BackgroundAtrial fibrillation (AF) is the most common sustained cardiac arrhythmia resulting in mortality and morbidity. Gaps in oral anticoagulation and education of patients regarding AF have been identified as areas that require improvement.Methods and ResultsA before‐and‐after study of 433 patients with newly diagnosed AF in the 3 emergency departments in Nova Scotia from January 1, 2011 until January 31, 2014 was performed. The “before” phase underwent the usual‐care pathway for AF management; the “after” phase was enrolled in a nurse‐run, physician‐supervised AF clinic. The primary outcome was a composite of death, cardiovascular hospitalization, and AF‐related emergency department visits. A propensity analysis was performed to account for differences in baseline characteristics.ResultsA total of 185 patients were enrolled into the usual‐care group, and 228 patients were enrolled in the AF clinic group. The mean age was 64±15 years and 44% were women. In a propensity‐matched analysis, the primary outcome occurred in 44 (26.2%) patients in the usual‐care group and 29 (17.3%) patients in the AF clinic group (odds ratio 0.71; 95% CI [0.59, 1]; P=0.049) at 12 months. Prescription of oral anticoagulation was increased in the CHADS 2 ≥2 group (88.4% in the AF clinic versus 58.5% in the usual‐care group, P<0.01).ConclusionsAdoption of this integrated management approach for the burgeoning population of AF may provide an overall benefit to cardiovascular morbidity and mortality.

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This Canadian Cardiovascular Society position statement is focused on the management of sustained ventricular tachycardia (VT) and ventricular fibrillation (VF) that occurs in patients with structural heart disease (SHD), including previous myocardial infarction, dilated cardiomyopathy, and other forms of nonischemic cardiomyopathy. This patient population is rapidly increasing because of advances in care and improved overall survival of patients with all forms of SHD. In this position statement, the acute and long-term management of VT/VF are outlined, and the many unique aspects of care in this population Scope of the Position StatementThis Canadian Cardiovascular Society position statement is focused on the acute and long-term management of sustained ventricular tachycardia (VT) and ventricular fibrillation (VF) in patients with structural heart disease (SHD), defined by the presence of abnormal myocardium and scar. SHD includes conditions such as myocardial infarction (MI), dilated cardiomyopathies, hypertrophic cardiomyopathy, infiltrative cardiomyopathies (eg, sarcoidosis), and arrhythmogenic right ventricular cardiomyopathy

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The response to atrial overdrive pacing during WCT with 1:1 AV relationship can rapidly diagnose or rule out VT as a mechanism of tachycardia.

Background: The comparative efficacy of antiarrhythmic drug therapy (AAD) versus ventricular tachycardia (VT) ablation in arrhythmogenic right ventricular cardiomyopathy (ARVC) is unknown. Objectives: We compared outcomes of AAD and/or beta blocker (BB) therapy to VT ablation (with AAD/BB) in ARVC patients with recurrent VT. Methods: In a multicenter retrospective study, 110 ARVC patients (38±17 years, 83% male) with a minimum of 3 VT episodes were included; 77 (70%) were initially treated with AAD/BB and 32 (29%) underwent ablation. Subsequently, 43 of the 77 patients treated with AAD/BB-only also underwent ablation. Overall, 75 patients underwent ablation. Results: When comparing initial AAD/BB therapy (n=77) and VT ablation (n=32) after ≥3 VT episodes, a single ablation procedure rendered 35% of patients free of VT at 3 years compared to 28% of AAD/BB-only treated patients (p=0.46). Of the 77 AAD/BB treated patients, 43 subsequently had ablation. For all 75 patients who had ablation, 56% were VT-free at 3 years after the last ablation. Epicardial ablation was used in 53% and was associated with lower VT recurrence after the last ablation (endocardial/epicardial vs. endocardial-only; 71% vs. 47% three-year VT-free survival, p=0.05). Importantly, there was no difference in survival free of death or transplantation between the ablation-and AAD/BB-only treated patients (p=0.61). Conclusion: Amongst ARVC patients with a high VT burden, mortality and transplantation-free survival is not significantly different between drug-and ablationtreated patients. These patients have a high risk of recurrent VT despite drug therapy. Combined endocardial/epicardial ablation is associated with reduced VT recurrence compared to endocardial-only ablation.

A 49-year-old man with no previous cardiac history presented to hospital with 2-week history of progressive dyspnea and orthopnea. He was diagnosed with severe heart failure and pulmonary edema, and responded to intravenous (IV) diuretics and morphine. His electrocardiogram revealed narrow complex tachycardia at 140 beats per minute (Fig. 1). Initially, carotid sinus massage, intravenous adenosine 6 and 12 mg, and diltiazem 25 mg were tried, but did not influence his tachycardia. Echocardiography study showed mild left ventricular (LV) dilation with severe systolic dysfunction with an ejection fraction 20%. Intravenous amiodarone was initiated with a 300 mg bolus, followed by 1 mg/minute infusion with slight slowing of tachycardia to 130 beats Dr. Gardner served as principal investigator in a research study funded by the Heart and Stroke foundation of Nova Scotia and received significant funding for their work on Electrocardiographic Characteristics of Arrhythmogenic Right Ventricular Dysplasia. Figure 1. Presenting ECG showing narrow complex tachycardia with HR 140 beats.per minute, but his tachycardia never terminated with drug therapy.Thus, he underwent an electrophysiology study. His tachycardia was terminated with burst ventricular pacing and ventricular extrastimuli, but restarted promptly. The onset of the tachycardia is shown below (Fig. 2). Burst atrial pacing was attempted during the tachycardia (Fig. 3). What is the mechanism of this tachycardia? DiscussionThe tachycardia electrocardiogram (Fig. 1) demonstrates a relatively narrow complex tachycardia with cycle length of 430 ms, right axis deviation, and no visible P waves. The QRS duration is 108 ms with rSr' pattern in V1. Based on this ECG, supraventricular tachycardia (SVT), particularly atrioventricular nodal reentrant tachycardia (AVNRT), was suspected; however, it was unusual that SVT was not affected by adenosine or diltiazem.The HV interval measured 53 ms during sinus rhythm; however, during tachycardia, it was only 30 ms (Fig. 2). There was a 1:1 VA relationship during tachycardia with the earliest atrial activation recorded near the His bundle region, suggesting a normal concentric retrograde atrial activation. Entrainment of the tachycardia from the right ventricular apex resulted in VAHV response (not shown here). The atrium could not be preexcited when the His bundle was refractory.