Publications by authors named "Siva K Mulpuru"

113 Publications

Catheter Ablation of Ventricular Tachycardia in Patients with Post-Infarction Left Ventricular Aneurysm.

J Cardiovasc Electrophysiol 2021 Oct 19. Epub 2021 Oct 19.

Department of Cardiovascular Diseases, Division of Heart Rhythm Services, Mayo Clinic, Rochester, MN.

Background: While VT in the setting of post-myocardial infarction LVA is not uncommonly encountered, there is scarcity of data regarding the safety, efficacy and outcomes of ablation of VT in this subset of patient.

Methods: Our study included consecutive patients aged ≥18 with post-myocardial infarction LVA who presented to Mayo Clinic for catheter ablation of VT between 2002-2018.

Results: Of 34 patients, mean age was 70.4±9.1 years; 91% were male. Mean LVEF was 29±9.7% and LVEDD was 64.9±6.6mm. The site of the LVA was apical in 21 patients (62%).15 patients (44%) presented with electrical storm or incessant VT. 9 patients (26%) had a history of intra-cardiac thrombus. All except for 1 patient had at least 1 VT originating from the aneurysm. Mean number of VTs was 2.9±1.7. All patients underwent ablation at the site of the aneurysm. Ablation outside the aneurysm was performed in 13 patients (38%). Low voltage, fractionated potentials and/or late potentials at the aneurysmal site were present in all cases. Complete elimination of all VTs was achieved in 18 (53%) while elimination of the clinical VT with continued inducibility of nonclinical VTs was achieved in a further 11 patients (32%). 2 patients developed cardiac tamponade requiring pericardiocentesis. During a mean follow-up period of 2.3±2.4 years, 11 patients (32%) experienced VT recurrence. Freedom from all-cause mortality at 1 year follow-up was 94%.

Conclusion: RFA targeting the aneurysmal site is a feasible and reasonably effective management strategy for clinical VTs in patients with post-infarction LVA. This article is protected by copyright. All rights reserved.
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http://dx.doi.org/10.1111/jce.15273DOI Listing
October 2021

Use of Flecainide in Stable Coronary Artery Disease: An Analysis of Its Safety in Both Nonobstructive and Obstructive Coronary Artery Disease.

Am J Cardiovasc Drugs 2021 Sep 18;21(5):563-572. Epub 2021 Jun 18.

Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ, USA.

Background: Flecainide is a class IC antiarrhythmic drug that is contraindicated in patients who have a history of myocardial infarction, but its effect on mortality and risk of proarrhythmia in patients with stable obstructive and nonobstructive epicardial coronary artery disease (CAD) has not been assessed.

Objective: We sought to compare the safety of flecainide administration in patients who had angiographic evidence of either no or minimal CAD versus nonobstructive CAD, and those who underwent nuclear stress testing with perfusion defects versus those without perfusion defects.

Methods: We conducted a retrospective chart review of 348 patients who were treated with flecainide for at least 1 year duration and underwent evaluation for CAD with coronary angiography or myocardial perfusion imaging (MPI) stress testing within 3 months of initiating flecainide. We compared overall mortality and proarrhythmia between varying levels of CAD and perfusion defects.

Results: There was a similar 10-year survival between those with no or minimal CAD, nonobstructive CAD, and obstructive CAD (p = 0.6). Additionally, there was no difference in arrhythmia burden, including sustained ventricular tachycardias or frequent premature ventricular contractions (> 5% daily burden; p = 0.25). There was also no increase in mortality among those who had reversible perfusion defects >0% compared with those without, among subjects who underwent MPI (p = 0.14). On subgroup analysis, there was no increased risk in all-cause mortality with any specific coronary artery involvement, or with obstructive multivessel CAD (p = 0.89).

Conclusion: Flecainide use is not associated with an increase in either all-cause mortality or ventricular arrhythmias in low-risk patients with stable nonobstructive CAD.
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http://dx.doi.org/10.1007/s40256-021-00483-9DOI Listing
September 2021

Electromagnetic interference from left ventricular assist device in patients with transvenous implantable cardioverter-defibrillator.

Pacing Clin Electrophysiol 2021 Jul 21;44(7):1163-1175. Epub 2021 May 21.

Cardiovascular Division, Mayo Clinic Arizona, Phoenix, Arizona, USA.

Background: Many advanced heart failure patients have both a left ventricular assist device (LVAD) and an implantable cardioverter-defibrillator (ICD). This study examines incidence, clinical impact, and management of LVAD-related EMI.

Methods: We performed a three-center retrospective analysis of transvenous ICD implanted patients with LVAD implanted between January 1, 2005 and December 31, 2020. The primary outcome was EMI after LVAD implantation, categorized as LVAD-related noise or telemetry interference.

Results: The rate of LVAD-related EMI among the 737 patients (mean age 58.6 ± 12.8 years) studied was 5.0%. Telemetry interference (1.5%) compromised ICD interrogation in all patients. This was resolved successfully with use of a metal shield, encased wand, radiofrequency tower, different ICD programmer or by increasing distance between ICD programmer and LVAD (n = 6). ICD replacement was required to reestablish successful communication in three patients. LVAD-related noise (3.5%) led to oversensing (n = 4), inappropriate mode switches (n = 4), noise reversion (n = 3), inhibition of pacing (n = 2), inappropriate detection as atrial fibrillation (AF) (n = 2) and inappropriate detection as ventricular tachycardia (VT) and/or ventricular fibrillation (VF) (n = 2). This noise interference persisted (n = 3), resolved spontaneously (n = 16), resolved with programming change (n = 6) or required lead revision (n = 1).

Conclusions: EMI from LVAD impacts ICD function, although, the incidence rate is low. Physicians implanting both, LVAD in patients with ICD (more common) or ICD in patients with LVAD, should be aware of possible interferences. Telemetry failure not resolved by metal shielding was overcome by ICD generator replacement to a different manufacturer. In most cases, LVAD-related noise resolves spontaneously.
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http://dx.doi.org/10.1111/pace.14265DOI Listing
July 2021

Novel mapping techniques for rotor core detection using simulated intracardiac electrograms.

