Use Of Amiodarone Research Articles

Delayed Release of Amiodarone Causing Late-Onset Thyrotoxicosis

Introduction: Amiodarone is an antiarrhythmic medication associated with a wide range of adverse effects, including thyroid dysfunction.1 Thyrotoxicosis without underlying Graves' disease or nodules is classified as Type II, or destructive, amiodarone-induced thyrotoxicosis (AIT).2 However, few cases have been reported in whom AIT occurs months after cessation of medication use. We describe a case of late-onset Type II AIT, diagnosed in the setting of atrial fibrillation (AF), 10 months after last known dose of amiodarone. Description of the Case: A 51-year-old man presented with palpitations and an electrocardiogram showing AF with rapid ventricular response. His history was notable for a diagnosis of AF, treated with ablation and multiple courses of amiodarone, most recently 1 year prior with a cumulative dose of 22.4 g for 12 weeks. Serum laboratory tests showed newly suppressed thyroid-stimulating hormone <0.02 (0.3–4.7 mcIU/mL) and elevated free thyroxine 1.9 (0.8–1.7 ng/dL). Thyroid autoantibodies to thyroid peroxidase and thyrotropin receptor and thyroid-stimulating immunoglobulins were absent. He had no recent exposure to biotin or iodinated contrast and reported no recent viral illness or neck pain. He had a 9 kg weight loss in the preceding few months secondary to decreased appetite. Family history was significant for mother and nephew with autoimmune thyroid disease. Thyroid ultrasonography showed no nodules. An iodine-123 uptake scan showed homogeneous bilateral decreased uptake most consistent with destructive thyroiditis. Methimazole treatment, started empirically at presentation, was discontinued. Thyroid function tests normalized within 3 months with no therapy needed. Discussion: Delayed-onset AIT may occur after cessation of amiodarone therapy. To our knowledge, only one case series of eight patients has been reported in whom late-onset thyrotoxicosis occurred after amiodarone cessation.3 Amiodarone contains a significant amount of iodine and releases about 100 to 300 times of the recommended daily intake. It is a lipophilic complex primarily stored within adipose tissue, with a long half-life of up to 100 days. Our patient's rapid weight loss may have contributed to a delayed release of amiodarone from lipid stores, thereby triggering Type II AIT. This case emphasizes the importance of considering AIT in all patients with history of amiodarone use, even months after cessation of therapy, when supported by presentation and diagnostic tests. Patient Consent: Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. No competing financial interests exist for any of the authors. Runtime of video: 4 mins 12 secs

An Integrative Comparative Study Between Digoxin and Amiodarone as an Emergency Treatment for Patients With Atrial Fibrillation With Evidence of Heart Failure: A Systematic Review and Meta-Analysis.

The emergency treatment of atrial fibrillation (AF) involves utilizing two strategies. The first strategy normally involves permitting the atrial fibrillation to persevere as the ventricular rate is controlled. The other method involves utilizing anti-arrhythmic drugs in cardioversion and attempting to maintain sinus rhythm. Different pharmacological treatments, including digoxin and amiodarone, have been used to manage AF. A literature review on amiodarone and digoxin in the treatment of AF among patients with heart failure (HF) has shown that both drugs have potential risks. Therefore, we are conducting this systematic review and meta-analysis to compare the effectiveness of amiodarone and digoxin in the treatment of AF among patients with evidence of HF.A literature search of relevant articles was conducted on six electronic databases (PubMed, Web of Science, Medline, ScienceDirect, Cochrane Library, and Google Scholar) from 2000 to 2022. The search yielded seven studies that had met the inclusion criteria. Our meta-analysis of four studies showed that there was no significant difference in the reduction of heart rate after treatment with either amiodarone or digoxin (mean difference (MD): -5.44; 95% confidence interval (CI): -9.53 to -1.34; I2 = 25%; p = 0.26). On the other hand, the statistical analysis showed that amiodarone had a better effect on the conversion to sinus rhythm than digoxin (63% versus 35%, respectively).Based on evidence from our meta-analysis, the clinical effect of amiodarone and digoxin in the emergency treatment of AF on heart rate control was unclear. However, amiodarone has a significant impact on the restoration of sinus rhythm compared with digoxin and can be considered the first-line drug regimen in conversion to sinus rhythm for AF patients with evidence of heart failure. However, the use of amiodarone and digoxin is complicated by adverse events and all-cause mortality.

Evaluating pharmacists' knowledge, attitude, and practices toward amiodarone cross-reactivity with iodine: a cross-sectional pilot study.

