...all subgroups showed a similar reduction, except for patients with nonischemic cardiomyopathy and those with a ventricular assist device, which may be explained by the known high risk of VT ...recurrence in these 2 groups.4,5 Third, despite advancements in VT ablation, the yearly trend of hospitalizations post-CA did not improve. ...detailed information such as first versus repeated ablation, type of ablation, and pharmacologic data are not available in the NRD. ...VT CA is followed by a reduction in hospitalizations, beginning 30 days postprocedure and resulting from a decrease in cardiac dysrhythmia-related hospitalizations.
The COVID-19 pandemic accelerated adaption of a telehealth care model. We studied the impact of telehealth on the management of atrial fibrillation (AF) by electrophysiology providers in a large, ...multisite clinic. Clinical outcomes, quality metrics, and indicators of clinical activity for patients with AF during the 10-week period of March 22, 2020 to May 30, 2020 were compared with those from the 10-week period of March 24, 2019 to June 1, 2019. There were 1946 unique patient visits for AF (1,040 in 2020 and 906 in 2019). During 120 days after each encounter, there was no difference in hospital admissions (11.7% vs 13.5%, p = 0.25) or emergency department visits (10.4% vs 12.5%, p = 0.15) in 2020 compared with 2019. There was a total of 31 deaths within 120 days, with similar rates in 2020 and 2019 (1.8% vs 1.3%, p = 0.38). There was no significant difference in quality metrics. The following clinical activities occurred less frequently in 2020 than in 2019: offering escalation of rhythm control (16.3% vs 23.3%, p <0.001), ambulatory monitoring (29.7% vs 51.7%, p <0.001), and electrocardiogram review for patients on antiarrhythmic drug therapy (22.1% vs 90.2%, p <0.001). Discussions about risk factor modification were more frequent in 2020 compared with 2019 (87.9% vs 74.8%, p <0.001). In conclusion, the use of telehealth in the outpatient management of AF was associated with similar clinical outcomes and quality metrics but differences in clinical activity compared with traditional ambulatory encounters. Longer-term outcomes warrant further investigation.
The prevalence of atrial fibrillation (AF) increases with age, reaching 10% among those over 80 years old.1 Long-term anticoagulation (AC) is effective in reducing strokes among patients with AF at ...increased risk of thromboembolic events.2 The safety and effectiveness of AC among nonagenarians are poorly understood, since these patients were underrepresented in the pivotal trials of AC.1 Although age is an independent risk factor for stroke in patients with AF, the net clinical benefit of AC may be mitigated by an increased risk of bleeding.3,4 We sought to explore the real-world safety and effectiveness of AC among nonagenarians using a large national administrative database. ...these results likely apply to relatively healthy nonagenarians who may be more likely to be prescribed AC. Unmatched Propensity matched Nonagenarians(77,451) Age < 90(764,044) P. value Nonagenarians (77,451) Age < 90 (77,451) P. value Women 63.7 46.2 <0.001 63.7 62.9 =0.001 Iron deficiency anemia 20.2 17.2 <0.001 20.2 20.3 =0.61 Heart failure 27.3 20.0 <0.001 27.3 28.1 =0.001 Chronic lung disease 17.8 23.0 <0.001 17.8 18.4 =0.004 Coagulopathy 5.6 5.4 =0.03 5.6 5.7 =0.23 Depression 7.3 8.6 <0.001 7.3 7.7 =0.001 Diabetes mellitus 14.5 24.4 <0.001 14.5 15.0 =0.008 Hypertension 66.3 64.8 <0.001 66.3 67.2 =0.001 Chronic liver disease 0.5 1.7 <0.001 0.5 0.5 =0.48 Metastatic cancer 0.7 1.3 <0.001 0.7 0.8 =0.38 Obesity, BMI ≥30 2.2 14.3 <0.001 2.2 2.3 =0.16 Peripheral vascular disease 10.4 10.4 =0.94 10.4 10.7 =0.04 Psychiatric disorder 1.8 2.4 <0.001 1.8 1.9 =0.22 Pulmonary hypertension 5.8 4.4 <0.001 5.8 5.9 =0.52 Chronic kidney disease 24.9 20.8 <0.001 24.9 24.6 =0.17 Solid tumor without metastasis 1.7 1.9 <0.001 1.7 1.9 =0.02 Valvular heart disease 12.2 7.7 <0.001 12.2 12.5 =0.13 Table 1.
