Release date: 2017-02-07
There are many arrhythmia related achievements in 2016. The authors selected a set of articles to provide potentially influential information in everyday practice.
First, arrhythmia and catheter ablation
1. supraventricular tachycardia: diagnosis and treatment
Supraventricular tachycardia (SVT) remains a common cause of emergency hospitalization. The REVERT study evaluated the best and most effective first-aid strategy for SVT and compared the modified posture (15 seconds in the supine position after 15 seconds of leg elevation) with the standard Valsalva action (ie, forced exhalation to bring the pressure gauge to 40 mmHg, And insist on 15 seconds). The proportion of patients with SVT termination in the modified posture group (43%, n=214) was significantly higher than that in the standard exercise group (17%, n=214; P <0.0001). Therefore, patients in the study group who required adenosine (50% vs. 69%) or emergency antiarrhythmia therapy (57% vs. 80%) had a significant reduction in termination of arrhythmia events, and there was no difference in discharge time. This finding may significantly affect daily practice and reduce drug-related discomfort in patients with SVT during emergency treatment. The latest SVT diagnosis and treatment can be found in the 2016 EHRA / ESC consensus on SV treatment.
2. Atrial fibrillation: pathophysiology, risk, treatment opportunities and new ESC AF guidelines
An atrial remodeling trial and clinical study led to a rigorous scientific discussion of the pathophysiology of atrial fibrillation, particularly the driver of AF progression. The results showed that atrial adipose tissue (previously considered a strong risk factor for AF development) was gradually replaced by fibrotic tissue that underlies AF progression. These data may further explain the link between obesity and AF described in recent clinical studies. However, these studies have also shown that weight loss does not significantly reduce the burden of AF, and I am now particularly interested in whether the reduction in AF burden can be consistent with myocardial remodeling, and vice versa (Figure 1). MRI-based fibrosis detection and quantification can record changes in myocardium over time and provide further insight into important aspects of future AF pathology. (Fig. 2) However, various methodological barriers need to be overcome, mainly due to the thin atrial wall, and proper protocols are essential. Controlling heart rate is the most common treatment option for AF patients worldwide. The best medication data that supports heart rate control to alleviate symptoms and reduce the risk associated with atrial fibrillation is limited and somewhat controversial. A recent study in Taiwan analyzed the long-term effects of beta-blockers, calcium channel blockers, and digitalis on heart rate in patients with persistent atrial fibrillation. After adjusting for baseline differences, the researchers found that 43 879 patients with beta blockers and 18,466 patients treated with calcium channel blockers had a significantly lower risk of death than 168,678 patients who did not receive any control of heart rate. Group of patients. In contrast, patients treated with digoxin have a higher risk of death. A recent meta-analysis of drugs that control heart rate did not show that beta blockers have this beneficial effect. These findings contribute to future debates about the effects of heart rate medications on the risk of all-cause mortality in patients with persistent AF, and randomized trials are needed to address this related problem.
Figure 1. Different kinetics of scar progression with progressive fibrosis over a three-year period following atrial fibrillation ablation. Panel (A) depicts patients with little or no increase in cardiac fibrosis, while panel (B) depicts patients with a large increase in cardiac fibrosis at 1 and 3 years (green) that coincide with multiple recurrence.
Figure 2 MRI imaging of atrial wall fibrosis. The MRI cross section is at the level of the left atrium (left) and the 5-chamber view (right). Atrial fibrosis can be detected in various areas of the atrial wall (white spots). Only the left atrial appendage (LAA) has no scars.
Patients with aortic stenosis are often accompanied by AF, and may have "occult" or progressive AF (so-called "new AF") early in the surgery or after transfemoral valve replacement (TAVI). In fact, Compared with patients with sinus rhythm, patients with atrial fibrillation undergoing surgery or TAVI intervention have a higher risk of stroke and bleeding and a higher overall mortality rate. A recent clinical update on this topic indicates that the incidence of new-onset AF in TAVI may be lower than in surgical valve replacement. However, this optimal treatment strategy for patient rhythm and heart rate control remains unclear, especially the role of amiodarone in AF perioperative prevention and traditional rhythm control, and the role of catheter ablation as a rhythm control strategy. Further evaluation in clinical studies and trials. Another controversial issue concerns the optimal anticoagulant regimen, especially for patients with TAVI: AF patients after TAVI are eligible for NOAC treatment? Is vitamin K antagonist a better choice? Although specialized large-scale clinical trials have good evidence to support the use of NOAC after TAVI, this important question remains unanswered.
