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Stuart J Connolly

Publications and source records attributed to Stuart J Connolly.

At least 19 recordsLinked to original sources
PubMed2007

Prognostic value of blood pressure measured during hospitalization after acute myocardial infarction: an insight from survival trials.

BACKGROUND: The prognostic value of blood pressure measured during hospitalization after acute myocardial infarction (MI) has not been investigated, particularly with regard to arrhythmic death. METHODS: A total of 3311 placebo patients (2612 men, median age 64 years; range 23-92) from the EMIAT, CAMIAT, SWORD, TRACE and DIAMOND-MI studies with left ventricular ejection fraction less than 40% or asymptomatic ventricular arrhythmia surviving more than 45 days after MI were pooled. Systolic and diastolic blood pressures and pulse pressures were measured soon after MI (median 6 days, range 0-53 days). Mortality up to 2 years was examined using Cox regression. RESULTS: At the 2-year follow-up, after adjustment for age, sex, smoking, previous MI, hypertension, heart rate, New York Heart Association functional class, baseline treatments, study effect and diastolic blood pressure, reduced systolic blood pressure measured during hospitalization after acute MI significantly increased the risk of all-cause mortality [hazard ratio (HR) for 10% increase in systolic blood pressure 0.80, 95% confidence interval (CI) 0.71-0.90; P < 0.001] and arrhythmic mortality (HR 0.73, 95% CI 0.61-0.86; P = 0.001). Reduced diastolic blood pressure significantly increased the risk of all-cause mortality (HR 0.87, 95% CI 0.77-0.98; P = 0.02) and arrhythmic mortality (HR 0.80, 95% CI 0.68-0.93; P = 0.005). CONCLUSION: In post-MI patients with left ventricular ejection fraction less than 40% or asymptomatic ventricular arrhythmia, reduced blood pressure measured during hospitalization after MI significantly predicts all-cause mortality and arrhythmic mortality, and can be reliably used to identify patients who are at risk of dying after MI.

Adult↗
PubMed2006

Effect of amiodarone and sotalol on ventricular defibrillation threshold: the optimal pharmacological therapy in cardioverter defibrillator patients (OPTIC) trial.

BACKGROUND: Many patients with implanted cardioverter defibrillators (ICDs) receive adjunctive antiarrhythmic drug therapy, most commonly amiodarone or sotalol. The effects of these drugs on defibrillation energy requirements have not been previously assessed in a randomized controlled trial. METHODS AND RESULTS: The Optimal Pharmacological Therapy in Cardioverter Defibrillator Patients (OPTIC) trial was a randomized clinical trial evaluating the efficacy of amiodarone plus beta-blocker and sotalol versus beta-blocker alone for reduction of ICD shocks. Within OPTIC, a prospectively designed substudy evaluated the effects of the 3 treatment arms on defibrillation energy requirements. Defibrillation thresholds (DFTs) were measured (binary step-down protocol) at baseline and again after 8 to 12 weeks of therapy in 94 patients, of whom 29 were randomized to receive beta-blocker therapy (control group), 35 to amiodarone plus beta-blocker, and 30 to sotalol. In the control group, the mean DFT decreased from 8.77+/-5.15 J at baseline to 7.13+/-3.43 J (P=0.027); in the amiodarone group, DFT increased from 8.53+/-4.29 to 9.82+/-5.84 J (P=0.091). In the sotalol group, DFT decreased from 8.09+/-4.81 to 7.20+/-5.30 J (P=0.21). DFT changes in the beta-blocker and the amiodarone group were significantly different (P=0.006). In all patients, adequate safety margins for defibrillation were maintained. No clinical variable predicted baseline DFT or changes in DFT on therapy. CONCLUSIONS: Although amiodarone increased DFT, the effect size with modern ICD systems is very small. Therefore, DFT reassessment after the institution of antiarrhythmic drug therapy with amiodarone or sotalol is not routinely required.

Adrenergic beta-Antagonists↗
PubMed2006

Cardiovascular outcomes with atrial-based pacing compared with ventricular pacing: meta-analysis of randomized trials, using individual patient data.

