Warfarin is the most common oral anticoagulant drug, especially in low-income and emerging countries, because of the high cost of direct oral anticoagulant (DOACs), or when warfarin is the only ...proven therapy (mechanical prosthetic valve and kidney dysfunction). The quality of warfarin therapy is directly associated with dose management. Evidence shows that pharmaceutical care achieves a better quality of therapy with warfarin. However, there are no studies showing this intervention in a specific patient group with poor quality of anticoagulation in a long period after the end of the follow-up by a pharmacist. Thus, the aim of this study was to evaluate whether the quality of warfarin therapy driven by a pharmacist remains stable in the long term after the end of follow up with a pharmacist, in AF patients with poor quality of anticoagulation.
This is a prospective study, which evaluated about 2,620 patients and selected 262 patients with AF and poor quality of anticoagulation therapy with warfarin (TTR<50% - based on the last three values of international normalized ratio). Pharmacist-driven therapy management was performed up to 12 weeks. Data from patients were evaluated 1 year after the end of the follow-up with pharmacist.
Comparison between mean TTR after 12 weeks of pharmaceutical care (54.1%) and mean TTR one year after the end of the pharmaceutical care (56.5%; p=0.081) did not achieve statistical difference, demonstrating that the increment of quality due to intervention of 12 weeks was maintained for 1 year after intervention.
The long-term impact of pharmaceutical care was beneficial for patients with AF and poor quality of warfarin anticoagulation. This design might be an important strategy to treat a subgroup of patients without proven effectiveness of warfarin.
Arrhythmogenic right ventricular cardiomyopathy (ARVC), a rare inherited disease, causes ventricular tachycardia, sudden cardiac death, and heart failure (HF). We investigated ARVC clinical features, ...genetic findings, natural history, and the occurrence of life-threatening arrhythmic events (LTAEs), HF death, or heart transplantation (HF-death/HTx) to identify risk factors.
The clinical course of 111 consecutive patients with definite ARVC, predictors of LTAE, HF-death/HTx, and combined events were analyzed in the entire cohort and in a subgroup of 40 patients without sustained ventricular arrhythmia before diagnosis.
The 5-year cumulative probability of LTAE was 30% and HF-death/HTx was 10%. Predictors of HF-death/HTx were reduced right ventricle ejection fraction (HR: 0.93;
=0.010), HF symptoms (HR: 4.37;
=0.010), epsilon wave (HR: 4.99;
=0.015), and number of leads with low QRS voltage (HR: 1.28;
=0.001). Each additional lead with low QRS voltage increased the risk of HF-death/HTx by 28%. Predictors of LTAE were prior syncope (HR: 1.81;
=0.040), number of leads with T wave inversion (HR: 1.17;
=0.039), low QRS voltage (HR: 1.12;
=0.021), younger age (HR: 0.97;
=0.006), and prior ventricular arrhythmia/ventricular fibrillation (HR: 2.45;
=0.012). Each additional lead with low QRS voltage increased the risk of LTAE by 17%. In patients without ventricular arrhythmia before clinical diagnosis of ARVC, the number of leads with low QRS voltage (HR: 1.68;
=0.023) was independently associated with HF-death/HTx.
Our study demonstrated the characteristics of a specific cohort with a high prevalence of arrhythmic burden at presentation, male predominance, younger age and HF severe outcomes. Our main results suggest that the presence and extension of low QRS voltage can be a risk predictor for HF-death/HTx in ARVC patients, regardless of the arrhythmic risk. This study can contribute to the global ARVC risk stratification, adding new insights to the international current scientific knowledge.
