Rate Control In Patients Research Articles

Resting Heart Rate and Associated Factors in Patients with Chronic Heart Failure in Cameroon: A Cross-sectional Study in Sub-saharan Africa

Introduction: Controlled heart rate has been associated with better prognosis in patients with chronic heart failure (CHF). Radial pulse palpation is a simple and useful method to evaluate heart rate control especially in limited resources setting such as sub-Saharan Africa. However, data on heart rate control in patients with heart failure are scarce in our context. Therefore, we sought to investigate heart rate control in patients followed for chronic heart failure in Cameroon. Methodology: We conducted a cross-sectional study from January to September 2017 in three specialized cardiology centers of Cameroon. We included patients with chronic heart failure, normal sinus rhythm without recent cardiac events. Resting heart rate was measured by pulse palpation after 05 minutes of rest, three (03) times over 60 seconds. An uncontrolled heart rate was defined as HR ≥70bpm. Results: Overall, 213 patients with a mean age of 63±15 years were included. About 64.8% of patients have a heart rate above recommended targets (≥70 bpm). There was no significant association between age, gender, NYHA stage, cardiovascular risk factors or current therapies and heart rate control. Conclusion: Uncontrolled heart rate is frequent in patients with chronic heart failure in our context with more than half presenting a resting heart rate above currently recommended values.

Rhythm Control Versus Rate Control in Patients With Atrial Fibrillation and Heart Failure With Preserved Ejection Fraction: Insights From Get With The Guidelines-Heart Failure.

BackgroundLimited data exist to guide treatment for patients with heart failure with preserved ejection fraction and atrial fibrillation, including the important decision regarding rate versus rhythm control.Methods and ResultsWe analyzed the Get With The Guidelines—Heart Failure (GWTG‐HF) registry linked to Medicare claims data from 2008 to 2014 to describe current treatments for rate versus rhythm control and subsequent outcomes in patients with heart failure with preserved ejection fraction and atrial fibrillation using inverse probability weighted analysis. Rhythm control was defined as use of an antiarrhythmic medication, cardioversion, or AF ablation or surgery. Rate control was defined as use of any combination of β‐blocker, calcium channel blocker, and digoxin without evidence of rhythm control. Among 15 682 fee‐for‐service Medicare patients, at the time of discharge, 1857 were treated with rhythm control and 13 825 with rate control, with minimal differences in baseline characteristics between groups. There was higher all‐cause death at 1 year in the rate control compared with the rhythm control group (37.5% and 30.8%, respectively, P<0.01). The lower 1‐year all‐cause death in the rhythm control group remained after risk adjustment (adjusted hazard ratio, 0.86; 95% CI, 0.75–0.98; P=0.02).ConclusionsRhythm control in patients aged 65 and older with heart failure with preserved ejection fraction and AF was associated with a lower risk of 1 year all‐cause mortality. Future prospective randomized studies are needed to explore this potential benefit.

Heightened risk of intensive rate control in patients with atrial fibrillation who are obese or have type 2 diabetes: A critical review and re-evaluation.

Atrial fibrillation (AF) is common in patients with obesity and diabetes; the arrhythmia (if long-standing) is typically managed by rate control and anticoagulation. However, the coexistence of these two metabolic disorders complicates therapeutic options for rate control. The likely pathogenesis of AF in these patients is an expansion of epicardial adipose tissue whose inflammation is transmitted to the left atrium causing electromechanical remodeling. However, this same process is also transmitted to the left ventricle (LV), impairing its distensibility and its ability to tolerate volume, leading to heart failure with preserved ejection fraction. Unfortunately, the latter diagnosis (although commonly present in patients with AF and a coexistent metabolic disorder) is often ignored. To achieve rate control, physicians prescribe intensive treatment with atrioventricular (AV) nodal-blocking drugs, often at doses that are titrated to blunt exercise as well as resting heart rate responses. However, strict rate control (target rate, <80/min) is associated with somewhat worse outcomes than lenient rate control (target rate, <110/min). Furthermore, any rate slowing that facilitates diastolic filling may aggravate filling pressures that are already disproportionately increased because the LV is stiff and overfilled as a result of cardiac inflammation. Rate slowing in AF with beta blockers may not achieve the benefit expected from the blockade of adrenergically mediated cardiotoxicity, and some AV nodal-blocking drugs (digoxin and dronedarone) can increase the risk of death in patients with AF. Finally, cardiac fibrosis in obesity and diabetes may affect the conduction system, which can predispose to serious bradyarrhythmias if patients are prescribed AV nodal-blocking drugs.