BACKGROUND: Several randomized trials have compared atrial-based (dual-chamber or atrial) pacing with ventricular pacing in patients with bradycardia. No trial has shown a mortality reduction, and only 1 small trial suggested a reduction in stroke. The goal of this review was to determine whether atrial-based pacing prevents major cardiovascular events. METHODS AND RESULTS: A systematic review was performed of publications since 1980. For inclusion, trials had to compare an atrial-based with a ventricular-based pacing mode; use a randomized, controlled, parallel design; and have data on mortality, stroke, heart failure, or atrial fibrillation. Individual patient data were obtained from 5 of the 8 identified studies, representing 95% of patients in the 8 trials, and a total of 35 000 patient-years of follow-up. There was no significant heterogeneity among the results of the individual trials. There was no significant reduction in mortality (hazard ratio [HR], 0.95; 95% confidence interval [CI], 0.87 to 1.03; P=0.19) or heart failure (HR, 0.89; 95% CI, 0.77 to 1.03; P=0.15) with atrial-based pacing. There was a significant reduction in atrial fibrillation (HR, 0.80; 95% CI, 0.72 to 0.89; P=0.00003) and a reduction in stroke that was of borderline significance (HR, 0.81; 95% CI, 0.67 to 0.99; P=0.035). There was no convincing evidence that any patient subgroup received special benefit from atrial-based pacing. CONCLUSIONS: Compared with ventricular pacing, the use of atrial-based pacing does not improve survival or reduce heart failure or cardiovascular death. However, atrial-based pacing reduces the incidence of atrial fibrillation and may modestly reduce stroke.

Arrhythmias, Cardiac↗
PubMed2006

Efficacy of azimilide for the maintenance of sinus rhythm in patients with paroxysmal atrial fibrillation in the presence and absence of structural heart disease.

Azimilide hydrochloride (azimilide), an investigational antiarrhythmic drug, has shown variable efficacy in preventing atrial fibrillation (AF). This study was designed to assess its efficacy in maintaining sinus rhythm in patients with paroxysmal AF and heart disease. Patients with symptomatic paroxysmal AF were screened for 1 month by transtelephonic monitoring. After recording 1 episode of AF in the screening period, they were randomized to receive azimilide 125 mg or placebo once daily. Patients were stratified by the presence or absence of congestive heart failure or coronary heart disease (CHF/CHD). A maximum of 220 patients without CHF/CHD were randomized, with the remainder having CHF/CHD. Patients with CHF/CHD were monitored for 3 days during loading. The primary efficacy analysis was the time to the first symptomatic recurrence of AF in the CHF/CHD group. Secondary analyses were the time to the first recurrence in the entire population and the time to the first recurrence in those with significant structural heart disease. The median time to recurrence of AF in the CHF/CHD group was 10 days in the 2 treatment arms. Nonsignificant trends were seen toward efficacy of azimilide in the CHF/CHD group (hazard ratio 1.28, 95% confidence interval 0.97 to 1.70, p=0.087), structural heart disease group (hazard ratio 1.22, 95% confidence interval 0.96 to 1.56, p=0.11), and overall group (hazard ratio 1.22, 95% confidence interval 1.00 to 1.49, p=0.053). No patient died. In conclusion, azimilide showed a nonsignificant trend toward efficacy in maintaining sinus rhythm in patients with AF.

Anti-Arrhythmia Agents↗
PubMed2006

Stroke prevention in patients with atrial fibrillation: the diagnosis and management of hypertension by specialists.

BACKGROUND: Hypertension is common in patients with atrial fibrillation (AF) and is an important cause of stroke. OBJECTIVES: To determine how effectively hypertension is managed among specialist-treated outpatients with AF. METHODS: Investigators reviewed the charts of patients with a diagnosis of AF cared for by medical specialists to determine the change in blood pressure, patterns of antihypertensive drug use and the role of the specialist in the management of hypertension. RESULTS: Of 209 patients with AF, 118 had a history of hypertension or an office blood pressure greater than 140/90 mmHg. Blood pressure was measured at 73% of all visits. Hypertension was identified as an important problem in 57% of patients and antihypertensive therapy was either initiated or suggested in 77%. One year after the initial specialist visit, systolic blood pressure was significantly lower (140+/-20 mmHg at one year versus 148+/-23 mmHg initially; P=0.015); however, there was no change in diastolic blood pressure (80+/-12 mmHg at one year versus 81+/-16 mmHg initially; P=0.602) and only 50% of patients had a blood pressure less than 140/90 mmHg. In contrast, the percentage of patients receiving warfarin increased from 46% to 78% (P=0.0001). CONCLUSIONS: In patients treated by specialists for AF, systolic blood pressure is significantly reduced during follow-up; however, 50% of patients continue to have suboptimal blood pressure control. In many patients, hypertension is not identified as an important comorbid illness and antihypertensive therapy is neither recommended nor initiated by the specialist. Greater specialist involvement in the identification and treatment of hypertension in patients with AF could lead to an important, additional reduction in stroke.