Catheter ablation of paroxysmal atrial fibrillation: burning or freezing? The efficacy of transcatheter point-by-point radiofrequency ablation (RF) and balloon ablation for paroxysmal atrial fibrillation has been debated for many years, but the results are unknown. We now know that two ablation techniques result in the same rhythm results and have similar rates of complication. In a multicenter clinical trial conducted by FIRE AND ICE International, 762 patients with paroxysmal AF were randomly assigned to receive isolated pulmonary vein radiofrequency ablation or cryoablation. During the 1.5-year follow-up period, there was no significant difference in the incidence of clinical treatment failure after ablation between the two groups (ie, atrial fibrillation, atrial flutter or atrial tachycardia recurrence, antiarrhythmic drugs or repeated ablation): hypothermia The ablation group was 34.6%, and the radiofrequency ablation group was 35.9%. Both techniques proved to be equally safe, with a combined incidence of death and cerebrovascular events, as well as treatment-related serious adverse events, of 10.2% and 12.8%, respectively (P = ns). The relatively high incidence of side effects was consistent with previous prospective study data. There was no difference in quality of life assessment after ablation between the two study groups. In a subsequent study, the same author reported a lower rate of repeated ablation, DC cardioversion, and all-cause rehospitalization during follow-up in the cryoablation group. Similarly, the Freeze AF study included 315 patients with paroxysmal AF who were compared with cryo-balloon assisted and RF-assisted ablation. The results of these two studies, characterized by limited use of newly introduced techniques in the RF group, have helped to confirm that cryo-balloon assisted ablation is a valuable alternative to RF-assisted ablation for paroxysmal atrial fibrillation. However, whether RF-based ablation strategies can improve rhythm control in patients with paroxysmal atrial fibrillation and low-voltage areas remains an assessment.
The STAR AF II study included 589 patients with persistent AF who were randomly assigned to three study groups at a 1:4:4 ratio, comparing the effects of transcatheter PVI with RF current with PVI plus linear ablation, PVI plus atrial complex fragmentation potential. (CFAE) the effect of ablation. There were no significant differences in the proportion of patients with recurrent AF (59%, 49%, 46%) after 18 months of follow-up. These results differ from a recent meta-analysis report that analyzed a limited sequence that showed a 51% reduction in the relative risk of recurrent AF in patients receiving PVI linear ablation compared with patients receiving only PVI. The difference in the results of these two studies highlights the value of randomized studies for validating previously used less rigorous methods. New research is needed to confirm current findings, explore new ablation protocols, and determine the best strategy for patients with persistent AF after the first ablation failure.
The optimal antiarrhythmic treatment after ablation of the patient remains to be determined. In a short-term study of antiarrhythmic drugs after atrial fibrillation catheter ablation, 2038 patients were randomized to receive antiarrhythmic drugs and placebo for treatment of paroxysmal, persistent, or permanent atrial fibrillation after radiofrequency catheter ablation. During the 3-month treatment period, the risk of recurrent atrial tachyarrhythmia was reduced in the antiarrhythmic drug treatment group, whereas antiarrhythmic drugs had no effect on clinical outcomes at subsequent time points.
Does catheter ablation have an effect on AF and/or mortality? In a recent Swedish national registration study (n=361913), Friberg et al. evaluated the impact of AF ablation on clinical outcomes. The investigators used propensity score matching, the same number of patients in the two groups (2836 patients in each group), one group received atrial fibrillation ablation, and one group did not receive ablation treatment. The 51 characteristics of the two groups were similar. After adjusting for known confounding factors, the incidence of AF ablation and all-cause mortality (HR = 0.50; 95% CI = 0.37-0.62) and ischemic stroke (HR = 0.69; 95% CI = 0.510.93) was significantly reduced. related. The majority of AF ablation reduced ischemic stroke in the CHA2DS2VASc score > 2 subgroup (HR = 0.39; 95% CI = 0.19-0.78), the most patients who did not receive cardioversion more than 6 months after ablation Obvious (HR = 0.68; 95% CI = 0.48-0.97). This controversial topic requires random research of the appropriate size. Prior to completion of these studies, high-risk patients (according to the CHADS-VASc score) should be treated with anticoagulant therapy for life after ablation - a strong support for the 2016 ESC AF treatment guidelines.
