Publications by authors named "Santabhanu Chakrabarti"

44 Publications

Bystanders are less willing to resuscitate out-of-hospital cardiac arrest victims during the COVID-19 pandemic.

Resusc Plus 2020 Dec 5;4:100034. Epub 2020 Oct 5.

Faculty of Medicine, University of British Columbia, Canada.

Aim: The COVID-19 pandemic may influence the willingness of bystanders to engage in resuscitation for out-of-hospital cardiac arrest. We sought to determine if and how the pandemic has changed willingness to intervene, and the impact of personal protective equipment (PPE).

Methods: We distributed a 12-item survey to the general public through social media channels from June 4 to 23, 2020. We used 100-point scales to inquire about participants' willingness to perform interventions on "strangers or unfamiliar persons" and "family members or familiar persons", and compared mean willingness during time periods prior to and during the COVID-19 pandemic using paired -tests.

Results: Survey participants ( = 1360) were from 26 countries; the median age was 38 years (IQR 24-50) and 45% were female. Compared to prior to the pandemic, there were significant decreases in willingness to check for breathing or a pulse (mean difference -10.7% [95%CI -11.8, -9.6] for stranger/unfamiliar persons, -1.2% [95%CI -1.6, -0.8] for family/familiar persons), perform chest compressions (-14.3% [95%CI -15.6, -13.0], -1.6% [95%CI -2.1, -1.1]), provide rescue breaths (-19.5% [95%CI -20.9, -18.1], -5.5% [95%CI -6.4, -4.6]), and apply an automated external defibrillator (-4.8% [95%CI -5.7, -4.0], -0.9% [95%CI -1.3, -0.5]) during the COVID-19 pandemic. Willingness to intervene increased significantly if PPE was available (+8.3% [95%CI 7.2, 9.5] for stranger/unfamiliar, and +1.4% [95%CI 0.8, 1.9] for family/familiar persons).

Conclusion: Willingness to perform bystander resuscitation during the pandemic decreased, however this was ameliorated if simple PPE were available.
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http://dx.doi.org/10.1016/j.resplu.2020.100034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7534822PMC
December 2020

Anticoagulation for Patients With Atrial Fibrillation and End-Stage Renal Disease on Dialysis: A National Survey.

Can J Cardiol 2020 Dec 10. Epub 2020 Dec 10.

Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada.

Patients with atrial fibrillation (AF) have a significant increased risk of embolic stroke. Patients with end-stage renal disease who are on dialysis have an increased risk of both embolic stroke and bleeding. Stroke-prevention studies with the use of anticoagulation for AF patients have excluded patients on dialysis, so there remains no consensus on their management. We developed and implemented a pan-Canadian multidisciplinary survey to explore the current beliefs and practices concerning patients with AF on dialysis. We developed an online investigator-designed survey with both quantitative and qualitative responses with the use of a secure university-affiliated electronic service. The survey was distributed to physicians via the QxMD platform and directly to internal medicine, cardiology, and nephrology residency program directors for distribution to faculty members. 130 participants responded, including 46 cardiologists, 45 nephrologists, 30 general internists, and 9 other physicians. The preferred anticoagulant was warfarin. The CHADS score used to initiate anticoagulation was highly variable, with specialties differing in use of a CHADS threshold of ≥ 1 (P < 0.001) and the impact of previous transient ischemic attack/stroke (P = 0.02). Calciphylaxis history affected the decision to prescribe anticoagulation. Specialties differed in thresholds used to consider direct oral anticoagulants for dialysis patients, with nephrologists more likely to prescribe anticoagulation at higher CHADS scores. Our survey demonstrated significant heterogeneity of anticoagulation use for stroke prevention in patients with AF on dialysis. Physician specialty and patient risk profiles contributed to the observed variability. This study reemphasises the need for clinical trials, large observational studies, and consensus guidelines to address evidence-based equipoise.
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http://dx.doi.org/10.1016/j.cjca.2020.12.005DOI Listing
December 2020

Atrial arrhythmias and thromboembolic complications in adults post Fontan surgery.

Open Heart 2020 10;7(2)

Department of Medicine, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada

Objective: Patients with Fontan surgery experience late complications in adulthood. We studied the factors associated with the development and maintenance of atrial arrhythmias and thromboembolic complications in an adult population with univentricuar physiology post Fontan surgery.

Methods: Single centre retrospective cohort study of patients ≥18 years of age with Fontan circulation followed at our quaternary care centre for more than 1 year were included. Univariate and multivariate regression models were used where applicable to ascertain clinically significant associations between risk factors and complications.

Results: 93 patients were included (age 30.2±8.8 years, 58% men). 28 (30%) had atriopulmonary Fontan connection, 35 (37.6%) had lateral tunnel Fontan and 29 (31.1%) had extracardiac Fontan pathway. After a mean of 7.27±5.1 years, atrial arrhythmia was noted in 37 patients (39.8%), of which 13 developed had atrial fibrillation (14%). The presence of atrial arrhythmia was associated with the number of prior cardiac surgeries/procedures, increasing age and prior atriopulmonary Fontan operation. Thromboembolic events were present in 31 patients (33%); among them 14 had stroke (45%), 3 had transient ischaemic attack (9.7%), 7 had pulmonary embolism (22.6%) and 5 had atrial thrombus with imaging (16.1%). The presence of thromboembolic events was only associated with age and the presence of cirrhosis in multivariate analysis.

Conclusions: Atrial arrhythmias are common in adults with Fontan circulation at an early age, and are associated with prior surgical history and increasing age. Traditional risk factors may not be associated with atrial arrhythmia or thromboembolism in this cohort.
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http://dx.doi.org/10.1136/openhrt-2019-001224DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7566428PMC
October 2020

Atrial Arrhythmias in Clinically Manifest Cardiac Sarcoidosis: Incidence, Burden, Predictors, and Outcomes.

J Am Heart Assoc 2020 09 20;9(17):e017086. Epub 2020 Aug 20.