IntroductionIodine is a vital mineral of the human body that acts by maintaining the health of the thyroid gland. Research has shown that iodine-rich food allergy (i.e., seafood allergy) is not caused by iodine itself; instead, it is caused by other proteins including tropomyosin and parvalbumin in shellfish and fish, respectively. Amiodarone is a commonly used antiarrhythmic agent containing a significant amount of iodine.ObjectiveThis study’s objective was to assess pharmacists’ knowledge, attitude, and practices toward the misconception of iodine allergy and the cross-reactivity with amiodarone.MethodsIn February 2020, a cross-sectional study was conducted by sending out an online survey to three pharmaceutical organizations (Saudi Pharmaceutical Society, Kuwait Pharmaceutical Association, and Oman Pharmaceutical Society). Additionally, an electronic questionnaire was administered to pharmacists attending the Dubai International Pharmaceuticals and Technologies Conference and Exhibition 2020 (DUPHAT). Chi-square or Fisher’s exact test, when appropriate, were used to compare categorical variables. The statistical analyses were carried out using SPSS software.ResultsData were collected from 66 respondents. However, only 61 (92.4%) were included in the final analysis following the exclusion of incomplete responses. The mean age of participants was 35 ± 8.48 years. The majority of participants did not have the Board of Pharmacy Specialties Certification (54.1%). Moreover, (41%) of participants licensed as pharmacists with more than 10 years of initial pharmacy licensure. Forty-three (70.5%) of participants had the misconception that iodine allergy should be considered before amiodarone administration, 20/32 (62.5%) of whom considered iodine allergy alone thought that premedication with corticosteroids and/or antihistamines is necessary. Concerning iodine allergy and amiodarone use, there was no significant difference in knowledge between the pharmacists who have board certification and those who did not.ConclusionPharmacists’ misconception concerning iodine allergy and cross-reactivity with amiodarone was evident. Implementation of educational programs targeting pharmacists is necessary to correct these misconceptions.

Concurrent administration of amiodarone and atenolol in the treatment of coronary artery disease complicated with arrhythmia, and its effect on serum levels of CD40L, TNF-α and IL-6

Purpose: To investigate the efficacy of the combination of amiodarone and atenolol in the treatment of patients with coronary artery disease (CAD) complicated with arrhythmia, and its effect on serum levels of CD-40L, TNF-α and IL-6.Methods: One hundred and twenty CAD patients with arrhythmia on admission in The First People'sHospital of Shuangliu District Chengdu, China were assigned to groups A and B, each having 60 patients. Amiodarone was administered to all the patients, while atenolol was additionally given to patients in group A. Levels of heart function indicators, inflammatory factors, blood pressure, heart rate, adverse reaction rate (ARR) and overall efficacy were evaluated for the two groups.Results: There were significantly improved levels of heart function indicators, and lower levels of CD40L, TNF-α and IL-6 in group A, when compared with group B (p &lt; 0.001). Moreover, treatment effectiveness was higher in group A than in group B (p &lt; 0.05). However, there was no significant difference (p &gt; 0.05) in ARR between groups A and B.Conclusion: The combined use of amiodarone and atenolol improves heart function indicators in patients with CAD and arrhythmia, reduces the levels of inflammatory factors, normalizes blood pressure and heart rate, and lowers ARR. However, further clinical trials on this combined therapy are required prior to its use in clinical practice.

Amiodarone Use and All‐Cause Mortality in Patients With a Continuous‐Flow Left Ventricular Assist Device

BackgroundAtrial and ventricular arrhythmias are commonly encountered in patients with advanced heart failure, with amiodarone being the most commonly used antiarrhythmic drug in continuous‐flow left ventricular assist device (CF‐LVAD) recipients. The purpose of this study was to assess the impact of amiodarone use on long‐term all‐cause mortality in ptients with a CF‐LVAD.Methods and ResultsA retrospective multicenter study of CF‐LVAD was conducted at 5 centers including all CF‐LVAD implants from 2007 to 2015. Patients were stratified based on pre–CF‐LVAD implant amiodarone use. Additional use of amiodarone after CF‐LVAD implantation was also evaluated. Primary outcome was all‐cause mortality during long‐term follow‐up. Kaplan‐Meier curves were used to assess survival outcomes. Multivariable Cox regression was used to identify predictors of outcomes. Propensity matching was done to address baseline differences. A total of 480 patients with a CF‐LVAD (aged 58±13 years, 81% men) were included. Of these, 170 (35.4%) were on chronic amiodarone therapy at the time of CF‐LVAD implant, and 310 (64.6%) were not on amiodarone. Rate of all‐cause mortality over the follow‐up period was 32.9% in the amiodarone group compared with 29.6% in those not on amiodarone (P=0.008). Similar results were noted in the propensity‐matched group (log‐rank, P=0.04). On multivariable Cox regression analysis, amiodarone use at baseline was independently associated with all‐cause mortality (hazard ratio, 1.68 [95% CI, 1.1–2.5]; P=0.01).ConclusionsAmiodarone use was associated with significantly increased rates of all‐cause mortality in CF‐LVAD recipients. Earlier interventions for arrhythmias to avoid long‐term amiodarone exposure may improve long‐term outcomes in CF‐LVAD recipients and needs further study.

