Frequency Of Paroxysmal Atrial Fibrillation Research Articles

Promising areas of renal denervation application

The review systematizes the latest data on renal denervation (RDN) potential in the treatment of pathologies associated with sympathetic hyperactivation. Despite the controversial results obtained at the beginning of its clinical application, the antihypertensive effect and safety of RDN were subsequently convincingly proven in a number of large randomized studies, which is reflected in current clinical guidelines. Study of RDN effect on the course of resistant hypertension, positive effects on other conditions associated with sympathetic hyperactivation were also identified. In particular, on the course of chronic kidney disease, chronic heart failure, as well as on the decrease of the frequency of paroxysmal atrial fibrillation and ventricular arrhythmia episodes, which ultimately may help for wider method implementation in routine clinical practice. For a long time, many studies have been aimed at identifying the effect of RDN on carbohydrate metabolism and improving the diabetes control. However, despite this, this issue still remains open and the possible future prospects for using RDN to improve the control and prognosis of diabetes in patients with this pathology are currently unclear.

Quantification of atrial cardiomyopathy disease severity by electroanatomic voltage mapping and cardiac magnetic resonance imaging

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): The authors acknowledge the support of the British Heart Foundation Centre for Research Excellence Award III (RE/18/5/34216). SEW is supported by the British Heart Foundation (FS/20/26/34952). Background Atrial late gadolinium enhancement (Atrial-LGE) and electroanatomic voltage mapping (Atrial-EAVM) quantify the anatomical and functional extent of atrial cardiomyopathy. Prior studies provide conflicting information relating to the level of agreement between these modalities for the assessment of atrial cardiomyopathy disease severity. Purpose We aimed to explore the relationships between, and outcomes from, these contrasting measures of atrial cardiomyopathy disease severity in patients with atrial fibrillation undergoing ablation. Methods Atrial-LGE and Atrial-EAVM was performed in patients undergoing first-time ablation for atrial fibrillation. Atrial cardiomyopathy disease severities were quantified using CEMRGApp and OpenEP[1] for Atrial-LGE and Atrial-EAVM, respectively. Correlations between modalities, their relationships with clinical features and their relationships with arrhythmia recurrence were assessed. Results Atrial-LGE and Atrial-EAVM quantification of atrial cardiomyopathy disease was performed In 123 atrial fibrillation patients (60±10 years, paroxysmal (n=58), persistent (n=65)) (Figure 1, panel A). Atrial-EAVM was moderately correlated with Atrial-LGE (r=0.41, P<0.001), with a mean fibrosis burden of 32.4±21.8% (Figure 1, panel B). The strength of the correlation was dependent on the thresholds chosen to define abnormal atrial tissue. The thresholds yielding the strongest correlation were IIR >0.97 (for Atrial-LGE) and voltage <1.17 mV (for Atrial-EAVM). Using these thresholds, agreement between modalities was strongest amongst patients in the highest tertile of fibrosis burden (mean of differences 5.9% (95% CI -30.4% to 42%)). Fibrosis burden was greater for Atrial-LGE than Atrial-EAVM (46.4±7.48% versus 13.7±7.13%, P<0.005) for patients in the lowest tertile of fibrosis burden (Figure 1, panel C). These patients were younger, had smaller atria and a greater frequency of paroxysmal atrial fibrillation than patients in the higher tertiles of fibrosis burden (Figure 2). Atrial cardiomyopathy disease severity was greater in patients with arrhythmia recurrence for both Atrial-EAVM (39.3±23.1% versus 28.5±20.2%, P=0.010) and Atrial-LGE (58.69±11.60 versus 53.33±9.63, P=0.011). In multivariable analysis, Atrial-LGE (OR 1.04 (95% CI 1.00-1.09), P=0.037) was independently associated with arrhythmia recurrence. Conclusions We demonstrate for the first time that the level of agreement between Atrial-EAVM and Atrial-LGE is dependent on the level of atrial cardiomyopathy disease severity. The functional consequences of atrial cardiomyopathy are most evident in patients with the highest anatomical extent of disease. This explains variations in prior studies and will inform future clinical applications of these techniques.