Aged↗
PubMed2006

Comparison of beta-blockers, amiodarone plus beta-blockers, or sotalol for prevention of shocks from implantable cardioverter defibrillators: the OPTIC Study: a randomized trial.

CONTEXT: Implantable cardioverter defibrillator (ICD) therapy is effective but is associated with high-voltage shocks that are painful. OBJECTIVE: To determine whether amiodarone plus beta-blocker or sotalol are better than beta-blocker alone for prevention of ICD shocks. DESIGN, SETTING, AND PATIENTS: A randomized controlled trial with blinded adjudication of events of 412 patients from 39 outpatient ICD clinical centers located in Canada, Germany, United States, England, Sweden, and Austria, conducted from January 13, 2001, to September 28, 2004. Patients were eligible if they had received an ICD within 21 days for inducible or spontaneously occurring ventricular tachycardia or fibrillation. INTERVENTION: Patients were randomized to treatment for 1 year with amiodarone plus beta-blocker, sotalol alone, or beta-blocker alone. MAIN OUTCOME MEASURE: Primary outcome was ICD shock for any reason. RESULTS: Shocks occurred in 41 patients (38.5%) assigned to beta-blocker alone, 26 (24.3%) assigned to sotalol, and 12 (10.3%) assigned to amiodarone plus beta-blocker. A reduction in the risk of shock was observed with use of either amiodarone plus beta-blocker or sotalol vs beta-blocker alone (hazard ratio [HR], 0.44; 95% confidence interval [CI], 0.28-0.68; P<.001). Amiodarone plus beta-blocker significantly reduced the risk of shock compared with beta-blocker alone (HR, 0.27; 95% CI, 0.14-0.52; P<.001) and sotalol (HR, 0.43; 95% CI, 0.22-0.85; P = .02). There was a trend for sotalol to reduce shocks compared with beta-blocker alone (HR, 0.61; 95% CI, 0.37-1.01; P = .055). The rates of study drug discontinuation at 1 year were 18.2% for amiodarone, 23.5% for sotalol, and 5.3% for beta-blocker alone. Adverse pulmonary and thyroid events and symptomatic bradycardia were more common among patients randomized to amiodarone. CONCLUSIONS: Despite use of advanced ICD technology and treatment with a beta-blocker, shocks occur commonly in the first year after ICD implant. Amiodarone plus beta-blocker is effective for preventing these shocks and is more effective than sotalol but has an increased risk of drug-related adverse effects.Clinical Trials Registration ClinicalTrials.gov Identifier: NCT00257959.

Adrenergic beta-Antagonists↗
PubMed2006

ASymptomatic atrial fibrillation and Stroke Evaluation in pacemaker patients and the atrial fibrillation Reduction atrial pacing Trial (ASSERT).

Asymptomatic atrial fibrillation (AF) is common and may have the same prognostic implications as symptomatic AF. Among patients receiving dual-chamber pacemakers, it is now possible to quantify asymptomatic AF accurately. Most of these episodes are of short duration, often lasting only seconds to minutes and are called atrial high-rate episodes (AHRE) to distinguish them from the longer episodes of overt AF. To understand properly the clinical importance of asymptomatic AF, a large study of pacemaker patients without clinically overt AF is required. ASSERT is a multicenter, cohort follow-up, and single-blinded randomized trial in elderly hypertensive patients with a pacemaker recently implanted for sinus or atrioventricular node disease. The goals of this trial are to evaluate whether the detection of AHRE with pacemaker telemetry predicts an increased risk of stroke and other vascular events and to evaluate if atrial overdrive pacing reduces symptomatic AF. ASSERT is evaluating the hypothesis that among pacemaker patients without a previous history of AF, detection of AHRE predicts an increased risk of stroke and systemic embolism. The second hypothesis to be tested is that overdrive atrial pacing will reduce the risk of symptomatic AF in pacemaker patients without a previous history of AF. Finally, a 400-patient substudy will use the noninvasive testing capabilities of the patients' pacemaker to evaluate changes in atrial electrophysiology over 2 years. This substudy will determine if atrial electrical remodeling is detectable in pacemaker patients and if it is associated with the development of AF.