Division of Cardiology University of Ottawa Heart Institute Ottawa ON Canada.

Background Recent data have suggested a substantial incidence of atrial arrhythmias (AAs) in cardiac sarcoidosis (CS). Our study aims were to first assess how often AAs are the presenting feature of previously undiagnosed CS. Second, we used prospective follow-up data from implanted devices to investigate AA incidence, burden, predictors, and response to immunosuppression. Methods and Results This project is a substudy of the CHASM-CS (Cardiac Sarcoidosis Multicenter Prospective Cohort Study; NCT01477359). Inclusion criteria were presentation with clinically manifest cardiac sarcoidosis, treatment-naive status, and implanted with a device that reported accurate AA burden. Data were collected at each device interrogation visit for all patients and all potential episodes of AA were adjudicated. For each intervisit period, the total AA burden was obtained. A total of 33 patients met the inclusion criteria (aged 56.1±7.7 years, 45.5% women). Only 1 patient had important AAs as a part of the initial CS presentation. During a median follow-up of 49.1 months, 11 of 33 patients (33.3%) had device-detected AAs, and only 2 (6.1%) had a clinically significant AA burden. Both patients had reduced burden after CS was successfully treated and there was no residual fluorodeoxyglucose uptake on positron emission tomography scan. Conclusions First, we found that AAs are a rare presenting feature of clinically manifest cardiac sarcoidosis. Second, AAs occurred in a minority of patients at follow-up; the burden was very low in most patients. Only 2 patients had clinically significant AA burden, and both had a reduction after CS was treated. Registration URL: https://www.clini​caltr​ials.gov; unique identifier NCT01477359.
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http://dx.doi.org/10.1161/JAHA.120.017086DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7660760PMC
September 2020

Efficacy and Safety of Same-Day Discharge for Atrial Fibrillation Ablation.

JACC Clin Electrophysiol 2020 06 29;6(6):609-619. Epub 2020 Apr 29.

Heart Rhythm Services, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada.

Objectives: The purpose of this study was to evaluate the efficacy, health care utilization, and safety of a same-day discharge protocol.

Background: Catheter ablation of atrial fibrillation (AF) is the most common ablation performed. Increasing volumes of AF ablation are placing demands on hospital resources. In response, our institutions developed a same-day discharge protocol for AF ablation.

Methods: This was a multicenter cohort study of all patients undergoing AF ablation from 2010 to 2014 at 2 major centers. The primary efficacy outcome was the proportion of successful same-day discharges. The primary health care utilization outcome was 30-day hospital readmission for any reason. The primary safety outcome was a composite of 30-day death, stroke/transient ischemic attack or embolism, or bleeding requiring hospitalization.

Results: A total of 3,054 patients underwent AF ablation from 2010 to 2014 and met inclusion criteria. Same-day discharge was achieved in 79.2% (2,418 of 3,054). Hospital readmission at 30 days was 7.7% for the same-day discharge group, 10.2% for those who remained in the hospital overnight without complications (p = 0.055 for comparison with same-day discharge), and 19.5% (p < 0.001) for those who remained in the hospital with procedural complications (7.7%). Complication rates from discharge to 30 days (excluding immediate procedural complications) were 0.37% for the same-day discharge group, 0.36% (p = 0.999) for those kept overnight without complications, and 2.5% (p = 0.044) for those with initial procedural complications.

Conclusions: Same-day discharge after AF ablation is feasible in the majority of patients with use of a standardized protocol. This approach was not associated with higher hospital readmission or complication rates after discharge.
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http://dx.doi.org/10.1016/j.jacep.2020.02.009DOI Listing
June 2020

Driving Restrictions and Early Arrhythmias in Patients Receiving a Primary-Prevention Implantable Cardioverter-Defibrillator (DREAM-ICD) Study.

Can J Cardiol 2020 08 28;36(8):1269-1277. Epub 2020 May 28.

Heart Rhythm Services, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada. Electronic address:

Background: Current guidelines recommend 4 weeks of private driving restriction after implantation of a primary-prevention implantable cardioverter-defibrillator (ICD). These driving restrictions result in significant inconvenience and social implications. Advances in medical treatment and ICD programming have lowered the overall rate of device therapies. The objective of this study was to assess the incidence of ICD therapies at 30, 60, and 180 days after implantation.

Methods: Driving Restrictions and Early Arrhythmias in Patients Receiving a Primary-Prevention Implantable Cardioverter-Defibrillator (DREAM-ICD) was a retrospective cohort study conducted at 2 Canadian university centres enrolling patients with new implantation of a primary-prevention ICD. Device programming was standardised according to current guidelines. A total of 803 patients were enrolled.

Results: The cumulative rates of appropriate ICD therapies at 30, 60, and 180 days were 0.12%, 0.50%, and 0.75%, respectively. There was no syncope during the first 6 months. The median duration to the first appropriate ICD therapy was 208 (range 23-1109) days after implantation. The rate of inappropriate ICD therapies at 30 days was only 0.2%. Overall, < 13.6% of all appropriate ICD therapies occurred within the first 6 months after implantation.

Conclusions: The rate of appropriate ICD therapies within the first 30 days after device insertion is extremely low in contemporary primary prevention cohorts with guideline-concordant device programming. There was no increased risk for ventricular arrhythmia early after ICD insertion. The results of DREAM-ICD suggest the need for a revision of the existing driving restrictions for primary-prevention ICD recipients.
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http://dx.doi.org/10.1016/j.cjca.2020.05.029DOI Listing
August 2020

Mobile subcutaneous implantable cardioverter-defibrillator leads to oversensing and inappropriate shocks.

HeartRhythm Case Rep 2019 Jul 18;5(7):371-373. Epub 2019 Apr 18.

Heart Rhythm Services, Division of Cardiology, St. Paul's Hospital, University of British Columbia, Vancouver, Canada.