P375The impact of hypothyroidism on hospitalization frequency and cost-effectiveness among patients with atrial fibrillation

Abstract Background thyroid disorders are a well-known fact of high risk developing of atrial fibrillation (AF). While it is established that hyperthyroidism increases AF incidence, data of the effect of hypothyroidism on AF and heart failure is contradictory. Purpose to examine effect of untreated hypothyroidism on frequency of paroxysmal AF, state of the permanent AF and chronic heart failure (CHF) which is the main cause of high rate repeated hospitalizations. Methods This retrospective study was conducted among patients (pts) with AF, who were admitted to the hospital from June 2018 till June 2019. They were divided into 2 groups: 1-st group – pts with AF and hypothyroidism and 2-nd group – euthyroid pts (by using hormonal replacement therapy) with AF. All pts were surveyed about their age, gender, medical history, therapy, number and reasons for hospitalization for the past 12 months. Reference range of TSH was 0,4-4,0 mU/L. Results A total of 75 pts, 57,3% (n = 43) women, 41,3% (n = 31) men, mean age 70,5 years (SD 6,7) were enrolled in the research. 1-st group consist of 66,7% (n = 24) women, 33,3% (n = 12) men, mean age 70,3 years (SD 6,8), paroxysmal AF 38,9% (n = 14), permanent AF 61,1% (n = 22), first diagnosed hypothyroidism during hospitalization 61,1% (n = 22), mean TSH 9,3 mU/L (SD 3,7), 33,3 % (n = 12) were re-admitted 2 and more times, mean hospitalization duration 7,1 day (SD 1,1). 2-nd group consist of 51,3% (n = 20) women, 48,7% (n = 19) men, mean age 70,6 years (SD 10,6), paroxysmal AF 35,9% (n = 14), permanent AF 64,1% (n = 25), mean TSH 2,1 mU/L (SD 1,12), 17,9 % (n = 7) were hospitalized 2 times, mean hospitalization duration 5,9 day (SD 0,9). Reasons for hospitalization in the 1-st group were pharmacological cardioversion (n = 8) and decompensated CHF (n = 4), in the 2-nd group were pharmacological cardioversion (n = 2) and decompensated CHF (n = 5). Average cost of whole hospitalization in the 1-st group was 252$ (SD 8,1), in the 2-st group – 221 $ (SD 5,2). As an example, average cost for patient with CHF and AF per month in Ukraine is 45 $. Conclusion Tight control of thyroid function ensures optimal dose of hormonal replacement therapy and decrease number of repeated hospitalizations and average hospitalization duration in patients with AF and hypothyroidism. As a result, we receive improving of cost-effectiveness of hospitalization AF pts.

Adult Monozygotic Twins With Hypertrophic Cardiomyopathy and Identical Disease Expression and Clinical Course

A unique clinical circumstance involving middle-aged male identical twins with obstructive hypertrophic cardiomyopathy (HC) is reported. The concordance of morphologic (i.e., phenotype) findings and clinical course between the 2 patients is remarkable, including timing of the onset and progression of heart failure due to left ventricular outflow tract obstruction, frequency of paroxysmal atrial fibrillation and beneficial response to surgical myectomy and Cox-Maze IV procedure (performed 14 days apart). Histopathology of resected ventricular septal muscle showed identical hallmarks of HC including myocyte disorganization, small vessel disease, and myocardial fibrosis. A missense variant of the CRYAB gene was identified as potentially relevant to the pathogenesis of HC in the twins. Taken together, these observations support a powerful genetic determinant for the morphologic and clinical expression of HC, with little or no environmental influence.