The Association Between Subclinical Thyroid Dysfunction and Recurrence of Atrial Fibrillation After Catheter Ablation.

ObjectiveThe aim of this study was to evaluate the association between subclinical thyroid dysfunction and the recurrence of atrial fibrillation (AF) after radiofrequency catheter ablation (RFCA).MethodsWe examined the association between subclinical thyroid dysfunction and the recurrence of AF at a large university-affiliated cardiac arrhythmia center in China. Data were collected from consecutive patients who underwent RFCA for AF, excluding those with a history of hypothyroidism, hyperthyroidism, or ongoing medical treatment for hypothyroidism or hyperthyroidism, biochemically defined overt thyroid disease, and long-term use of amiodarone before admission. The primary end point was the recurrence of AF in a time-to-event analysis. We compared outcomes in patients who had subclinical hyperthyroidism or hypothyroidism with those who had euthyroid state, using a multivariable Cox model with inverse probability weighting and propensity score matching.ResultsIn all, 93 patients were excluded from 435 consecutive patients who underwent RFCA for AF. Of the remaining 342 patients for the analysis, the prevalence of subclinical hyperthyroidism and subclinical hypothyroidism were 26 (7.6%) and 41 (12.0%), respectively; during a median follow-up of 489 days, 91 patients (26.6%) developed a primary end point event. In the main analysis of the multivariable Cox model, only subclinical hyperthyroidism [hazard ratio: 3.07, 95% confidence interval (CI): 1.54–6.14] was associated with an increased risk of end point event after adjusting for potential confounders. However, the association between subclinical hypothyroidism and the end point event was not significant (hazard ratio: 0.66, 95% CI: 0.31–1.43). Results were consistent either in multiple sensitivity analyses or across all subgroups of analysis. Compared with individuals with free triiodothyronine (fT3) in the lowest quintile, those with fT3 in the highest quintile had an HR of 2.23 (95% CI: 1.16–4.28) for recurrence of AF. With the increase of thyroid-stimulating hormone (TSH), a reduction in the risk of recurrence of AF was detected in the adjusted model, and the hazard ratio (HR) per standard deviation (SD) increase was 0.82 (95% CI: 0.68–0.98).ConclusionIn this retrospective cohort study involving patients who underwent RFCA for AF, patients with subclinical hyperthyroidism were associated with a markedly higher prevalence of recurrence of AF, whereas patients with subclinical hypothyroidism had a similar recurrence rate of AF compared to those with the euthyroid state.

AMIODARONE-INDUCED PNEUMOTOXICITY AT LOWER DOSES THAN EXPECTED

TYPE: Late Breaking Abstract TOPIC: Lung Pathology PURPOSE: To determine if doses of amiodarone lower than 400 mg per day can result in increased risk of lung injury, such as pneumonitis or pulmonary fibrosis. METHODS: We used TriNetX, a federated, global research network that provides access to anonymized medical record information from more than 75 million patients in 55 large healthcare organizations. We created four patient cohorts consisting of patients on 100, 200, and 400 mg of amiodarone per day, as well as a control group not taking amiodarone. Patients with a history of lung disease were excluded. The 4 cohorts were evaluated for the endpoints of pneumonitis (ICD-10 code J84), and for the subset of pulmonary fibrosis (ICD-10 code J84.10). RESULTS: We found that at a low dose of 100 mg of amiodarone, risk of pneumonitis increased almost 4-fold (2.163% vs 0.554%), and the risk of pulmonary fibrosis was 2.2-fold increased (0.801% vs 0.355%). Doses of 100 vs 200 mg had comparable pneumonitis but at 200 mg the fibrosis risk increased significantly. See Fig. 1. Figure 1. Rates of pneumonitis and fibrosis at different amiodarone doses CONCLUSIONS: Amiodarone-associated pneumonitis and pulmonary fibrosis occur in a dose-dependent fashion, but doses of 100 and 200 mg had similar overall risk. All three amiodarone cohorts had significant risk elevation compared to the control group. CLINICAL IMPLICATIONS: The use of amiodarone at any dose can be associated with significant pulmonary toxicity compared to patients that are not taking it. Practitioners should be aware of these risks and properly inform and monitor patients who receive amiodarone treatment. DISCLOSURE: Nothing to declare. KEYWORD: Amiodarone pulmonary toxicity

Effect of Sacubitril-Valsartan on Restoration and Maintenance of Sinus Rhythm in Patients With Persistent Atrial Fibrillation.

