Background: Oral sotalol is a class III antiarrhythmic commonly used for the maintenance of sinus rhythm in patients with atrial fibrillation (AF). Recently, the Food and Drug Administration (FDA) approved the use of IV sotalol loading, based primarily on modeling data for the infusion. We aimed to describe a protocol and experience with IV sotalol loading for elective treatment of adult patients with AF and atrial flutter (AFL). Methods: We present our institutional protocol and retrospective review of initial patients treated with IV sotalol for AF/AFL at the University of Utah Hospital between September 2020 and April 2021. Results: Eleven patients received IV sotalol for initial loading or dose escalation. All patients were male, aged 56-88 years (median 69). Mean QT interval (QTc) intervals increased from baseline (mean 384 ms) immediately after infusion of IV sotalol (mean change 42ms), but no patient required discontinuation of the medication. Six patients were discharged after 1 night; 4 patients were discharged after 2 nights; and 1 patient was discharged after 4 nights. Nine patients underwent electrical cardioversion prior to discharge (2 prior to load; 7 post-load on the day of discharge). There were no adverse events during the infusion or within 6 months of discharge. Persistence of therapy was 73% (8 of 11) at mean 9.9 weeks to follow up, with no discontinuations for adverse effects. Conclusions: We employed a streamlined protocol that was successfully implemented to facilitate the use of IV sotalol loading for atrial arrhythmias. Our initial experience suggests feasibility, safety, and tolerability while reducing hospitalization duration. Additional data are needed to augment this experience as IV sotalol use is broadened across different patient populations.
Objective: To determine if health-related quality of life (HRQoL) improvement after cardiac resynchronization therapy (CRT) correlates with improved left-ventricular ejection fraction (EF). Background: CRT was reported to improve EF and HRQoL in clinical trials of heart failure with reduced EF (HFrEF). It is unknown if improvements in HRQoL reflect EF response to CRT. Methods: We included HFrEF patients who underwent CRT and had both pre-and post-CRT HRQoL assessment. EF response was categorized as absent (0% change or decrease), modest (0%-19% increase), or significant (>20% increase). We examined the associations between EF response and generic (PROMIS) and HF-specific (KCCQ-12) HRQoL. Results:The group included 115 patients with mean age of 65 years and baseline EF of 31%; 39% were female (n = 45). Nineteen percent (n = 22) had significant, 57% (n = 66) modest, and 23% (n = 27) absent EF responses. AF burden across significant (8.9%), modest (4.8%), and absent EF responders (1.4%) was similar (P = 0.20). Significant improvements in , P = 0.003), current health visual analog scale (49.1-55.9, P = 0.042), PROMIS fatigue (58.9-55.1, P = 0.026), and PROMIS satisfaction (42.7-46.4, P = 0.020) resulted following CRT across all groups. There was no association between significant EF improvement and HRQoL by 44.4%; modest response, 33.3%; and significant response,22.2%) at 1 year (P = 0.52 across all groups). Conclusion: CRT was associated with a modest to significant EF response in a majority of patients. However, EF response did not significantly correlate with generic or HF-specific HRQoL measures. Further investigations are warranted into determinants of improved HRQoL following CRT.
Introduction: Emerging evidence supports more aggressive rhythm control of atrial fibrillation (AF) among heart failure (HF) patients. Yet, the impact of AF on symptom status in HF and the relationship to rate control have not been well studied in the setting of prolonged, ambulatory monitoring. Hypothesis: Patient-triggered symptomatic events (PTSEs) can predict the simultaneous presence of atrial tachycardia/AF (ATAF) on cardiac event monitors(CEM) among HF patients with documented atrial arrhythmia. Methods: All UHealth HF patients with at least 1 ATAF event over ≥7 days on CEMs were retrospectively reviewed. Tetrachoric correlation analysis between PTSEs and ATAF events and t-tests of mean heart rates(HR) were performed. Results: A total of 3,162 events were analyzed among 185 HF patients. The mean age was 68 years and 43% were female; 61% had CAD; the mean ejection fraction was 54% (SD 16%); and 74% were on beta-blockers. There were 2347 ATAF events, 1031 PTSEs, and 216 symptomatic ATAF events. Of PTSEs, 21.0% were ATAF, and of ATAF events, 9.2% were symptomatic. Overall mean HR of PTSEs was 94bpm (SD 29), lower than asymptomatic events, 103bpm (SD 29, p<0.001). Mean HR of symptomatic ATAF events was 117bpm (SD 35), compared with asymptomatic ATAF (110bpm, SD 31, p=0.008). See Figure 1. PTSEs were less likely to predict simultaneous ATAF compared to sinus rhythm, with a moderate inverse tetrachoric correlation of -0.69 (bootstrapped 95% CI -0.65, -0.72). Conclusion: Among patients with AF & HF, symptoms are a poor marker of atrial arrhythmia. PTSEs on ambulatory monitoring are not correlated with ATAF events in a clinically meaningful association and are not adequately explained by the heart rate differences. Classic symptom-based treatment of AF and HF should give way to more comprehensive quality-of-life and substrate guides for therapy.
Introduction: Guidelines regarding rhythm control for atrial arrhythmias (AT/AF) are primarily based on symptom burden. Ambulatory electrocardiogram (AECG) monitoring is often performed to evaluate AT/AF burden and guide clinical decision-making. Yet, to date, little is known about the correlation of symptoms reported during AECG with recorded AT/AF. Methods: University of Utah patient AECGs with at least one AT/AF event over 7 or more days of monitoring were retrospectively reviewed - only events with symptoms or with AT/AF were included (other arrhythmias were rare and excluded). Patient triggered symptoms included reported shortness of breath, tiredness, palpitations, dizziness, or passing out. Tetrachoric correlation analysis was performed to evaluate the correlation between symptoms and AT/AF episodes. Results: We identified 742 patients with a mean age of 64 years, 50% female, 22% with chronic heart failure, overall mean CHA 2 DS 2 -VASc score of 2.5 and 67% with scores ≥2. There were 6,289 symptomatic events and 6,900 AT/AF episodes. Among these were 1,025 (16%) episodes of shortness of breath, 854 (14%) of tiredness, 2,660 (42%) of palpitations, 794 (13%) of dizziness, and 95 (2%) of passing out. Symptomatic events were less likely to predict simultaneous AT/AF compared to sinus rhythm on AECG, with a moderate inverse tetrachoric correlation of -0.66 (range -1 to 1, with 1 representing perfect positive correlation). Conclusion: Patient-triggered symptomatic events were inversely correlated with recorded AT/AF events and represented an unacceptable marker of actual arrhythmia. A more holistic approach to assessment of ATAF symptoms is needed to improve patient selection for rhythm control therapy.
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