Contribution of Holter ECG in the etiologic diagnosis of the ischemic stroke in Brazzaville (Congo)

To determine the prevalence of the rhythmic disorders during ischemic stroke, and to identify the predictive factors of paroxysmal atrial fibrillation (PAF). It was about a cross-sectional study, descriptive and analytical, conducted to Brazzaville between January 2012 and December 2016. It is related to a consecutive series of 267 patients victims of a transient ischemic attack ( n = 17) or ischemic stroke ( n = 250), documented by cerebral tomodensitometry or brain MRI. All these patients profited from a recording 24 h Holter ECG, carried out within the framework of etiologic research. The principal recorded rhythmic anomalies were indexed, and the logistic regression allowed the identification of the predictive factors of PAF. They were 164 men (61.4%) and 103 women (38.6%), old on average of 60.2 ± 12.1 years. The main cardiovascular risk factors were hypertension (80.1%), diabetes (13.5%), and tobacco use (6.7%). The 24 h Holter ECG, normal in 216 cases (81%), was pathological in 51 cases (19%). The principal recorded anomalies consisted into ventricular ectopic beats ( n = 32), PAF ( n = 7), supraventricular ectopic beats ( n = 5), non-sustained ventricular tachycardia ( n = 4), sustained ventricular tachycardia ( n = 2), and type 2 atrioventricular block ( n = 1). The frequency of PAF was 2.6%. In bivariate analysis, it was not noted correlation between PAF and sex ( P = 0.55), hypertension ( P = 0.42), diabetes ( P = 0.64), and tobacco use ( P = 0.61). In multivariate analysis, only the age was the predictive factor of PAF during ischemic stroke ( P = 0.0134). It comes out from this preliminary study that the emboligenous arrhythmias are relatively rare during ischemic stroke in Brazzaville. PAF, though little attends, remains primarily correlated at the age. Its systematic research at the old subjects contributes to improve the assumption of responsibility.

PT246 Frequency of Paroxysmal Atrial Fibrillation in Acute Arterial Occlusion Patients With Sinus Rhythm and Its Relationship With Atrial Size

PT246 Frequency of Paroxysmal Atrial Fibrillation in Acute Arterial Occlusion Patients With Sinus Rhythm and Its Relationship With Atrial Size

Efficacy of atrial substrate modification based on dominant frequency of paroxysmal atrial fibrillation

BackgroundThe endpoint of ablation procedures is suggested to be non-inducibility of paroxysmal atrial fibrillation (PAF). However, the prognosis of induced AF/atrial tachycardia (AT) after pulmonary vein isolation (PVI) in PAF patients remains unclear. MethodsA total of 122 PAF patients were divided into the following 3 groups: Group 1, 79 without AF/AT induced after PVI; Group 2, 21 with AF/AT induced or sustained after PVI, and followed by a high-dominant frequency (DF) and continuous complex fractionated atrial electrogram (CFAE) site ablation and, if necessary, linear ablation; and Group 3, 22 with external cardioversion of AF/AT induced or sustained after PVI. High-DF (DF≥8Hz) and continuous CFAE (fractionated intervals≤50ms) sites were targeted. The ablation endpoint was non-inducibility of PAF. ResultsIn Group 2, AF terminated in 2 patients with a high-DF and continuous CFAE site ablation. In 4 patients, AF induced after cardioversion did not terminate with left atrium linear ablation, and required additional cardioversion. Common atrial flutter in 2 patients terminated with cavotricuspid isthmus ablation. An AT terminated with a roofline ablation. Finally, no AF/AT could be induced in any of the patients in Group 2 after all the procedures. The cumulative freedom from AF/AT recurrence without antiarrhythmic drugs in Groups 1 and 2 was significantly greater than that in Group 3 after 1 procedure during 12 months of follow-up (90% and 91% vs. 64%, Log-rank test P=0.001 and P=0.033, respectively). ConclusionsAtrial substrate ablation may improve the clinical outcome after ablation in patients after PVI with residual arrhythmia inducibility.

Beneficial effects of losartan for prevention of paroxysmal atrial fibrillation in patients with sick sinus syndrome: analysis with memory function of pacemaker.