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http://dx.doi.org/10.1016/j.hrcr.2019.04.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6630194PMC
July 2019

Comparison of Ajmaline and Procainamide Provocation Tests in the Diagnosis of Brugada Syndrome.

JACC Clin Electrophysiol 2019 04 27;5(4):504-512. Epub 2019 Mar 27.

Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada. Electronic address:

Objectives: The authors studied the response rates and relative sensitivity of the most common agents used in the sodium-channel blocker (SCB) challenge.

Background: A type 1 Brugada electrocardiographic pattern precipitated by an SCB challenge confers a diagnosis of Brugada syndrome.

Methods: Patients undergoing an SCB challenge were prospectively enrolled across Canada and the United Kingdom. Patients with no prior cardiac arrest and family histories of sudden cardiac death or Brugada syndrome were included.

Results: Four hundred twenty-five subjects underwent SCB challenge (ajmaline, n = 331 [78%]; procainamide, n = 94 [22%]), with a mean age of 39 ± 15 years (54% men). Baseline non-type 1 Brugada ST-segment elevation was present in 10%. A total of 154 patients (36%) underwent signal-averaged electrocardiography, with 41% having late potentials. Positive results were seen more often with ajmaline than procainamide infusion (26% vs. 4%, p < 0.001). On multivariate analysis, baseline non-type 1 Brugada ST-segment elevation (odds ratio [OR]: 6.92; 95% confidence interval [CI]: 3.15 to 15.2; p < 0.001) and ajmaline use (OR: 8.76; 95% CI: 2.62 to 29.2; p < 0.001) were independent predictors of positive results to SCB challenge. In the subgroup undergoing signal-averaged electrocardiography, non-type 1 Brugada ST-segment elevation (OR: 9.28; 95% CI: 2.22 to 38.8; p = 0.002), late potentials on signal-averaged electrocardiography (OR: 4.32; 95% CI: 1.50 to 12.5; p = 0.007), and ajmaline use (OR: 12.0; 95% CI: 2.45 to 59.1; p = 0.002) were strong predictors of SCB outcome.

Conclusions: The outcome of SCB challenge was significantly affected by the drug used, with ajmaline more likely to provoke a type 1 Brugada electrocardiographic pattern compared with procainamide. Patients undergoing SCB challenge may have contrasting results depending on the drug used, with potential clinical, psychosocial, and socioeconomic implications.
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http://dx.doi.org/10.1016/j.jacep.2019.01.026DOI Listing
April 2019

The impact of steerable sheaths on unblinded contact force during catheter ablation for atrial fibrillation.

J Interv Card Electrophysiol 2020 Apr 30;57(3):417-424. Epub 2019 Jan 30.

Heart Rhythm Services, Division of Cardiology, Department of Medicine, University of British Columbia, #211-1033 Davie Street, Vancouver, BC, V6E 1M7, Canada.

Purpose: The purpose of this study was to evaluate the impact of steerable sheaths on multiple contact force parameters during atrial fibrillation (AF) ablation. Steerable sheaths are commonly used during AF ablation, at an additional cost to standard fixed-curve sheaths. However, there is little data on their incremental value in the era of contact force-guided radiofrequency ablation.

Methods: This multi-center cohort study included consecutive patients undergoing index pulmonary vein (PV) isolation with a force-sensing catheter. Operators employed either only steerable or only fixed-curve sheaths. Operators targeted a force of 10-40 g for each ablation lesion. Automated ablation lesion assessment software with standardized settings was employed.

Results: Of 85 subjects, 52 and 33 underwent ablation with steerable and fixed-curve sheaths, respectively. The steerable sheath group showed significantly higher average and maximum forces, but predominantly for the right PVs. The proportion of lesions with ≥ 10% of time with less than 10 g of force was lower in the steerable sheath group (adjusted odds ratio 0.56, steerable vs. fixed; 95% confidence interval 0.35, 0.89, p = 0.01). Improved stability was seen in the posterior aspect of both PV pairs. The proportion of RF time-in-target (the proportion of RF time meeting lesion criteria) was not different between the two groups (p = 0.176).

Conclusions: Even with contemporary contact force targets, steerable sheath use in AF ablation is associated with better average and maximum contact force and increased stability in comparison to fixed-curve sheaths.
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http://dx.doi.org/10.1007/s10840-019-00514-1DOI Listing
April 2020

Delivery of Peer Support Through a Self-Management mHealth Intervention (Healing Circles) in Patients With Cardiovascular Disease: Protocol for a Randomized Controlled Trial.

JMIR Res Protoc 2019 Jan 11;8(1):e12322. Epub 2019 Jan 11.

Faculty of Health Sciences, Simon Fraser University, Vancouver, BC, Canada.

Background: Cardiovascular disease (CVD) is a leading cause of hospitalization and death around the world. The prevalence of CVD is increasing and, therefore, development and investigation of effective programs to help people better self-manage their CVD and prevent secondary complications are needed.

Objective: In this paper, we report on a protocol to evaluate Healing Circles-an evidence-based and patient-informed peer support mobile health program designed to facilitate self-management and support patients in their recovery from and management of CVD. We hypothesize that individuals with CVD who use Healing Circles will experience greater improvements to their self-management ability than individuals receiving usual care.

Methods: In this single-blinded (assessor) randomized controlled trial, 250 community-living individuals with CVD will be randomized on a 1:1 basis to either Healing Circles or Usual Care. The primary outcome of self-management will be measured using the Health Education Impact Questionnaire version 3.0. Secondary outcomes include self-efficacy with chronic disease management, health-related quality of life, health resource use and costs, and electronic health literacy. Measurements will be taken at the baseline and every 6 months for 24 months.

Results: The study started recruitment in September 2017. Individuals are currently being recruited for participation, and existing participants are currently on follow-up. Measurements will be taken every 6 months until the study end, which is anticipated in December 2019.