Safety and Efficacy Outcomes of Combined Leadless Pacemaker and Atrioventricular Nodal Ablation for Atrial Fibrillation Using a Single Femoral Puncture Approach

Atrioventricular nodal (AVN) ablation with permanent pacemaker (PPM) insertion is indicated for rate control in patients with atrial fibrillation (AF) who remain unresponsive to rate or rhythm control strategies. The leadless PPM (Micra Transcatheter Pacing System [TPS], Medtronic, Minneapolis, MN, USA) has the advantage of eliminating transvenous lead and pacemaker pocket-related complications. The aim of this case series was to determine the outcomes of patients who had undergone combined Micra TPS and AVN ablation, performed via a single femoral approach. A retrospective review was undertaken on patients who had undergone concurrent procedures, across two major hospitals in Perth, Western Australia. Procedural details were obtained from a cardiac devices database whilst patient demographics and clinical information were determined from medical records. Fourteen (14) patients underwent concurrent Micra TPS insertion and AVN ablation for symptomatic AF. The average age was 73±9.2 years, and 43% of them were males. There was no acute procedural/device related complication. Over a median follow-up duration of 9 months (36% completing 12-month follow-up), there was no incidence of device complications, in particular device dislodgement, malfunction or infection. One patient had a resuscitated ventricular fibrillation (VF) arrest event with new onset cardiomyopathy during follow-up and required Micra TPS removal. One patient died at 33 days post procedure from a non-cardiac cause. Device performance was excellent with stable sensing and pacing thresholds during the follow-up period. Our study has shown that combined leadless PPM (Micra TPS) implantation and AVN ablation using a single femoral approach is feasible, with good safety and efficacy profile in the short-medium term. Long-term data involving larger cohorts is needed to confirm the findings of this study and determine the clinical usefulness of this combined approach.

Relationships between maintenance of sinus rhythm and clinical outcomes in patients with heart failure with preserved ejection fraction and atrial fibrillation

BackgroundAlthough atrial fibrillation (AF) is associated with exacerbation of heart failure with preserved ejection fraction (HFpEF), the relationships between maintenance of sinus rhythm (SR) and clinical outcomes in HFpEF is unknown. We investigated whether maintenance of SR was associated with better prognosis compared with rate control in patients with concomitant HFpEF and AF. MethodsWe conducted a retrospective, observational study of 283 patients with HFpEF and AF. Of these, 107 patients achieved maintenance of SR by catheter ablation and/or antiarrhythmic drugs (rhythm control) and 176 were treated with rate control. The propensity score (PS) for each patient in both treatment groups was estimated, resulting in selectively matched subgroups of 79 patients each. All-cause death and a composite of cardiovascular death or hospitalization for heart failure (HF) were analyzed. ResultsDuring a median follow-up period of 24 months, all-cause mortality was comparable between groups; however, maintenance of SR was significantly associated with a lower incidence of the composite endpoint [adjusted hazard ratio (HR), 0.30; 95% confidence interval, 0.18–0.98; p=0.04] in the PS-matched cohort. The PS-adjusted multivariable analysis based on 283 pre-matched patients also revealed that rhythm control was associated with a lower rate of the composite endpoint (adjusted HR, 0.27; 95% CI, 0.12–0.61; p=0.002). Subgroup analyses suggested that rhythm control was consistently related to the composite endpoint across a wide spectrum of HFpEF patients. ConclusionsMaintenance of SR was associated with a lower risk of composite of cardiovascular death or hospitalization for HF in patients with HFpEF and AF. A randomized trial is necessary to confirm this result.

