BackgroundAtrial fibrillation is associated with higher mortality. Identification of causes of death and contemporary risk factors for all‐cause mortality may guide interventions.Methods and ResultsIn the Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF) study, patients with nonvalvular atrial fibrillation were randomized to rivaroxaban or dose‐adjusted warfarin. Cox proportional hazards regression with backward elimination identified factors at randomization that were independently associated with all‐cause mortality in the 14 171 participants in the intention‐to‐treat population. The median age was 73 years, and the mean CHADS 2 score was 3.5. Over 1.9 years of median follow‐up, 1214 (8.6%) patients died. Kaplan–Meier mortality rates were 4.2% at 1 year and 8.9% at 2 years. The majority of classified deaths (1081) were cardiovascular (72%), whereas only 6% were nonhemorrhagic stroke or systemic embolism. No significant difference in all‐cause mortality was observed between the rivaroxaban and warfarin arms (P=0.15). Heart failure (hazard ratio 1.51, 95% CI 1.33–1.70, P<0.0001) and age ≥75 years (hazard ratio 1.69, 95% CI 1.51–1.90, P<0.0001) were associated with higher all‐cause mortality. Multiple additional characteristics were independently associated with higher mortality, with decreasing creatinine clearance, chronic obstructive pulmonary disease, male sex, peripheral vascular disease, and diabetes being among the most strongly associated (model C‐index 0.677).ConclusionsIn a large population of patients anticoagulated for nonvalvular atrial fibrillation, ≈7 in 10 deaths were cardiovascular, whereas <1 in 10 deaths were caused by nonhemorrhagic stroke or systemic embolism. Optimal prevention and treatment of heart failure, renal impairment, chronic obstructive pulmonary disease, and diabetes may improve survival.Clinical Trial Registration URL: https://www.clinicaltrials.gov/. Unique identifier: NCT00403767.

Our data suggest that ventricular tachyarrhythmias may not always be the primary mechanism of syncope and sudden death in patients with HCM. The ICD seems to have a less important impact on prognosis in patients with HCM than in patients with other etiologies of aborted sudden death.

Aim Concern exists about the benefit of implantable defibrillator therapy in elderly patients. We assessed the utility of implantable defibrillator therapy and its effect on mortality in patients 70 years and older and compared results in this group to those in younger patients. Methods and resultsThirty-two out of 200 consecutive patients (16%) were 70 years or older at the time of implantation of a defibrillator. When comparing elderly to younger patients no significant differences were noted with respect to presenting arrhythmia, left ventricular ejection fraction or presence of an old myocardial infarction. Elderly patients had a higher prevalence of ischaemic heart disease, while in the younger group more patients had idiopathic ventricular tachycardia. Cumulative survival curves (Kaplan-Meier method) for all-cause mortality, sudden cardiac death and non-sudden cardiac death were constructed for elderly and younger patients. No significant differences for cumulative survival from all-cause mortality (75 vs 74%), sudden cardiac death (0 vs 4%) and non-sudden cardiac death (97 vs 93%) were found. The incidence of appropriate shocks during follow-up was comparable (65 vs 72%).

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ApresentaçãoAs diretrizes para o diagnóstico e tratamento das arritmias cardíacas surgiram a partir da filosofia da Sociedade Brasileira de Cardiologia (SBC) de manter atualizadas as informações de procedimentos relacionados ao diagnóstico e tratamento de pacientes com cardiopatias.O Departamento de Arritmias e Eletrofisiologia Clínica (DAEC) decidiu realizar um documento mais amplo que nos consensos realizados anteriormente, revisando criticamente, não apenas as informações das especialidades intervencionistas, como a eletrofisiologia invasiva e a estimulação cardíaca artificial, mas propondo diretrizes para temas anteriormente não abordados, de especial interesse dos cardiologistas clínicos, como as indicações e interpretações dos métodos não invasivos e o tratamento clínico das arritmias cardíacas.Nestas diretrizes, que contaram com a participação de 50 especialistas considerados os mais destacados nas respectivas áreas, procuramos estabelecer normas técnicas para a realização dos procedimentos intervencionistas, como qualificação e habilitação dos recursos humanos, condições de segurança dos serviços e equipamentos indispensáveis para realização destes procedimentos. Estas informações podem ser úteis às instituições governamentais e organizações privadas que custeiam a sua execução, além de representarem a preocupação prioritária do DAEC com a segurança do paciente.Seguindo as orientações da diretoria científica da SBC, as indicações clínicas para realização dos procedimentos e testes diagnósticos foram reavaliadas com espírito crítico, baseado em publicações científicas e, quando possível, na análise custo-efetividade.O resultado deste trabalho será útil a todos os membros da SBC, que sem dúvida receberão um manuscrito realizado com cuidado e rigor científico. Cruz (1997-1998) Mauricio Ibrahim Scanavacca (1999 Sérgio Rassi (2001Rassi ( -2002 COLABORAÇÃO: Mauricio Ibrahim Scanavacca B) Aceitável• Aceitável e segura, clinicamente útil, mas não confirmado definitivamente ainda por estudo randomizado amplo ou por metanálise B1) Evidência muito boa B2) Evidência razoável C) Inaceitável• Clinicamente sem utilidade, pode ser prejudicial Níveis de Definição EvidênciaNível 1Dados derivados de revisões sistemáticas/metanálises com resultados bem definidos ou dados provenientes de estudos clínicos randomizados, incluindo grande número de pacientes. Nível 2Dados derivados de um número limitado de estudos clínicos randomizados, incluindo pequeno número de pacientes. Nível 3Dados derivados de análise cuidadosa de estudos não-randomizados ou de registros observacionais. Nível 4A recomendação se baseia primariamente em práticas comuns, conjeturas racionais, modelos fisiopatológicos e consenso de especialistas, sem referência aos estudos anteriores. 6 IntroduçãoA decisão da utilização de métodos diagnósticos complementares para investigação de pacientes em medicina baseia-se na capacidade destes métodos em confirmar ou afastar a hipótese diagnóstica levantada durante a observação clínica sistemática. A falta de critério...

BackgroundThere are innumerous indicators to assure the quality of a service. However, medical competence and the proper performance of a procedure determine its final quality. The Brazilian Society of Cardiac Arrhythmias recommends minimum parameters necessary to guarantee the excellence of ambulatory electrocardiographic monitoring services.ObjectiveTo recommend minimum medical competences and the information required to issue a Holter monitoring report.MethodsThis study was grounded in the concept of evidence-based medicine and, when evidence was not available, the opinion of a writing committee was used to formulate the recommendation. That committee consisted of professionals with experience on the difficulties of the method and management in providing services in that area.ResultsThe professional responsible for the Holter monitoring analysis should know cardiovascular pathologies and have consistent formation on electrocardiography, including cardiac arrhythmias and their differential diagnoses. The report should be written in a clear and objective way. The minimum parameters that comprise a Holter report should include statistics of the exam, as well as quantification and analysis of the rhythm disorders observed during monitoring. ConclusionAmbulatory electrocardiographic monitoring should be performed by professionals knowledgeable about electrocardiographic analysis, whose report should comprise the minimum parameters mentioned in this document.

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