Resumo Fundamento No tratamento da fibrilação atrial (FA), a arritmia sustentada mais frequente, com ablação por cateter (ABL) ou cardioversão elétrica (CVE), o período periprocedimento é uma das ...fases mais críticas. Atualmente, o uso de novos anticoagulantes orais de ação direta (DOAC) é cada vez mais frequente, no entanto, no mundo real, ainda existem poucos dados de estudos sobre a incidência de trombo no átrio esquerdo (TrAE) ou contraste espontâneo denso (CE) no ecocardiograma transesofágico (ETE). Objetivo Analisar a prevalência de TrAE, por ETE, em pacientes em uso de DOAC submetidos à CVE/ABL. Secundariamente: avaliar a associação de comorbidades com a presença de trombos e CE. Métodos Estudo de coorte retrospectivo, unicêntrico, com pacientes do Ambulatório de Arritmia (InCor-HCFMUSP). Foram selecionados e analisados dados clínicos e ecocardiográficos no prontuário da instituição de pacientes com indicação de procedimentos e em uso de DOACs. Considerado um nível de significância de 5%. Resultados Foram incluídos 354 pacientes, no total de 400 procedimentos, de março de 2012-março de 2018. TrAE foi encontrado em 11 pacientes (2,8%), associado com idade avançada (p=0,007) e CHA2DS2-VASc maior (p<0,001). Foi encontrado CE no AE no procedimento antes da ETE em 29 pacientes (7,3%), com menor FEVE (p <0,038) e maior dimensão do AE (p <0,0001). Conclusão A incidência de TrAE e CE em pacientes em uso de DOAC no contexto de CVE/ABL de FA, embora pequena, não é desprezível. Pacientes com escore CHA2DS2-VASc maior, principalmente mais idosos e com diâmetro do AE maior, são mais propensos a esses achados ecocardiográficos.
The goal of this study was to develop a risk score model for patients with Brugada syndrome (BrS).
Risk stratification in BrS is a significant challenge due to the low event rates and conflicting ...evidence.
A multicenter international cohort of patients with BrS and no previous cardiac arrest was used to evaluate the role of 16 proposed clinical or electrocardiogram (ECG) markers in predicting ventricular arrhythmias (VAs)/sudden cardiac death (SCD) during follow-up. Predictive markers were incorporated into a risk score model, and this model was validated by using out-of-sample cross-validation.
A total of 1,110 patients with BrS from 16 centers in 8 countries were included (mean age 51.8 ± 13.6 years; 71.8% male). Median follow-up was 5.33 years; 114 patients had VA/SCD (10.3%) with an annual event rate of 1.5%. Of the 16 proposed risk factors, probable arrhythmia–related syncope (hazard ratio HR: 3.71; p < 0.001), spontaneous type 1 ECG (HR: 3.80; p < 0.001), early repolarization (HR: 3.42; p < 0.001), and a type 1 Brugada ECG pattern in peripheral leads (HR: 2.33; p < 0.001) were associated with a higher risk of VA/SCD. A risk score model incorporating these factors revealed a sensitivity of 71.2% (95% confidence interval: 61.5% to 84.6%) and a specificity of 80.2% (95% confidence interval: 75.7% to 82.3%) in predicting VA/SCD at 5 years. Calibration plots showed a mean prediction error of 1.2%. The model was effectively validated by using out-of-sample cross-validation according to country.
This multicenter study identified 4 risk factors for VA/SCD in a primary prevention BrS population. A risk score model was generated to quantify risk of VA/SCD in BrS and inform implantable cardioverter-defibrillator prescription.
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Background Brugada syndrome and long-QT syndrome may account for at least one third of unexplained sudden cardiac deaths. Dental care in patients with cardiac channelopathies is challenging because ...of the potential risk of life-threatening events. We hypothesized that the use of local dental anesthesia with lidocaine with and without epinephrine is safe and does not result in life-threatening arrhythmias in patients with channelopathies. Methods and Results We performed a randomized, double-blind pilot trial comparing the use of 2% lidocaine without a vasoconstrictor and with 1:100 000 epinephrine in 2 sessions of restorative dental treatment with a washout period of 7 days (crossover trial). Twenty-eight-hour Holter monitoring was performed, and 12-lead electrocardiography, digital sphygmomanometry, and anxiety scale assessments were also conducted at 3 time points. Fifty-six dental procedures were performed in 28 patients (18 women, 10 men) with cardiac channelopathies: 16 (57.1%) had long-QT syndrome, and 12 (42.9%) had Brugada syndrome; 11 (39.3%) of patients had an implantable defibrillator. The mean age was 45.9±15.9 years. The maximum heart rate increased after the use of epinephrine during the anesthesia period from 82.1 to 85.8 beats per minute (P=0.008). In patients with long-QT syndrome, the median corrected QT was higher, from 450.1 to 465.4 ms (P=0.009) at the end of anesthesia in patients in whom epinephrine was used. The other measurements showed no statistically significant differences. No life-threatening arrhythmias occurred during dental treatment. Conclusions The use of local dental anesthesia with lidocaine, regardless of the use of a vasoconstrictor, did not result in life-threatening arrhythmias and appears to be safe in stable patients with cardiac channelopathies. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT03182777.