J Cardiovasc Electrophysiol 2021 05 22;32(5):1268-1280. Epub 2021 Feb 22.

Department of Biomedical Engineering, University of Minnesota, Minneapolis, Minnesota, USA.

Background: Catheter ablation is associated with limited success rates in patients with persistent atrial fibrillation (AF). Currently, existing mapping systems fail to identify critical target sites for ablation. Recently, we proposed and validated several techniques (multiscale frequency [MSF], Shannon entropy [SE], kurtosis [Kt], and multiscale entropy [MSE]) to identify pivot point of rotors using ex-vivo optical mapping animal experiments. However, the performance of these techniques is unclear for the clinically recorded intracardiac electrograms (EGMs), due to the different nature of the signals.

Objective: This study aims to evaluate the performance of MSF, MSE, SE, and Kt techniques to identify the pivot point of the rotor using unipolar and bipolar EGMs obtained from numerical simulations.

Methods: Stationary and meandering rotors were simulated in a 2D human atria. The performances of new approaches were quantified by comparing the "true" core of the rotor with the core identified by the techniques. Also, the performances of all techniques were evaluated in the presence of noise, scar, and for the case of the multielectrode multispline and grid catheters.

Results: Our results demonstrate that all the approaches are able to accurately identify the pivot point of both stationary and meandering rotors from both unipolar and bipolar EGMs. The presence of noise and scar tissue did not significantly affect the performance of the techniques. Finally, the core of the rotors was correctly identified for the case of multielectrode multispline and grid catheter simulations.

Conclusion: The core of rotors can be successfully identified from EGMs using novel techniques; thus, providing motivation for future clinical implementations.
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http://dx.doi.org/10.1111/jce.14948DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8119376PMC
May 2021

Liposomal bupivacaine during subcutaneous implantable cardioverter defibrillator implantation for pain management.

Pacing Clin Electrophysiol 2021 03 3;44(3):513-518. Epub 2021 Feb 3.

Department of cardiovascular diseases, Mayo Clinic Rochester, Rochester, Minnesota, USA.

Background: The subcutaneous implantable cardioverter-defibrillator (S-ICD) has a larger generator and its implantation involves more dissection and tunneling compared to traditional transvenous defibrillator system. Liposomal bupivacaine, an extended-release bupivacaine with 72 h of duration has been used for postoperative pain management in patients undergoing S-ICD implantation. Our aim was to compare postoperative pain and opioid prescription patterns among patients undergoing S-ICD implantation who received intraprocedural liposomal bupivacaine and those who did not.

Methods: We performed a retrospective analysis of all patients who underwent subcutaneous ICD implantation from January 1, 2013 to March 30, 2018 at the Mayo Clinic in Rochester, Minnesota. Patients were categorized into those who received liposomal bupivacaine and those who did not. Data on inpatient pain score, outpatient opioid prescription rates at discharge, and doses based on oral morphine equivalents (OME) were collected.

Results: A total of 104 patients underwent S-ICD implantation. Intraprocedural liposomal bupivacaine was used in 69% of patients. Patients who received intraprocedural liposomal bupivacaine had similar mean inpatient pain scores (2.9 vs. 2.9, p = .786). There was also no difference in the rate of inpatient opioid administration (79.2% vs. 87.5%, p = .4139), outpatient opioid prescription (23.6% vs. 12.5%, p = .29), or mean OME (41.7-mg vs. 16.6-mg, p = .188) when comparing patients those who received intraprocedural liposomal bupivacaine and those who did not.

Conclusion: Intraprocedural liposomal bupivacaine administration was not associated with any significant impact on postoperative pain scores, inpatient opioid administration, and outpatient opioid prescription rates or OME amounts at discharge.
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http://dx.doi.org/10.1111/pace.14175DOI Listing
March 2021

Long-Term Clinical Outcomes of Underdosed Direct Oral Anticoagulants in Patients with Atrial Fibrillation and Atrial Flutter.

Am J Med 2021 06 12;134(6):788-796. Epub 2021 Jan 12.

Department of Cardiovascular Diseases, Mayo Clinic, Phoenix Ariz.

Background: Although direct oral anticoagulants (DOACs) have been shown to be effective at reducing the risk of stroke in patients with atrial fibrillation/flutter (AF), they are sometimes underdosed off-label to mitigate their associated higher bleeding risk. We sought to evaluate frequency and clinical outcomes of inappropriate underdosing of DOACS in patients with AF.

Methods: We conducted a study of subjects with AF who had a clinical indication for stroke prophylaxis (with a congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke or transient ischemic attack, vascular disease, age 65 to 47 years, sex category [CHADS-VASc] of 2 or greater) and were prescribed 1 of the 4 clinically approved DOACs (apixaban, rivaroxaban, dabigatran, or edoxaban). We compared all-cause mortality, composite of stroke and systemic embolism, composite of myocardial infarction (MI), acute coronary syndromes (ACS), and coronary revascularization, and major bleeding between patients appropriately dosed and inappropriately underdosed.

Results: A total of 8125 patients met inclusion criteria, with a mean follow up of 2.2 ± 2 years. Of those, 1724 patients (21.2%) were inappropriately dosed. After adjusting for baseline variables, there was no difference in all-cause mortality, risk of stroke or systemic embolism, International Society on Thrombosis and Haemostasis (ISTH) major bleeding, or composite of myocardial infarction, acute coronary syndromes, or coronary revascularization between patients appropriately dosed and inappropriately underdosed. In subgroup analysis, only apixaban demonstrated an increased incidence all-cause mortality (hazard ratio [HR] 1.24, 95% confidence interval [CI] 1.03-1.49) with inappropriate underdosing. There was no difference in the remaining clinical outcomes noted on subgroup analysis.

Conclusion: Underdosing of DOACs did not minimize risk of bleeding, systemic embolization or all-cause mortality in patients with AF. Inappropriate underdosing with apixaban in particular was associated with increased all-cause mortality.
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http://dx.doi.org/10.1016/j.amjmed.2020.12.022DOI Listing
June 2021

Inappropriate Dosing of Direct Oral Anticoagulants in Patients with Atrial Fibrillation.