The new AF guidelines emphasize individualized, refined strategies for patients with atrial fibrillation. Importantly, the guide describes the role of new AF risk factors, the importance of lifestyle changes for mitigating AF loads and reducing AF-related risks. In addition, the benefits of AF comprehensive treatment, AF heart disease teams and patients participating in joint decision-making are also proposed, and specific actions are recommended to provide optimal treatment options for AF patients.
3. Prevention of stroke
A sub-analysis of the recent ARISTOTLE study reported an interesting finding, the "obesity paradox." Of the 17,913 patients enrolled in the study, 7159 were obese, 6702 were overweight, and 4052 were normal. During the 1.8-year follow-up period, high body weight was associated with a lower risk of all-cause mortality (overweight, HR = 0.67; 95% CI = 0.59-0.78; obesity, HR = 0.63; 95% CI = 0.54-0.74). This benefit extends to women's stroke risk (P = 0.048), but men do not benefit. People without obesity are associated with different bleeding risks. A possible explanation for this finding is that earlier and more rigorous combination of drugs, lifestyle changes, and better metabolic reserves may ultimately affect the mid-term prognosis of obese patients.
Another interesting finding was observed in the recent subanalysis of the Engage AF-TIMI 48 study. The study showed that compared with vitamin K antagonist (VKA) treatment, the all-cause mortality rate of the edoxaban 30 mg group (HR = 0.92; 95% CI = 0.83-1.01, P = 0.08) was lower than that of the ydoxaban 60 mg. Group (HR = 0.87; 95% CI = 0.79-0.96, P = 0.006). Although the risk of ischemic stroke was significantly increased in the low-dose group of edoxaban (HR = 1.41; 95% CI = 1.19-1.67, P < 0.001), but not in the high-dose group (hr = 1; 95% ci = 0.83-1.19, p = 0.97). The lower overall mortality rate of edoxaban patients was mainly due to a significant reduction in the rate of lethal bleeding in the edoxaban group (especially in the low-dose group). These findings have led us to focus more on the risks and benefits associated with balanced dosing or oral anticoagulants and to shift the goal of drug therapy from thromboembolic events to cardiovascular disease. In addition, further subgroup analyses can demonstrate the consistent clinical safety and safety of edoxaban in other high-risk subgroups (eg, elderly and patients with increased risk of falling), so the drug is reasonable for preventing stroke select.
A recent randomized controlled trial (Ensure AF) showed that the efficacy and safety of oral edoxaban 60 mg once daily in perioperative atrial fibrillation was similar to VKA. Using an early or delayed strategy 30 days after cardioversion, the total incidence of stroke, MI, peripheral embolism, and cardiovascular death in 1095 patients with edoxaban was 0.5%, compared with 1104 patients treated with VKA. The incidence was 1.0% (OR 0.46; 95% CI = 0.12-1.43). Similarly, the incidence of peripheral hemorrhage was also observed to be lower in both groups (0.3% and 0.5%) (OR 0.61; 95% CI = 0.09-3.13). These results are similar to the recently reported X-VeRT study by Cappato et al., which compared the efficacy of oral rivaroxaban and VKA in the same clinical setting. Both studies are not sufficient to test the non-inferiority hypothesis. However, the high reproducibility of the primary efficacy and safety results of both studies made NOAC a valuable alternative to VKA.
Three of the four new oral anticoagulants (NOACs) previously studied in large phase III clinical trials were marketed, and many studies reported after the market provided practical evidence for the efficacy and safety of these new drugs. Camm et al. analyzed the efficacy and safety of rivaroxaban in real life in a previous registry study, with major bleeding (2.1 / 100 patient-years) and stroke events (0.7 during approximately 1 year of follow-up) The incidence of /100 patient-years was low and was the same as observed in the Rocket AF study. Recently, the results of three studies using the claims database as a data source were reported. The REVISIT-US study used population-reported overall estimates of ischemic stroke and intracranial hemorrhage to infer clinical net benefit. Real-life use of rivaroxaban (n=22822) and apixaban (n=8166) reduced the overall incidence of ischemic stroke and intracranial hemorrhage by 39% (HR 0.61; 95% CI = 0.45-0.82) And 37% (HR 0.63; 95% CI = 0.35-1.12). Recently, the same authors reported that dabigatran has similar benefits to VKA.