BackgroundExisting studies have shown that sacubitril-valsartan ameliorated atrial remodeling in atrial fibrillation (AF) and favored maintenance of sinus rhythm in patients with AF and heart failure. However, the effect of sacubitril-valsartan in patients with persistent AF is yet unknown. We aimed to evaluate the effect of sacubitril-valsartan on restoration and maintenance of sinus rhythm in patients with persistent AF who underwent electrical cardioversion (ECV).MethodConsecutive patients with persistent AF who underwent ECV between 1 January 2016 and 30 September 2020 were investigated in this retrospective cohort study. All eligible patients were categorized into sacubitril-valsartan users and sacubitril-valsartan non-users based on whether they received treatment with sacubitril-valsartan or not. The endpoint was ineffictive ECV, defined as the composite of failure to terminate AF or any recurrence of AF during 30 days follow-up.ResultsA total of 76 patients were enrolled in this study, including 28 sacubitril-valsartan users and 48 non-users. Within a follow-up of 30 days after ECV, the endpoint had occurred in 7 (25%) of 28 sacubitril-valsartan users and 25 (52%) of 48 non-users. Significantly lower rate of ineffictive ECV in sacubitril-valsartan users compared with non-users was shown in Kaplan-Meier survival curves (P = 0.02; Log-rank test). Multivariate Cox regression analysis indicated that sacubitril-valsartan use (hazard ratio [HR], 0.35; 95% confidence interval [CI], 0.14–0.91), amiodarone use (HR, 0.32; 95% CI, 0.13–0.78), left atrial diameter ≤ 39 mm (HR, 0.21; 95% CI, 0.06–0.71) were independently associated with a decreased rate of ineffective electrical cardioversion.ConclusionUse of sacubitril-valsartan is associated with a significantly decreased risk of ineffective ECV compared with non-users in patients with persistent AF.

Stereoselective interaction of tolvaptan with amiodarone under racemic metabolic impact by CYP3A5 genotypes in heart failure patients.

The diuretic effect of tolvaptan is largely blood level-dependent although it does exhibit interindividual differences according to cytochrome P450 (CYP) 3A5 genotype. This study aimed to investigate the pharmacokinetic relationship between plasma tolvaptan and its monohydroxylate enantiomers and the factors affecting their metabolism in heart failure patients. Japanese heart failure patients (n = 88) receiving oral tolvaptan (median dosage 7.5mg/day) were enrolled. Blood samples were collected prior to the dosing on day 6 or later after first administration to determine the plasma concentrations of tolvaptan and its monohydroxylate enantiomers. Gene polymorphisms of CYP3A5, carbonyl reductase (CBR) 1/3, and ATP-binding cassette subfamily B member (ABCB) 1 were analyzed for their impact on tolvaptan pharmacokinetics. Serum laboratory test values and concomitant use of amiodarone were evaluated as factors related to tolvaptan metabolism. The median of the sum of the 5S- and 5R-tolvaptan plasma concentrations was 48.9 (range, 15.3-100) ng/mL. CYP3A5 genotypes significantly affected the concentration ratio of all enantiomeric metabolites to tolvaptan, while the other metabolic-related gene polymorphisms had no influence. A negative correlation was found between serum albumin and the enantiomeric ratio of tolvaptan and monohydroxylate DM-4111. Concomitant use of amiodarone increased the plasma levels of whole tolvaptan but significantly decreased the metabolic ratios of 5R-tolvaptan. 5S-tolvaptan was selectively synthesized from ketone MOP-21826 by CBR1 with a substantially smaller reaction velocity compared to tolvaptan monohydroxylation by CYP3A4/5. This study clarified the racemic impact of CYP3A5 genotypes on tolvaptan metabolism. Amiodarone may stereoselectively interact with R-forms rather than S-forms of tolvaptan.

Comparison of Frequency of Ventricular Tachyarrhythmia in Men-Versus-Women in Patients with Implantable Cardioverter-Defibrillator for Primary Prevention

Current guidelines do not account for possible sex differences in the risk of ventricular tachyarrhythmia (VTA). We sought to identify specific factors associated with increased risk for VTA in women implanted with a primary prevention implantable cardioverter-defibrillator (ICD). Our study cohort consisted of 4,506 patients with an ICD or cardiac resynchronization therapy-defibrillator who were enrolled in the 4 landmark MADIT studies - MADIT-II, MADIT-RISK, MADIT-CRT and MADIT-RIT (1,075 women [24%]). Fine and Gray regression models were used to identify female-specific risk factors for the primary end point of VTA, defined as ICD-recorded, treated, or monitored, sustained ventricular tachycardia ≥170 beats per minute or ventricular fibrillation. At 3.5 years of follow-up, the cumulative incidence of VTA was significantly lower in women than men (17% vs 26%, respectively; p <0.001 for the entire follow-up). Use of amiodarone at enrollment, Black race, and history of previous myocardial infarction without previous revascularization was found to be independent risk factors of VTA in women. Of these factors, only Black race was associated with a statistically significant risk increase in men. At 3.5 years, the cumulative incidence of VTA in women with one or more of these risk factors was 27% compared with 14% in women with none of the risk factors (hazard ratio [confidence interval]=2.08 [1.49 to 2.91]). In conclusion, our study, comprising 4 landmark ICD clinical trials, shows that sex and race have the potential to be used for improved risk stratification of patients who are candidates for primary prevention ICD.