Aged↗
PubMed2006

Risks and benefits of combining aspirin with anticoagulant therapy in patients with atrial fibrillation: an exploratory analysis of stroke prevention using an oral thrombin inhibitor in atrial fibrillation (SPORTIF) trials.

BACKGROUND: Aspirin is used in combination with anticoagulant therapy in patients with atrial fibrillation (AF), but evidence of additional efficacy is not available. METHODS: We compared ischemic events and bleeding in the SPORTIF III and IV randomized trials of anticoagulation with warfarin (international normalized ratio 2-3) or fixed-dose ximelagatran. Low-dose aspirin (<100 mg/d) was allowed based on prevailing guidelines. RESULTS: The 14% of patients receiving aspirin more often had diabetes (27.5% vs 23%, P < .01), coronary artery disease (69% vs 41%, P < .01), previous stroke or transient ischemic attack (26% vs 20%, P < .01), and left ventricular dysfunction (41% vs 36%, P < .01). Addition of aspirin to either warfarin or ximelagatran was associated with no reduction in stroke or systemic embolism. Major bleeding occurred significantly more often with aspirin plus warfarin (3.9% per year) than with warfarin alone (2.3% per year, P < .01), aspirin plus ximelagatran (2.0% per year), or ximelagatran alone (1.9% per year). The rate of myocardial infarction with aspirin and warfarin (0.6% per year) was not significantly different from that with ximelagatran alone (1.0% per year), warfarin alone (1.0% per year), or aspirin and ximelagatran (1.4% per year). CONCLUSIONS: Aspirin combined with anticoagulant therapy was associated with no reduction in stroke, systemic embolism, or myocardial infarction in patients with AF. Aspirin combined with warfarin was associated with an incremental rate of major bleeding of 1.6% per year. No increased major bleeding occurred with aspirin and ximelagatran. These results suggest that the risks associated with addition of aspirin to anticoagulation in patients with AF outweigh the benefit.

Aged↗
PubMed2006

Age of first faint in patients with vasovagal syncope.

INTRODUCTION: Understanding whether vasovagal syncope is a lifelong disorder might shed insight into its physiology and affect management strategies. Accordingly, we determined the age of the first syncopal spell in adult patients who sought care for syncope. METHODS AND RESULTS: Patients were 42 +/- 18 years old with 64% women. They had had a median 8 syncope spells (interquartile range [IQR]: 4, 20) with a median frequency of 1.0 syncopal spells per year. The range of syncopal spells was 1-3,375, and the range of duration of history of syncope was 0.003-70 years. The first syncopal spell occurred at ages 0-81 in a skewed distribution, with a marked mode age of 13 years, a median age of 18 years (IQR 12, 37), and a mean age of 26 +/- 20 years. The distributions were statistically indistinguishable across countries (P = 0.50), among Canadian regions (P = 0.69), and between the studies (P = 0.49). The same modal values were seen in males and females, and in patients <40 and > or =40 years old. However, patients > or =40 years had median ages of onset older than patients <40 years (36 +/- 23 vs 17 +/- 8 years). Patients had a recalled history of syncopal spells of median duration of 10 years (IQR: 2, 23), with a range of 0.003-70 years. An age of onset <44 years was 86% accurate for vasovagal syncope. CONCLUSION: The most common age at which vasovagal syncope first presents is 13 years, and patients remain at risk of syncope for many years. Lifelong coping strategies may be desirable.

Adolescent↗
PubMed2005

Prevention of atrial fibrillation with angiotensin-converting enzyme inhibitors and angiotensin receptor blockers: a meta-analysis.