Conclusions: Healing Circles is a novel program aimed toward improving self-management through peer support. Given our real-world study design, our findings will be readily translatable into practice. If the results support our hypothesis, it will indicate that Healing Circles is an effective intervention for improving self-management and reducing health care use.

Trial Registration: ClinicalTrials.gov NCT03159325; https://clinicaltrials.gov/ct2/show/NCT03159325 (Archived by WebCite at http://www.webcitation.org/74DvxVKUd).

International Registered Report Identifier (irrid): DERR1-10.2196/12322.
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http://dx.doi.org/10.2196/12322DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6330197PMC
January 2019

Sensitivity and specificity of chest imaging for sarcoidosis screening in patients with cardiac presentations.

Sarcoidosis Vasc Diffuse Lung Dis 2019 1;36(1):18-24. Epub 2019 May 1.

Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, ON.

Background: Patients with sarcoidosis can present with cardiac symptoms as the first manifestation of disease in any organ. In these patients, the use of chest imaging modalities may serve as an initial screening tool towards the diagnosis of sarcoidosis through identification of pulmonary/mediastinal involvement; however, the use of chest imaging for this purpose has not been well studied. We assessed the utility of different chest imaging modalities for initial screening for cardiac sarcoidosis (CS).

Methods And Results: All patients were investigated with chest x-ray, chest computed tomography (CT) and/or cardiac/thorax magnetic resonance imaging (MRI). We then used the final diagnosis (CS versus no CS) and adjudicated imaging reports (normal versus abnormal) to calculate the sensitivity and specificity of individual and combinations of chest imaging modalities. We identified 44 patients (mean age 54 (±8) years, 35.4% female) and a diagnosis of CS was made in 18/44 patients (41%). The sensitivity and specificity for screening for sarcoidosis were 35% and 85% for chest x-ray, respectively (AUC 0.60; 95%CI 0.42-0.78; p value=0.27); 94% and 86% for chest CT (AUC 0.90; 95%CI 0.80-1.00; p value <0.001); 100% and 50% for cardiac/thorax MRI (AUC 0.75; 95%CI 0.56-0.94; p value=0.04).

Conclusions: During the initial diagnostic workup of patients with suspected CS, chest x-ray was suboptimal as a screening test. In contrast CT chest and cardiac/thorax MRI had excellent sensitivity. Chest CT has the highest specificity among imaging modalities. Cardiac/thorax MRI or chest CT could be used as an initial screening test, depending on local availability.
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http://dx.doi.org/10.36141/svdld.v36i1.6865DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7247116PMC
June 2020

Just flip it!-CRT implantation in a patient with dextrocardia and situs inversus totalis.

J Arrhythm 2018 Dec 6;34(6):656-658. Epub 2018 Oct 6.

Heart Rhythm Services - St-Paul's Hospital University of British Columbia Vancouver BC Canada.

Implantation of a cardiac resynchronization therapy (CRT) device in patients with congenital heart disease may be challenging because of the particular underlying anatomy. We present the case of a right-sided transvenous implantation of a dual-chamber CRT-D device in a patient with situs inversus totalis and mirror image dextrocardia. To facilitate our anatomic orientation and to overcome unusual hand-eye coordination problems, we decided to flip the fluoroscopic image projection by 180° (right-left), creating the optical impression of a "normalized" heart position (levocardia). This simple approach allowed us to successfully implant the device using a conventional left-sided CRT delivery system.
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http://dx.doi.org/10.1002/joa3.12120DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6288602PMC
December 2018

Anticoagulation for Thromboembolic Risk Reduction in Adults With Congenital Heart Disease.

Can J Cardiol 2017 12 19;33(12):1597-1603. Epub 2017 Aug 19.

Department of Medicine, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada. Electronic address:

Adults with congenital heart disease (ACHD) represent one of the fastest expanding groups of patients in contemporary practice with unique and often complex management pathways. ACHD have a higher risk of thromboembolism not only from their complex physiology and anatomy but also from substrates such as valvular heart disease, atrial arrhythmias, cyanosis, and ventricular dysfunction, resulting in significant morbidity and mortality. Thromboembolic event rates in ACHD have been shown to be related to Congestive Heart Failure, Hypertension, Age (≥75 years), Diabetes, Stroke/Transient Ischemic Attack, Vascular Disease, Age (65-74 years), Sex (Female) (CHADS-VASc) scores (0.75%, 1.24%, and 2.65% per patient-year for CHADS-VASc scores of 0, 1, and ≥ 2 respectively), but are likely more strongly associated with disease complexity. However, optimum anticoagulation strategies have not been studied extensively in this group, mostly because of their heterogeneity and complex clinical profiles. Individual comorbidities, disease severity, and the presence of prosthetic material must be taken into consideration when determining the ideal anticoagulation strategy in pregnant patients. With improving survival and expanding treatment options, the requirement of thromboprophylaxis is steadily increasing, however, safety, choice, and duration of anticoagulation strategies in this group has not been well studied. In this review we aim to highlight the current understanding of antithrombotic therapy in the ACHD population, with discussion regarding special considerations in unique clinical situations relevant to ACHD.
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http://dx.doi.org/10.1016/j.cjca.2017.08.009DOI Listing
December 2017

Experience with bisoprolol in long-QT1 and long-QT2 syndrome.

J Interv Card Electrophysiol 2016 Nov 9;47(2):163-170. Epub 2016 Jul 9.

Heart Rhythm Services, Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.

Background: The protective effect of beta-blockers in patients with inherited Long-QT syndrome is well established. Recent reports have suggested that beta-blockers are not equally effective in Long-QT (LQT). Bisoprolol is an attractive candidate for use in LQT because of its cardioselective properties and favorable side-effect profile.

Methods: We performed a retrospective cohort study of 114 consecutive patients with gene-positive Long-QT syndrome type 1 (LQT1) or Long-QT syndrome type 2 (LQT2) treated with bisoprolol, nadolol or atenolol with a total of 580 person-years of follow-up. Electrocardiogram (ECG) parameters and cardiac events during follow-up were compared. In addition, exercise treadmill testing was performed in bisoprolol-treated patients.

