Paroxysmal supraventricular tachycardia (PSVT) is a common arrhythmia that, although usually benign, can occur unpredictably, cause disabling symptoms and significantly impair quality of life. If spontaneous resolution does not occur, the only current self-treatment is for the patient to attempt vagal maneuvers, however, these are frequently unsuccessful. Hospital attendance is then required for intravenous therapy. Etripamil, an intranasal calcium channel blocker similar to verapamil, may be able to fill this therapeutic gap, allowing rapid self-treatment of PSVT at home. This narrative review discusses the latest evidence for etripamil and its potential role in future clinical practice.
Background: General anaesthesia (GA) is the gold standard for AF ablation (AFA) but approximately 50% of cases are performed under conscious sedation (CS). Compared to GA, CS is associated with inferior clinical results, In addition, pateints frequently experience pain and anxiety. However, financial and logistical restrictions mean that universal use of GA is unlikely in the foreseeable future. Accordingly, a pressing need exists to develop an alternative to current CS regimes. Technique: Remifentanil is a potent ultra-short-acting synthetic opioid with has rapid onset and offset. The remifentanil patient controlled analgesia (PCA) system is an established technique on labour wards with a good safety profile and high patient satisfaction. In both AF ablation and labour, recurring short episodes of intense visceral pain are interspersed with less painful periods. We performed a safety and feasibility study of PCA for PVI and provide our experience of our initial six cases, the first such cases to be reported. Methods: After IV paracetamol and midazolam premedication, patients received a background Remifentanil infusion (0.05-0.07mcg/kg/min) with 20mcg boluses on demand via the PCA with 2 minute lockout. An anesthetist and anaesthetic assistant were present throughout and blood pressure sedation level and respiratory parametres were closely monitored. Results: 5 of the 6 patients male with a mean age of 60.3 years (range 47-71). 3 were redo procedures and 5 had persistent AF. Two patients underwent electrical cardioversion. The mean remifentanyl dose was 864.5 mcg (403-1411) with an infusion time of 145.2 (96-180) minutes. Median PCA demands were 11 (2-59) against 6.5 (2-22) delivered. Mean midazolam dosage was 2.4mg (1.5-3.5). No serious complications occurred. Mild was treated with ondansetron. Using a 10cm Visual Analogue Scale (10=best) operators and patients scored the technique very favourably. Although patients did report some pain, 3 reported only a single episode, and 2 more reported between 0-15 minutes of pain. The most frequently reported site of pain was the groin, relating to insertion, manipulation or removal of venous sheaths. In response we extended the remifentanyl provision to cover these events. All patients reported that they would have PCA for a future PVI and those who had previously experienced CS stated a preference for PCA. Conclusion: This first report is encouraging that PCA may be a safe and effective alternative to CS achieving high satisfaction ratings from both clinicians and patients. After further protocol refinement we plan a multi-centre trial and would welcome expressions of interest.
Introduction: An integral aspect of atrial fibrillation (AF) management involves better symptom control, incorporating a rate control, rhythm control, or a combination strategy. The 2020 ESC Guidelines suggest that rhythm control strategy should be recommended for symptomatic patients, to mitigate their symptoms and improve the quality of life. However, adequately powered randomized control trials and prospective 'real-world' registries are needed to fully assess the impact of early rhythm control strategies on clinical outcomes in patients with AF.Objective: In this narrative review, we discuss clinical outcomes following rhythm management approach among patients with AF, considering the effectiveness of an early intervention strategy.Expert opinion: Patients involvement and shared decision-making are crucial when deciding the optimal management strategy among patients with AF. For those with newly diagnosed symptomatic AF, an early invasive approach such as catheter ablation may have a role in preventing AF progression and subsequent pathophysiological changes.