Renin-angiotensin system (RAS) inhibitors may be useful in preventing the occurrence of paroxysmal atrial fibrillation (PAF). However, evaluation of such effect is difficult because many PAF episodes are asymptomatic and not all episodes are detected by intermittent electrocardiographic monitoring. A pacemaker has been developed with dedicated functions for AF detection and electrocardiogram storage. Accordingly, we examined the effect of losartan, an angiotensin receptor blocker on PAF occurrence using this new modality. We enrolled 70 consecutive patients who had undergone dual-chamber pacemaker implantation for sick sinus syndrome. Finally, 62 patients participated in the study. Thirty patients were randomized to the losartan group (mean 43 ± 12 mg/day) and 32 patients to the control group. They were followed up for 3 months. The frequency, the maximum duration and the total duration of PAF recorded by the stored electrocardiograms for the last 1 month during the observation period and study period were compared between the two groups. The change in the frequency of PAF from the observation period in the losartan and control groups was similar (-35 ± 25 vs. -67 ± 62 times; NS). However, the change in the maximum duration and the total duration of PAF was significantly shorter in the losartan group than in the control group (-493 ± 158 vs. -10 ± 69 min; p < 0.05, and -4007 ± 2334 vs. 1119 ± 714 min; p < 0.05, respectively). Losartan suppressed the maximum duration and the total duration of PAF in patients with sick sinus syndrome without hemodynamic changes. This is the first study to show the effect of a renin-angiotensin system inhibitor on the secondary prevention of PAF using the dedicated functions of a pacemaker for PAF detection and electrocardiogram storage.

Newly diagnosed atrial fibrillation linked to wake-up stroke and TIA

Based on the higher frequency of paroxysmal atrial fibrillation during night and early morning hours, we sought to analyze the association between newly diagnosed atrial fibrillation and wake-up ischemic cerebrovascular events. We prospectively assessed every acute ischemic stroke and TIA patient admitted to our hospital between 2008 and 2011. We used a forward step-by-step multiple logistic regression analysis to assess the relationship between newly diagnosed atrial fibrillation and wake-up ischemic stroke or TIA, after adjusting for significant covariates. The study population comprised 356 patients, 274 (77.0%) with a diagnosis of acute ischemic stroke and 82 (23.0%) with TIA. A total of 41 (11.5%) of these events occurred during night sleep. A newly diagnosed atrial fibrillation was detected in 27 patients of 272 without known atrial fibrillation (9.9%). We found an independent association between newly diagnosed atrial fibrillation and wake-up ischemic stroke and TIA (odds ratio 3.6, 95% confidence interval 1.2-7.7, p = 0.019). The odds of detecting a newly diagnosed atrial fibrillation were 3-fold higher among wake-up cerebrovascular events than among non-wake-up events. The significance of this independent association between newly diagnosed atrial fibrillation and wake-up ischemic stroke and TIA and the role of other comorbidities should be investigated in future studies.

A simple score for predicting paroxysmal atrial fibrillation in acute ischemic stroke

Background and purposeOur aim in this study was to investigate factors associated with paroxysmal atrial fibrillation (PAF) in acute stroke patients and to develop a risk score to predict the presence of PAF. MethodsWe retrospectively enrolled patients with acute ischemic stroke within 24h of onset between June 2006 and April 2008. Patients with sustained AF were excluded. Patients were divided into two groups according to the presence of PAF: the PAF group or the non-PAF group. The clinical factors associated with PAF were investigated. Furthermore, we devised a new risk score to predict the presence of PAF. ResultsThere were 215 patients enrolled. The PAF group had 32 (14.9%) patients. Multivariate logistic regression analysis demonstrated that NIHSS score≥8 (OR, 4.2; 1.38–12.88), left atrial size≥3.8cm (OR, 4.8; 1.65–13.66), mitral valvular disease (OR, 7.5; 2.17–25.90), and plasma BNP level≥144pg/ml (OR, 12.8; 4.12–40.00) were independent factors associated with PAF. We developed a risk score from these variables (total score 0 to 5): NIHSS score≥8 (1 point); left atrial size≥3.8cm (1 point); mitral valvular disease (1 point); and BNP level≥144pg/ml (2 points). The frequency of PAF was 0% with a score of 0, 4% with a score of 1, 14% with a score of 2, 26% with a score of 3, 50% with a score of 4 and 100% with a score of 5 ConclusionOur simple score can predict the presence of PAF during hospitalization in acute ischemic stroke.