Results: Fifty-nine patients were treated with bisoprolol, 39 with atenolol and 16 with nadolol. Overall, 59 % were females and 62 % had LQT1. Baseline heart rate and corrected QT (QTc) interval were similar between the groups. QTc shortening was observed in individuals on bisoprolol (ΔQTc -5 ± 31 ms; p = 0.049) and nadolol (ΔQTc -13 ± 16 ms; p = 0.02) but not on atenolol (ΔQTc +9 ± 24 ms; p = 0.16). Median follow-up was similar for bisoprolol and nadolol (3 years), but longer for atenolol (6 years; p = 0.03); one cardiac event occurred in the bisoprolol group (1.7 %) and two events occurred in the atenolol group (5.1 %; p = 0.45), whereas none occurred in nadolol-treated patients. Beta-blocker efficacy was not affected by the underlying genotype. The antiadrenergic effect of bisoprolol correlated with the reduction of peak heart rates at exercise testing.

Conclusions: Bisoprolol treatment results in QTc shortening in gene-positive LQT1 and LQT2 patients and is well tolerated during long-term administration. The equivalence of bisoprolol for protection from ventricular arrhythmia in LQT patients compared to established beta-blockers remains unknown. Further large-scale studies are required.
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http://dx.doi.org/10.1007/s10840-016-0161-2DOI Listing
November 2016

The Canadian Arrhythmogenic Right Ventricular Cardiomyopathy Registry: Rationale, Design, and Preliminary Recruitment.

Can J Cardiol 2016 12 21;32(12):1396-1401. Epub 2016 Apr 21.

QEII Health Sciences Center, Halifax, Nova Scotia, Canada.

Background: Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a complex and clinically heterogeneous arrhythmic condition. Incomplete penetrance and variable expressivity are particularly evident in ARVC, making clinical decision-making challenging.

Methods: Pediatric and adult cardiologists, geneticists, genetic counsellors, ethicists, nurses, and qualitative researchers are collaborating to create the Canadian ARVC registry using a web-based clinical database. Biological samples will be banked and systematic analysis will be performed to examine potentially causative mutations, variants, and biomarkers. Outcomes will include syncope, ventricular arrhythmias, defibrillator therapies, heart failure, and mortality.

Results: Preliminary recruitment has enrolled 365 participants (aged 42.7 ± 17.1 years; 50% women), including 129 probands and 236 family members. Previous cardiac arrest occurred in 28 (8%) participants, syncope occurred in 43 (12%) participants, and 46% of probands had a family history of sudden death. Overall yield of genetic testing was 36% for a disease-causing mutation and 20% for a variant of unknown significance. Target enrollment is 1000 affected patients and 500 unaffected family member controls over 7 years. The cross-sectional and longitudinal data collected in this manner will allow a robust assessment of the natural history and clinical course of genetic subtypes.

Conclusions: The Canadian ARVC Registry will create a population-based cohort of patients and their families to inform clinical decisions regarding patients with ARVC.
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http://dx.doi.org/10.1016/j.cjca.2016.04.004DOI Listing
December 2016

Long-term right ventricular implantable cardioverter-defibrillator lead performance in arrhythmogenic right ventricular cardiomyopathy.

Heart Rhythm 2016 10 16;13(10):1964-70. Epub 2016 Jun 16.

University of British Columbia, Vancouver, British Columbia, Canada. Electronic address:

Background: Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a progressive disease characterized by replacement of normal myocardium by fibrofatty tissue. The right ventricular (RV) apex is the typical target for implantable cardioverter-defibrillator (ICD) lead placement, raising concerns for suboptimal lead performance in medium- to long-term follow-up.

Objective: The purpose of this study was to determine whether placement of ICD leads at the RV apex was associated with performance deterioration of medium-term leads in ARVC patients compared to non-ARVC patients.

Methods: In this multicenter, retrospective, case-control study, ICD lead performance measures of R-wave, impedance, and pacing thresholds were compared at baseline and between 1-year and 5-year postimplantation follow-up using mixed-effect models adjusted for age and sex.

Results: One hundred one ARVC patients (49 women, age 50.6 ± 14.5 years) were compared to 56 control patients (37 women, age 48.2 ± 14.2 years). The mean difference in R wave between years 1 and 2 was -0.85 mV (P = .16) compared to a mean difference at years 5 and 6 of -1.85 mV (P = .02). There was no difference in impedance or pacing threshold or in lead lifetime between the 2 groups over 6-year follow-up (5.91 ± 3.89 years vs 5.48 ± 3.70 years, P = .239).

Conclusion: In ARVC patients with ICD leads implanted in the RV apex, ventricular sensing deteriorates significantly during medium-term follow-up. Septal RV lead placement should be explored as the first choice at implantation.
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http://dx.doi.org/10.1016/j.hrthm.2016.06.021DOI Listing
October 2016

Outcome of Apparently Unexplained Cardiac Arrest: Results From Investigation and Follow-Up of the Prospective Cardiac Arrest Survivors With Preserved Ejection Fraction Registry.

Circ Arrhythm Electrophysiol 2016 Jan;9(1):e003619

From the Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada (A.R.M.H., C.C., K.G., M.T.B., C.S., M.J., S.C., A.D.K.); Department of Cardiovascular Sciences, Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada (B.G.); Division of Cardiology, Department of Medicine, Queen's University, Kingston, ON, Canada (C.S.S.); University of Ottawa Heart Institute, Ottawa, ON, Canada (D.H.B.); Division of Cardiology, Department of Medicine, Western University, London, ON, Canada (G.J.K., R.Y.); Department of Medicine, Quebec Heart and Lung Institute, Quebec City, QC, Canada (J.C.); Division of Cardiology, Department of Medicine, Population Health Research Institute, Hamilton, ON, Canada (J.S.H.); Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada (M.T.); Division of Cardiology, Department of Medicine, QEII Health Sciences Center, Halifax, NS, Canada (M.G.); Division of Cardiology, Department of Medicine, University Health Network, Toronto, ON, Canada (M.H.G., V.S.C.); Division of Cardiology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada (P.A.); Division of Cardiology, Department of Medicine, Royal Jubilee Hospital, Victoria, BC, Canada (R.L.); and Division of Cardiology, Department of Pediatrics, BC Children's Hospital, Vancouver, BC, Canada (S.S.).