Should His Bundle Pacing Be Preferred over Cardiac Resynchronization Therapy Following Atrioventricular Junction Ablation?

Atrial fibrillation (AF) and heart failure (HF) are associated with high morbidity and mortality, which is particularly detrimental when patients develop rapid ventricular rates (RVR). Atrioventricular junction (AVJ) ablation with pacemaker implantation has been used as a method of achieving rate control in patients with incessant AF with RVR. Right ventricular only pacing is known to be harmful in the setting of HF. His bundle pacing (HBP) and biventricular (BiV) pacing both offer durable pacing solutions that offer more physiologic activation. This review describes the benefits and drawbacks of HBP and BiV pacing in HF patients after AVJ ablation.

Abstract TMP93: Comparative Occurrence of Ischemic Stroke with Rhythm versus Rate Control Strategy in a National Prospective Cohort of Atrial Fibrillation

Introduction: Comparative occurrence of ischemic stroke for rhythm versus rate control in patients with non-valvular atrial fibrillation (NVAF) has been still inconclusive. The aim of this study was to compare differences of ischemic stroke occurrence between the rhythm and rate control strategies in AF patients. Methods: The CODE-AF registry prospectively enrolled 6,280 consecutive patients who were treated for NVAF at 10 tertiary referral centers in South Korea. Of these, 2,513 (40.0%) NVAF patients (age, 67±10 years; male, 61.8%) were clinically followed up for 1-year and divided into rate control 1,233 (49.0%) and rhythm control 1280 (51.0%) group. Results: Those treated with the rhythm control group were younger, and had less proportions of underlying disease compared to those treated with the rate control strategy. After propensity score matching analysis, 1,800 of these patients was compared and analyzed between rate control and rhythm control group. Those treated with the rhythm control group were similar in the baseline characteristics including CHA 2 DS 2 -VASC score compared to those treated with the rate control strategy. The rate of oral anticoagulation, all bleeding, and hospitalization were also similarly between two groups. The incidence rate of ischemic stroke in the rhythm control group was significantly lower than rate control group (0.7 vs. 6.9 per 1000 person-years, p=0.011). Conclusion: In this national prospective AF cohort, the rhythm control strategy demonstrated beneficial effect to lower the risk of ischemic stroke during 1-year follow-up compared to rate control strategy.

Frequency of "on-label" use of intravenous diltiazem for rate control in patients with acute-onset atrial fibrillation or atrial flutter.

The study was designed to characterize "on-label" use of i.v. diltiazem in patients with acute atrial fibrillation or flutter (AFF). An IRB-approved, single-center, retrospective, observational design was used. Eligible patients had acute AFF with heart rate >120 bpm and received i.v. diltiazem from June 1, 2012, to June 30, 2014. The primary outcome was frequency of on-label use of i.v. diltiazem, defined as use of at least one FDA-approved weight-based bolus dose followed by an infusion, if appropriate, in the absence of contraindications. A total of 300 patients were screened; 97 patients were included for analysis. I.V. diltiazem was used on-label in only 14 patients (14%). Of the 96 patients who received an initial diltiazem bolus injection, the median dose was significantly higher in patients for whom the diltiazem dose was on-label, as follows: 17.5 mg (interquartile range [IQR]), 10-20 mg vs. 10.0 mg (IQR, 10-20 mg), p < 0.02). Twenty-nine patients (35%) in the off-label group had a therapeutic response to diltiazem alone compared with 8 patients (57%) in the on-label group (p = 0.11). More patients treated with off-label diltiazem bolus injection required additional rate control medications (41% vs. 7%, p < 0.04). In most patients, i.v. diltiazem was not used in accordance with FDA labeling. For most, i.v. diltiazem doses were lower than recommended and many of these patients required additional rate control medications to achieve a therapeutic response.