Recurrence rates of atrial fibrillation ablation according to body mass Index, a nationwide, registry-based danish study

Abstract Funding Acknowledgements Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Novo Nordisk supported the project. Background The proportion of people with obesity is rapidly rising, and the number of overweight patients undergoing ablation for atrial fibrillation (AF) is also increasing. The link between body mass index (BMI), and AF prevalence is well-established but the impact of BMI on the risk of recurrent AF after ablation is less elucidated. Therefore, data pertaining to recurrence rates of ablations according to BMI in large, unselected cohorts of patients is still warranted. Purpose To examine the risk of recurrent AF after AF ablation by BMI. Method Using Danish nationwide registries, all Danish patients above 18 years who underwent first-time AF ablation from January 1st 2010 to December 31st 2018 were identified and included at the date of ablation. The patients were categorized by BMI; underweight: &amp;lt; 18.5 kg/m2; normal weight: 18.5-24 kg/m2; overweight 25-29 kg/m2; obese 30-34 kg/m2; morbidly obese &amp;gt; 34 kg/m2. Recurrent AF was defined using a composite endpoint comprising claimed prescriptions of anti-arrhythmic drugs, hospital admissions due to AF, re-ablation, or electrical cardioversions. The cumulative incidence of recurrent AF by BMI at 1- and 5-year follow-up after a blanking period of 90 days, was estimated using the Aalen-Johansen estimator, takin death as competing risk in to account. The relative rates of recurrent AF by BMI were examined using Cox models adjusted for sex, age, procedure-year, heart failure, ischemic heart disease, chronic obstructive pulmonary disease, chronic kidney disease, hypertension, and diabetes. Results The study cohort consisted of 9,229 patients. Median age [IQR] decreased from 64 [60, 75] in the normal weight group to 60 [53, 66] in the morbidly obese. The number of patients with a CHA2DS2-VASc score of 2 or more increased from 48% in normal-weight to 65% in morbidly obese. Use of amiodarone increased by BMI category, while the use of Class 1C anti-arrhythmic medication remained stable. Figures 1 and 2 show the 1- and 5-year cumulative incidence of recurrent AF, Hazard Ratios (HR), and 95% Confidence Intervals (CI 95%) stratified by BMI categories and depict that the risk of recurrent AF increased incrementally and significantly in overweight groups compared to normal weight patients, both in 1- and 5-year follow-up. Underweight patients demonstrated non-significantly increased risk of recurrent AF, both in 1- and 5-year follow-up. Conclusion In this large nationwide study examining recurrent AF post AF ablation, we found that recurrence rates of AF increased incrementally according to BMI, both in short- and long-term follow-up. Therefore, aggressive weight management in overweight patients could potentially provide substantial benefits and improve short- and long-term outcomes after ablation.

Impact of P-glycoprotein and/or CYP3A4-interacting drugs on the risk-benefit profile of NOACs in patients with atrial fibrillation: a meta-analysis

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Research Foundation Flanders (FWO) Background P-glycoprotein (P-gp) and CYP3A4-interacting drugs influence plasma levels of non-vitamin K antagonist oral anticoagulants (NOACs). However, the clinical relevance is questioned. Purpose A critical appraisal of the impact of pharmacokinetically-interacting drugs on the effectiveness and safety of NOACs in patients with atrial fibrillation (AF). Methods After searching Pubmed and Embase, phase III randomized controlled trials (RCTs) and longitudinal observational cohort studies on the impact of concomitantly used P-gp/CYP3A4-interacting drugs on the risk-benefit profile of NOACs in AF patients during a mean/median follow-up of ≥6 months were included. A fixed effects meta-analysis was performed with the Mantel-Haenszel method. Results Fifteen studies were included (10 post hoc analyses of RCTs, 5 observational studies), investigating 21,711 and 306,421 NOAC-treated AF patients with and without P-gp/CYP3A4 inhibitor use respectively, while only one study included P-gp/CYP3A4 inducers. In NOAC-treated AF patients, concomitant use of P-gp/CYP3A4 inhibitors was associated with significantly higher major bleeding (relative risk (RR) 1.10, 95% confidence interval (CI) (1.01-1.19)) and all-cause mortality risks (RR 1.14, 95%CI (1.05-1.23)) compared to not using P-gp/CYP3A4 inhibitors, while the risks of stroke/SE (RR 0.88, 95%CI (0.77-1.01)), intracranial bleeding (RR 0.89, 95%CI (0.68-1.15)) and gastro-intestinal bleeding (RR 1.09, 95%CI (0.91-1.30)) were not significantly different. Concomitant use of amiodarone with NOACs was associated with lower thromboembolic (RR 0.75, 95%CI (0.61-0.92)), but higher mortality risks (RR 1.21, 95%CI (1.05-1.39)). Co-administration of verapamil or diltiazem was associated with higher major bleeding risks (RR 1.64, 95%CI (1.31-2.06)), but no significantly different thromboembolic or mortality risks. Conclusions Given the higher bleeding and mortality risks in NOAC-treated AF patients concomitantly using P-gp/CYP3A4 inhibitors compared to NOAC users not taking interacting drugs, close monitoring of these patients is warranted, including regular medication review and addressing modifiable bleeding risk factors. Regarding P-gp/CYP3A4 inducers, a considerable research gap was identified, necessitating more research on their impact.