Am J Cardiol 2021 04 29;144:52-59. Epub 2020 Dec 29.

Department of Cardiovascular Medicine, Division of Heart Rhythm Services, Mayo Clinic, Rochester, Minnesota. Electronic address:

Direct Oral Anticoagulants (DOACs) require dose adjustment based on specific patient characteristics, making them prone to incorrect dosing. The current study aimed to evaluate the prevalence of inappropriate DOAC dosing, its predictors, and corresponding outcomes in a single-center cohort of atrial fibrillation (AF) patients. We reviewed all patients with AF treated at Mayo Clinic with a DOAC (Apixaban, Rivaroxaban, or Dabigatran) between 2010 and 2017. Outcomes examined were ischemic stroke /transient ischemic attack (TIA)/embolism and bleeding. 8,576 patients (mean age 69.5 ± 11.9 years, 35.1 % female, CHADS-VASc 3.0±1.8) received a DOAC (38.6% apixaban, 35.8% rivaroxaban, 25.6% dabigatran). DOAC dosing was inappropriate in 1,273 (14.8%) with 1071 (12.4%) receiving an inappropriately low dose, and 202(2.4%) an inappropriately high dose. Patients prescribed inappropriate doses were older (72.4 ± 11.7 vs 69.0 ± 11.8, p <0.0001), more likely to be female (43.1% vs 33.7%, p <0.0001), had a higher CHADS-VASc score (3.4 ± 1.8 vs 2.9 ± 1.8, p <0.0001) and a greater Charlson co-morbidity index (3.5 ± 3.3 vs 2.9 ± 3.2, p<0.0001). Over 1.2 ±1.6 years (median 0.5 years) follow up; there was no significant difference in the incidence of stroke and/or TIA and/or embolism and bleeding between patients who were inappropriately dosed versus appropriately dosed. In conclusion, DOAC dosing was not in compliance with current recommendations in 15% of AF patients. Patients at higher risk of stroke and/or TIA based on older age, female gender, and higher CHADS-VASc score were more likely to be underdosed, but there was no significant difference in outcomes including stroke/TIA/embolism and bleeding.
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http://dx.doi.org/10.1016/j.amjcard.2020.12.062DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8088343PMC
April 2021

VIEgram - Analysis and Visualization of Intracardiac Electrograms on Patient-Specific 3D Atria Model.

Annu Int Conf IEEE Eng Med Biol Soc 2020 07;2020:2606-2609

Over the last few years, the use of cardiac mapping for effective diagnosis and treatment of arrhythmias has increased significantly. In the clinical environment, electroanatomical mapping (EAM) is performed during the electrophysiological procedures using proprietary systems such as CARTO, EnSite Precision, RHYTHMIA, etc. These systems generate the 3D model of patient-specific atria with the electrical activity (i.e., intracardiac electrograms (iEGMs)) displayed on it, for further identification of the sources of arrhythmia and for guiding cardiac ablation therapy. Recently, several novel techniques were developed to perform iEGMs analysis to more accurately identify the arrhythmogenic sites. However, there is a difficulty in incorporating the results of iEGMs analysis back to EAM systems due to their proprietary constraints. This created a hurdle in the further development of novel techniques to help navigate patient-specific clinical ablation therapy. Thus, we developed an open source software, VIEgram, that allows researchers to visualize the results of the various iEGMs analysis on a patient-specific 3D atria model. It eliminates the dependency of the academic environment on the proprietary EAM systems, thereby making the process of retrospective mapping extremely convenient and time efficient. Here, we demonstrate the features of VIEgram such as visual inspection of iEGMs, flexibility in implementing custom iEGMs analysis techniques and interpolation schemes, and spatial analysis.
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http://dx.doi.org/10.1109/EMBC44109.2020.9175917DOI Listing
July 2020

Catheter Ablation for Atrial Fibrillation in Patients With Concurrent Heart Failure.

Am J Cardiol 2020 12 28;137:45-54. Epub 2020 Sep 28.

Mayo Clinic, Rochester, Minnesota.

Due to limited real-world data, the aim of this study was to explore the impact of catheter ablation (CA) for atrial fibrillation (AF) in heart failure (HF). This retrospective cohort study identified 119,694 patients with AF and HF from the Nationwide Readmissions Database (NRD) from 2016 to 2017. Propensity-matching was generated using demographics, comorbidities, hospital and other characteristics through multivariate logistic regression. Greedy's propensity score match (1:15) algorithm was used to create matched data. The primary end point was a composite of HF readmission and mortality at 1 year. Secondary outcomes include HF readmission, mortality, AF readmission, and any-cause readmission at 1 year. Of the 119,694 patients, 63,299 had HF with reduced ejection fraction (HFrEF), and 56,395 had HF with preserved ejection fraction (HFpEF). In the overall HFrEF cohort, the primary outcome was similar (HR, 95% confidence interval, p-value) (1.01, 0.91 to 1.13, 0.811). AF readmission (0.41, 0.33 to 0.49, <0.001) and any readmission (0.87, 0.82 to 0.93, <0.001) were reduced with CA. In the propensity-matched HFrEF cohort, results were unchanged (primary outcome: 1.10, 0.95 to 1.27, 0.189; AF readmission: 0.46, 0.36 to 0.59, <0.001; any readmission: 0.89, 0.82 to 0.98, 0.015). In the overall HFpEF cohort, the primary outcome was similar (0.90, 0.78 to 1.04, 0.154). AF readmission was reduced with CA (0.54, 0.44 to 0.65, <0.001). In the propensity-matched HFpEF cohort, results were unchanged (primary outcome 1.10, 0.92 to 1.31, 0.289; AF readmission 0.44, 0.33 to 0.57, <0.001). CA did not reduce mortality and HF readmission at one year irrespective of the type of HF, but significantly reduce readmission due to AF.
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http://dx.doi.org/10.1016/j.amjcard.2020.09.035DOI Listing
December 2020

Inappropriate Defibrillator Shocks During Cervical Medial Branch Radiofrequency Ablation: A Case Report.

