Coronary artery ectasia is found in 3 to 8% of patient's undergoing angiography and may sometimes induce acute myocardial infarction. Some articles reported a recurrence of acute coronary syndrome (ACS) in the presence of coronary artery ectasia (CAE). Our study aims to summarize the latest evidence on whether the use of anticoagulant in addition to SAPT/DAPT (single antiplatelet/dual antiplatelet) treating ACS with CAE patients is necessary. Since the trials concerning our objectives were scarce, we pooled case reports/series. We performed a comprehensive search on case reports/series on coronary artery ectasia that presented with acute coronary syndrome published until March 2019. We collected 13 cases from 11 reports. Out of 13 patients, 5 (38.5%) took DAPT only without anticoagulant and 8 (61.5%) took anticoagulant ± DAPT. Three out of five (60%) who took DAPT only, experienced recurrences at 1st and 2nd months' follow-up. The other two (40%) was uneventful at a mean of two months' follow-up. Eight patients who took anticoagulant were uneventful for a mean of 8.4 months. Those who took anticoagulant were at lower risk of experiencing ACS recurrence (p = 0.035). Two of the patients who experienced recurrence became 6 and 12 months free after optimal anticoagulation. The author of this study proposed that anticoagulant must be considered should SAPT/DAPT failed to provide adequate protection to the recurrence of ACS, especially in CAE patients who did not have other obvious stenotic lesions. However, the evidence is weak since this study only pooled case reports/series.
Background Diagnosis‐to‐ablation time (DTAT) has been postulated to be one of the predictors of atrial fibrillation (AF) recurrence, and it is a “modifiable” risk factor unlike that of many electrocardiographic or echocardiographic parameters. This development may change our consideration for ablation. In this systematic review and meta‐analysis, we aim to analyze the latest evidence on the importance of DTAT and whether they predict the AF recurrence after catheter ablation. Methods We performed a comprehensive search on topics that assess diagnosis‐to‐ablation time (DTAT) and AF recurrence from inception up until August 2019 through PubMed, EuropePMC, Cochrane Central Database, and http://ClinicalTrials.gov. Results There was a total of 3548 patients from six studies. Longer DTAT was associated with increased risk for AF recurrence in all studies included. Meta‐analysis of these studies showed that DTAT had a hazard ratio (HR) of 1.19 [1.02, 1.39], P = .03; I2: 92% for AF recurrence. Upon sensitivity analysis by removing a study, HR became 1.24 [1.16, 1.32], P < .001; I2: 29%. Meta‐analysis on DTAT time >3 years had HR 1.73 [1.54, 1.93], P < .001; I2: 45% for the recurrence of AF. Upon subgroup analysis of data that compared >6 years to <1 year, the HR was 1.93 [1.62, 2.29], P < .001; I2: 0%. Conclusion Longer DTAT time is associated with an increased risk of AF recurrence. Hence, determining management at the earliest possible moment to avoid delay is of utmost importance.
Background Risk stratification in patients with asymptomatic Brugada Syndrome is challenging, and despite recent advances, there is no clear evidence. The first‐degree atrioventricular block was hypothesized to be a predictor of arrhythmic events. Measurement of the PR interval and diagnosing atrioventricular block from surface ECG is easy, noninvasive, and cost‐effective. We aimed to assess the latest evidence on PR interval or first‐degree atrioventricular block and major arrhythmic events related to Brugada Syndrome. Methods We performed a comprehensive search in PubMed for “atrioventricular block” OR “PR interval” and “Brugada syndrome.” We included studies that have a component of PR interval and/or first‐degree atrioventricular block and major arrhythmic events related to Brugada Syndrome including syncope/VT/VF/appropriate ICD shocks/ICD implantation. Results We included 1526 subjects from 7 studies. Pooled mean difference of PR interval in 4 studies showed a significant difference [MD 10.77 ms (2.97‐18.57) P = 0.007, moderate‐high heterogeneity I2 = 53% P = 0.08]. On sensitivity analysis by removing a study, it became MD 6.50 ms [1.97‐11.03], P = 0.005, heterogeneity I2 = 0% P = 0.52. Indicating that PR interval was prolonged by small margin. Pooled analysis of the association between a first‐degree atrioventricular block and major arrhythmic events was significant [OR 3.33 (2.02‐5.50) P < 0.001, low heterogeneity I2 = 0% P = 0.57]. Conclusion First‐degree AV block is associated with more frequent major arrhythmic events in Brugada syndrome patients. PR interval seemed to be prolonged but is yet to be determined whether the PR interval association is still significant if it did not cross the first‐degree AVB threshold.
