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    <recommendedItem id="20100101_19_441"
                     title="Be Ready for Drug-Induced Vfib, Groups Urge (CME/CE)"
                     score="0.011"
                     href="http://www.medpagetoday.com/Cardiology/Arrhythmias/tb/18358?impressionId=1265800311660"
                     
      Awareness of medication-induced torsade de pointes and a preset protocol for treating it could save lives in the hospital with swift action to prevent cardiac arrest, according to a joint statement from two professional associations.&lt;br&gt;
&lt;br&gt;These cases &quot;should be avoidable&quot; with consistent electrocardiographic monitoring of patients receiving drugs known to prolong the QT interval, the American Heart Association and American College of Cardiology wrote in a statement endorsed by the American Association of Critical-Care Nurses.&lt;br&gt;
&lt;br&gt;The rare arrhythmia often provides telltale signs on ECG an hour or so before ventricular fibrillation, according to writing committee chair Barbara J. Drew, RN, PhD, of the University of California San Francisco, and colleagues.&lt;/p&gt;
&lt;p&gt;However, the statement made no one-size-fits-all recommendation on what cardiac monitoring should entail, given hospital-to-hospital differences in equipment that range from fully automated QT-monitoring systems at the high end to a computer-assisted electronic caliper feature at the other.&lt;/p&gt;
&lt;p&gt;&quot;Of utmost importance, however, is that a hospital protocol be established so that a single consistent method is used by all healthcare professionals charged with the responsibility for cardiac monitoring,&quot; Drew&apos;s group wrote.&lt;/p&gt;
&lt;p&gt;This protocol should stipulate which equipment to use for QT measurement, how to determine the end of the T wave, the formula for heart rate correction, lead-selection criteria, and the importance of measuring the same lead in the same patient over time, they said.&lt;/p&gt;
&lt;p&gt;The new statement, published online in &lt;em&gt;Circulation: Journal of the American Heart Association&lt;/em&gt; and the &lt;em&gt;Journal of the American College of Cardiology&lt;/em&gt;, included the following signs of impending torsade de pointes: &lt;ul&gt; &lt;li&gt;An increase of 60 ms in heart-rate&amp;#8211;corrected QT interval (QTc) from the preadministration baseline&lt;/li&gt; &lt;li&gt;Marked QTc interval prolongation of more than 500 ms&lt;/li&gt; &lt;li&gt;The characteristic &quot;twisting&quot; of the points on ECG as T-U wave distortion becomes more exaggerated in the beat after a pause&lt;/li&gt; &lt;li&gt;Visible (macroscopic) T-wave alternans&lt;/li&gt; &lt;li&gt;New-onset ventricular ectopy&lt;/li&gt; &lt;li&gt;Couplets and &lt;span&gt;nonsustained&lt;/span&gt; polymorphic ventricular tachycardia initiated in the beat after a pause&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;Prompt recognition of these ECG harbingers allows for treatment with intravenous magnesium, removal of the drug that induced the condition, and correction of electrolyte abnormalities and other exacerbating factors, including the prevention of bradycardia and long pauses with temporary pacing if necessary, according to the new statement.&lt;/p&gt;
&lt;p&gt;Prior guidelines on ventricular arrhythmias provided little help with prevention of torsade de pointes in the hospital but did recommend discontinuation of whatever drug induced long QT syndrome.&lt;/p&gt;
&lt;p&gt;The most common drugs associated with this potentially fatal arrhythmia are antibiotics, antipsychotics, and antiarrhythmia drugs.&lt;/p&gt;
&lt;p&gt;Administration in the hospital is more likely to be associated with torsade de pointes than is treatment of an outpatient population with the same drug, Drew&apos;s group noted.&lt;/p&gt;
&lt;p&gt;Hospitalized patients are often elderly, with comorbidities such as underlying heart disease and renal or hepatic dysfunction. They are also more likely to get intravenous push of the drugs.&lt;/p&gt;
&lt;p&gt;Clinical risk factors for torsade de pointes include: &lt;ul&gt; &lt;li&gt;A preexisting long QTc interval of more than 500 ms&lt;/li&gt; &lt;li&gt;Concurrent use of more than one QT-prolonging drug&lt;/li&gt; &lt;li&gt;Rapid infusion of a QT-prolonging drug intravenously&lt;/li&gt; &lt;li&gt;Heart disease, such as MI or heart failure&lt;/li&gt; &lt;li&gt;Advanced age&lt;/li&gt; &lt;li&gt;Female sex&lt;/li&gt; &lt;li&gt;Hypokalemia&lt;/li&gt; &lt;li&gt;Hypomagnesemia&lt;/li&gt; &lt;li&gt;Hypocalcemia&lt;/li&gt; &lt;li&gt;Treatment with diuretics&lt;/li&gt; &lt;li&gt;Impaired hepatic drug metabolism, whether from hepatic dysfunction or drug-drug interactions&lt;/li&gt; &lt;li&gt;Bradycardia&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;Drew reported conflicts of interest with GE Healthcare and Philips.&lt;/p&gt;&lt;p&gt;Co-authors reported conflicts of interest with Medtronic, Pfizer, PGxHealth, FAMILION, GE HealthCare, Philips Healthcare, Abbott, Bristol-Myers Squibb, sanofi-aventis, Schering Plough, Inovise, Siloam, ArgiNOx, Astellas, Daiichi Sankyo/Lilly, Heartscape Technologies, Biosite, Inovise, Medicines Co., Millennium Pharmaceuticals, PDL BioPharma, Roche Diagnostics, Scios, Mortara Instrument, Cardiac Science, MDS Pharma, Medicure, St. Jude, Adolor, ARCA, AstraZeneca, Avanir, Cardiome, CardioDx, Novartis, Ortho Diagnostics, Sanofi, Vanderbilt/Clinical Data, iCardiac Technologies, LipoScience, Anthera, Abbott Vascular, Novo Nordisk, Roche, Biotronic, and Boston Scientific.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_297"