Catheter ablation for atrial fibrillation in heart failure with reduced ejection fraction: a systematic review and meta-analysis of randomized controlled trials

BackgroundPrevious randomized controlled trials (RCT)s showed similar outcomes in patients with atrial fibrillation (AF) and heart failure with reduced ejection fraction (HFrEF) treated with anti-arrhythmic drugs (AAD) compared to rate control therapy. We sought to evaluate whether catheter ablation is superior to medical therapy in patients with AF and HFrEF.MethodsWe searched electronic databases for all RCTs that compared catheter ablation and medical therapy (with or without use of AAD). We used random-effects models to summarize the studies. The primary end-point was all-cause mortality. Secondary outcomes included heart failure-related hospitalizations and change in left ventricular ejection fraction (LVEF).ResultsWe retrieved and summarized 7 randomized controlled trials, enrolling 856 patients (429 in the catheter ablation arm and 427 in the medical therapy arm). Compared with medical therapy (including use of AAD), AF catheter ablation was associated with a significant reduction in mortality (risk ratio 0.50; 95% confidence interval [CI]: 0.34 to 0.74; P = 0.0005) and heart failure-related hospitalizations (risk ratio 0.56; 95% CI: 0.44 to 0.71; P < 0.0001). Furthermore, catheter ablation led to significant improvements in LVEF (weighted mean difference, 7.48; 95% CI: 3.71 to 11.26; P < 0.0001).ConclusionsCompared to medical therapy, including use of AAD, catheter ablation for AF was associated with a significant reduction in mortality and heart failure-related hospitalizations as well as an improvement in LVEF in patients with HFrEF. Larger trials are needed to confirm whether rhythm control with ablation is superior to rate control in patients with AF and heart failure.

A study on prescribing pattern of drugs in patients with rheumatic heart disease at tertiary care hospital

Introduction: Rheumatic heart disease (RHD) is a common cardiac problem. Medical therapy is directed toward secondary prophylaxis and supportive treatment for heart failure (HF), rhythm disorder and anticoagulation to prevent thromboembolism. Drug utilization patterns thus provide a favorable feedback to physicians and help to modify treatment strategies.&#x0D; Materials and Methods: This is a cross sectional study on 140 patients with RHD who received care at Nobel Medical College Teaching Hospital from October 2017 to September 2018. A semi structured questionnaire was administered to record the demographic characteristics, co-morbid conditions and use of different drugs.&#x0D; Results: Mean age was 50.09 ± 10.99 years. RHD was more common in females (75.7%). Penicillin prophylaxis was prescribed for 38 (27.1%) patients. Out of which, 22.8% were on daily oral penicillin and 4.2% were receiving three weekly benzathine benzylpenicillin. Beta blockers were the most frequently used drug for heart rate control for patients (51.4%) with both atrial fibrillation (AF) and/or symptomatic mitral stenosis (MS). Digoxin was used in 10% and calcium channel blockers were used in 3.5% of patients who have AF. Different diuretics were used in 88.5% of patients with features of systemic or pulmonary congestion. Out of 20 cases of AF, eleven (55%) were receiving aspirin and nine (45%) were on oral anticoagulants. Out of nine patients receiving warfarin, only four (20%) had therapeutic international normalized ratio (INR).&#x0D; Conclusions: This study focuses on prescription pattern of drugs for different indications in patients with RHD. There is a need for improved use of secondary prophylaxis to prevent recurrence of RF and antithrombotic in patients with AF.