OBJECTIVES: This study was designed to identify all randomized clinical trial data evaluating angiotensin-converting enzyme inhibitors or angiotensin receptor blockers for the prevention of atrial fibrillation (AF), to estimate the magnitude of this effect and to identify patient subgroups most likely to benefit. BACKGROUND: Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) reduce morbidity and mortality in patients with heart failure, vascular disease, and hypertension. Several reports suggest that they may also prevent the development of AF. METHODS: A systematic review of the literature was performed to identify all reports of the effect of ACEIs or ARBs on the development of AF. Eligible studies had to be randomized, controlled, parallel-design human trials of an ACEI or ARB that collected data on the development of AF. RESULTS: A total of 11 studies, which included 56,308 patients, were identified: 4 in heart failure, 3 in hypertension, 2 in patients following cardioversion for AF, and 2 in patients following myocardial infarction. Overall, ACEIs and ARBs reduced the relative risk of AF by 28% (95% confidence interval [CI] 15% to 40%, p = 0.0002). Reduction in AF was similar between the two classes of drugs (ACEI: 28%, p = 0.01; ARB: 29%, p = 0.00002) and was greatest in patients with heart failure (relative risk reduction [RRR] = 44%, p = 0.007). Overall, there was no significant reduction in AF in patients with hypertension (RRR = 12%, p = 0.4), although one trial found a significant 29% reduction in patients with left ventricular (LV) hypertrophy. In patients following cardioversion, there appears to be a large effect (48% RRR), but the confidence limits are wide (95% CI 21% to 65%). CONCLUSIONS: Both ACEIs and ARBs appear to be effective in the prevention of AF. This benefit appears to be limited to patients with systolic left ventricular dysfunction or LV hypertrophy. The use of these drugs following cardioversion appears promising but requires further study.

Angiotensin Receptor Antagonists↗
PubMed2005

Temporal trends on the risk of arrhythmic vs. non-arrhythmic deaths in high-risk patients after myocardial infarction: a combined analysis from multicentre trials.

AIMS: An understanding of the temporal trends on the risks of arrhythmic death (AD) vs. non-arrhythmic deaths (NAD) after myocardial infarction (MI) is crucial in deciding the optimal timing for risk stratification and treatment window for prophylactic antiarrhythmic treatment. However, contemporary data on such information is lacking. METHODS AND RESULTS: Individual patient data were pooled from the placebo arms of EMIAT, CAMIAT, SWORD, TRACE, and DIAMOND-MI who had a recent MI and left ventricular ejection fraction (LVEF) <40% or frequent ventricular premature beats (VPBs). Temporal trends were investigated for all studies from day 45 after acute myocardial infarction (AMI) to account for different recruitment periods between trials, and then from the onset of MI for TRACE and DIAMOND-MI that recruited patients within 2 weeks after MI. In total, 3104 patients (median age 65, range: 23-92; 2471 males) were pooled from all five studies, with a total of 487 deaths at 2-year follow-up; 220 deaths were ADs and 172 were NADs. The risks of both AD and NAD were highest in the first 6 months but the risk of AD was consistently higher than that of NAD throughout the 2-year period [rate of death/100 person-year at risk (AD/NAD): 8.09/6.07 (45 days to 6 months), 4.07/3.35 (>6-12 months), 4.34/3.60 (>12-18 months), 3.76/2.77 (>18-24 months)]. There were significant interactions between the temporal trends of mortalities and gender (P=0.03) and history of hypertension (P=0.04). A similar trend was observed when mortality was measured from time of onset of MI from the combined TRACE and DIAMOND-MI dataset. CONCLUSION: Our study provided the first contemporary evidence that in high-risk post-MI patients with LVEF <40% or frequent VPBs, the risk of AD was higher than that of NAD for up to 2 years although in female patients, they became increasingly more likely to die from NAD after 6 months. Therefore, risk stratification of post-MI patient at high risk of AD remains a worthwhile exercise. However, the risks of AD (and NAD) were highest in the first 6 months after AMI and level-off thereafter, suggesting that the optimal window period for risk stratification for implantable cardioverter defibrillator after AMI is in the first 6 months.

Adult↗
PubMed2005

Prognostic impact of demographic factors and clinical features on the mode of death in high-risk patients after myocardial infarction--a combined analysis from multicenter trials.