Impact of the Preprocedural Frequency of Paroxysmal Atrial Fibrillation on the Clinical Outcome after Catheter Ablation

Pulmonary vein antral isolation (PVAI) is a recommended treatment for symptomatic drug-refractory paroxysmal atrial fibrillation (PAF). PAF naturally progresses toward persistent AF with an increase in the frequency and duration of AF. The objective of this study was to evaluate whether the preprocedural AF frequency had an impact on the AF recurrence after PVAI in patients with symptomatic PAF. A total of 362 consecutive patients (61.0 ± 9.8 years; 274 males) with drug-refractory PAF who underwent PVAI were included. The preprocedural frequency of PAF was daily, weekly, monthly, and yearly in 145 (40.1%), 112 (30.9%), 90 (24.9%), and 15 (4.1%) patients, respectively. There were no significant differences in any of the preprocedural variables between the four groups, except for the number of ineffective antiarrhythmic drugs (AADs). PVAI was successfully performed in all patients. At 12 months after the initial procedure, 63.5% of the entire group of patients were free of AF recurrences without any AADs, respectively. A Cox regression multivariate analysis of the variables including the AF frequency, age, gender, duration of AF, presence of hypertension or structural heart disease, left atrial size, left ventricular ejection fraction, and body mass index demonstrated that the AF frequency was not an independent predictor of AF recurrence after a single ablation procedure (P = 0.194). This study demonstrated that the preprocedural AF frequency did not predict AF recurrence after PVAI in patients with PAF. From the clinical point of view, an additional AF classification based on the preprocedural AF frequency might not be valuable in patients undergoing PVAI.

Detection of Asymptomatic Paroxysmal Atrial Fibrillation with the Trans-Telephonic Electrocardiograph System

Paroxysmal atrial fibrillation (PAF) carries an equally high annual stroke rate as chronic atrial fibrillation (AF). Furthermore, the frequency and duration of PAF are thought to be associated with stroke risk. In this pilot study, a trans-telephonic electrocardiograph (TTE) monitoring system was used to detect asymptomatic PAF and to study the relationship between ischemic stroke and the frequency of PAF. Between December 2004 and April 2006, 70 patients enrolled in the TTE monitoring program. Patients either transmitted electrocardiograms (ECGs) daily or upon experiencing cardiac symptoms. Of the 70 patients included, 25 were diagnosed with PAF. In total, 11% (855/7,768) of the recordings were diagnosed as PAF, yet less than 2% of total calls collected and less than 17% of all the calls with PAF were associated with obvious symptoms. Four patients developed five ischemic strokes resulting in a calculated annual stroke rate of 0.56%. Patients with stroke had more episodes of AF (56.5±106.3 versus 6.7±85.9, p=0.685) and symptomatic AF episodes (9.8±17.5 versus 4.9±8.1, p=0.381) than the patients who did not have a stroke, but the differences were not statistically significant because of the low numbers of patients and episodes. Most PAF episodes were asymptomatic, and the TTE system could easily detect these episodes. Furthermore, these four patients tended to have more episodes of PAF and more symptomatic attacks of PAF than patients who did not have a stroke.

Pulmonary vein isolation to treat paroxysmal atrial fibrillation: conventional versus multi-electrode radiofrequency ablation