Background: The Cardiac Arrest Survivors with Preserved Ejection Fraction Registry (CASPER) enrolls patients with apparently unexplained cardiac arrest and no evident cardiac disease to identify the pathogenesis of cardiac arrest through systematic clinical testing. Exercise testing, drug provocation, advanced cardiac imaging, and genetic testing may be useful when a cause is not apparent.

Methods And Results: The first 200 survivors of unexplained cardiac arrest from 14 centers across Canada were evaluated to determine the results of investigation and follow-up (age, 48.6±14.7 years, 41% female). Patients were free of evidence of coronary artery disease, left ventricular dysfunction, or evident repolarization syndromes. Advanced testing determined a diagnosis in 34% of patients at baseline, with a diagnosis emerging during follow-up in 7% of patients. Of those who were diagnosed, 28 (35%) had an underlying structural condition and 53 (65%) had a primary electric disease. During a mean follow-up of 3.15±2.34 years, 23% of patients had either a shock or an appropriate antitachycardia pacing from their implantable cardioverter defibrillator, or both. The implantable cardioverter defibrillator appropriate intervention rate was 8.4% at 1 year and 18.1% at 3 years, with no clear difference between diagnosed and undiagnosed subjects, or between those diagnosed with a primary electric versus structural pathogenesis.

Conclusions: Obtaining a diagnosis in previously unexplained cardiac arrest patients requires systematic clinical testing and regular follow-up to unmask the cause. Nearly half of apparently unexplained cardiac arrest patients ultimately received a diagnosis, allowing for improved treatment and family screening. A substantial proportion of patients received appropriate implantable cardioverter defibrillator therapy during medium-term follow-up.

Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00292032.
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http://dx.doi.org/10.1161/CIRCEP.115.003619DOI Listing
January 2016

Friendly Fire During RF: Be Firm but Gentle!

J Cardiovasc Electrophysiol 2016 Mar 13;27(3):296-7. Epub 2016 Jan 13.

Heart Rhythm Services, Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, Canada.

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http://dx.doi.org/10.1111/jce.12894DOI Listing
March 2016

Cardiac Sarcoidosis.

Clin Chest Med 2015 Dec 11;36(4):657-68. Epub 2015 Sep 11.

Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, Ontario K1Y 4 W7, Canada.

Studies suggest clinically manifest cardiac involvement occurs in 5% of patients with pulmonary/systemic sarcoidosis. The principal manifestations of cardiac sarcoidosis (CS) are conduction abnormalities, ventricular arrhythmias, and heart failure. Data indicate that an 20% to 25% of patients with pulmonary/systemic sarcoidosis have asymptomatic (clinically silent) cardiac involvement. An international guideline for the diagnosis and management of CS recommends that patients be screened for cardiac involvement. Most studies suggest a benign prognosis for patients with clinically silent CS. Immunosuppression therapy is advocated for clinically manifest CS. Device therapy, with implantable cardioverter defibrillators, is recommended for some patients.
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http://dx.doi.org/10.1016/j.ccm.2015.08.008DOI Listing
December 2015

Lead Integrity Alert Is Useful for Assessment of Performance of Biotronik Linox Leads.

J Cardiovasc Electrophysiol 2015 Dec 16;26(12):1340-5. Epub 2015 Oct 16.

Heart Rhythm Services, University of British Columbia, British Columbia, Canada.

Introduction: Medtronic's Lead Integrity Alert (LIA) software algorithm is useful for detecting abnormal parameters across various ICD-lead families. However, its utility in the assessment of the Biotronik Linox™ family of high-voltage (HV) leads is unknown.

Methods: We conducted a retrospective cohort study to assess the performance of the LIA algorithm to detect abnormalities and lead failure in Linox ICD-leads. All LIA-enabled Medtronic devices connected to an active Linox lead were included. The alerts were adjudicated by 2 blinded electrophysiologists and correlated with clinical data.

Results: Between 2008 and 2012, data from 208 patients with 564 patient-years of follow-up were available for analysis. The median follow-up duration was 32 (IQR 21-41 months). Twenty-one LIA triggers were noted in 20 different patients. The median delay until a positive LIA was 32 months (IQR 21-41 months) postimplant with a 5-year lead survival free from LIA of 76%. Ninety-five percent (19/20) LIA alerts were true lead failures. The most common LIA triggers were short V-V intervals (85%) and nonsustained ventricular tachycardia (85%). Abrupt changes of the ICD-lead impedance occurred in 5/20 triggers. Inappropriate ICD-shocks were strongly associated with a positive LIA (30% vs. 7.4%; P = 0.006). Of the explanted Linox leads 53% had visible abnormalities. The sensitivity, specificity, and positive predictive value for lead failure in the presence of a LIA trigger were 87%, 99.5%, and 95.2%, respectively.

Conclusions: A positive LIA trigger in Biotronik Linox ICD-leads is highly predictive of lead failure. LIA is useful in ongoing surveillance of lead performance.
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http://dx.doi.org/10.1111/jce.12832DOI Listing
December 2015

Nothing inside the heart - Combining epicardial pacing with the S-ICD.

HeartRhythm Case Rep 2015 Nov 4;1(6):419-423. Epub 2015 Sep 4.

Division of Cardiac Electrophysiology, University of British Columbia - St. Paul's Hospital, Vancouver, Canada.

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http://dx.doi.org/10.1016/j.hrcr.2015.04.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5419715PMC
November 2015

Preventing cardiac implantable electronic device infections.