BACKGROUND: Contemporary information is lacking on the effect of demographic features and clinical features on the specific mode of mortality after myocardial infarction (MI) in the thrombolytic era. HYPOTHESIS: The aims of this study were (1) to examine the risk and trend of a different mode of mortality (i.e., all-cause, arrhythmic, and nonarrhythmic cardiac mortality) in high-risk patients post MI with reduced left ventricular ejection fraction (LVEF) or ventricular arrhythmias; and (2) to assess the predictive value of demographic and clinical variables in the prediction of specific modes of death in high-risk patients post MI in the thrombolytic era. METHODS: In all, 3,431 patients receiving placebo (2,700 men, median age 64 +/- 11 years) from the EMIAT, CAMIAT, SWORD, TRACE, and DIAMOND-MI studies, with LVEF < 40% or ventricular arrhythmia were pooled. Risk factors for mortality among patients surviving > or = 45 days after MI up to 2 years were examined using Cox regression. Short-term survival (from onset of MI to Day 44 after MI) was also examined for TRACE and DIAMOND-MI, in which patients were recruited within 2 weeks of MI. RESULTS: After adjustment for treatment and study effects, age, previous MI/angina, increased heart rate, and higher New York Heart Association functional class increased the risk of all-cause, arrhythmic, and cardiac mortality. Male gender, history of hypertension, low baseline systolic blood pressure, and Q wave were predictive of all-cause and arrhythmic mortality, whereas diabetes was only predictive of all-cause mortality. Smoking habit and atrial fibrillation had no prognostic value. Similar parameters were also predictive of short-term mortality, but not identical. CONCLUSIONS: Our study has shown that in high-risk patients post MI, who have been preselected using LVEF or frequent ventricular premature beats, demographic and clinical features are powerful predictors of mortality in the thrombolytic era. We propose that demographic and clinical factors should be considered when designing risk stratification or survival studies, or when identifying high-risk patients for prophylactic implantable cardiodefibrillator therapy.

Aged↗
PubMed2005

Progression to chronic atrial fibrillation after the initial diagnosis of paroxysmal atrial fibrillation: results from the Canadian Registry of Atrial Fibrillation.

BACKGROUND: After its initial diagnosis, atrial fibrillation (AF) may progress from paroxysmal to chronic AF (CAF). The rate of progression and risk factors for progression are not clearly defined. METHODS: The Canadian Registry of Atrial Fibrillation (CARAF) enrolled patients from 6 Canadian cities at the time of their first electrocardiographic diagnosis of AF. Comprehensive clinical and echocardiographic data were collected and patients were followed annually, carefully documenting clinical outcomes, recurrence of paroxysmal AF, and progression to CAF. Baseline clinical, electrocardiographic, and echocardiographic variables were evaluated by univariate Cox proportionate hazards analysis. A stepwise approach was used to model the association between echocardiographic and clinical variables with progression to CAF. RESULTS: A total of 757 patients with a baseline diagnosis of paroxysmal AF were evaluated. Median follow-up was 8.0 years (range 2 days to 11.1 years). The probability of progression to CAF by 1 year was 8.6% and thereafter there was a slow but steady progression to 24.7% by 5 years. By 5 years, the probability of documented recurrence of any AF (chronic or paroxysmal) was 63.2%. Increasing age, significant aortic stenosis or mitral regurgitation, left atrial enlargement, and diagnosis of cardiomyopathy were independently associated with progression to CAF. A more rapid heart rate during AF was associated with decreased risk of progression. CONCLUSIONS: After the initial diagnosis of paroxysmal AF, there is a slow but steady progression to CAF. Baseline echocardiographic variables, age, cardiomyopathy, and heart rate were independently associated with progression to CAF.

Adolescent↗
PubMed2005

Left Atrial Appendage Occlusion Study (LAAOS): results of a randomized controlled pilot study of left atrial appendage occlusion during coronary bypass surgery in patients at risk for stroke.

AIM: This pilot study assessed the safety and efficacy of left atrial appendage (LAA) occlusion, performed at the time of coronary artery bypass grafting (CABG). METHODS AND RESULTS: At the time of CABG, 77 patients with risk factors for stroke were randomized to LAA occlusion or control. The LAA was occluded using sutures or a stapling device. Completeness of occlusion was assessed with transesophageal echocardiography. There were no significant differences in cardiopulmonary bypass duration, perioperative heart failure, atrial fibrillation, or bleeding between the 2 groups. During surgery, there were 9 appendage tears, all of which were repaired easily with sutures. Among patients having a postoperative transesophageal echocardiography, complete occlusion of the LAA was achieved in 45% (5/11) of cases using sutures and in 72% (24/33) using a stapler, P = .14. The rate of LAA occlusion by individual surgeons increased from 43% (9/21) to 87% (20/23) after performing 4 cases (P = .0001). After a mean follow-up of 13 +/- 7 months, 2.6% of patients had thromboembolic events. CONCLUSIONS: LAA occlusion at the time of CABG is safe. The rate of complete occlusion improves, to acceptable levels, with increased experience and the use of a stapling device. A large trial is needed to determine if LAA occlusion prevents stroke.

