Natriuretic peptide NP; B‐type NP (BNP), N‐terminal proBNP (NT‐proBNP), and midregional proANP (MR‐proANP) concentrations are quantitative plasma biomarkers for the presence and severity of ...haemodynamic cardiac stress and heart failure (HF). End‐diastolic wall stress, intracardiac filling pressures, and intracardiac volumes seem to be the dominant triggers. This paper details the most important indications for NPs and highlights 11 key principles underlying their clinical use shown below.
NPs should always be used in conjunction with all other clinical information.
NPs are reasonable surrogates for intracardiac volumes and filling pressures.
NPs should be measured in all patients presenting with symptoms suggestive of HF such as dyspnoea and/or fatigue, as their use facilitates the early diagnosis and risk stratification of HF.
NPs have very high diagnostic accuracy in discriminating HF from other causes of dyspnoea: the higher the NP, the higher the likelihood that dyspnoea is caused by HF.
Optimal NP cut‐off concentrations for the diagnosis of acute HF (very high filling pressures) in patients presenting to the emergency department with acute dyspnoea are higher compared with those used in the diagnosis of chronic HF in patients with dyspnoea on exertion (mild increase in filling pressures at rest).
Obese patients have lower NP concentrations, mandating the use of lower cut‐off concentrations (about 50% lower).
In stable HF patients, but also in patients with other cardiac disorders such as myocardial infarction, valvular heart disease, atrial fibrillation or pulmonary embolism, NP concentrations have high prognostic accuracy for death and HF hospitalization.
Screening with NPs for the early detection of relevant cardiac disease including left ventricular systolic dysfunction in patients with cardiovascular risk factors may help to identify patients at increased risk, therefore allowing targeted preventive measures to prevent HF.
BNP, NT‐proBNP and MR‐proANP have comparable diagnostic and prognostic accuracy.
In patients with shock, NPs cannot be used to identify cause (e.g. cardiogenic vs. septic shock), but remain prognostic.
NPs cannot identify the underlying cause of HF and, therefore, if elevated, must always be used in conjunction with cardiac imaging.
The left atrial posterior wall is a potential ablation target in patients with recurrent atrial fibrillation despite durable pulmonary vein isolation or in patients with roof-dependent atrial ...tachycardia (AT). Pulsed-field ablation (PFA) offers efficient and safe posterior wall ablation (PWA), but available data are scarce.
Consecutive patients undergoing PWA using PFA were included. Posterior wall ablation was performed using a pentaspline PFA catheter and verified by 3D-electroanatomical mapping. Follow-up was performed using 7-day Holter ECGs 3, 6, and 12 months after ablation. Recurrence of any atrial arrhythmia lasting more than 30 s was defined as failure. Lesion durability was assessed during redo procedures. Posterior wall ablation was performed in 215 patients (70% males, median age 70 IQR 61-75 years, 67% redo procedures) and was successful in all patients (100%) by applying a median of 36 (IQR 32-44) PFA lesions. Severe adverse events were cardiac tamponade and vascular access complication in one patient each (0.9%). Median follow-up was 7.3 (IQR 5.0-11.8) months. One-year arrhythmia-free outcome in Kaplan-Meier analysis was 53%. A redo procedure was performed in 26 patients (12%) after a median of 6.9 (IQR 2.4-11) months and showed durable PWA in 22 patients (85%) with only minor lesion regression. Among four patients with posterior wall reconnection, three (75%) presented with roof-dependent AT.
Posterior wall ablation with this pentaspline PFA catheter can be safely and efficiently performed with a high durability observed during redo procedures. The added value of durable PWA for the treatment of atrial fibrillation remains to be evaluated.
The clinical utility of procalcitonin in the diagnosis and management of pneumonia remains controversial.
We assessed the clinical utility of procalcitonin in 2 prospective studies: first, a ...multicenter diagnostic study in patients presenting to the emergency department with acute dyspnea to directly compare the diagnostic accuracy of procalcitonin with that of interleukin 6 and C-reactive protein (CRP) in the diagnosis of pneumonia; second, a randomized management study of procalcitonin guidance in patients with acute heart failure and suspected pneumonia. Diagnostic accuracy for pneumonia as centrally adjudicated by 2 independent experts was quantified with the area under the ROC curve (AUC).
Among 690 patients in the diagnostic study, 178 (25.8%) had an adjudicated final diagnosis of pneumonia. Procalcitonin, interleukin 6, and CRP were significantly higher in patients with pneumonia than in those without. When compared to procalcitonin (AUC = 0.75; 95% CI, 0.71-0.78), interleukin 6 (AUC = 0.80; 95% CI, 0.77-0.83) and CRP (AUC = 0.82; 95% CI, 0.79-0.85) had significantly higher diagnostic accuracy (
= 0.010 and
< 0.001, respectively). The management study was stopped early owing to the unexpectedly low AUC of procalcitonin in the diagnostic study. Among 45 randomized patients, the number of days on antibiotic therapy and the length of hospital stay were similar (both
= 0.39) in patients randomized to the procalcitonin-guided group (n = 25) and usual-care group (n = 20).