DERIVATION AND VALIDATION OF THE CONTINUE-ONE-TWO-HOLD PROTOCOL FOR OPTIMIZING PERI-CARDIOVERSION RATE CONTROL MEDICATIONS

Most patients with atrial fibrillation (AF) are prescribed rate control medications . There are no guidelines for adjustment of these medications prior to electrical cardioversion (DCCV). We sought to derive and validate a pre-procedural medication adjustment protocol that maintains peri-cardioversion rate control and avoids bradycardia, conversion pauses, need for pacing, and CPR after DCCV. Retrospectively derived and prospectively validated an algorithm in patients undergoing DCCV at our multidisciplinary AF clinic. Each patient taking an AV nodal blocker was given adjustment instructions based on their ECG heart rate two days before DCCV. Medication dosages were standardized based on dose equivalency tables (Table 1). The magnitude of dosage reduction was compared with peri-cardioversion heart rates, where rate control was considered adequate if the 30-minute pre-DCCV and five-minute post-DCCV heart rates were both within 50 to 100 bpm. In the derivation cohort, we assessed the effectiveness of all medication adjustment strategies and evaluated which strategy was effective for the highest proportion of patients from 2015 to 2017. This strategy was then prospectively evaluated as a protocol in the validation cohort for one year onwards. Patients with atrial flutter or pacemaker were excluded. A total of 71 patients were included in the derivation cohort (mean age 65.5 ± 10.3 years; 73% male). The strategy with the highest proportion of patients achieving adequate peri-cardioversion rate control was i) CONTINUE AV nodal blocker when two-day pre-DCCV heart rate ≥100 bpm, ii) reduce dose by ONE increment when 80 to 99 bpm, iii) reduce dose by TWO increments when 60 to 79 bpm, and iv) HOLD when <60 bpm. When this CONTINUE-ONE-TWO-HOLD protocol (Figure 1) was evaluated in the validation cohort of 48 consecutive patients (mean age 63.1 ± 10.1 years; 77% male), 37 (77%) patients achieved adequate peri-cardioversion rate control. Proportion of patients with post-procedural bradycardia was significantly reduced from 69% to 48% between cohorts (P=0.02). Of the 11 inadequate cases, four patients had pre-DCCV heart rates >100 bpm and 2 had post-DCCV heart rates <50 bpm, but these patients were already experiencing tachycardia and bradycardia respectively before medication adjustment. There were no conversion pauses ≥five seconds, need for pacing, or CPR post-procedure in patients following the CONTINUE-ONE-TWO-HOLD protocol in either cohort. The CONTINUE-ONE-TWO-HOLD protocol is a feasible and effective pre-procedural strategy of optimizing medications for peri-cardioversion rate control in patients with AF.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Functional status with rhythm- versus rate-control strategy for persistent atrial fibrillation.

Introduction Recent studies have shown that rhythm control does not provide additional benefit over rate control in terms of morbidity or mortality and is less cost effective in patients with atrial fibrillation (AF). It remains to be determined if any of the treatment strategies should be favored on the basis of the quality of life (QoL) or functional capacity. Objectives This HOT CAFE substudy was conducted to compare the functional status of patients with persistent AF assigned either to rate or rhythm control strategy. Patients and methods We enrolled 205 patients (mean [SD] age, 60.8 [11.2] years) with persistent AF who were randomly assigned either to rate or rhythm control strategies. The New York Heart Association (NYHA) functional classification, intensity of arrhythmia‑related symptoms, exercise tolerance, and QoL were analyzed. Results After a mean (SD) of 1.7 (0.4) years, the NYHA class and QoL improved in both groups. Both strategies lead to improvement in AF‑related symptoms. Treadmill test duration and maximal workload increased over time in both groups. In terms of NYHA class improvement, rhythm control was superior to rate control in patients with AF and hypertension (odds ratio [OR], 1.89; 95% CI, 0.98-3.65; P = 0.055) and in those with moderate HF (OR, 2.04; 95% CI, 1.03-4.06; P = 0.04). When success was considered as left ventricular function improvement, the rhythm‑control strategy also proved to be superior in patients with hypertension (OR, 2.64; 95% CI, 1.21-5.74; P = 0.01) and those with NYHA class II or III (OR, 4.27; 95% CI, 1.25-9.85; P <0.001). Conclusions Rate- and rhythm‑control strategies improved functional status in patients with persistent AF. However, rhythm control might be more appropriate for patients with AF and hypertension and those with moderate HF.

Should clinicians consider avoiding digoxin in patients with AF?

