Background: In patients with an implantable cardioverter-defibrillator (ICD), shocks are associated with increased morbidity and mortality. Therefore, we conducted this study to evaluate the efficacy and safety of antiarrhythmic drugs and catheter ablation (CA) in the treatment of ventricular tachyarrhythmias (VT) in patients with an ICD. Methods: An electronic database search for randomized controlled trials that evaluated antiarrhythmic drugs and CA in patients with ICD was conducted. The primary outcome was recurrent VT. Secondary outcomes were ICD shocks and any deaths. Bayesian and frequentist network meta-analyses were performed to calculate hazard ratios (HRs) and 95% credible intervals (CrIs)/CIs. Results: Twenty-two randomized controlled trials were identified (3828 total patients; age 64.3±11.4; 79% males). The use of amiodarone was associated with a significantly reduced rate of VT recurrence compared with control (HR=0.34 [95% CrI=0.15–0.74]; absolute risk difference=−0.23 [95% CrI=−0.23 to −0.09]; number needed to treat=4). Sotalol was associated with increased risk of VT recurrence compared with amiodarone (HR=2.88 [95% CrI=1.35–6.46]). Compared with control, amiodarone (HR=0.33 [95% CrI=0.15–0.76]; absolute risk difference=−0.17 [95% CrI=−0.32 to −0.06]; number needed to treat=6) and CA (HR=0.52 [95% CrI=0.30–0.89; absolute risk difference=−0.12 [95% CrI=−0.24 to −0.03]; number needed to treat=8) were associated with significantly reduced ICD shocks. Compared with amiodarone, sotalol was associated with significantly increased ICD shocks (HR=2.70 [95% CrI=1.17−6.71]). The rate of death was not significantly different between the competing strategies. The node-splitting method showed no inconsistency. Conclusions: Among patients with an ICD, amiodarone significantly reduced VT recurrence and ICD shocks, while CA reduced ICD shocks. Sotalol significantly increased VT recurrence and ICD shocks compared with amiodarone. The long-term side effects of amiodarone and early complications of CA should be weighed carefully according to specific patient characteristics.

Takotsubo cardiomyopathy (TC) is increasingly recognized in neurocritical care population especially in postmenopausal females. We are presenting a 61-year-old African American female with past medical history of epilepsy, bipolar disorder, and hypertension who presented with multiple episodes of seizures due to noncompliance with antiepileptic medications. She was on telemetry which showed ST alarm. Electrocardiogram (ECG) was ordered and showed ST elevation in anterolateral leads and troponins were positive. Subsequently Takotsubo cardiomyopathy was diagnosed by left ventriculography findings and absence of angiographic evidence of obstructive coronary artery disease. Echocardiogram showed apical hypokinesia, ejection fraction of 40%, and systolic anterior motion of mitral valve with hyperdynamic left ventricle, in the absence of intracoronary thrombus formation in the angiogram. Electroencephalography showed evidence of generalized tonic-clonic seizure. She was treated with supportive therapy. This case illustrates importance of ECG in all patients with seizure irrespective of cardiac symptoms as TC could be the cause of Sudden Unexpected Death in Epilepsy (SUDEP) and may be underdiagnosed and so undertreated.

The use of ibrutinib for the treatment of chronic lymphocytic leukemia (CLL) and other hematologic malignancies is blooming. Atrial fibrillation is a known side effect of ibrutinib but cardiomyopathy was not reported previously. We present an 88-year-old man with CLL who was admitted to the hospital with new-onset atrial fibrillation and symptomatic systolic congestive heart failure one month after ibrutinib initiation. Although ibrutinib was discontinued, the patient continues to have a low ejection fraction four months after discontinuation. Ischemic heart disease was ruled out with normal cardiac catheterization. This case highlights a possible new side effect of ibrutinib that needs to be monitored while patients receive this medication.