Risk of pericardiac effusion after cardiac implantable electronic device implantation a nationwide study

Abstract Funding Acknowledgements Type of funding sources: None. Background Procedural pericardiac effusion (PE) is considered a major complication to implantation of cardiac implantable electronic devices (CIED), including permanent pacemakers (PM), cardiac resynchronization therapy devices with defibrillators (CRT-D) or without (CRT-P), and implantable cardioverter defibrillators (ICD), as it can cause life threatening cardiac tamponade. Very little is known about risk factors for procedural PE. Aim To identify the patient- and procedure related risk factors associated with clinically relevant procedural PE. Methods &amp; Results This is a nationwide retrospective observational cohort study based on data on 51.599 patients from the Danish Pacemaker Register. Included were all Danish patients who received their first PM, CRT or ICD from 2000 – 2018. Procedural PE was defined related to the invasive procedure if it occurred within 1 months after the invasive procedure and no cancer was diagnosed before the procedure. Pre-specified risk factors, including sex, age, year, implantation center-type and device type were analyzed by multivariable logistic regression models to estimate the association with PE. A total of 78 (0.2%) patients were diagnosed with procedural PE, with a median age of 73 years and 43% were females. In adjusted logistic regression analysis age &amp;gt; 70, heart failure [aOR 1.64 (1.01;2.67)], ischemic heart disease [aOR 1.84 (1.13;2.99)], direct oral anticoagulation [aOR 1.77 (1.13–2.77.)], amiodarone use [aOR 3.03 (1.75–5.22)], beta blocking agent [aOR 2.26 (1.23 –4.14)], university hospitals [aOR 2.59 (1.18 –5.67)] and PM implantation [aOR 3.38 (1.77;6.45)], were associated with PE. Conclusion Procedural PE is a rare complication after CIED implantation in Denmark. Importantly most of the risk factors for PE are modifiable. Optimizing the modifiable risk factors may reduce the risk of complication.

The Chinese burden of atrial fibrillation review of atrial fibrillation studies in China.

Atrial fibrillation (AF) is one of the most common heart rate disorders, but most relevant studies are mainly focused on Europe and The United States, while information about AF in the Chinese population is scarce. The purpose of this study was to provide a review of the literature on atrial fibrillation in China. A literature search (Medline 2001-2021) identified studies reporting the prevalence or incidence of AF, risk factors for AF, comorbidities of AF, and use of antithrombotic therapy in China. This report focuses on descriptive analytical data. Studies reported a wide variation in the prevalence of AF, with a range of community-based and hospital-based AF rates (from 0.49% to 8.8% and 4.4% to 35.7%). Aspirin and warfarin use was found to be particularly low in community-based studies in China, and warfarin and amiodarone use was higher in hospital-based studies than in other countries. Stroke is the most common complication of atrial fibrillation. More high-quality studies are needed to improve our understanding of the burden of atrial fibrillation in China. Efforts should be made to improve community delivery and monitoring of antithrombotic therapy after AF. Due to China's large population, the number of patients with untreated AF and the risk of accompanying complications can be high, so the impact on healthcare resources can be significant.

A multicenter retrospective cohort study on predicting the risk for amiodarone pulmonary toxicity

BackgroundAmiodarone is one of the most commonly used anti-arrhythmic agents. Amiodarone pulmonary toxicity is a potentially fatal adverse effect associated with amiodarone use. Previous studies on the epidemiology and risk factors for amiodarone pulmonary toxicity showed diverse results.MethodsA multicenter retrospective cohort study was conducted to identify clinic-epidemiologic markers associated with amiodarone pulmonary toxicity for development of a prediction rule. Patients taking amiodarone who were managed in 3 centres in Hong Kong from 2005 to 2015 were included in this study. Penalized logistic regression was used to model the outcome as it is rare.ResultsA total of 34 cases with amiodarone pulmonary toxicity were identified among 1786 patients taking amiodarone for at least 90 days from 2005 to 2015. The incidence of amiodarone pulmonary toxicity was estimated to be 1.9%. The risk factors for amiodarone pulmonary toxicity included advanced age (OR 1.047, 95% CI 1.010–1.085, p = 0.013), ventricular arrhythmia (OR 2.703, 95% CI 1.053–6.935, p = 0.039), underlying lung disease (OR 2.511, 95% CI 1.146–5.501, p = 0.021) and cumulative dose of amiodarone (OR 4.762, 95% CI 1.310–17.309 p = 0.018).ConclusionsThe incidence of amiodarone pulmonary toxicity in Chinese patients in Hong Kong is estimated to be 1.9% in this study. Age, underlying lung disease, ventricular arrhythmia and cumulative dose of amiodarone are associated with the development of amiodarone pulmonary toxicity. A prediction rule was developed to inform the risk of developing amiodarone pulmonary toxicity.