Use of digoxin in patients with atrial fibrillation (AF) was associated with an increased risk of death—specifically when serum concentrations were 1.2 ng/mL or higher or when treatment was newly initiated, according to results of a new analysis published in the Journal of the American College of Cardiology.1J Am Coll Cardiol. 2018; 71: 1063-1074Crossref PubMed Scopus (85) Google Scholar These results are concerning because current practice guidelines recommend use of digoxin for rate control in patients with AF, particularly those with heart failure. Therefore, clinicians must now take this new data into consideration and determine if digoxin is an optimal choice for this patient population. Lopes and colleagues conducted an analysis of data from patients enrolled in the ARISTOTLE (Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation) trial to determine the association between digoxin use and death. The researchers performed a post-hoc digoxin subgroup analysis of data from 17,897 patients, with 5,824 patients receiving digoxin and 12,073 not on this therapy at baseline, to determine the time to all-cause mortality, cardiovascular and noncardiovascular mortality, and sudden cardiac death. A propensity score–adjusted analysis was used to assess the association between digoxin use and mortality, and for new digoxin users during the trial versus propensity-matched control patients. In addition, patients with heart failure were assessed as a subgroup (n = 6,693), as was the effect of serum digoxin concentrations on outcomes. The researchers reported that baseline digoxin use was not associated with an increased risk of all-cause mortality, cardiovascular mortality, noncardiovascular-related death, sudden cardiac death, or heart failure hospitalization, although the rates of these events were all numerically higher in the digoxin group compared with no baseline digoxin use. No significant differences were observed in patients who had or did not have heart failure. In the 4,434 patients in which baseline serum digoxin concentrations were measured at baseline, patients with digoxin levels of 1.2 ng/mL or more did have a significant increase in the risk of death (adjusted hazard ratio 1.56 [95% CI 1.20–2.04]). They noted that after adjustment for potential confounders, baseline serum digoxin concentrations as a continuous variable exhibited a direct relationship with overall mortality. Specifically, for every 0.5 ng/mL increase in baseline serum digoxin concentrations, an increase in the risk of death was observed in the overall population. This was seen in patients with and without heart failure. Finally, for the analysis of new digoxin users in the trial compared with matched controls, the new users had a significantly higher total mortality (adjusted hazard ratio 1.78 [95% CI 1.37–2.31]). Again, these results were consistent, regardless of whether the patients had heart failure. Digoxin has been used for many years in patients with cardiac conditions, given its availability since the 1930s. The researchers pointed out that approximately one-third of patients with AF worldwide are treated with digoxin, and the 2016 AF guidelines continue to give digoxin a Class I recommendation for patients with a reduced or preserved left ventricular ejection fraction. The authors concluded, “In the absence of randomized trial data showing its efficacy and safety, digoxin should be used with caution and with monitoring of its serum concentration in patients with AF, and should preferably be avoided if symptoms can be alleviated with other treatments.” In an accompanying editorial, the author summarized digoxin’s long history and commented on the current results and potential confounders to the analysis.2J Am Coll Cardiol. 2018; 71: 1075-1077Crossref PubMed Scopus (3) Google Scholar Despite potential limitations, he wrote, “for the majority of patients with AF, there is no reason to believe that there is any benefit but rather possible or probable harm of digoxin compared with other atrioventricular nodal agents.”

Catheter ablation versus rate control in patients with atrial fibrillation and heart failure: A multicenter study.