                     title="Ablation Therapy Controls Atrial Fibrillation (CME/CE)"
                     score="0.002"
                     href="http://www.medpagetoday.com/Cardiology/Arrhythmias/tb/18152?impressionId=1265800311660"
                     
      If initial drug therapy fails to control paroxysmal atrial fibrillation, the next step should be radiofrequency catheter ablation, researchers said.&lt;br&gt;
&lt;br&gt;In a prospective randomized trial, catheter ablation succeeded in preventing fibrillation and other forms of treatment failure in 66% of patients, according to David J. Wilber, MD, of Loyola University Medical Center in Maywood, Ill., and colleagues.&lt;br&gt;
&lt;br&gt;By comparison, only 16% of patients who got renewed drug therapy were free from treatment failure by the end of nine months of follow-up, Wilber and colleagues reported in the Jan. 27 issue of the &lt;em&gt;Journal of the American Medical Association&lt;/em&gt;.&lt;br&gt;
&lt;br&gt;The trial was stopped early, in fact, after a Bayesian analysis showed the predictive probability of success for the catheter treatment to be 99.9%.&lt;p&gt;&lt;/p&gt;
&lt;p&gt;The study &quot;confirmed resoundingly&quot; that catheter ablation is the way to go after a patient has failed an initial attempt to control the heart rhythm with drugs, Wilber told &lt;em&gt;MedPage Today&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;&quot;This is really a procedure that&apos;s come of age,&quot; he said.&lt;/p&gt;
&lt;p&gt;Although anti-arrhythmic drugs are the usual first-line therapy, they are only inconsistently effective, Wilber said  --  about half of all patients will have a recurrence of fibrillation within six months to a year.&lt;/p&gt;
&lt;p&gt;Also, he said, the drugs have a range of adverse events associated with them that range from nuisance effects, such as dizziness, to more serious consequences, such as inflammation of the liver, lung, or thyroid.&lt;/p&gt;
&lt;p&gt;Several smaller studies have suggested that catheter ablation is more effective and has fewer adverse events, but Wilder and colleagues conducted a study that eventually analyzed results in 167 patients from several centers in the U.S. and elsewhere.&lt;/p&gt;
&lt;p&gt;The primary endpoint was freedom from symptomatic atrial fibrillation, although total atrial fibrillation was also measured. The protocol also defined treatment failure in some other cases, including a need for a repeat ablation procedure more than 80 days after the first.&lt;/p&gt;
&lt;p&gt;Patients were eligible for the study if they did not respond to at least one anti-arrhythmic drug and had experienced at least three symptomatic fibrillation episodes within the six months before randomization, the researchers reported in the journal.&lt;/p&gt;
&lt;p&gt;Most of those randomized to the drug therapy arm of the study were treated with either flecainide (Tambocor) or propafenone (Rythmol).&lt;/p&gt;
&lt;p&gt;Analysis showed that, at the end of the nine-month effectiveness evaluation period: &lt;ul&gt; &lt;li&gt;66% of patients in the ablation group remained free from protocol-defined treatment failure compared with 16% of those treated with drugs. The hazard ratio was 0.30 (with a 95% confidence interval from 0.19 to 0.47, which was significant at &lt;em&gt;P&lt;/em&gt;&amp;lt;0.001). &lt;/li&gt; &lt;li&gt;70% of ablation patients had no recurrences of symptomatic atrial arrhythmia compared with 19% of those getting drugs. (The hazard ratio was 0.24, with a 95% confidence interval from 0.15 to 0.39, which was significant at &lt;em&gt;P&lt;/em&gt;&amp;lt;0.001). &lt;/li&gt; &lt;li&gt;63% of patients treated by ablation were free of any recurrent atrial arrhythmia, symptomatic or not, compared with 17% of those treated with drugs. (The hazard ratio was 0.29; with a 95% confidence interval from 0.18 to 0.45, also significant at &lt;em&gt;P&lt;/em&gt;&amp;lt;0.001).&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;Major treatment-related adverse events within the first 30 days occurred in 8.8% of patients treated with drugs and 4.9% of those treated with catheter ablation, the researchers said.&lt;/p&gt;
&lt;p&gt;The study has some limitations, the researchers said, including the fact that most of the investigators had considerable experience with the ablation procedure. Outcomes in centers with less experience may vary, they said.&lt;/p&gt;
&lt;p&gt;In addition, the study did not address longer-term outcomes such as mortality, risk of stroke, heart failure, or progression of atrial fibrillation into a more persistent arrhythmia.&lt;/p&gt;
&lt;p&gt;The researchers also noted that study volunteers were relatively young and had less cardiovascular comorbidity than most people with paroxysmal atrial fibrillation. The result may not generalize to patients with significant left ventricular dysfunction, more persistent forms of fibrillation, or advanced heart failure, they said.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was supported by funded by Biosense Webster, which provided the catheters used.&lt;/p&gt;&lt;p&gt;Wilber reported financial links with Biosense Webster, Boston Scientific, Medtronic, St. Jude Medical, sanofi-aventis, and Blackwell/Futura. Most other authors reported financial links with a range of industrial organizations, including Biosense Webster. Two authors are employees of the company.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_3_525"
                     title="ACEP: Investigational Drug Converts Afib to Sinus Rhythm"
                     score="-0.006"
                     href="