In patients presenting with dyspnea, diagnostic accuracy of procalcitonin for pneumonia is only moderate and lower than that of interleukin 6 and CRP. The clinical utility of procalcitonin was lower than expected.
Pneumonia has diverse and often unspecific symptoms. As the role of biomarkers in the diagnosis of pneumonia remains controversial, it is often difficult to distinguish pneumonia from other illnesses causing shortness of breath. The current study prospectively enrolled unselected patients presenting with acute dyspnea and directly compared the diagnostic accuracy of procalcitonin, interleukin 6, and CRP for the diagnosis of pneumonia. In this setting, diagnostic accuracy of procalcitonin for pneumonia was lower as compared to interleukin 6 and CRP. The clinical utility of procalcitonin was lower than expected.
NCT01831115.
Abstract
Aims
The safety of Ablation Index (AI)-guided 50 W ablation for atrial fibrillation (AF) remains uncertain, and mid-term clinical outcomes have not been described. The interplay between AI ...and its components at 50 W has not been reported.
Methods and results
Eighty-eight consecutive AF patients (44% paroxysmal) underwent AI-guided 50 W ablation. Procedural and 12-month clinical outcomes were compared with 93 consecutive controls (65% paroxysmal) who underwent AI-guided ablation using 35–40 W. Posterior wall isolation (PWI) was performed in 44 (50%) and 23 (25%) patients in the 50 and 35–40 W groups, respectively, P < 0.001. The last 10 patients from each group underwent analysis of individual lesions (n = 1230) to explore relationships between different powers and the AI components. Pulmonary vein isolation was successful in all patients. Posterior wall isolation was successful in 41/44 (93.2%) and 22/23 (95.7%) in the 50 and 35–40 W groups, respectively (P = 0.685). Radiofrequency times (20 vs. 26 min, P < 0.001) and total procedure times (130 vs. 156 min, P = 0.002) were significantly lower in the 50 W group. No complication or steam pop was seen in either group. Twelve-month freedom from arrhythmia was similar (80.2% vs. 82.8%, P = 0.918). A higher proportion of lesions in the 50 W group were associated with impedance drop >7 Ω (54.6% vs. 45.5%, P < 0.001). Excessive ablation (AI >600 anteriorly, >500 posteriorly) was more frequent in the 50 W group (9.7% vs. 4.3%, P < 0.001).
Conclusion
Ablation Index-guided 50 W AF ablation is as safe and effective as lower powers and results in reduced ablation and procedure times. Radiofrequency lesions are more likely to be therapeutic, but there is a higher risk of delivering excessive ablation.
Abstract
Aims
Leadless cardiac pacemaker (PM) implantation differs from conventional PM implantation. While the procedure has been considered safe, recent real-world data raised concerns about the ...learning curve of new operators and their implantation quality. The goal of this study was to investigate the influence of the first operator’s experience on leadless PM implantation quality and procedural efficiency.
Methods and results
We performed a bicentric analysis of all Micra TPS™ implantations in two large tertiary referral hospitals. We assessed both leadless PM implantation quality based on the absence of complications (requiring intervention or prolonged hospitalization), good electrical performance (pacing threshold ≤ 1.5 V/0.24 ms, R-wave amplitude > 5 mV), and acceptable fluoroscopy duration (<10 min) as well as procedural efficiency in relation to the operator’s experience. Univariate and multivariate logistic regression analyses were performed to identify predictors for implantation quality and procedural efficiency. Leadless PM implantation was successful in 106/111 cases (95.5%). Three patients (2.7%) experienced acute complications (one cardiac tamponade, one femoral bleeding, one posture-related PM exit block). Multivariate analysis showed that implantation quality of more experienced first operators was higher odds ratio 1.09 (95% confidence interval 1.00–1.19), P = 0.05. Procedural efficiency increased with operator experience as evidenced by an inverse correlation of procedure time, time to the first deployment, fluoroscopy time, and the number of procedures performed (all P < 0.05).
Conclusion
The operator’s learning curve is a critical factor for leadless PM implantation quality and procedural efficiency.
We compared 2 high-sensitivity cardiac troponin (hs-cTn)-based 2-h strategies in patients presenting with suspected acute myocardial infarction (AMI) to the emergency department (ED): the 2-h ...accelerated diagnostic protocol (2h-ADP) combining hs-cTn, electrocardiogram, and a risk score, and the 2-h algorithm exclusively based on hs-cTn concentrations and their absolute changes.
Analyses were performed in 2 independent diagnostic cohorts European Advantageous Predictors of Acute Coronary Syndrome Evaluation (APACE) study, Australian-New Zealand 2-h Accelerated Diagnostic Protocol to Assess patients with chest Pain symptoms using contemporary Troponins as the only biomarker (ADAPT) study employing hs-cTnT (Elecsys) and hs-cTnI (Architect). The final diagnosis was adjudicated by 2 independent cardiologists.