...we used the Nationwide Inpatient Sample (NIS) and Nationwide Readmission Database (NRD) to compare temporal trends, in-hospital mortality, and readmission rates associated with early and delayed ...CA strategies. Timing of CA was determined using the NIS/NRD variable “PRDAYn,” which represents the number of days from admission to procedure.3,4 Primary outcomes were trends of early versus delayed CA and in-hospital mortality using the NIS in all hospitalizations and prespecified patient subgroups (gender, age ≤65 or >65 years, diabetes, hypertension, atrial fibrillation, chronic kidney disease, chronic lung disease, heart failure, history of coronary artery bypass grafting, and history of percutaneous coronary intervention). ...the timing of CA was recorded in days, not hours, so it is unclear how many patients with a very high-risk criteria underwent immediate CA (<2 hours).
Fragmented QRS (fQRS) is a marker of conduction block due to myocardial scar that presents in electrocardiography (ECG) as an additional one or more R wave (R') or notching in the S wave nadir in ...contiguous leads. However, fQRS description on premature ventricular contractions (PVCs) has not been previously described. We describe a case of a 67-year-old male with a past medical history of prediabetes, hypertension and coronary artery disease who presented after an ophthalmic procedure with asymptomatic PVCs and episodes of bigeminy. Initial ECG showed an isolated fQRS in V2. However, during PVCs significant extrasystoles fragmentation was seen in other coronary territories. Upon reviewing his most recent cardiac catheterization, it showed a 40% ostial and 70% distal left anterior descending stenosis with a mid-segment patent stent, 95% first diagonal stenosis and totally occluded proximal right coronary artery. Identification of diffuse fQRS known to be associated with myocardial scar, sustained arrhythmic events and sudden cardiac death, particularly when seen in the inferior leads, became extremely relevant in our patient. We noted that ejection fraction reduction from 52% to 34% on his last coronary intervention was crucial to decide if an implantable cardioverter-defibrillator would be needed. PVC fragmentation might be a new ECG marker that could uncover both scar and arrhythmia potential in patients at risk of adverse cardiac events.
We report a case of ST-elevation myocardial infarction (STEMI) due to septic emboli secondary to
endocarditis in a 32-year-old male patient with a past medical history of infectious endocarditis ...requiring mechanical aortic, mitral and tricuspid valve replacement presented with sharp chest pain and shortness of breath. Electrocardiogram demonstrated an acute inferior STEMI. Coronary angiography revealed occlusion of the terminal left anterior descending (LAD) artery associated with a large apical wrap-around segment exhibiting TIMI 0 flow. Primary angioplasty was not performed given the distal location of the embolus. Clinical suspicion for septic or thrombotic coronary artery embolism was high given the patient's history of mechanical valve prosthesis and in the setting of sub-therapeutic INR. Transesophageal echocardiography revealed a new mobile echodensity on the mitral prosthesis consistent with vegetation.
was isolated from blood cultures, confirming the diagnosis of endocarditis.
is a rare cause of prosthetic valve endocarditis and should remain in the differential of septic coronary artery embolism among patients with features of infectious endocarditis.
A 35-year-old Hispanic male presented at an outside facility with chest pain a few days after a long road trip. The initial electrocardiogram (EKG) showed sinus tachycardia with no other abnormality. ...His D-dimer was positive but a subsequent computed tomography angiography (CTA) of the chest was negative for pulmonary embolism. An echocardiogram showed trace pericardial effusion with a normal ejection fraction (EF) of 70% and severe asymmetric septal hypertrophy. Satisfactory Doppler signals to assess the gradient across the left ventricle outflow tract (LVOT) could not be obtained on echocardiogram. The patient was diagnosed with acute pericarditis, which was treated medically with an improvement of his symptoms. Later, he presented to our facility for an outpatient cardiac magnetic resonance (CMR) with and without contrast, which showed severe asymmetric septal hypertrophy measuring 29 mm with substantial patchy myocardial delayed enhancement and systolic anterior motion of the mitral leaflet with flow dephasing of LVOT. These findings were diagnostic of hypertrophic obstructive cardiomyopathy. CMR also showed signs consistent with pericarditis. A Holter monitor was unremarkable for arrhythmia. A stress echocardiogram did not demonstrate any drop in blood pressure during exercise. His interventricular septum measured 29 mm on cardiac magnetic resonance imaging (MRI), which was very close to the 30 mm cut-off for an implantable cardioverter-defibrillator (ICD). In addition, he had a marked delayed enhancement in the hypertrophied septum due to gadolinium uptake, which is also considered a high-risk feature for sudden cardiac death. After discussions between the patient, cardiologist, cardiac imaging specialist, and electrophysiologist, a subcutaneous ICD was pursued, which was successfully implanted. He was started on medical treatment. He was followed closely in the clinic and has remained asymptomatic for the past two years.
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