A A Pract 2020 Sep;14(11):e01286

Division of Cardiovascular Anesthesia, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota.

A 52-year-old woman with a history of cervical spondylosis, nonischemic dilated cardiomyopathy, and complete heart block with implantation of a cardiac resynchronization therapy defibrillator (Inogen XR, Boston Scientific, Natick, MA) underwent bilateral fluoroscopy-guided radiofrequency ablation of the medial branch nerves at C4, C5, and C6 levels at an ambulatory surgery center. After completion of the seemingly routine procedure, several alerts, including 1 inappropriate shock, were received via Boston Scientific's remote monitoring system. Tracings also showed that pacing inhibition occurred. When performing radiofrequency ablation in patients with a cardiac implantable electronic device, it is imperative to follow published best practice recommendations to minimize the risk of adverse events.
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http://dx.doi.org/10.1213/XAA.0000000000001286DOI Listing
September 2020

Trends in reported industry payments to physicians practicing cardiac electrophysiology from 2013 to 2018 in the United States.

J Cardiovasc Electrophysiol 2020 12 7;31(12):3106-3114. Epub 2020 Oct 7.

Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA.

Introduction: The need for transparency in financial relationships in the healthcare system, has culminated in Open Payments database, managed by the Center for Medicare and Medicaid Services (CMS). Since its inception in 2013, the trend in such payments to physicians practicing cardiac electrophysiology was not examined.

Methods And Results: Payment information reported to CMS from January 2013 to December 2018 was obtained from the publicly available Open Payments data set using the online query tool. The data were analyzed by an individual provider and by state. An in-depth analysis of payments in the year 2018 payments was performed. From 2014 to 2018, there was an 18% increase in the total number of payments reported from 88 877 payments in 2014 to 105 000 in 2018. Despite the increase in the total number of payments reported, the average payment steadily decreased over time, resulting in an overall reduction in the total amount of payments from 2014 to 2018 ($34.9 million to $28.2 million). Payments to the top 5% of individual recipients have also decreased over this time. In 2018, 2888 unique providers received reportable payments, a total of 105 000 payments, with a median payment amount of $1378 (interquartile range: $165-$5781). The majority of these payments were for food and beverage (82%) and travel/lodging (10%). The top five payers include Boston Scientific, Medtronic Vascular, Abbott Laboratories, Janssen Pharmaceuticals, and Biotronik.

Conclusion: Among cardiac electrophysiologists, there is increased reporting of payments in the Open Payments program over time, with a notable decrease in the payment amount.
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http://dx.doi.org/10.1111/jce.14754DOI Listing
December 2020

Ventricular asystole in the presence of a biventricular device.

J Cardiovasc Electrophysiol 2020 11 19;31(11):3031-3035. Epub 2020 Aug 19.

Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA.

In pacemaker-dependent patients with a newly implanted cardiac device, acute lead dislodgement constitutes one of the most common causes of loss of capture and ventricular asystole. In a biventricular system, it would be expected that such a potentially catastrophic event would be prevented with back-up right ventricular pacing unless both leads dislodge.
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http://dx.doi.org/10.1111/jce.14715DOI Listing
November 2020

A Tough Time Running Around the Block.

Circ Heart Fail 2020 08 15;13(8):e007182. Epub 2020 Jul 15.

Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN.

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http://dx.doi.org/10.1161/CIRCHEARTFAILURE.120.007182DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7438251PMC
August 2020

Clinical implications of elective replacement indicator setting changes in patients with dual-chamber pacemaker devices.

J Cardiovasc Electrophysiol 2020 10 24;31(10):2704-2710. Epub 2020 Jul 24.

Department of Cardiovascular Disease, Mayo Clinic, Rochester, Minnesota, USA.

Objective: This study sought to determine if single-chamber operation and/or loss of rate response (RR) during elective replacement indicator (ERI) in patients with dual-chamber pacemakers lead to increased symptom burden, healthcare utilization, and atrial fibrillation (AF).

Background: Dual-chamber pacemakers often change from dual- to single-chamber pacing mode and/or lose RR functionality at ERI to preserve battery. Single-chamber pacing increases the incidence of heart failure, AF, and pacemaker syndrome suggesting these changes may be deleterious.

Methods: A retrospective analysis of 700 patients was completed. Three comparisons were analyzed: Comparison 1: mode change and RR loss versus no change; Comparison 2: RR loss only versus no change; Comparison 3: mode change only versus no change (in patients with no RR programmed at baseline).

Results: In Comparison 1, 121 (46%) patients with setting changes experienced symptoms (most often dyspnea and fatigue/exercise intolerance) versus 3 (4%) without setting changes (p < .0001). Similar results were noted in Comparisons 2 and 3 (p = .0016 and p = .0001, respectively). In Comparison 1, patients with setting change sought provider contact more than patients without setting changes (p = .0001). A significant difference was not noted in Comparison 2 or 3. Overall 14 (2%) patients were hospitalized, all of whom had setting changes.

Conclusions: Setting changes at ERI including a change from dual- to single-chamber pacing and/or loss of RR results in a significantly increased symptom burden and increased healthcare utilization.
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http://dx.doi.org/10.1111/jce.14677DOI Listing
October 2020

Burden of Arrhythmias in Acute Myocardial Infarction Complicated by Cardiogenic Shock.

Am J Cardiol 2020 06 6;125(12):1774-1781. Epub 2020 Apr 6.

Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.

