As the developing world increasingly uses generic ART, the clinician must be constantly vigilant for treatment-related adverse events.

Background Therapeutic hypothermia (TH) improves outcomes following cardiac arrest in small clinical trials. Objective To study real-world utilization and outcomes in U.S. hospitals. Design Retrospective cohort study Setting California hospitals Patients Patients eligible for therapeutic hypothermia after cardiac arrest. Interventions We analyzed all discharges from California (1999-2008) to identify patients eligible for TH after cardiac arrest. Patients were considered eligible for TH if both cardiac arrest and anoxic brain injury were among the administrative diagnoses (n = 46,833). Patients undergoing TH (n = 204) were identified through billing codes. Measurements TH utilization and in hospital mortality Results Use of TH increased over the study period with 87.3% (178/204) of TH occurring between 2006 and 2008. Few hospitals appeared to perform TH over the study period (47/419, 11.2%). Utilization of TH was concentrated in a few centers, with the top 3 of 419 centers accounting for 31.4% (64/204) of cases. Patients undergoing TH were younger, less likely to be male, more likely to be treated at teaching centers, and had similar co-morbidities compared to eligible individuals who did not undergo TH. The adjusted odds ratio for hospital mortality among patients undergoing TH was 0.80 (95% CI 0.60-1.06, p=0.11). Conclusions TH utilization appears low but implementation is increasing. Case selection and referral biases limit the analysis of the relationship between center TH volume and in hospital mortality.

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BackgroundRecent studies investigating the implications of additional ablation guided by dormant pulmonary vein (PV) conduction testing using adenosine showed conflicting results, and the data about atrial fibrillation (AF) recurrence after trigger site elimination in adenosine-induced AF are still lacking.MethodsOf 846 patients with paroxysmal AF (PAF) who underwent PV isolation (PVI), adenosine test after PVI was performed in 148 patients.ResultsPVI was successfully achieved in 846 patients. We excluded 58 patients due to loss to the follow-up. A higher rate of AF recurrence was found in the group without adenosine test (136/644, 21%) compared to the group with adenosine test (20/144, 13%, log-rank P=0.047). In multivariate analysis model for AF freedom during the follow-up period, the only significant clinical predictor of AF freedom was adenosine test (hazard ratio [HR] 1.97; 95% confidence interval [CI]: 1.2–3.23; P=0.007).Among 148 patients with adenosine test, 114 (77%) patients showed neither dormant conductions nor AF-induced, 22 (15%) showed positive dormant conductions only, and 12 (8%) revealed adenosine-induced AF (6 of them also showed dormant conduction). After additional ablation in positive dormant conduction group and adenosine-induced AF group, AF recurrence was noted in 4/21 (19%) patients in positive dormant conduction group and 2/11 (18%) patients in adenosine-induced AF group, which was not different from that of patients in negative dormant conduction/ no AF-induced group (14/112, 12%, log-rank P=0.67).ConclusionsAdenosine test after PVI to confirm the absence of dormant conduction and triggers initiating AF is beneficial to improve the outcomes after catheter ablation of PAF.

Aim Ensuring adherence to guideline-directed medical therapy (GDMT) is an effective strategy to reduce mortality and readmission rates for heart failure (HF). Use of a checklist is one of the best tools to ensure GDMT. The aim was to develop a consensus document with a robust checklist for stabilized acute decompensated HF patients with reduced ejection fraction. While there are multiple checklists available, an India-specific checklist that is easy to fill and validated by regional and national subject matter experts (SMEs) is required. Methodology A total of 25 Cardiology SMEs who consented to participate from India discussed data from literature, current evidence, international guidelines and practical experiences in two national and four regional meetings. Results Recommendations included HF management, treatment optimization, and patient education. The checklist should be filled at four time points- (a) transition from intensive care unit to ward, (b) at discharge, (c) 1st follow-up and (d) subsequent follow-up. The checklist is the responsibility of the consultant or the treating physician which can be delegated to a junior resident or a trained HF nurse. Conclusion This checklist will ensure GDMT, simplify transition of care and can be used by all doctors across India. Institutions, associations, and societies should recommend this checklist for adaptability in public and private hospital. Hospital administrations should roll out policy for adoption of checklist by ensuring patient files have the checklist at the time of discharge and encourage practice of filling it diligently during follow-up visits.

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Introduction: Left atrial hypertension is one of the pathophysiologies of heart failure with preserved ejection fraction. We hypothesized that left atrial pressure response (LAPR) to incremental pacing is higher in patients with atrial fibrillation (AF) and can predict left ventricular diastolic dysfunction. Methods: Patients requiring left atrial access as a part of a therapeutic procedure for AF (n=204, AF group) or supraventricular tachycardia (n=34, control group) were analyzed (male n=183, 54±12 years old). LAPR was measured during incremental pacing. Results: Baseline left atrial pressure and LAPR at all pacing rates were not different between the AF and control groups. They were higher in patients with a high E/e’ (≥ 8) than in those with a low E/e’ (< 8). LAPR at a pacing interval of 400ms and E/e' were positively correlated (r=0.373, p<0.001). Body mass index and a high E/e' were independent predictors of pacing-induced left atrial hypertension. Conclusions: The LAPR to incremental pacing was constant regardless of AF. The non-invasive echocardiographic marker E/e' reflected pacing-induced left atrial hypertension.

Introduction Activation mapping guided catheter ablation (CA) of ventricular arrhythmias (VAs) is limited in some cases when it is only relied on bipolar electrogram (EGM). We hypothesized that activation mapping with use of combined bipolar and unipolar EGM facilitates to identify the focal origin of VAs and results in reduction of recurrence rate of CA of VAs. Methods We analyzed the data of patients undergoing repeat ablations for idiopathic out-flow tract VAs. The EGM of the 1 st and 2 nd ablations were compared for earliest local activation time (LAT), presence of discrete potentials, and polarity reversal, unipolar potential morphology (QS or non-QS), potential amplitude and activation slope. Results Thirty-seven patients were included. The Local activation time was significantly earlier in the 2nd ablation as compared to the 1st procedure (36.90 msec vs 31.85 msec, P < 0.01). The incidence of discrete potentials and polarity reversal were similar in both procedures (51% vs 57%, P = 0.8 and 62% in both the occasions, respectively). The unipolar voltage was similar in both occasions (6.94 mV vs 7.22 mV in repeat ablations, P = 0.7). The recurrence rate (5.7%) was significantly lower with routine use of combined unipolar and bipolar EGMs, as compared to the use of bipolar EGM alone (16.7%) Conclusions Use of both bipolar and unipolar electrograms helps in better delineation of the sites of earliest activation for effective ablation of VAs. Use of unipolar electrograms in addition to bipolar electrograms is associated with lower long term recurrence rate.