Another real-world analysis compared apixaban (n=15 390), dabigatran (n=28 614) and rivaroxaban (n=32 350) with Huafa in the OptumLabs database (OLDW). The safety and effectiveness of the forest. It was found that dabigatran (HR 0.98, 95% CI 0.76-1.26, P = 0.98) and rivaroxaban (HR 0.93, 95% CI 0.72-1.19, P = 0.56) were similar to warfarin. The risk of ischemic stroke was reduced and the risk of apixaban was lower (HR 0.67, 95% CI 0.46-0.98, P = 0.04). Compared with warfarin, rivaroxaban (HR 1.04, 95% CI 0.90-1.20, P = 0.60) had similar risk of major bleeding, dabigatran (HR 0.79, 95% CI 0.67-0.94, P < 0.01) And the risk of apixaban (hr 0.45, 95% ci 0.3~0.59, p <0.001) was lower. <>
The FDA recently analyzed the prognosis of 52,240 dabigatran-treated patients and 66,651 rivaroxaban-treated patients (>65 years). The results showed that rivaroxaban patients had a lower risk of thromboembolic stroke compared with dabigatran (HR, 0.81; 95% CI, 0.65-1.01; P = 0.07). At the same time, rivaroxaban increased intracranial hemorrhage (HR, 95% CI, 1.20-2.26; P = 0.002) and severe extracranial hemorrhage (HR, 1.48; 95% CI, 1.32) compared with dabigatran. 1.67; P <0.001), mortality increased (hr, 1.15; 95% ci, 1.00-1.32; p = 0.051).
In fact, available evidence suggests that any real-world analysis also has some possible limitations, including participation in confounding, short-term follow-up, selected patient populations, inconsistent measurement results (ie, definition of major bleeding), inadequate external review, and incomplete follow-up. This limits the generalizability of the results. The only conclusion that can be drawn from post-marketing research data is that the results of these studies are consistent with the safety and efficacy of NOAC observed in large randomized clinical trials in medical institutions around the world. Therefore, the current 2016 Atrial Fibrillation Guidelines recommend the use of NOAC as a first-line treatment in patients with atrial fibrillation who are starting anticoagulant therapy, Level I, Level A. In contrast, aspirin is considered a Class III recommendation (possibly harmful) because its efficacy is limited and the risk of bleeding is often underestimated.
4. Ventricular arrhythmia and sudden cardiac death
Ventricular tachycardia (VT) catheter ablation is an important technique for the treatment of patients with recurrent VT (Figure 3). However, there are few randomized clinical trials evaluating the potential benefits of catheter ablation and antiarrhythmic drug therapy. The recently published VANISH trial included patients with drug-refractory ventricular tachycardia with ischemic cardiomyopathy who were randomized to receive baseline antiarrhythmic drugs plus VT catheter ablation or escalation of antiarrhythmic drugs. In the latter group, amiodarone was increased to 300 mg / d, after which treatment with mexiletine was required clinically. During the 27-month follow-up period, the number of deaths, VT storm events, or appropriate ICD shocks in the escalation group (127 patients) was significantly higher than in the ablation group (132 patients) (69% vs. 59%; HR = 0.72; 95%) CI = 0.53-0.98). However, although the ablation group was observed to benefit from a reduction in VT recurrence, there was no difference in overall survival, suggesting that other factors, such as structural heart disease and progressive heart failure, play an important role in the prognosis of these patients.
Figure 3 Intima and epicardial VT ablation. Three-dimensional mapping of the left ventricular endocardial surface (A) and the adventitia (BD) with superimposed coronary angiography to detect the coronary artery in which the epicardium is located. Although only a small area of ​​low voltage can be detected in the endocardium (A, red area), the epicardial surface shows extensive fibrosis (D). The pink dot indicates the ablation site.
