Premature ventricular complexes (PVCs) are the most common ventricular arrhythmia that are encountered in the clinical practice. Recent data suggests that high PVC burden may lead to the development ...of PVC-induced cardiomyopathy (PVC-CM) even in patients without structural heart disease. Treatment for effective suppression of PVCs, can reverse PVC-CM. Both antiarrhythmic drugs (AADs) and catheter ablation (CA) are recognized treatment modalities for any cardiac arrhythmias. However, with increasing preference of CA, the role of AADs needs further defining regarding their efficacy, safety, indications and patient selection to treat PVC-CM.
To ascertain the role of AADs to treat PVC-CM; whether they are indicated to treat PVC-CM, and if so, when, we interrogated PubMed and other search engines for English language publications with key words premature ventricular complexes (PVCs), cardiomyopathy, anti-arrhythmic drugs, catheter ablation, and pharmacological agents. All publications were carefully reviewed and scrutinized by the authors for their inclusion in the review paper. For illustration of cases, ethical standard was observed as per the 1975 Declaration of Helsinki, and the patient was treated as per the prevailing standard of care. Informed consent was obtained from the patient for conducting the ablation procedure.
Our literature search specifically the pharmacological treatment of PVC-CM with AADs revealed significant paradigm shift in treatment approach for PVCs and PVC-induced cardiomyopathy. No major large, randomized control trials of AADs versus CA for PVC-CM were found. We found that beta-blockers and calcium channel blockers are particularly effective in the treatment of PVCs originating from right ventricular outflow tract. For Class Ic AADs - flecainide and propafenone, small clinical studies showed Class Ic AADs to be effective in PVC suppression, but their usage was not recommended in patients with significant coronary artery disease. Mexiletine was found to have modest effect on PVC suppression. Studies showed sotalol to significantly reduce PVCs frequency in patients receiving both low and high doses. Studies also showed amiodarone to have higher successful PVC suppression, but not recommended as a first-line treatment for patients with idiopathic PVCs in the absence of symptoms and left ventricular dysfunction. For dronedarone, no major clinical data were available.
Based on the available data in the literature, we conclude that AADs play important role in the treatment of PVC-induced cardiomyopathy. However, appropriate patient selection criteria are vitally important, and in general terms AADs are indicated or polymorphic PVCs, epicardial PVCs; and when CA procedure is contraindicated, or not feasible or failed.
During catheter ablation (CA) of tachycardia, conventional point-by-point mapping may be hindered due to hemodynamic instability. We performed open-window mapping (CARTO, Biosense Webster, USA) in a ...patient who developed hemodynamic instability during orthodromic atrioventricular reciprocating tachycardia (AVRT) and unwarranted induction of AVRT during attempts to map accessory pathway (AP) with ventricular pacing. With over 11,000 points acquired rapidly, the system accurately identified AP at the mitral valve (MV) annulus where the application of single radiofrequency (RF) lesion promptly eliminated AP's conduction. Our case illustrates the utility of open-window mapping for the ablation of AVRT.
With significant correlation shown between intrathoracic impedance and intrathoracic fluid volume, the utility of OptiVol fluid index (Medtronic, Minneapolis, MN, USA) in the management of patients ...with heart failure has been well-described. Although intrathoracic impedance is mainly affected by the changes in the intrathoracic fluid volume, a "false-positive" OptiVol fluid index can occur in the absence of overt congestive heart failure. We present a case of false positive Optivol fluid index elevation in a woman following breast reconstruction surgery.
Sophisticated dual‐chamber atrioventricular and rate‐responsive pacing therapies, cardiac resynchronization therapy (CRT), detection and therapies for ventricular tachycardia and fibrillation (VT/VF) ...form some major components of multitask functions of current implantable cardioverter defibrillators (ICDs). Appropriate programming of these devices is necessary for them to perform all such tasks precisely. In this report, we describe a case of a patient with Chagas cardiomyopathy with marked cardiomegaly, scarred ventricles, prior epicardial and endocardial ablations and on antiarrhythmic pharmacotherapy for VT, who presented with symptomatic wide complex tachycardia at a slower rate than definition of VT, and in whom programming for detection and therapy for “slow” VT could not be performed due to default technological limitation of the CRT‐D.
Inpatient hyperglycemia is common and is linked to adverse patient outcomes. New methods to improve glycemic control are needed.
To determine whether a virtual glucose management service (vGMS) is ...associated with improved inpatient glycemic control.
Cross-sectional analyses of three 12-month periods (pre-vGMS, transition, and vGMS) between 1 June 2012 and 31 May 2015.
3 University of California, San Francisco, hospitals.
All nonobstetric adult inpatients who underwent point-of-care glucose testing.
Hospitalized adult patients with 2 or more glucose values of 12.5 mmol/L or greater (≥225 mg/dL) (hyperglycemic) and/or a glucose level less than 3.9 mmol/L (<70 mg/dL) (hypoglycemic) in the previous 24 hours were identified using a daily glucose report. Based on review of the insulin/glucose chart in the electronic medical record, recommendations for insulin changes were entered in a vGMS note, which could be seen by all clinicians.
Proportion of patient-days classified as hyperglycemic, hypoglycemic, and at-goal (all measurements ≥3.9 and ≤10 mmol/L ≥70 and ≤180 mg/dL during the pre-vGMS, transition, and vGMS periods).
The proportion of hyperglycemic patients decreased by 39%, from 6.6 per 100 patient-days in the pre-vGMS period to 4.0 per 100 patient-days in the vGMS period (difference, -2.5 95% CI, -2.7 to -2.4). The hypoglycemic proportion in the vGMS period was 36% lower than in the pre-vGMS period (difference, -0.28 CI, -0.35 to -0.22). Forty severe hypoglycemic events (<2.2 mmol/L <40 mg/dL) occurred during the pre-vGMS period compared with 15 during the vGMS period.