Introduction: The addition of contact force (CF) sensing information may facilitate wide area circumferential ablation (WACA). We present data from an interim analysis of the first multicentre randomised controlled trial studying the impact of (CF) sensing information on the ablation of paroxysmal atrial fibrillation (AF). Method: At 7 UK centres, patients undergoing first time paroxysmal AF ablation were randomised to ablation with or without CF data available to the operator. The planned recruitment is 120 patients with 1 year follow up. Using a 3D mapping system and the SmartTouch CF-sensing catheter (Biosense Webster), all patients underwent WACA. Following this, a wait time of 60 minutes was observed before checking for acute electrical pulmonary vein (PV) reconnection. If the PV remained isolated at 60 minutes 18mg adenosine was administered intravenously. The primary end point was acute PV reconnection whether spontaneous or adenosine induced. Each PV was assessed separately, though in cases of a common trunk these were taken as one vein. Where procedures were terminated prematurely for whatever reason, PVs that remained isolated but had not completed the 1 hour waiting period were excluded from the analysis of acute PV reconnection. Follow up is ongoing and outcomes are not reported here. Results: Currently, 91 of 120 patients have been recruited (44 randomised to blinded group, 47 to unblinded group). The mean age was 59±10years, 52.7% male, CHA2DS2VASC 1.5±1.6, duration of AF 36 (6-289) months. There were no significant differences in baseline characteristics between groups. There were no significant differences in the procedural parameters for the procedures as a whole (Table) or for the same parameters for each PV pair separately (p>0.05). There was a significant reduction in the proportion of pulmonary veins that reconnected acutely in the unblinded group, and this was driven by a reduction in left sided reconnections (Table). There were two tamponades and one minor pericardial effusion, all in the unblinded arm (p=0.24). Conclusion: Based on our interim analysis, addition of contact force sensing data had no impact on procedure time, fluoroscopy use, or the amount of ablation used, but did reduce the rate of acute pulmonary vein reconnection suggesting more effective application of ablation lesions. Whether this translates to improved success rates will be assessed on completion of the study.
<b><i>Introduction:</i></b> Existing randomised controlled trials assessing the safety and efficacy of left atrial appendage occlusion (LAAO) in atrial fibrillation (AF) were of relatively small sample size or included patients who could receive oral anticoagulant treatment after device implantation. We compared the outcomes of patients with newly diagnosed AF who received percutaneous LAAO or direct oral anticoagulant (DOAC) treatment, in a large population from a global federated health network (TriNetX). <b><i>Methods:</i></b> Patients with AF treated with percutaneous LAAO were matched with those treated with DOAC between December 1, 2010, and October 1, 2018. Outcomes were all-cause mortality, ischaemic stroke, and intracranial haemorrhage (ICH) at 5 years. <b><i>Results:</i></b> We included 200 patients with AF, who received either LAAO or DOAC. The risk of all-cause mortality, ischaemic stroke, and ICH at 5 years was not significantly different between the two groups (risk ratio [RR] for all-cause mortality: 1.52, 95% confidence interval (CI): 0.97–2.38, RR for ischaemic stroke: 1.09, 95% CI: 0.51–2.36, and RR for ICH: 1.0, 95% CI: 0.44–2.30). <b><i>Conclusion:</i></b> Patients newly diagnosed with AF, eligible for DOAC, showed similar 5-year risk of death, ischaemic stroke, and ICH when comparing those who underwent percutaneous LAAO to those receiving DOAC. Future randomised controlled trials are needed to confirm the findings and advise changes in guidelines.
Objective Stroke-risk in atrial fibrillation (AF) can be significantly reduced by appropriate thromboembolic prophylaxis. However, National Institute for Health and Care Excellence estimates suggest that up to half of eligible patients with AF are not anticoagulated, with severe consequences for stroke prevention. We aimed to determine the outcome of an innovative Primary Care AF (PCAF) service on anticoagulation uptake in a cohort of high-risk patients with AF in the UK. Methods The PCAF service is a novel cooperative pathway providing specialist resources within general practitioner (GP) practices. It utilises a four-phase protocol to identify high-risk patients with AF (CHA 2 DS 2 -VASc ≥1) who are suboptimally anticoagulated, and delivers Consultant-led anticoagulation assessment within the local GP practice. We assessed rates of anticoagulation in high-risk patients before and after PCAF service intervention, and determined compliance with newly-initiated anticoagulation at follow-up. Results The PCAF service was delivered in 56 GP practices (population 386 624; AF prevalence 2.1%) between June 2012 and June 2014. 1579 high-risk patients with AF with suboptimal anticoagulation (either not taking any anticoagulation or taking warfarin but with a low time-in-therapeutic-range) were invited for review, with 86% attending. Of 1063 eligible patients on no anticoagulation, 1020 (96%) agreed to start warfarin (459 (43%)) or a non-vitamin K antagonist oral anticoagulant (NOAC, 561 (53%)). The overall proportion of eligible patients receiving anticoagulation improved from 77% to 95% (p<0.0001). Additionally, 111/121 (92%) patients suboptimally treated with warfarin agreed to switch to a NOAC. Audit of eight practices after 195 (185–606) days showed that 90% of patients started on a new anticoagulant therapy had continued treatment. Based on data extrapolated from previous studies, around 30–35 strokes per year may have been prevented in these previously under-treated high-risk patients. Conclusions Systematic identification of patients with AF with high stroke-risk and consultation in PCAF consultant-led clinics effectively delivers oral anticoagulation to high-risk patients with AF in the community.
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