There are limited data on arrhythmias in acute myocardial infarction with cardiogenic shock (AMI-CS). Using a 17-year AMI-CS population from the National Inpatient Sample, we identified common arrhythmias - atrial fibrillation (AF), atrial flutter, supraventricular tachycardia, ventricular tachycardia, ventricular fibrillation, and atrioventricular blocks (AVB). Admissions with concomitant cardiac surgery were excluded. Outcomes of interest included temporal trends, predictors, in-hospital mortality, and resource utilization in cohorts with and without arrhythmias. Of the 420,319 admissions with AMI-CS during 2000 to 2016, arrhythmias were noted in 213,718 (51%). AF (45%), ventricular tachycardia (35%) and ventricular fibrillation (30%) were the most common arrhythmias. Compared with those without, the cohort w`ith arrhythmias was more often male, of white race, with ST-segment elevation AMI-CS presentation, and had higher rates of cardiac arrest and acute organ failure (all p <0.001). Temporal trends of prevalence revealed a stable trend of atrial and ventricular arrhythmias and declining trend in AVB. The cohort with arrhythmias had higher unadjusted (42% vs 41%; odds ratio [OR] 1.03 [95% confidence interval 1.02 to 1.05]; p <0.001), but not adjusted (OR 1.01 [95% CI 0.99 to 1.03]; p = 0.22) in-hospital mortality compared with those without. The cohort with arrhythmias had longer hospital stay (9 ± 10 vs 7 ± 9 days; p <0.001) and higher hospitalization costs ($124,000 ± 146,000 vs $91,000 ± 115,000; p <0.001). In the cohort with arrhythmias, older age, female sex, non-white race, higher co-morbidity, presence of acute organ failure, and cardiac arrest, predicted higher in-hospital mortality. In conclusion, cardiac arrhythmias in AMI-CS are a marker of higher illness severity and are associated with greater resource utilization.
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http://dx.doi.org/10.1016/j.amjcard.2020.03.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7261623PMC
June 2020

Appropriate cohort selection and its impact on a meta-analysis evaluating the efficacy of direct oral anticoagulants post-percutaneous coronary intervention.

Eur Heart J 2020 05;41(17):1700

Department of Cardiovascular Disease, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054, USA.

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http://dx.doi.org/10.1093/eurheartj/ehaa081DOI Listing
May 2020

Clinical Outcomes of Various Management Strategies for Symptomatic Bradycardia.

Clin Med Res 2020 08 14;18(2-3):75-81. Epub 2020 Feb 14.

Division of Cardiovascular Diseases, Mayo Clinic Hospital, Phoenix, Arizona, USA; Current affiliation: MercyOne Waterloo Heart Care, Waterloo, Iowa, USA.

Objective: To determine clinical outcomes of various management strategies for reversible and irreversible causes of symptomatic bradycardia in the inpatient setting.

Design: Retrospective observational study.

Setting: Emergency room and inpatient.

Participants: Patients presenting to the emergency department with symptomatic bradycardia.

Methods: We retrospectively reviewed electronic health records of 518 patients from two Mayo Clinic campuses (Rochester and Phoenix) who presented to the emergency department with symptomatic bradycardia (heart rate ≤50 beats/minute) from January 1, 2010 through December 31, 2015. Sinus bradycardia was excluded. The following management strategies were compared: observation, non-invasive management (medications with/without transcutaneous pacing), early permanent pacemaker (PPM) implantation (≤2 days), and delayed PPM implantation (≥3 days). Study endpoints included length of stay and adverse events related to bradycardia (syncope, central line-associated bloodstream infections, cardiac arrest, and in-hospital mortality). Patients who received a PPM were further stratified by weekend hospital admission.

Results: Heart block occurred in 200 (38.6%) patients, and atrial arrhythmias with slow ventricular response occurred in 239 (46.1%) patients. Reversible causes of bradycardia included medication toxicity in 22 (4.2%) patients and hyperkalemia in 44 (8.5%) patients. Adverse events were similar in patients who underwent early compared to delayed PPM implantation (6.6% vs 12.5%, P=.20), whereas adverse events were higher in patients who received temporary transvenous pacing (19.1% vs 3.4%, P<.001). Weekend admissions were associated with increased temporary transvenous pacing, prolonged median time to PPM implantation by 1 day, and prolonged median length of stay by 2 days.

Conclusions: Delayed PPM implantation was not associated with an increase in adverse events. Weekend PPM implantation should be considered to reduce temporary transvenous pacing and shorten length of stay.
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http://dx.doi.org/10.3121/cmr.2019.1507DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7428208PMC
August 2020

Venoarterial Extracorporeal Membrane Oxygenation Support for Ventricular Tachycardia Ablation: A Systematic Review.

ASAIO J 2020 Sep/Oct;66(9):980-985

From the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.

Refractory ventricular tachycardia (VT) and electrical storm are frequently associated with hemodynamic compromise requiring mechanical support. This study sought to review the current literature on the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) for hemodynamic support during VT ablation. This was a systematic review of all published literature from 2000 to 2019 evaluating patients with VT undergoing ablation with VA-ECMO support. Studies that reported mortality, safety, and efficacy outcomes in adult (>18 years) patients were included. The primary outcome was short-term mortality (intensive care unit stay, hospital stay, or ≤30 days). The literature search identified 4,802 citations during the study period, of which seven studies comprising 867 patients met the inclusion criteria. Periprocedural VA-ECMO was used in 129 (15%) patients and all were placed peripherally. Average inducible VTs were 2-3 per procedure and ablation time varied between 34 mins and 4.7 hours. Median ages were between 61 and 68 years with 93% males. Median duration of VA-ECMO varied between 140 minutes and 6 days. Short-term mortality was 15% (19 patients), with the most frequent causes being refractory VT, cardiac arrest, and acute heart failure. All-cause mortality at the longest follow-up was 25%. Major bleeding, vascular/access complications, limb ischemia, stroke, and acute kidney injury were reported with varying frequency of 1-6%. In conclusion, VA-ECMO is used infrequently for hemodynamic support for VT ablation. Further data on patient selection, procedural optimization, and clinical outcomes are needed to evaluate the efficacy of this strategy.
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http://dx.doi.org/10.1097/MAT.0000000000001125DOI Listing
March 2021

Postoperative opioid prescription patterns and new opioid refills following cardiac implantable electronic device procedures.

Heart Rhythm 2019 12 21;16(12):1841-1848. Epub 2019 Oct 21.