Heart Rhythm 2015 Nov 30;12(11):2344-56. Epub 2015 Jun 30.

Divisions of Cardiology. Electronic address:

Cardiac implantable electronic devices (CIEDs) have dramatically improved clinical outcomes in patients with heart disease, and the number of CIED-related procedures being performed continues to grow. Unfortunately, the rate of device-related infection (DRI) is increasing disproportionately to the rate of implantation, with DRI rates of >2% in many series. This increase in DRI is a consequence of the increased number of patients with a higher burden of comorbidities, who are more susceptible to infection and are undergoing more complex device procedures. Identification of high-risk patients is an important component of procedural planning, and targeted therapy and surveillance may be beneficial in certain groups. An understanding of the pathophysiology of DRI has facilitated more effective and widespread use of prophylactic antibiotics; however, current guidelines for antibiotic prophylaxis are based on a relatively small evidence base. Clinical equipoise remains regarding the optimal prophylactic regimen, and we are continuing to learn how best to manage these patients. In this review, we discuss the epidemiology and pathophysiology of DRI and its clinical presentation, the risk factors for DRI, and the existing and emerging evidence supporting strategies to prevent DRI.
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http://dx.doi.org/10.1016/j.hrthm.2015.06.043DOI Listing
November 2015

Sex is associated with differences in individual trajectories of change in social health after implantable cardioverter-defibrillator.

Circ Cardiovasc Qual Outcomes 2015 Mar 24;8(2 Suppl 1):S21-30. Epub 2015 Feb 24.

From the University of British Columbia, Vancouver, Canada (S.B.L., J.L.J., K.H., M.T.B., S.C., C.R.K., S.T., J.A.Y.L.W., P.A.R.) and Trinity Western University, Langley, Canada (R.S.); Department of Cardiology and Cardiac Programs, St. Paul's Hospital and Vancouver General Hospital, Vancouver, BC, Canada (S.B.L., M.T.B., S.C., C.R.K., S.T., J.A.Y.L.W); and Providence Health Care, Centre for Health Evaluation and Outcome Sciences, Vancouver, BC, Canada (R.S.).

Background: Social health is a dimension of quality of life, and refers to people's involvement in, and satisfaction with social roles, responsibilities, and activities. The implantable cardioverter-defibrillator is associated with changes in overall quality of life, but little is known about sex differences in individual trajectories of change in social health.

Methods And Results: We prospectively measured changes in 3 subscales of the SF-36v2 generic health questionnaire (role physical, role emotional, and social functioning), 2 Patient-Reported Outcomes Measurement Information System short forms (satisfaction with participation in social roles and satisfaction with participation in discretionary social activities), and the Florida Patient Acceptance Survey before and at 1, 2, and 6 months after implantation. Individual growth models of temporal change were estimated. The scores of the 6 indicators improved with time. The unconditional model demonstrated significant (fixed effects: P<0.05; covariance parameters: P<0.10) residual variability in the individual trajectories. In the conditional model, men and women differed significantly in their rates of change in the scores of 3 of the 6 measures. Although men's mean scores exceeded women's mean scores on all indicators at baseline (range of relative mean difference: 11.0% to 17.8%), the rate of women's change resulted in a reversal in relative standing at 6 months after implantation, with the mean scores of women exceeding the men's by 4.5% to 5.6%.

Conclusions: Men and women differed in their trajectories of change in social health, both in terms of their starting points (ie, baseline scores) and their rates of change.
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http://dx.doi.org/10.1161/CIRCOUTCOMES.114.001607DOI Listing
March 2015

H1N1-associated sinus node dysfunction.

Heart Asia 2015 13;7(1):16-7. Epub 2015 Mar 13.

Division of Cardiology , University of British Columbia , Vancouver, British Columbia , Canada.

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http://dx.doi.org/10.1136/heartasia-2014-010522DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4832765PMC
June 2016

Life threatening causes of syncope: channelopathies and cardiomyopathies.

Auton Neurosci 2014 Sep 22;184:53-9. Epub 2014 Apr 22.

Division of Cardiology, University of British Columbia, Vancouver, BC, Canada. Electronic address:

Syncope is common, has a high recurrence rate and carries a risk of morbidity and, dependent on the cause, mortality. Although the majority of patients with syncope have a benign prognosis, syncope as a result of cardiomyopathy or channelopathy carries a poor prognosis. In addition, the identification of these disorders allows for the institution of treatments, which are effective at reducing the risk of both syncope and mortality. It is for these reasons that the identification of a cardiomyopathy or channelopathy in patients with syncope is crucial. This review article will describe the characteristics of common cardiomyopathies and channelopathies and their investigation.
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http://dx.doi.org/10.1016/j.autneu.2014.04.003DOI Listing
September 2014

Procainamide infusion in the evaluation of unexplained cardiac arrest: from the Cardiac Arrest Survivors with Preserved Ejection Fraction Registry (CASPER).

Heart Rhythm 2014 Jun 18;11(6):1047-54. Epub 2014 Mar 18.

Queen׳s University, Kingston, Ontario, Canada.

Background: Provocative testing with sodium channel blockers is advocated for the evaluation of unexplained cardiac arrest (UCA) with the primary purpose of unmasking the typical ECG features of Brugada syndrome. The Cardiac Arrest Survivors with Preserved Ejection Fraction Registry (CASPER) systematically assesses subjects with UCA or a family history of sudden death (FHSD).

Objective: The purpose of this study was to determine the clinical yield of procainamide infusion in a national registry of subjects with either UCA or a FHSD.

Methods: Subjects with either UCA or a FHSD without evidence of a Brugada pattern at baseline underwent procainamide testing (15 mg/kg to a maximum of 1 g at 50 mg/min). A test was considered positive for Brugada pattern if there was an increase in ST elevation >1 mm or if there was >1 mm of new ST elevation in leads V1 and/or V2. Genetic testing was performed on the basis of phenotype detection.