Aged↗
PubMed2005

Cost-effectiveness of physiologic pacing: results of the Canadian Health Economic Assessment of Physiologic Pacing.

OBJECTIVES: The purpose of this study was to determine the cost-effectiveness of physiologic pacemakers. BACKGROUND: The Canadian Trial of Physiologic Pacing (CTOPP) was a large randomized trial that evaluated the efficacy of physiologic pacing compared with ventricular pacing. CTOPP also included a prospective cost-effectiveness substudy. METHODS: Resource usage and costs were collected from a subset of 472 patients (of 1,094) who received a physiologic pacemaker and 586 (of 1,474) who received a ventricular pacemaker. Costs included initial pacemaker implantation and all health care follow-up costs over a follow-up of 5.2 years. Costs are reported in 2004 Canadian dollars (1 Canadian dollar = 0.76 US dollars), with adjustments for censoring. Incremental cost-effectiveness was estimated as the ratio of the difference (treatment-control) in mean cost to the difference in life expectancy (mean survival), with costs and effects discounted at 3% per year. RESULTS: Over a mean follow-up of 3.1 years, physiologic pacing was associated with a gain of 0.01 life-years. This benefit increases to 0.25 life-years in the subgroup of patients with an intrinsic (unpaced) heart rate < or =60 bpm. Physiologic pacing was more expensive than ventricular (16,833 Canadian dollars vs 13,857 US dollars), largely because of the increased cost of dual-chamber devices. Among all substudy patients, the incremental cost-effectiveness of physiologic pacing is 297,600 Canadian dollars per life-year gained; however, this value falls to 16,343 Canadian dollars in patients with an intrinsic heart rate >60. CONCLUSIONS: In the short term, a strategy of routine implantation of physiologic pacemakers is not cost-effective by currently accepted standards. The selective use of these devices in patients likely to be pacemaker dependent appears to be cost-effective. Further studies with longer follow-up and which consider the benefit of reducing nonfatal cardiac events would be valuable.

Arrhythmias, Cardiac↗
PubMed2005

Role of the renin-angiotensin-aldosterone system in atrial fibrillation and cardiac remodeling.

PURPOSE OF REVIEW: This review summarizes recent clinical trial evidence showing a reduction in the development and recurrence of atrial fibrillation with angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor-blocking agents (ARBs). It then explores the possible mechanisms for this effect based on current animal models and limited human study. RECENT FINDINGS: Post hoc analyses of trials in patients with heart failure, hypertension, or myocardial infarction have observed reductions in atrial fibrillation among patients treated with ACE inhibitors or ARBs. Recent studies of these agents in animal models of atrial fibrillation suggest that they may prevent atrial fibrillation by reversing the cardiac structural and electrical changes, known as cardiac remodeling, that lead to the development of atrial fibrillation. This concept is also supported by two prospective studies showing that ACE inhibitors and ARBs prevent the recurrence of atrial fibrillation after electrical cardioversion. SUMMARY: Inhibition of the renin-angiotensin-aldosterone system is a novel concept for the treatment of atrial fibrillation that may target the underlying substrate of atrial fibrillation. Further human research is required to determine whether ACE inhibitors and ARBs prevent atrial fibrillation, and if so, whether this is a result of blood pressure lowering alone or a specific effect of these agents. Ongoing research will establish whether ACE inhibitors or ARBs have specific benefits in patients with atrial fibrillation.

Angiotensin Receptor Antagonists↗
PubMed2005

Therapies for the prevention of stroke and other vascular events in atrial fibrillation and atrial flutter.

Stroke is the major clinical cause of atrial fibrillation (AF). Treatments to reduce the risk of stroke and other vascular events are an important part of AF management. Oral anticoagulation is effective against stroke and has an acceptable risk of adverse events (primarily bleeding). Acetylsalicylic acid is less effective than oral anticoagulants but better tolerated. Anticoagulants are recommended for AF patients with risk factors for stroke.

Atrial Fibrillation↗