Recurrent ventricular tachycardia is an important risk factor for sudden cardiac death in patients with tetralogy of Fallot. Catheter ablation is difficult to perform due to the complex anatomical features that result from surgical repair. However, fine electroanatomical reconstruction and cardiac conduction mapping in the surgical field can effectively identify the key conduction isthmus that promotes VT. A large quadruple tetralogy study showed that isthmic ablation of the isthmus can cause VT to terminate in most patients and is no longer induced. In patients with effective ablation, the VT recurrence rate is very low, demonstrating the benefits of this approach.
In a recent study, Kudenchuck et al. compared the efficacy of standard amiodarone, lidocaine, and saline placebo after standard treatment, including 3,026 cases of out-of-hospital cardiac arrest, refractory ventricular fibrillation (VF). Or adult patients with pulseless VT after at least one defibrillation. There were 974 patients in the amiodarone group, 993 patients in the lidocaine group, and 1059 patients in the placebo group. There were no differences in survival rates at the time of discharge from the three groups (24%, 24%, and 21%, respectively) and neurological observations. Interestingly, active drug therapy was associated with higher survival rates in patients with bystander cardiac arrest (P = 0.05), but no bystander cardiac arrest did not benefit. These findings are directed to the use of intravenous antiarrhythmic drugs in patients with cardiac arrest who have no bystanders outside the hospital, but can be applied to patients with bystander cardiac arrest.
Second, the heart electronic device
Implantable defibrillator treatment
Who can benefit from ICD and who can't benefit? The issue is still inconclusive. In a randomized study of 1116 patients with symptomatic systolic heart failure due to non-coronary artery disease (DANISH trial), Kober et al found that after long-term follow-up (68 months), conventional treatment was compared with conventional treatment alone. Implantable cardioverter defibrillator (ICD) treatment did not provide significant protection. In this study, patients in the ICD group had a 50% relative risk of sudden death (highly significant), which was offset by death from other cardiovascular causes and non-cardiovascular death. During the first 5 years of follow-up, all time-event curves tend to support ICD therapy, and then the trend converges. These results have contributed significantly to the debate about the use of ICD for primary prevention in patients with non-ischemic cardiomyopathy. In fact, a subgroup analysis of patient age showed significant statistical interactions. Younger patients (<59 years of age) benefited from all-cause mortality from icd, while older patients did not. In addition, the diversity of cardiomyopathy reports has made the surveyed population quite diverse. The sample size of previous studies is not sufficient to evaluate the superiority of icd therapy and drug therapy, so further research is needed. In summary, the results of the danish study are important, emphasizing that clinical practice (when deciding to choose icd implantation, especially for patients with non-ischemic heart disease) should consider competition risk and death patterns.
These results are consistent with a recent large-scale prospective multicenter cardiac resynchronization therapy (CRT) registry study. In the study, 1705 patients were enrolled in CRT-P (535 patients) or CRT-D (1170 patients), and the corrected death risk after CRT-P vs. CRT-D was 1.54 (CI 1.07-2.21, P = 0.0209). However, 95% of the excess death in the CRT-P group is due to an increase in non-cardiac sudden death, thus reaffirming the importance of individualized competitive risk analysis prior to implantation.
In a recent report, Vehmemijer et al. conducted a comprehensive review and meta-analysis of the indications, efficacy, and safety of ICD therapy in adult patients with congenital heart disease. A total of 2,162 patients (66% of men) in 24 studies were enrolled, with an average age of 37 years at the time of implantation. 53% of patients were primary prevention (95% CI = 43.5-62.7%), with non-sustained VT being the most common indication, followed by LV dysfunction, inducible VT, syncope, palpitations or threatened syncope. The most common cause is tetralogy of Fallot, transposition of the great arteries, congenital corrective transposition of the great arteries, ventricular or atrial septal defect and others. During the 3.6-year follow-up period, 24% of patients received appropriate ICD intervention, while 22% of ICD interventions were inappropriate, including defibrillation and/or anti-tachycardia pacing. The patient's all-cause mortality rate was 10%. These data (involving relatively high complication rates and inappropriate treatment of ICDs) provide an argument for a well-rounded decision-making process.