For patients with symptomatic atrial fibrillation (AF), a curvilinear multi-electrode ablation (MEA) catheter has been reported to be successful to achieve pulmonary vein (PV) isolation. However, this approach has not been compared prospectively with conventional PV isolation (CPVI) using a standard circular mapping catheter and 3D electro-anatomic mapping. In this prospective non-randomized study, we compared the efficacy of these two techniques. Of 185 consecutive patients, age 54.6 ± 10.1 years, with symptomatic paroxysmal AF (PAF), 96 patients underwent PV isolation by CPVI and 89 patients underwent MEA to isolate the PVs. CPVI was performed by encircling the left- and right-sided PVs. During MEA, the PV ablation catheter (Medtronic, USA) was used to isolate PVs with duty-cycled radiofrequency energy. The mean procedure time was 171.73 ± 52.87 min for CPVI and 133.25 ± 37.99 min for MEA, respectively (P < 0.001). The mean fluoroscopy time was 31.07 ± 14.97 for CPVI and 30.07 ± 11.45 min for MEA (P = 0.651). At 12 months, 80% of patients who underwent CPVI and 82% of patients who underwent MEA were free of symptomatic PAF off antiarrhythmic drug therapy (P = 0.989). Among the variables of age, gender, duration and frequency of PAF, left ventricular ejection fraction, left atrial size, structural heart disease, and the ablation technique, only an increased left atrial size was an independent predictor of recurrent PAF. Left atrial flutter occurred after CPVI in two patients and after MEA ablation in three patients. In patients undergoing catheter ablation for PAF, MEA and CPVI proved equally efficacious.

Echocardiographic predictors of frequency of paroxysmal atrial fibrillation (AF) and its progression to persistent AF in hypertensive patients with paroxysmal AF: Results from the Japanese Rhythm Management Trial II for Atrial Fibrillation (J-RHYTHM II Study)

Little is known about associations among echocardiographic variables, frequency of atrial fibrillation (AF), and progression from paroxysmal to persistent AF. The purpose of this study was to investigate echocardiographic predictors of frequency of paroxysmal AF and its progression to persistent AF in hypertensive patients with paroxysmal AF. We used data from 286 patients with paroxysmal AF and hypertension in the Japanese Rhythm Management Trial II for Atrial Fibrillation (J-RHYTHM II Study). Echocardiographic evaluation was performed at baseline. Endpoints were (1) percent of AF days measured daily by transtelephonic monitoring over 1 year and (2) development of persistent AF, defined as incidence of AF lasting for longer than 7 days and/or need for electrical cardioversion. Univariate and multivariate linear regression analysis was performed to evaluate the association between echocardiographic variables and percent of AF days. Cox proportional hazards analysis was used to examine the association between echocardiographic variables and development of persistent AF. Among echocardiographic variables, increased left atrial dimension (LAD) was associated with more AF days and development of persistent AF: a 10-mm increase in LAD was associated with a 6.5% increase in AF days (95% confidence interval 2.7%-10.3%) and an 84% increased risk of developing persistent AF (hazard ratio 1.84, 95% confidence interval 1.28-2.67). These associations remained significant after adjustment for age, sex, and other potential confounding factors. Increased LAD is associated with more AF days and progression from paroxysmal to persistent AF in patients with paroxysmal AF and hypertension. Increased LAD may be a good echocardiographic predictor of AF frequency and progression.

Randomized trial of angiotensin II-receptor blocker vs. dihydropiridine calcium channel blocker in the treatment of paroxysmal atrial fibrillation with hypertension (J-RHYTHM II Study)

Atrial fibrillation (AF) is a common arrhythmia frequently associated with hypertension. This study was designed to test the hypothesis that lowering blood pressure by angiotensin II-receptor blockers (ARB) has more beneficial effects than by conventional calcium channel blockers (CCB) on the frequency of paroxysmal AF with hypertension. The Japanese Rhythm Management Trial II for Atrial Fibrillation (J-RHYTHM II study) is an open-label randomized comparison between an ARB (candesartan) and a CCB (amlodipine) in the treatment of paroxysmal AF associated with hypertension. Using daily transtelephonic monitoring, we examined asymptomatic and symptomatic paroxysmal AF episodes during a maximum 1 year treatment. The primary endpoint was the difference in AF frequency between the pre-treatment period and the final month of the follow-up. The secondary endpoints included cardiovascular events, development of persistent AF, left atrial dimension, and quality-of-life (QOL). The study enrolled 318 patients (66 years, male/female 219/99, 158 in the ARB group and 160 in the CCB group) treated at 48 sites throughout Japan. At baseline, the frequency of AF episodes (days/month) was 3.8 ± 5.0 in the ARB group vs. 4.8 ± 6.3 in the CCB group (not significant). During the follow-up, blood pressure was significantly lower in the CCB group than in the ARB group (P < 0.001). The AF frequency decreased similarly in both groups, and there was no significant difference in the primary endpoint between the two groups. There were no significant differences between the two groups in the development of persistent AF, changes in left atrial dimension, occurrence of cardiovascular events, or changes in QOL. In patients with paroxysmal AF and hypertension, treatment of hypertension by candesartan did not have an advantage over amlodipine in the reduction in the frequency of paroxysmal AF (umin CTR C000000427).