Many trials have shown improvements in left ventricular function, exercise capacity, and quality of life after catheter ablation (CA) of atrial fibrillation (AF) in patients with heart failure (HF). We sought to evaluate the impact of CA on hard outcomes in a retrospective cohort study. AF patients with symptomatic HF from 3 hospitals were included. Our primary endpoint was major adverse cardiac events (MACEs), a composite of all-cause mortality, stroke, and unplanned hospitalization. In total, 90 patients underwent CA and 304 ones received rate control (RaC) were included. After a mean follow-up of 13.5 ± 5.3 months, 82.2% of patients in CA group got freedom from AF; all patients in RaC group remained in AF. CA group had a significant decreased risk of MACEs compared with RaC group (13.3% vs 29.3%, hazard ratio [HR] 0.51, 95% confidence interval [CI]: 0.32–0.82, P = .005). After propensity score matched for confounding factors, difference in MACEs remained significant between groups (13.3% vs 25.6%, HR 0.50, 95% CI: 0.26–0.98, P = .044). Multivariate regression analysis also indicated that CA was significantly associated with a lower risk of MACEs in overall cohort (HR 0.486, 95% CI: 0.253–0.933, P = .030) and in propensity-matched cohort (HR 0.482, 95% CI: 0.235–0.985, P = .045). Besides, age and NYHA class were associated with an increased risk of MACEs. In conclusion, the present study demonstrated that CA for AF in HF patients could reduce the risk of MACEs in a mid-term follow-up. Thus, CA may be a reasonable option for this population.

Achieving ventricular rate control in patients taking chronic beta-blocker therapy

Study Objective.The objective of this study is to evaluate the difference in response to ventricular rate control with intravenous (IV) metoprolol compared to IV diltiazem in patients taking chronic beta-blocker therapy who present to the emergency department (ED) in atrial fibrillation (AF) with rapid ventricular rate (RVR). MethodsThis was a single-center, retrospective study of adult patients taking chronic oral metoprolol. Chronic metoprolol therapy was defined as patients prescribed and taking oral metoprolol within 5days of study inclusion. Rate control was defined as either a decrease in ventricular rate<100bpm or <120bpm if the decrease was at least 20% from the presenting heart rate. ResultsA total of 332 patients were included, with 16 patients in the IV diltiazem group and 316 patients in the IV metoprolol group. In the diltiazem arm, 68.8% of patients achieved successful rate control compared to 42.4% of patients in the metoprolol group (p=0.067). Treatment with IV metoprolol resulted in more hospital admissions (58% vs. 6.25% with diltiazem, p<0.001). Treatment with diltiazem was associated with a greater incidence of bradycardia compared to IV metoprolol (13% vs. 0%, p=0.002). ConclusionsThe use of IV diltiazem was associated with a higher rate of successful response to rate control compared to IV metoprolol in patients in AF with RVR on chronic beta-blocker therapy, however the difference between groups was not statistically significant.

Clinical predictors of challenging atrioventricular node ablation procedure for rate control in patients with atrial fibrillation

IntroductionAtrioventricular node (AVN) ablation is usually a simple procedure but may sometimes be challenging. We aimed at identifying pre-procedural clinical predictors of challenging AVN ablation. MethodsPatients referred for AVN ablation from 2009 to 2015 were retrospectively included. Baseline clinical data, procedural variables and outcomes of AVN ablation were collected. A “challenging procedure” was defined 1) total radiofrequency delivery to get persistent AVN block≥400s, 2) need for left-sided arterial approach or 3) failure to obtain AVN ablation. Results200 patients were included (71±10years). A total of 37 (18.5%) patients had “challenging” procedures (including 9 failures, 4.5%), while 163 (81.5%) had “non-challenging” ablations. In multivariable analysis, male sex (Odds ratio (OR)=4.66, 95% confidence interval (CI): 1.74–12.46), body mass index (BMI, OR=1.08 per 1kg/m2, 95%CI 1.01–1.16), operator experience (OR=0.40, 95%CI 0.17–0.94), and moderate-to-severe tricuspid regurgitation (TR, OR=3.65, 95%CI 1.63–8.15) were significant predictors of “challenging” ablations. The proportion as a function of number of predictors was analyzed (from 0 to 4, including male sex, operator inexperience, a BMI>23.5kg/m2 and moderate-to-severe TR). There was a gradual increase in the risk of “challenging” procedure with the number of predictors by patient (No predictor: 0%; 1 predictor: 6.3%; 2 predictors: 16.5%; 3 predictors: 32.5%; 4 predictors: 77.8%). ConclusionsOperator experience, male sex, higher BMI and the degree of TR were independent predictors of “challenging” AVN ablation procedure. The risk increases with the number of predictors by patient.