Mayo Clinic Rochester, Rochester, Minnesota. Electronic address:

Background: Prescription opioids are a major cause of the opioid epidemic. Despite the invasive nature of cardiac implantable electronic device (CIED) procedures, data on opioid prescription patterns after CIED procedures are lacking.

Objective: The purpose of this study was to assess opioid prescribing patterns and the rates of new opioid refills (refills in previously opioid naïve patients) among patients undergoing CIED procedures.

Methods: We performed a retrospective analysis of all patients undergoing CIED procedures from January 1, 2010, to March 30, 2018, at the Mayo Clinic (Minnesota, Arizona, and Florida). Procedures were categorized into new implant, generator change, device upgrade, lead revision or replacement, and subcutaneous implantable cardiac defibrillator (S-ICD) procedures. The rates of postoperative opioid prescription and new opioid refills were analyzed. Wilcoxon rank sum and χ tests assessed variations.

Results: A total of 16,517 patients (mean age 70 ± 15; 36% female) underwent CIED procedures. Opioids were prescribed to 20.2% of the patients, among whom 80% were opioid naïve. Among opioid naïve patients who received opioids, 9.4% (95% confidence interval [CI] 8.3%-10.5%) had subsequent opioid refills. The percentage of patients who received more than 200 oral morphine equivalents of prescription was 38.8% (95% CI 37.2%-40.5%). Temporal trends revealed increasing rates of any opioid prescription, peaking in 2015 at 25.9%, with subsequent downtrend to 14.6% in 2018 (P <.001).

Conclusion: Postoperative opioid prescription rate after CIED procedures was 20.2%, with most patients being opioid naïve. Among opioid naïve patients who received opioids, 9.4% had subsequent opioid refills. This finding suggests that perioperative pain management in CIED procedures warrants meticulous attention.
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http://dx.doi.org/10.1016/j.hrthm.2019.08.011DOI Listing
December 2019

Segment of posterior tricuspid valve leaflet missing after lead extraction.

Eur Heart J Cardiovasc Imaging 2020 03;21(3):272

Department of Cardiovascular Diseases, Mayo Clinic, 200 1st St SW, Rochester, MN 55902, USA.

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http://dx.doi.org/10.1093/ehjci/jez234DOI Listing
March 2020

Stellate ganglion block and cardiac sympathetic denervation in patients with inappropriate sinus tachycardia.

J Cardiovasc Electrophysiol 2019 12 6;30(12):2920-2928. Epub 2019 Nov 6.

Department of Cardiovascular Diseases, Mayo Clinic Hospital, Phoenix, Arizona.

Background: Inappropriate sinus tachycardia (IST) remains a clinical challenge because patients often are highly symptomatic and not responsive to medical therapy.

Objective: To study the safety and efficacy of stellate ganglion (SG) block and cardiac sympathetic denervation (CSD) in patients with IST.

Methods: Twelve consecutive patients who had drug-refractory IST (10 women) were studied. According to a prospectively initiated protocol, five patients underwent an electrophysiologic study before and after SG block (electrophysiology study group). The subsequent seven patients had ambulatory Holter monitoring before and after SG block (ambulatory group). All patients underwent SG block on the right side first, and then on the left side. Selected patients who had heart rate reduction ≥15 beats per minute (bpm) were recommended to consider CSD.

Results: The mean (SD) baseline heart rate (HR) was 106 (21) bpm. The HR significantly decreased to 93 (20) bpm (P = .02) at 10 minutes after right SG block and remained significantly slower at 97(19) bpm at 60 minutes. Left SG block reduced HR from 99 (21) to 87(16) bpm (P = .02) at 60 minutes. SG block had no significant effect on blood pressure or HR response to isoproterenol or exercise (all P > .05). Five patients underwent right (n = 4) or bilateral (n = 1) CSD. The clinical outcomes were heterogeneous: one patient had complete and two had partial symptomatic relief, and two did not have improvement.

Conclusion: SG blockade modestly reduces resting HR but has no significant effect on HR during exercise. Permanent CSD may have a modest role in alleviating symptoms in selected patients with IST.
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http://dx.doi.org/10.1111/jce.14233DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6973270PMC
December 2019

Sudden cardiac arrest and ventricular arrhythmias following first type I myocardial infarction in the contemporary era.

J Cardiovasc Electrophysiol 2019 12 17;30(12):2869-2876. Epub 2019 Oct 17.

Department of Cardiovascular Diseases, Mayo Clinic, Phoenix, Arizona.

Introduction: Myocardial infarction (MI) is associated with an increase in subsequent heart failure (HF), recurrent ischemic events, sudden cardiac arrest, and ventricular arrhythmias (SCA-VA). The primary objective of the study to determine the role of intercurrent HF and ischemic events on the development of SCA-VA following first type I MI.

Methods And Results: A retrospective cohort study of patients experiencing first type 1 MI in Olmsted County, Minnesota (2002-2012) was conducted by identifying patients using the medical records linkage system (Rochester epidemiology project). Patients aged ≥18 years were followed from the time of MI till death or 31 July, 2017. Intercurrent HF and ischemic events were the primary exposures following MI and their association with outcome SCA-VA was assessed. Eight hundred and sixty-seven patients (mean age was 63 ± 14.5 years; 69% male; 49.8% ST-elevation myocardial infarction) who had their first type I MI during the study period were included. Majority of acute MI patients were revascularized using percutaneous coronary intervention and bypass surgery (628 [72.43%] and 87 [10.03%] respectively). During a mean follow-up of 7.69 ± 4.17 years, HF, recurrent ischemic events and SCA-VA occurred in 155 (17.9%), 245 (28.3%), and 40 (4.61%) patients respectively. Low ejection fraction (adjusted hazard ratio [HR] 0.95; 95% confidence interval [CI], 0.93-0.98; P < .001), intercurrent HF (adjusted HR 3.11; 95% CI, 1.39-6.95; P = .006) and recurrent ischemic events (adjusted HR 3.47; 95% CI, 1.68-7.18; P < .001) were associated with subsequent SCA-VA.