A Single Center Experience of Concomitant Administration of Sofosbuvir/Velpatasvir and Amiodarone After Heart or Lung Transplantation

<h3>Purpose</h3> There is a shortage of donor hearts and lungs available for transplantation. The development of sofosbuvir/velpatasvir (SOF/VEL), an antiviral against the hepatitis C virus (HCV), created an opportunity to expand the donor pool through the use of HCV viremic donors. Atrial fibrillation (AF) is a frequent complication after transplantation. SOF/VEL contains a warning against the concomitant usage of amiodarone and SOF/VEL due to symptomatic bradycardia. We sought to describe our experience with the co-administration of these agents after heart/lung transplantation. <h3>Methods</h3> Retrospective review of patients enrolled in a clinical trial of SOF/VEL after transplantation from HCV viremic donors to seronegative recipients and that received at least a dose of amiodarone. SOF/VEL was initiated on post-operative day 1. The use of amiodarone was at the discretion of the treatment team. We defined bradycardia as a heart rate < 60 bpm. <h3>Results</h3> A total of 11 (8 lung, 3 heart) patients received SOF/VEL and amiodarone. Three (27%) had a history of AF and 7 patients (64%) were on treatment prior to transplant. The median time from SOF/VEL to start of amiodarone was 1.2 days. The median cumulative dose of amiodarone was 9086mg (IQR: 2195 - 10952) over a median duration of concomitant administration of 25 days. While the number of documented bradycardic heart rates was low, 1.2% (90/7573), the majority of patients (64%) experienced at least one bradycardic episode. Of those patients, six (86%) required intervention and five (83%) had received concomitant beta blocker (BB) therapy during their episode, Table 1. All cases of bradycardia resolved after intervention. <h3>Conclusion</h3> The use of amiodarone in patients receiving SOF/VEL frequently resulted in bradycardic episodes; however, these occurred with the addition of BB. In patients requiring the combination of SOF/VEL and amiodarone, consideration is warranted before the addition of other bradycardia inducing medications.

Lower Incidence of Postoperative Atrial Arrhythmia After Prophylactic Donor Heart Tricuspid Annuloplasty in Orthotopic Heart Transplantation

<h3>Purpose</h3> Donor heart tricuspid valve annuloplasty (dTVA) may reduce incidence of tricuspid regurgitation after orthotopic heart transplantation (OHT) but data on short-term hemodynamics outcome after prophylactic dTVA is limited. We hypothesized that prophylactic dTVA could benefit post-operative hemodynamics by minimizing right atrial pressure and atrial fibrillation. In our program, we have two primary OHT surgeons, one who routinely uses a DeVega dTVA and one who does not, presenting an opportunity for the study. <h3>Methods</h3> We retrospectively evaluated 52 consecutive OHT recipients between January 2020 and September 2021. They were divided into standard bicaval OHT group (sOHT; n = 28) and bicaval OHT with De Vega dTVA group (dvTVA; n = 24). Incidence of atrial fibrillation, hemodynamics, intensive care unit (ICU) length of stay (LOS), total LOS and echocardiographic measurements were reviewed and analyzed. <h3>Results</h3> Of 52 OHT recipients, mean age was 54.4 ± 11.3 years and 13 (25%) were female. There was no difference between groups in ICU or total LOS, days on inotropic support and in-hospital mortality. Hemodynamically, mean central venous pressure (CVP) at one week, four weeks and three months was not significantly different between groups. Proportion of recipients with significant v wave from CVP tracing wave form in the sOHT group trended higher but without statistically significance compared to dvTVA group and lowered overtime (46.1% vs 26.1%, p = 0.23 at one week, 25.0% vs 20.8%, p = 0.75 at four weeks and 16.6% vs 9.5%, p = 0.67 at three months). However, at mean follow-up of 7.4 months, incidence of atrial arrhythmia including atrial fibrillation and atrial flutter in sOHT group was significantly higher than in dvTVA group (32.1% vs 8.3%, p = 0.046) and most of atrial arrhythmia episodes occurred within one month post-operatively. <h3>Conclusion</h3> We show that OHT recipients with dTVA have lower incidence of atrial arrhythmia and trend to have less significant atrial v waves compared with sOHT patients. Interestingly, over time, the v wave in sOHT recipients normalized, suggesting improvement in RV function. Further study is needed to evaluate long-term outcome with prophylactic dTVA in OHT, incidence of amiodarone use and long term survival.