A review of rate control in atrial fibrillation, and the rationale and protocol for the RATE-AF trial

Background and objectiveAtrial fibrillation (AF) is common and causes impaired quality of life, an increased risk of stroke and death as well as frequent hospital admissions. The majority of patients...

P826Rhythm versus rate control in patients with atrial fibrillation combined with left ventricular systolic dysfunction: a meta-analysis

P826Rhythm versus rate control in patients with atrial fibrillation combined with left ventricular systolic dysfunction: a meta-analysis

Effect of esmolol on hemodynamics and clinical outcomes in patients with septic shock

To evaluate the effect of heart rate control with esmolol on hemodynamics, inflammatory cytokines and clinical outcomes in patients with septic shock. A prospective randomized controlled trial was conducted. The patients with septic shock admitted to Department of Critical Care Medicine of China-Japan Friendship Hospital from August 2014 to October 2016 were enrolled. After 24 hours of resuscitation and other therapy, they were randomly divided into two groups by sealed envelope. The patients in experimental group was treated with continuous intravenous esmolol infusion for 24 hours, initial dose was 0.05 mg×kg-1×h-1, and was titrated to decrease the heart rate by 20% as compared with the value at the time of enrollment or below 95 bpm, while isotonic saline was given to control group through intravenous line at 3 mL/h for 24 hours. The differences in hemodynamic parameters at 0, 1, 4, 8, 12, 24 and 48 hours, as well as serum inflammatory cytokines and blood lactate (Lac) at 0, 12, and 24 hours, 28-day mortality were compared between the two groups. Seventy-six septic shock patients were admitted during the study, 12 were excluded for suspicious acute myocardial infraction (AMI) or acute left heart failure or for the history of chronic obstructive pulmonary disease (COPD), 4 were quitted the study for being unable to tolerate the lowest dose of esmolol, giving up treatment, or death within 24 hours. Finally, 60 patients completed the study, 30 patients in experimental group, and 30 in control group. There were no differences in gender, age, acute physiology and chronic health evaluation II (APACHE II) score and infection source between two groups, indicating the general data between the two groups were balanced and comparable. The decrease in heart rate was more markedly in experimental group than that of control group at 1, 4, 48 hours after esmolol administration (bpm: 97.4±16.5 vs. 110.9±19.6, 95.2±15.3 vs. 105.1±17.9, 86.4±12.1 vs. 97.2±22.6, all P < 0.05), cardiac index (CI) at 8, 24, 48 hours was significantly increased (mL×s-1×m-2: 57.2±13.5 vs. 46.5±11.0, 57.7±15.7 vs. 48.7±14.7, 61.2±16.5 vs. 51.5±14.7, all P < 0.05), and stroke volume index (SVI) at 4, 8, 24 hours was significantly increased (mL/m2: 34.1±6.9 vs. 29.0±8.7, 35.0±6.1 vs. 28.8±9.6, 38.3±10.1 vs. 31.9±13.2, all P < 0.05). Interleukin-1β (IL-1β) at 24 hours in experimental group was significantly higher than that of control group (ng/L: 0.15±0.06 vs. 0.13±0.05, P < 0.01). There were no differences in mean arterial pressure (MAP), Lac, white blood cell (WBC), IL-6, IL-10, and tumor necrosis factor-α (TNF-α) between the two groups, and no difference in 28-day mortality between experimental group and control group was found (30.0% vs. 36.7%,χ 2 = 0.300, P = 0.583). It is efficient and safe to use esmolol for heart rate control in patients with septic shock after resuscitation. Esmolol can improve cardiac performance without affecting blood pressure and Lac, but has no effect on inflammatory cytokines and prognosis.

693 - Clinical predictors of challenging atrioventricular node ablation for rate control in patients with atrial fibrillation

693 - Clinical predictors of challenging atrioventricular node ablation for rate control in patients with atrial fibrillation