Conclusion: SCA-VA occurred in a small proportion of patients after MI and is associated with intercurrent HF and recurrent ischemic events.
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http://dx.doi.org/10.1111/jce.14218DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8276850PMC
December 2019

Effective Use of Percutaneous Stellate Ganglion Blockade in Patients With Electrical Storm.

Circ Arrhythm Electrophysiol 2019 09 13;12(9):e007118. Epub 2019 Sep 13.

Division of Heart Rhythm Services, Department of Cardiovascular Medicine (Y.T., S.K., P.X., P.A.N., S.K.M., A.J.D., H.-C.L., M.J.A., S.J.A., T.M.M., P.A.F., Y.-M.C.), Mayo Clinic, Rochester, MN.

Background: Percutaneous stellate ganglion blockade (SGB) has been used for drug-refractory electrical storm due to ventricular arrhythmia (VA); however, the effects and long-term outcomes have not been well studied.

Methods: This study included 30 consecutive patients who had drug-refractory electrical storm and underwent percutaneous SGB between October 1, 2013, and March 31, 2018. Bupivacaine, alone or combined with lidocaine, was injected into the neck with good local anesthetic spread in the vicinity of the left stellate ganglion (n=15) or both stellate ganglia (n=15). Data were collected for patient clinical characteristics, immediate and long-term outcomes, and procedure-related complications.

Results: Clinical characteristics included age, 58±14 years; men, 73.3%; and left ventricular ejection fraction, 34±16%. At 24 hours, 60% of patients were free of VA. Patients whose VA was controlled had a lower hospital mortality rate than patients whose VA continued (5.6% versus 50.0%; =0.009). Implantable cardioverter-defibrillator interrogation showed a significant 92% reduction in VA episodes from 26±41 to 2±4 in the 72 hours after SGB (<0.001). Patients who died during the same hospitalization (n=7) were more likely to have ischemic cardiomyopathy (100% versus 43.5%; =0.03) and recurrent VA within 24 hours (85.7% versus 26.1%; =0.009). There were no procedure-related major complications.

Conclusions: SGB effectively attenuated electrical storm in more than half of patients without procedure-related complications. Percutaneous SGB may be considered for stabilizing ventricular rhythm in patients for whom other therapies have failed.
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http://dx.doi.org/10.1161/CIRCEP.118.007118DOI Listing
September 2019

Association between the Charlson comorbidity index and outcomes after implantable cardioverter defibrillator generator replacement.

Pacing Clin Electrophysiol 2019 09 6;42(9):1236-1242. Epub 2019 Aug 6.

Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota.

Background: Recipients of implantable cardioverter defibrillator (ICD) generator replacement with multiple medical comorbidities may be at higher risk of adverse outcomes that attenuate the benefit of ICD replacement. The aim of this investigation was to study the association between the Charlson comorbidity index (CCI) and outcomes after ICD generator replacement.

Methods: All patients undergoing first ICD generator replacement at Mayo Clinic, Rochester and Beth Israel Deaconess Medical Center, Boston between 2001 and 2011 were identified. Outcomes included: (a) all-cause mortality, (b) appropriate ICD therapy, and (c) death prior to appropriate therapy. Multivariable Cox regression analysis was performed to assess association between CCI and outcomes.

Results: We identified 1421 patients with mean age of 69.6 ± 12.1 years, 81% male and median (range) CCI of 3 (0-18). During a mean follow-up of 3.9 ± 3 years, 52% of patients died, 30.6% experienced an appropriate therapy, and 23.6% died without experiencing an appropriate therapy. In multivariable analysis, higher CCI score was associated with increased all-cause mortality (Hazard ratio, HR 1.10 [1.06-1.13] per 1 point increase in CCI, P < .001), death without prior appropriate therapy (HR 1.11 [1.07-1.15], P < .0001), but not associated with appropriate therapy (HR 1.01 [0.97-1.05], P = .53). Patients with CCI ≥5 had an annual risk of death of 12.2% compared to 8.7% annual rate of appropriate therapy.

Conclusions: CCI is predictive of mortality following ICD generator replacement. The benefit of ICD replacement in patients with CCI score ≥5 should be investigated in prospective studies.
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http://dx.doi.org/10.1111/pace.13762DOI Listing
September 2019

Achieving durable mitral isthmus block: Challenges, pitfalls, and methods of assessment.

J Cardiovasc Electrophysiol 2019 09 1;30(9):1679-1687. Epub 2019 Aug 1.

Department of Cardiovascular Diseases, Mayo Clinic Arizona, Phoenix, Arizona.

Background And Objectives: Macroreentrant atrial tachycardias often occur following atrial fibrillation ablation, most commonly due to nontransmural lesions in prior ablation lines. Perimitral atrial flutter is one such arrhythmia which requires ablation of the mitral isthmus. Our objectives were to review the literature regarding ablation of the mitral isthmus and to provide our approach for assessment of mitral isthmus block.

Methods: We review anatomical considerations, ablation strategies, and assessment of conduction block across the mitral isthmus, which is subject to several pitfalls. Activation sequence and spatial differential pacing techniques are discussed for assessment of both endocardial and epicardial bidirectional mitral isthmus block.

Results: Traditional methods for verifying mitral isthmus block include spatial differential pacing, activation mapping, and identification of double potentials. Up to 70% of cases require additional ablation in the coronary sinus (CS) to achieve transmural block. Interpretation of transmural block is subject to six pitfalls involving pacing output, differentiation of endocardial left atrial recordings from epicardial CS recordings, identification of a slowly conducting gap in the line, and catheter positioning during spatial differential pacing. Interpretation of unipolar electrograms can identify nontransmural lesions. We employ a combined epicardial and endocardial assessment of mitral isthmus block, which involves using a CS catheter for epicardial recording and a duodecapolar Halo catheter positioned around the mitral annulus for endocardial recording.

Conclusions: The assessment of transmural mitral isthmus block can be challenging. Placement of an endocardial mapping catheter around the mitral annulus can provide a precise assessment of conduction across the mitral isthmus.
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http://dx.doi.org/10.1111/jce.14079DOI Listing
September 2019

Outcome of combined cryo- and radiofrequency-catheter ablation in patients with supraventricular tachycardias.