BackgroundPrevalence of atrial fibrillation (AF) in patients with congenital heart disease (CHD) is on the rise. Anti-arrhythmic drugs are usually the first line of treatment in CHD, however, it is often ineffective and poorly tolerated. We aimed to perform a systematic review to assess the efficacy and safety of catheter ablation for AF in CHD.MethodsWe performed a comprehensive search on catheter ablation for atrial fibrillation in congenital heart disease up until July 2019 through several electronic databases.ResultsAblation of AF in patients with CHD had a modest 12 months AF freedom ranging from 32.8% to 63%, which can be increased by subsequent/repeat ablation. The complexity of CHD appears to have a significant effect on a study but not in others. Catheter ablation in ASD and persistent left superior vena cava had a high success rate. Overall, catheter ablation is safe whichever the type of CHD is.ConclusionCatheter ablation for AF in CHD had modest efficacy that can be increased by subsequent/repeat ablation and it also has an excellent safety profile. Ablation in complex CHD could also have similar efficacy, however, it is preferably done by experts in a high volume tertiary center.
Myocardial blush grade (MBG) is an indicator of microvascular perfusion and patency and an independent predictor of cardiac outcomes. QRS duration and fragmented QRS (fQRS) before reperfusion and its changes after reperfusion are shown to be associated with MBG. We aimed to assess the latest evidence on the association between fQRS and QRS duration with MBG in reperfusion therapy.We performed a comprehensive search on the association between fQRS and QRS duration in successful/impaired reperfusion measured by MBG.There were a total of 1,311 patients from six studies. A shorter QRS duration immediately and at 60 minutes after reperfusion attempt was associated with successful reperfusion, with a mean difference (MD) of –10.62 ms ([–15.55, –5.70]; p < 0.001; I 2 = 69%) and –15.66 ms ([–19.96, –11.37]; p < 0.001; I 2 = 77%), respectively, and upon sensitivity analysis, with exclusion of a study, heterogeneity decreases to 33 and 0%. QRS narrowing immediately and 60 minutes after reperfusion attempt was correlated with reperfusion, with an MD of –10.72 ([–16.57, –4.88] ; p < 0.001; I 2 = 97%) and –10.93 ([–14.00, –7.85]; p < 0.001; I 2 = 97%), lesser in impaired reperfusion, respectively. QRS duration on admission was not associated with reperfusion outcome. Two studies reported that fQRS was associated with impaired perfusion, with an odds ratio of 9.88 ([5.62–17.38]; p < 0.0001) and 4.74 ([2.45–9.20]; p < 0.0001), respectively.A longer QRS duration immediately and at 60 minutes after reperfusion attempt was associated with impaired perfusion. QRS narrowing after reperfusion attempt was correlated with successful reperfusion. fQRS was also associated with a higher probability of impaired perfusion.
Patients with atrial fibrillation (AF) for >48 hours who are a candidate for cardioversion should have transesophageal echocardiography (TEE) performed to exclude left atrial thrombus (LAT) that may cause systemic thromboembolism upon conversion to sinus rhythm. However, TEE facilities were limited mainly in developing countries and left atrial appendage may be a challenge to visualize by transthoracic echocardiography. In this article, we would like to discuss a patient that presented with AF >48 hours and is a candidate for cardioversion, however, there is no TEE at the facility. We performed a comprehensive search on whether d-dimer assay can be used to exclude LAT in this patient in order to perform safe cardioversion. Case IllustrationA 50 years-old man presented with exertional dyspnea and palpitation for 72 hours prior to admission. There was no chest pain, episode of syncope, or edema. The patient was limited by symptoms but hemodynamically stable. Electrocardiography showed AF with a ventricular rate of 140x/minute. The patient has a history of hypertension on treatment with captopril. There was no history of stroke and heart failure. There was no apparent reversible cause of AF based on a panel of laboratory examinations (Including a D-Dimer <250 ng/ml DDU). Based on CHADVASC scoring, this patient has a score of 1, a 0 Wells DVT score for thromboembolic probability, and a HAS-BLED Score of 1 for bleeding probability while on anticoagulants. After considerations, it was decided that cardioversion into sinus rhythm would be the best approach in this patient. This patient has an AF >48 hours of onset, hence, LAT should be excluded by the use of TEE. Unfortunately, there was no TEE facility nearby. The patient was anticoagulated for weeks, cardioversion was performed, and AF was converted into sinus rhythm. On 6 months' follow-up, the patient remained in sinus rhythm. DiscussionWe The clinical question is whether d-dimer assay can be used to exclude the diagnosis of LAT in patients presenting with AF >48 hours without the use of TEE or should patients be anticoagulated for weeks before attempting cardioversion. To answer this question, two independent authors (E.Y and V.C) performed a comprehensive and systematic search on studies on the use of D-Dimer assay to exclude the left atrial thrombus in patients with atrial fibrillation
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