Detecting paroxysmal atrial fibrillation after stroke

An ischemic stroke results from blockage of an artery in the brain. There are many causes of an ischemic stroke. Determining the cause guides treatment to prevent future strokes. One common cause of stroke is an abnormal heart rhythm called atrial fibrillation (AF). AF causes as many as 1 in 5 strokes. AF is diagnosed by recording the heart rhythm with an EKG. To prevent stroke from AF, a medicine called warfarin is used. However, AF can come and go, and a patient may not feel anything. When this happens, AF is called paroxysmal AF (PAF). If a stroke patient has PAF and it is not detected, the risk of a future stroke increases. Recently, doctors have used technology to monitor stroke patients outside of the hospital. In a study in this issue of Neurology ®, researchers looked at the frequency of PAF after stroke using a device called a transtelephonic EKG monitor (TTM).1 TTM is a pocket-sized device with dry electrodes that stick to the chest wall. When a patient presses a button, the device will record a 30-second EKG. The patient can send the EKG to a receiving center by dialing the center and holding the device up to the phone. The authors reviewed the records of patients admitted to their stroke center. All patients had been diagnosed with a stroke or TIA. A TIA is like a stroke but the symptoms go away quickly. All patients had been tested to determine the cause of their stroke or TIA. This testing included a brain MRI and a …

αB-Crystallin mutation in dilated cardiomyopathies: Low prevalence in a consecutive series of 200 unrelated probands

A unique clinical circumstance involving middle-aged male identical twins with obstructive hypertrophic cardiomyopathy (HC) is reported. The concordance of morphologic (i.e., phenotype) findings and clinical course between the 2 patients is remarkable, including timing of the onset and progression of heart failure due to left ventricular outflow tract obstruction, frequency of paroxysmal atrial fibrillation and beneficial response to surgical myectomy and Cox-Maze IV procedure (performed 14 days apart). Histopathology of resected ventricular septal muscle showed identical hallmarks of HC including myocyte disorganization, small vessel disease, and myocardial fibrosis. A missense variant of the CRYAB gene was identified as potentially relevant to the pathogenesis of HC in the twins. Taken together, these observations support a powerful genetic determinant for the morphologic and clinical expression of HC, with little or no environmental influence.

In-hospital complications of acute myocardial infarction in hypertensive subjects

Recent studies have shown a worse in-hospital outcome in hypertensive than in normotensive patients with acute myocardial infarction (AMI), which has been attributed to more frequent complications. The aim of this study was to investigate clinical patterns, risk factors, and in-hospital complications in hypertensive and normotensive patients with AMI. Of 4994 consecutive patients with AMI admitted to the intensive care unit, hypertensive patients with first infarction (n = 915; mean age 68.8 +/- 11.4 years) and 915 gender- and age-matched normotensive subjects were retrospectively studied. In the univariate analysis, hypertensive subjects presented more frequently non-Q-wave infarction and ST segment depression than did normotensive subjects, even if hypertensive subjects more frequently had diabetes, dyslipidemia, renal failure, peripheral artery disease, cerebrovascular disease, and chronic obstructive pulmonary disease (P < .01 for all). Hypertensive subjects less frequently presented with cardiogenic shock (4.0% v 11.6%; P < .01), atrioventricular block (4.9% v 7.4%; P = .02), ventricular fibrillation (2.2% v 3.7%; P = .04), cardiac rupture (0.1% v 0.9%; P = .02), and ventricular thrombosis (0.5% v 1.5%; P < .03), and a higher frequency of paroxysmal atrial fibrillation (9.2 v 5.6%; P < .01). Mortality was significantly higher in patients with anterior versus inferior infarction, for all normotensive and hypertensive subjects (13.7% v 7.1%; P < .001), but mortality was remarkably higher in normotensive than in hypertensive subjects (17.8% v 6.2%; P < .001), regardless of infarction site (anterior, 11.2% v 4.1%; P < .001; inferior, 4.4% v 1.9%; P < .001). Hypertensive subjects with first AMI have a better in-hospital outcome than age- and gender-matched normotensive subjects, perhaps due to a less severe extension of the infarction area or to a different pathophysiologic mechanism.