Results: Procainamide testing was performed in 174 subjects (age 46.8 ± 15.4 years, 47% female). Testing provoked a Brugada pattern in 12 subjects (6.9%), 5 of whom had no ST abnormalities at baseline. No subjects with a negative procainamide challenge were subsequently diagnosed with Brugada syndrome. Genetic testing was conducted in 10 of the 12 subjects with a provoked Brugada pattern and was positive for a mutation in the SCN5A gene in 1.

Conclusion: Irrespective of the baseline ECG, procainamide testing provoked a Brugada pattern in a significant proportion of subjects with UCA or a FHSD, thereby facilitating a diagnosis of Brugada syndrome, and is recommended in the workup of UCA.
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http://dx.doi.org/10.1016/j.hrthm.2014.03.022DOI Listing
June 2014

Three-dimensional assessment of left atrial appendage orifice geometry and potential implications for device closure.

Int J Cardiovasc Imaging 2014 Apr 6;30(4):819-23. Epub 2014 Mar 6.

Cardiac Imaging Division, Department of Radiology, St. Paul's Hospital, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada,

Transcatheter placement of left atrial closure device is an attractive therapy for patients with atrial fibrillation (AF), to avoid anticoagulation and reduce cerebrovascular events; however peri-device leaks occur. The geometry of the left atrial appendage (LAA) is not well understood, largely owing to limitations of 2-dimensional imaging techniques. We sought to better define the LAA orifice geometry, by performing 3-dimensional multi-detector computed tomography measurements. We prospectively recruited 105 consecutive patients referred for pulmonary vein ablation (PVA) and age-matched controls. Area, short and long-axis measurements were performed. Eccentricity was calculated as 1-(short axis/long axis). Multiple clinical variables were tested for their ability to predict appendage orifice eccentricity using univariate linear regression models. The PVA cohort demographics included; 25 (24%) females, mean age 59 years (SD = 10), median height (1.55-2.03), weight 89 (56-139) kg and body surface area 2.1 (1.61-2.58). In the PVA cohort, there was a significant difference between the long and short-axis; median short-axis dimension was 20.5 (12.9-35.4) mm, versus long-axis median 30.4 (17.7-43.8) (p < 0.001). Mean eccentricity score was 0.4. When compared with controls, there was a significant difference in the short and long-axis measurements (p < 0.001) as well as eccentricity (p = 0.04). All clinical variables tested showed limited ability to predict appendage eccentricity (p = NS). LAA ostium is an elliptical structure in the setting of AF with a high eccentricity index and uniformly significant differences between short and long-axis. There were significant differences between these parameters when compared with controls. A deeper appreciation of LAA geometry and eccentricity may allow for reduction in peri-closure leaks.
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http://dx.doi.org/10.1007/s10554-014-0393-0DOI Listing
April 2014

Evolution of clinical diagnosis in patients presenting with unexplained cardiac arrest or syncope due to polymorphic ventricular tachycardia.

Heart Rhythm 2014 Feb 14;11(2):274-81. Epub 2013 Nov 14.

Population Health Research Institute, McMaster University, Hamilton, Canada. Electronic address:

Background: A systematic evaluation of patients with unexplained cardiac arrest (UCA) yields a diagnosis in 50% of the cases. However, evolution of clinical phenotype, identification of new disease-causing mutations, and description of new syndromes may revise the diagnosis.

Objective: To assess the evolution in diagnosis among patients with initially UCA.

Methods: Diagnoses were reviewed for all patients with UCA recruited from the Cardiac Arrest Survivors with Preserved Ejection Fraction Registry with at least 1 year of follow-up.

Results: After comprehensive investigation of 68 patients (age 45.2 ± 14.9 years; 63% men), the initial diagnosis was as follows: idiopathic ventricular fibrillation (n = 34 [50%]), a primary arrhythmic disorder (n = 21 [31%]), and an occult structural cause (n = 13 [19%]). Patients were followed for 30 ± 17 months, during which time the diagnosis changed in 12 (18%) patients. A specific diagnosis emerged for 7 patients (21%) with an initial diagnosis of idiopathic ventricular fibrillation. A structural cardiomyopathy evolved in 2 patients with an initial diagnosis of primary electrical disorder, while the specific structural cardiomyopathy was revised for 1 patient. Two patients with an initial diagnosis of a primary arrhythmic disorder were subsequently considered to have a different primary arrhythmic disorder. A follow-up resting electrocardiogram was the test that most frequently changed the diagnosis (67% of the cases), followed by genetic testing (17%).

Conclusions: The reevaluation of patients presenting with UCA may lead to a change in diagnosis in up to 20%. This emphasizes the need to actively monitor the phenotype and also has implications for the treatment of these patients and the screening of their relatives.
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http://dx.doi.org/10.1016/j.hrthm.2013.11.008DOI Listing
February 2014

How to optimize rate control in clinical atrial fibrillation management.

Can J Cardiol 2013 Oct 24;29(10):1299-301. Epub 2013 Apr 24.

Division of Cardiology, Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada; Electrophysiology Service at the Montreal Heart Institute and the Department of Medicine, Université de Montréal, Montréal, Québec, Canada. Electronic address:

Atrial fibrillation (AF) is the most common sustained arrhythmia seen in clinical practice, and accounts for most arrhythmia-related emergency room visits and hospital admissions. The present-day management of AF is centred on improving arrhythmia-related symptoms, exercise tolerance, and quality of life, and reducing the morbidity and mortality associated with AF (ie, the prevention of stroke or systemic thromboembolism and tachycardia-induced cardiomyopathy). The contemporary management of AF is centred on the apparently competing strategies of rate and rhythm control, which are more appropriately viewed as complementary. This contemporary review will discuss the rationale underpinning the rate control strategy, and focus on practical aspects of undertaking a rate control strategy.
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http://dx.doi.org/10.1016/j.cjca.2013.01.015DOI Listing
October 2013