Information was not collected on patients' concurrent illnesses and treatment or physicians' responses to the vGMS notes.
Implementation of the vGMS was associated with decreases in hyperglycemia and hypoglycemia.
National Institutes of Health, the Wilsey Family Foundation, and the UCSF Clinical & Translational Science Institute.
Background
Catheter ablation is increasingly employed in the management of atrial fibrillation (AF). Data regarding safety of ablation of AF is largely derived from controlled clinical trials.
...Objectives
The aim of this study was to analyze safety and complications of AF ablation performed in a “real world” setting outside of clinical trials, and obtain insights on predictors of complications.
Methods
We utilized the National Inpatient Sample database, to identify all patients who underwent AF ablations between 2015 and 2017 using International Classification of Disease—Tenth revision codes. Complications were defined as per the Agency for Health Care Research and Quality Guidelines. Statistical tests including multivariate logistic regression were performed to determine predictors of complications.
Results
Among 14,875 cases of AF ablation between 2015 and 2017, a total of 1884 complications were identified among 1080 (7.2%) patients. Patients with complications were likely to be older and female with a higher burden of comorbidities. A 27% increase in complications was observed from 2015 to 2017, driven by an increase in pericardial complications. Multivariate regression analysis revealed that pulmonary hypertension (adjusted odds ratio aOR: 1.99, p = .041) and chronic kidney disease (CKD; aOR: 1.67, p = .024), were independent predictors of complications. Centers with higher procedural volumes were associated with lower complication rates.
Conclusions
Complication rates related to AF ablations remain substantially high. Presence of pulmonary hypertension and CKD are predictive of higher procedural complications. Furthermore, hospital procedure volume is an important factor that correlates with complication rates.
Osteoporosis and osteoporosis-related fractures are growing problems with the aging population and are associated with significant morbidity and mortality. At this time, other than parathyroid ...hormone analogs, all therapies for osteoporosis are antiresorptive. Therefore, researchers have focused efforts on development of more anabolic therapies. Understanding of the Wnt signaling pathway, which is critical for skeletal development, and the role of sclerostin in inhibition of Wnt signaling has led to the discovery of a novel therapeutic approach in the treatment of osteoporosis - sclerostin inhibition. In this review, we discuss the biology of Wnt signaling and sclerostin inhibition. We then discuss human disorders of decreased sclerostin function and animal models of sclerostin inhibition. Both have served to elucidate the effects of decreased sclerostin levels and function - increased bone mass and strength and fewer fractures. In addition, we review data from Phase I and II studies of the two humanized sclerostin monoclonal antibodies, romosozumab and blosozumab, both of which have had positive effects on bone mineral density. We conclude with a discussion of the ongoing Phase III studies of romosozumab. The available data support the potential for neutralizing sclerostin monoclonal antibodies to serve as anabolic agents in the treatment of osteoporosis.
The rising prevalence of diabetes in South Asians has significant health and economic implications. South Asians are predisposed to the development of diabetes due to biologic causes which are ...exacerbated by lifestyle and environmental factors. Furthermore, they experience significant morbidity and mortality from complications of diabetes, most notably coronary artery disease, cerebrovascular disease, and chronic kidney disease. Therefore, understanding the pathophysiology and genetics of diabetes risk factors and its associated complications in South Asians is paramount to curbing the diabetes epidemic. With this understanding, the appropriate screening, preventative and therapeutic strategies can be implemented and further developed. In this review, we discuss in detail the biologic and lifestyle factors that predispose South Asians to diabetes and review the epidemiology and pathophysiology of microvascular and macrovascular complications of diabetes in South Asians. We also review the ongoing and completed diabetes prevention and management studies in South Asians.
Pulmonary vein (PV) isolation (PVI) ablation as the first-line therapy for atrial fibrillation (AF) and repeat PVIs for patients who had symptomatic improvement with the index PVI but who develop AF ...recurrence are directed by practice guidelines. How many catheter ablation (CA) procedures constitute the definition of "multiple" ablations is not known. Whether atrial tachyarrhythmias (AF, atrial tachycardia AT, atrial flutter AFL) that occur post-ablation are due entirely to the proarrhythmic effects of CA or a continuum of the arrhythmia spectrum from the underlying atriopathy is debatable. Herein, we describe a case of a 65-year-old man with a CHA
DS
-VASc score of 5 points who suffered from atrial tachyarrhythmias for which seven CA procedures were performed. Because of symptomatic and drug-refractory AT/AFL that failed cardioversions, he requested another ablation procedure. During the eighth procedure, high-density three-dimensional electroanatomic mapping, including Coherent and Ripple mapping (CARTO
3; Biosense Webster, Diamond Bar, CA, USA), of AT/AFL was performed. Small discrete areas of relatively viable tissue within an extensively scarred left atrium and a macro-re-entrant circuit with early-meets-late activation between the left atrial anterior wall and the right superior PV were found. Radiofrequency ablation performed at this site resulted in the termination of the tachycardia, and bidirectional conduction block across the line was achieved. On clinical follow-ups and rhythm monitoring by an implantable loop recorder, the patient remained in sinus rhythm with significant clinical improvement. Our case suggests that, in patients with prior multiple CAs, additional clinically indicated ablation should be performed using high-density mapping to accurately identify arrhythmia mechanisms, elucidate the disease substrate, and restore the sinus rhythm successfully.
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