2. Subcutaneous implantable cardioverter defibrillator
In a recent study, Friedman et al. evaluated trends in early use of S-ICD and patient in-hospital outcomes. In September 2012 (the date the US FDA approved S-ICD) until March 2015, the National Cardiovascular Data Registry ICD Registry registered 393,734 ICD implants, and the researchers performed 1:1 on 5760 patients: 1 Trend-matched analysis comparing hospitalization outcomes in patients with S-ICD versus single-chamber (SC)-ICD and dual-chamber (DC)-ICD. Patients who received S-ICD during the study accounted for 0.9% of all ICD patients. Compared with SC-ICD and DC-ICD, patients receiving S-ICD were younger and more survivors of women, blacks, and dialysis and cardiac arrest. Interestingly, many patients have a large number of complications. The DFT test resulted in 99.7% of 2629 patients with successful defibrillation during intraoperative ventricular arrhythmia induction. The rate of hospitalization complications associated with S-ICD was lower (1.1%), similar to the SC-ICD group (1.0%) and lower than the DC-ICD group (1.2, P < 0.001). These results are preliminary observations of the effects of s-icd in everyday practice, and the safety of the implants is encouraging.
In addition, preliminary reports of subcutaneous ICD in patients with limited young congenital heart disease (mean age 34 years) showed a 100% success rate for device implantation and a 100% conversion rate for induced arrhythmias <80j. Randomized trials are needed to confirm these results and to assess the long-term clinical role of s-icd. The s-icd technology is still very young and growing rapidly. A new high-pass filter (smartpass for singular s-icd gen 2 and gen 2.5) was introduced in 2016 to reduce the risk of excessive t-wave perception in s-icd patients (theuns et al., published in hrs 2016). . The large effortless research model showed an 81% reduction in inappropriate defibrillation in modern devices compared to the first generation s-icd.
One of the major (perceived) limitations of current S-ICD is the lack of pacing capability, thus limiting its use in patients with known monomorphic VT or bradycardia pacing indications. This year, for the first time in animal models, it is possible to communicate with S-ICDs and wireless pacemakers, allowing single-shaped VTs to be terminated and wireless pacemakers to function as normal VVIs. These data are very useful for future improvements to the S-ICD system.
3. Wireless pacemaker
In the past few years, wireless pacing has been on the center of the field of bradycardia pacing, and important new data emerged in 2016. Preliminary results of 725 patients with Micra implantation were published in early 2016, and 292 of 297 patients with 6-month paired data demonstrated satisfactory electrical parameters (threshold, sensing, impedance). Of the 725 patients (4.0%), 25 had 28 serious complications, including 11 (1.9%) cardiac perforation and 1 death (0.1%). Follow-up visits by Cardiostim et al. confirmed these positive results again (mean follow-up of 7.7 ± 3.9 months). There are very few additional clinical events; most importantly, there have been no major shifts and embolisms. The Micra pacemaker is now implanted in more than 2,000 people, and the latter is also proven in the “real world†outside of clinical trials, thus placing special emphasis on the safety of the device.
4. Wearable cardioverter defibrillator
Several studies have demonstrated the effectiveness and safety of wearable cardioverter defibrillators. In a large German registry study, 94 (1.6%) patients were treated with WCD for ventricular tachycardia with an event rate of 8.4/100 patient years (95% confidence interval, 6.0-10.2) (German life jacket cycle 2016). Of the 120 patients with defibrillation, 112 (93%) survived for 24 hours after treatment, while in 2 patients (0.03%), cardiac arrest occurred, of which 1 died. Comprehensive data available, a recent American Heart Association scientific report indicates that this treatment is recommended in the following situations, which are very similar to ESC cardiac death prevention guidelines, including: (i) bridging treatment at risk of death, ICD can reduce cardiac output Sudden death (non-total mortality), such as 40 days of myocardial infarction; (ii) presence of implant contraindications or temporary interruption of ICD treatment (eg infection); (iii) increased risk of sudden cardiac death, but the risk will change over time Or disappearance of treatment of left ventricular dysfunction, such as recent ischemic heart disease patients with revascularization, new guidelines for recommending drug therapy for patients with non-ischemic dilated cardiomyopathy, or secondary cardiomyopathy with reversible etiology (patients with tachycardia and thyroid); (iv) transitional therapy as a definitive treatment (eg heart transplant). Given the uncertainty of research in this area, the authors' article provides a preliminary framework for clinical cardiac death prevention decision-making, but further research is needed to support these recommendations.
Source: Medical Pulse
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