AMI was the final diagnosis in 16.5% (95% CI, 14.6%-18.6%) of the 1372 patients in APACE, and 12.6% (95% CI, 10.7%-14.7%) of 1153 patients in ADAPT. The negative predictive value (NPV) and sensitivity for AMI were very high and comparable with both strategies using either hs-cTnT or hs-cTnI in both cohorts (all statistical comparisons nonsignificant). The percentage of patients triaged toward rule-out was significantly lower with the 2h-ADP (36%-43%) vs the 2-h algorithm (55%-68%) with both assays and in both cohorts (
< 0.001). The sensitivity of the 2h-ADP was higher for 30-day major adverse cardiovascular events.
Both algorithms provided very high and comparable safety as quantified by the NPV and sensitivity for AMI and major adverse cardiac events (MACE) at 30 days in patients triaged toward rule-out, although sensitivity for MACE at 30 days was lower with both algorithms in cohort 2. Although the 2-h algorithm was more efficacious, not all patients ruled out for AMI by this algorithm were appropriate candidates for early discharge. The 2h-ADP seems superior in the selection of patients for early discharge from the ED.
APACE: http://clinicaltrials.gov/show/NCT00470587ADAPT: Australia-New Zealand Clinical Trials Registry ACTRN12611001069943.
Background
The feasibility of significant weight reduction in a specialist arrhythmia service, and its impact on atrial fibrillation (AF) ablation outcomes are unclear. We aimed to assess these ...factors in a real‐world cohort in the United Kingdom.
Methods
Patients from one specialized arrhythmia clinic were instructed to follow the “Intermittent Fasting 5:2 diet” (“diet group”, n = 50), and their outcomes were compared to a propensity matched cohort who received no specific dietary advice (“control group”, n = 42). The primary outcome was recurrence of AF or atrial tachycardia (AT) at 12 months postablation, with or without drugs.
Results
Body weight and body mass index (BMI) at baseline were 105.0 (±15.3) kgs and 36.0 (±4.0), respectively. Baseline characteristics between the two groups were comparable. Patients in diet group experienced a mean weight loss of 8.2 (±7.1) kgs prior to AF ablation (P < .01 for comparison to baseline and control group). About 14 (28%) patients in the diet group lost >10% of their body weight. Overall, 11 (22%) patients in the diet group and five (12%) in the control group had AF recurrence at 1 year, P = .21. AF recurrence was similar in patients with BMI ≥ 35 (15%) as compared to BMI < 35 (19%), P = .60. There was one procedural complication (pulmonary edema) in the diet group.
Conclusion
It is feasible to achieve significant weight reduction in obese AF patients in a specialist arrhythmia clinic setting with unsupervised dietary advice. Low rates of procedural complications and excellent medium‐term success rates were observed in this traditionally challenging population. Additional improvements in outcomes were not demonstrable in patients who exhibited significant weight loss.
It is feasible to achieve significant weight reduction in obese AF patients in a specialist arrhythmia clinic setting with unsupervised dietary advice. Low rates of procedural complications and excellent medium‐term success rates were observed in this traditionally challenging population. Additional improvements in outcomes were not demonstrable in patients who exhibited significant weight loss.
Ablation index (AI)-guided ablation for posterior wall isolation (PWI) using high-power, short-duration remains untested. We sought to evaluate the acute outcomes of AI-guided 50 W ablation vs. ...conventional ablation, and investigate the differences in relationship between contact force (CF), time and AI in both groups.
Consecutive patients undergoing first-time AI-guided ablation with PWI using either 50 W or 35–40 W ablation were enrolled. Acute procedural metrics and individual lesion level ablation data were compared between groups.
40 patients (50 W: n = 20, 35–40 W: n = 20) with atrial fibrillation were included. Total procedure time was significantly reduced with 50 W (120 vs. 143 mins, p = 0.004) and there was a trend toward decreased ablation time (22 vs. 28 mins, p = 0.052). First pass and acute success of PWI were comparable between the 50 W and 35–40 W groups (10 vs. 8 patients, p = 0.525 and 20 vs. 19 patients, p = 1.000, respectively). Individual lesion analysis of all 959 RF applications (50 W: n = 458, 35–40 W: n = 501) demonstrated that 50 W ablation led to lower ablation time per lesion (10.4 vs. 13.0s, p < 0.001), and increased AI (471 vs. 461, p < 0.001) and impedance drop (7.4 vs. 6.9ohms, p = 0.007). Excessive ablations (AI>600 for roof line; AI>500 elsewhere) were more frequently observed in the 50 W group (9.0% vs. 4.6%, p = 0.007). CF had very good discriminative capability for excessive ablation in both groups. At 50 W, limiting the CF to <10 g reduced the number of excessive ablations on the floor line and within the posterior box to 12% and 4%,respectively. Recurrence of atrial arrhythmias at 12 months were comparable between the groups.
AI-guided 50 W RF ablation reduces the ablation time of individual lesions and total procedure time without compromising first pass and acute success rates of PWI or 12-month outcomes compared to conventional powers.
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