Role of Prophylactic Use of Amiodarone to Prevent Post-Operative Dysrhythmias in Patients with Low Ejection Fraction (EF ≤35%)

ABSTRACT:&#x0D; Objective:&#x0D; To determine the role of amiodarone prophylaxis in the prevention of dysrhythmias following coronary artery bypass grafting (CABG) in patients with low ejection fraction (EF).&#x0D; Methods:&#x0D; In this prospective comparative study, we included150 patients who underwent coronary artery bypass grafting (CABG) in Multan Institute of Cardiology within a duration of 07 months from Jan-2019 to Aug-2019 having low ejection fraction (EF ≤35%). In the intervention(amiodarone) group (N=75), 3 mg/Kg of amiodarone was given after removal of X-clamp and before weaning from cardiopulmonary bypass. while in the remaining 75 patients no anti-arrhythmic treatment was given in the peri-operative period. Occurrence of postoperative arrhythmia (AF and bradycardia) during the primary hospital stay after surgery was a primary study endpoint.&#x0D; Results:&#x0D; There was no significant difference between the mean age, gender and body mass index (BMI) of patients in the two groups. Regarding per-operative data, there was no significant difference in number of grafts in amiodarone group 3.9±0.53 and control group 3.04±0.50 (p-value 0.20). Frequency of Atrial fibrillation (AF) after the surgery was significantly differenced in both groups. In the amiodarone group, 13 (17.3%) patients developed POAF and in the control group, POAF occurred in 25 (33.3%) patients (p-value 0.024).&#x0D; Conclusion:&#x0D; Amiodarone prophylaxis significantly lower the incidence of POAF after CABG in patients with low EF. Amiodarone is easy to administer and is a valuable adjuvant for prevention of POAF.

Rare case of Torsades de Pointes in severe hypothyroidism: literature review and challenges in management

BackgroundHypothyroidism can manifest as several important cardiac abnormalities. There are few reports of ventricular dysrhythmias (VDs) in hypothyroidism. We described a rare case of VDs in severe hypothyroidism and reviewed the literature behind its management.Case presentationA 67-year-old gentleman, with poor compliance to treatment for Hashimoto’s thyroiditis, presented with palpitations to the Emergency Department. He had runs of non-sustained ventricular tachycardia (NSVT). He was treated with intravenous (IV) amiodarone and admitted to the intensive care unit for observation. He then developed recurrent Torsades de Pointes (Tdp) despite treatment with several anti-arhythmics. He required electrical cardioversion and eventual transvenous overdrive pacing (OP). VT recurred while he was on OP. VT resolved and he was weaned off OP only after adequate thyroid hormone replacement.ConclusionsVDs, including NSVT, Tdp, and VT, are rare and potentially lethal in hypothyroidism. Our case demonstrates important challenges in the management of severe hypothyroidism. Here, VDs are often refractory to treatment with drugs and electrical means. The choice(s) of anti-arrhthymics requires careful consideration and can be difficult before thyroid function tests are known. Amiodarone use should be cautioned as it is associated with thyroid dysfunction and QT interval prolongation.There is no literature to guide thyroid hormone replacement in this disease. Aggressive replacement is associated with adverse cardiovascular effects. Our case showed a fine balance between the risk of rapid thyroid hormone replacement and the urgency to terminate VDs. Its administration should be carefully monitored amidst bridging strategies like electrical cardioversion and OP to manage life-threatening VDs.

Radiographic pulmonary description of bilateral multifocal patchy with ground-glass opacifications needs careful evaluation in the Era of SARS-CoV-2

In the COVID-19 Era, multilobe ground-glass opacities (GGOs) and septal thickening on chest Computed Tomography (CT) have been recognized as a radiological finding highly suggestive for SARS-CoV-2 pneumonia. However, these findings can be misleading. Here, we report about an 81-year-old woman, evaluated in the Emergency Room (ER) for a traumatic hip fracture, who, despite negative molecular testing on the nasopharyngeal sample for SARS-CoV-2, was admitted to a COVID-Unit because of flu-like symptoms with GGOs and interlobular septal thickening on the chest CT. During the hospital stay, focusing on the patient’s medical history, the interstitial lung disease was defined to be a chronic complication of long-term use of Amiodarone and rheumatoid arthritis. Therefore, especially during SARS global pandemic, CT pathological findings suggestive for interstitial pneumopathy should be critically analyzed considering patient history. They can reflect, in fact, other pathological conditions different from SARS-CoV-2 infection as other viral and non-viral infections or chronic inflammatory diseases.