BACKGROUNDIn the treatment of atrial fibrillation (AF), the most frequently sustained arrhythmia, with catheter ablation (CA) or electrical cardioversion (ECV), the periprocedural period is one of ...the most critical phases. Currently, the use of new direct action oral anticoagulants (DOAC) is increasingly frequent; however, in the real world, there are still few data on studies on the thrombus incidence in the left atrium (TrLA) or dense spontaneous contrast (DSC) on transesophageal echocardiogram (TEE). OBJECTIVETo evaluate the prevalence of events and association with risk factors in patients using DOACs. Primary objective: to analyze the prevalence of thrombus in the LA by TEE in patients using DOAC undergoing ECV/CA. Second, evaluate the association of comorbidities with the presence of thrombi and DSC. METHODSRetrospective cohort, single-center study with patients followed at the Arrhythmia Outpatient Unit (InCor-HCFMUSP). Patients indicated for procedures and using DOACs were selected, and their clinical/echocardiographic data were analyzed. A significance level of 5% was considered. RESULTS354 patients were included, a total of 400 procedures, from March 2012-March 2018. Thrombus in the LA was found in 11 patients (2.8%), associated with advanced age (p=0.007) and higher CHA2DS2-VASc (p<0.001) score. DSC in the LA before TEE was found in 29 patients (7.3%), with lower LVEF (p<0.038) and greater LA dimension (p<0.0001). CONCLUSIONThe incidence of LA thrombus and DSC in patients using DOC in the context of AF ECV/CA, although small, is not negligible. Patients with higher CHA2DS2-VASc scores, especially older and with larger LA diameter, are more prone to these echocardiographic findings.
Resumo Fundamento No tratamento da fibrilação atrial (FA), a arritmia sustentada mais frequente, com ablação por cateter (ABL) ou cardioversão elétrica (CVE), o período periprocedimento é uma das ...fases mais críticas. Atualmente, o uso de novos anticoagulantes orais de ação direta (DOAC) é cada vez mais frequente, no entanto, no mundo real, ainda existem poucos dados de estudos sobre a incidência de trombo no átrio esquerdo (TrAE) ou contraste espontâneo denso (CE) no ecocardiograma transesofágico (ETE). Objetivo Analisar a prevalência de TrAE, por ETE, em pacientes em uso de DOAC submetidos à CVE/ABL. Secundariamente: avaliar a associação de comorbidades com a presença de trombos e CE. Métodos Estudo de coorte retrospectivo, unicêntrico, com pacientes do Ambulatório de Arritmia (InCor-HCFMUSP). Foram selecionados e analisados dados clínicos e ecocardiográficos no prontuário da instituição de pacientes com indicação de procedimentos e em uso de DOACs. Considerado um nível de significância de 5%. Resultados Foram incluídos 354 pacientes, no total de 400 procedimentos, de março de 2012-março de 2018. TrAE foi encontrado em 11 pacientes (2,8%), associado com idade avançada (p=0,007) e CHA2DS2-VASc maior (p<0,001). Foi encontrado CE no AE no procedimento antes da ETE em 29 pacientes (7,3%), com menor FEVE (p <0,038) e maior dimensão do AE (p <0,0001). Conclusão A incidência de TrAE e CE em pacientes em uso de DOAC no contexto de CVE/ABL de FA, embora pequena, não é desprezível. Pacientes com escore CHA2DS2-VASc maior, principalmente mais idosos e com diâmetro do AE maior, são mais propensos a esses achados ecocardiográficos.
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