J Cardiovasc Electrophysiol 2019 10 5;30(10):1960-1966. Epub 2019 Aug 5.

Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.

Background: There are few data regarding the outcome of a combined cryo- and radiofrequency (RF)-catheter ablation of various types of supraventricular tachycardias (SVTs) originating from near the normal conduction system.

Methods: We analyzed all patients undergoing combined cryo- and RF- catheter ablation at Mayo Clinic, Rochester, MN as part of the ablation of SVTs with potential risks of injury to the normal conduction system. This study aimed to assess the outcome of a combined cryo- and RF-catheter ablation of various types of SVTs.

Results: The study population consisted of 54 patients (38 ± 17 years, 32 men). A combined cryo- and RF-catheter ablation was attempted for septal accessary pathways (APs) in 26, atrioventricular nodal reentrant tachycardia (AVNRT) in 14, atrial tachycardia (AT) in 7, and junctional ectopic tachycardia in 7 patients. Forty-one patients (76%) were successfully ablated with cryoablation, and RF ablation after an unsuccessful cryoablation ablated the SVTs successfully at the same location in 6 patients (11%). Complication occurred in 1 patient (deep vein thrombosis). The cumulative freedom from SVT rate at 30 days after the procedure was 78% and there was no significant difference in the recurrence rate among the SVTs.

Conclusion: A combined cryo- and RF-catheter ablation is clinically effective in patients undergoing SVT ablation with the potential risk of injury to the normal conduction system.
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http://dx.doi.org/10.1111/jce.14068DOI Listing
October 2019

Electrophysiologic effects and outcomes of sympatholysis in patients with recurrent ventricular arrhythmia and structural heart disease.

J Cardiovasc Electrophysiol 2019 09 4;30(9):1499-1507. Epub 2019 Jul 4.

Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.

Introduction: Autonomic modulation has been used as a therapy to control recurrent ventricular arrhythmia (VA). This study was to explore stellate ganglion block (SGB) effect on cardiac electrophysiologic properties and evaluate the long-term outcome of cardiac sympathetic denervation (CSD) for patients with recurrent VA and structural heart disease (SHD).

Materials And Methods: Patients who had recurrent VA due to SHD were enrolled prospectively. Electrophysiologic study and ventricular tachycardia (VT) induction were performed before and after left and right SGB. VA burden and long-term outcomes were assessed for a separate patient group who underwent left or bilateral CSD for drug-refractory VA due to SHD.

Results: Electrophysiologic study of nine patients showed that baseline mean (SD) corrected sinus node recovery time (cSNRT) increased from 320.4 (73.3) ms to 402.9 (114.2) ms after left and 482.4 (95.7) ms after bilateral SGB (P = .03). SGB did not significantly change P-R, QRS, and Q-T intervals and ventricular effective refractory period, nor did the inducibility of VA. Nineteen patients underwent left (n = 14) or bilateral (n = 5) CSD. CSD reduced VA burden and appropriate ICD therapies from a median (interquartile range) of 2.5 (0.4-11.6) episodes weekly to 0.1 (0.0-2.4) episodes weekly at 6-month follow-up (P = .002). Three-year freedom from orthotopic heart transplant (OHT) and death was 52.6%. New York Heart Association functional class III/IV and VT rate less than 160 beats per minute were predictors of recurrent VA, OHT, and death.

Conclusion: SGB increased cSNRT without changing heart rate. CSD was more beneficial for patients with mild-to-moderate heart failure and faster VA.
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http://dx.doi.org/10.1111/jce.14030DOI Listing
September 2019

Efficacy of Pharmacologic and Cardiac Implantable Electronic Device Therapies in Patients With Heart Failure and Reduced Ejection Fraction: A Systematic Review and Network Meta-Analysis.

Circ Arrhythm Electrophysiol 2019 06 4;12(6):e006951. Epub 2019 Jun 4.

Division of Cardiovascular Diseases (J.Z.L., S.K.M.), Mayo Clinic Arizona, Phoenix.

Background The treatment of heart failure with reduced ejection fraction has been the subject of numerous randomized controlled trials involving medications and cardiac implantable electronic device therapies. As newer effective pharmacological therapies suggest significant reductions in all-cause mortality, the role of additional device therapy in heart failure with reduced ejection fraction deserves further scrutiny. Methods A systematic review and network meta-analysis on the effect of medication and device therapies in heart failure with reduced ejection fraction on all-cause mortality was performed. Randomized controlled trials published between January 1980 and July 2017 were identified using Medline, EMBASE, and Cochrane Controlled Register of Trials databases. Pcnetmeta package in R was used to calculate treatment arm-based estimated rates, rate ratios, and probability ranks with 95% credible intervals. Results Combination therapy of ACE (angiotensin-converting enzyme) inhibitors or ARBs (angiotensin receptor blockers) with β-blockers (BBs) alone or in addition to implantable cardiac defibrillators or cardiac resynchronization therapy with defibrillators demonstrated a significant reduction of all-cause mortality when compared with placebo. By probability rank, implantable cardiac defibrillator+ACE inhibitor or ARB+BB+mineralocorticoid receptor antagonist, implantable cardiac defibrillator+ACE inhibitor or ARB+BB, and angiotensin receptor-neprilysin inhibitor+BB+mineralocorticoid receptor antagonist combination therapies have the highest probability of being ranked the best treatment. There was no significant difference in the rate of mortality when comparing angiotensin receptor-neprilysin inhibitor+BB+mineralocorticoid receptor antagonist to implantable cardiac defibrillator+optimal pharmacological combination therapy. Conclusions BB and renin-angiotensin system blockers alone or in combination with defibrillator device therapy have robust evidence for a reduction in mortality compared with placebo. The comparative efficacy of pharmacological therapy with angiotensin receptor-neprilysin inhibitors and device therapy deserves further investigation.
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http://dx.doi.org/10.1161/CIRCEP.118.006951DOI Listing
June 2019
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