasovagal fainters with relative bradycardia during tilt-induced syncope.
Aims Aim of the present study was the development and the subsequent validation of a simple risk classification system for patients presenting with syncope to the emergency departments. Methods and ...results A group of 270 consecutive patients (145 females, mean age 59.5 years) presenting with syncope to the emergency departments of six community hospitals of the Lazio region of Italy was used as a derivation cohort for the development of the risk classification system. Data from the baseline clinical history, physical examination and electrocardiogram were used to identify independent predictors of total mortality within the first 12 months after the initial evaluation. Multivariate analysis allowed the recognition of the following predictors of mortality: (1) age >65 years; (2) cardiovascular disease in clinical history; (3) syncope without prodromes; and (4) abnormal electrocardiogram. The OESIL (Osservatorio Epidemiologico sulla Sincope nel Lazio) score was calculated by the simple arithmetic sum of the number of predictors present in every single patient. Mortality increased significantly as the score increased in the derivation cohort (0% for a score of 0, 0.8% for 1 point; 19.6% for 2 points; 34.7% for 3 points; 57.1% for 4 points; \batchmode \documentclassfleqn,10pt,legalpaper{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \(p{<}0,0001\) \end{document} for trend). A similar pattern of increasing mortality with increasing score was prospectively confirmed in a second validation cohort of 328 consecutive patients (178 females; mean age, 57.5 years). Conclusions Clinical and electrocardiographic data available at presentation to the emergency department can be used for the risk stratification of patients with syncope. The OESIL risk score may represent a simple prognostication tool that could be usefully employed for the triage and management of patients with syncope in emergency departments.
PDF