Monitoring the progression of the atrial electrical remodeling in patients with paroxysmal atrial fibrillation.

It is important to clarify how electrical remodeling develops in clinical cases of paroxysmal atrial fibrillation (PAF), because it has been suggested that this electrophysiological phenomenon promotes an increase in the frequency of PAF. In the present study, the f-f interval during PAF was analyzed from the ambulatory ECG recordings of 21 patients with PAF (total PAF duration >2/24 h with normal atrial size) to monitor the atrial electrophysiological changes. The patients were clinically followed-up for 6 months without any antiarrhythmic drugs. Before and after the follow-up period 24-h Holter monitoring was carried out and the duration of both the PAF and the f-f intervals during the PAF episode were evaluated. In selected cases, the atrial effective refractory period (ERP) was evaluated in an electrophysiologic study before and after the follow-up period. The total PAF duration was prolonged from 187+/-50 to 223+/-79 min (p=0.034) and the f-f interval was shortened from 0.14+/-0.03 to 0.12+/-0.02 ms (p=0.003). There was an inverse relationship between the changes in total PAF duration and f-f interval (p=0.027). The ERP was shortened from 214+/-15 to 194+/-5 ms (n=5, p=0.025) and there was a direct correlation between the changes in ERP and f-f interval (p=0.048). In clinical cases, the prolongation of the PAF was related to the shortening of the f-f interval during the PAF episodes and to the shortening of the atrial ERP. Electrical remodeling plays a role in promoting the development of the atrial fibrillation in patients with PAF.

Atrial septal pacing in the prevention of paroxysmal atrial fibrillation refractory to antiarrhythmic drugs

Background: Early reports have shown that pacing the atria at a site or sites other than the right atrial appendage may prevent atrial fibrillation. Our centre has shown that pacing the atrial septum reduces the duration of atrial activation which is an important determinant of predisposition to paroxysmal atrial fibrillation. Ablation of the atrioventricular (AV) node together with implantation of a pacemaker can control symptoms due to paroxysmal atrial fibrillation in patients in whom antiarrhythmic drugs have failed. The aim of this study was to investigate the effect of atrial septal pacing on patients who were candidates for AV node ablation. Methods: Atrial septal pacemakers were implanted in 28 patients with symptomatic, paroxysmal atrial fibrillation that had been unresponsive to two or more antiarrhythmic drugs. Pacing was not indicated for any reason other than the anticipated need to proceed to AV node ablation. Change in symptoms was assessed by quality of life questionnaires and recurrence of atrial fibrillation was measured objectively by pacemaker interrogation and ambulatory electrocardiographic monitoring. Results: Atrial septal pacing in combination with an antiarrhythmic agent resulted in a substantial subjective improvement in 19 patients (68%). Objective data confirmed similar findings; atrial fibrillation was completely or markedly reduced in 17 patients (60%). Six patients experienced a modest improvement in symptoms; in only four patients was it necessary to proceed to AV node ablation. Conclusions: Atrial septal pacing together with continuance of previously ineffective antiarrhythmic therapy may prevent or markedly reduce the frequency of paroxysmal atrial fibrillation and obviate the need to ablate the AV node.