Showing papers by "Paulus Kirchhof published in 2010"

Guidelines for the management of atrial fibrillation The Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC)

Abstract: Guidelines summarize and evaluate all currently available evidence on a particular issue with the aim of assisting physicians in selecting the best management strategy for an individual patient suffering from a given condition, taking into account the impact on outcome, as well as the risk–benefit ratio of particular diagnostic or therapeutic means. Guidelines are no substitutes for textbooks. The legal implications of medical guidelines have been discussed previously. A large number of Guidelines have been issued in recent years by the European Society of Cardiology (ESC) as well as by other societies and organizations. Because of the impact on clinical practice, quality criteria for development of guidelines have been established in order to make all decisions transparent to the user. The recommendations for formulating and issuing ESC Guidelines can be found on the ESC Web Site (http://www.escardio.org/guidelines-surveys/esc-guidelines/about/Pages/rules-writing.aspx). In brief, experts in the field are selected and undertake a comprehensive review of the published evidence for management and/or prevention of a given condition. A critical evaluation of diagnostic and therapeutic procedures is performed, including assessment of the risk–benefit ratio. Estimates of expected health outcomes for larger societies are included, where data exist. The level of evidence and the strength of recommendation of particular treatment options are weighed and graded according to pre-defined scales, as outlined in Tables 1 and 2 . View this table: Table 1 Classes of recommendations View this table: Table 2 Levels of evidence The experts of the writing panels have provided disclosure statements of all relationships they may have that might be perceived as real or potential sources of conflicts of interest. These disclosure forms are kept on file at the European Heart House, headquarters of the ESC. Any changes in conflict of interest that arise during the writing period must be notified to the ESC. The Task Force report received its entire financial support from …

Guidelines for the management of atrial fibrillation

Abstract: Guidelines summarize and evaluate all currently available evidence on a particular issue with the aim of assisting physicians in selecting the best management strategy for an individual patient suffering from a given condition, taking into account the impact on outcome, as well as the risk–benefit ratio of particular diagnostic or therapeutic means. Guidelines are no substitutes for textbooks. The legal implications of medical guidelines have been discussed previously. A large number of Guidelines have been issued in recent years by the European Society of Cardiology (ESC) as well as by other societies and organizations. Because of the impact on clinical practice, quality criteria for development of guidelines have been established in order to make all decisions transparent to the user. The recommendations for formulating and issuing ESC Guidelines can be found on the ESC Web Site (http://www.escardio.org/knowledge/guidelines/rules). In brief, experts in the field are selected and undertake a comprehensive review of the published evidence for management and/or prevention of a given condition. A critical evaluation of diagnostic and therapeutic procedures is performed, including assessment of the risk–benefit ratio. Estimates of expected health outcomes for larger societies are included, where data exist. The level of evidence and the strength of recommendation of particular treatment options are weighed and graded according to pre-defined scales, as outlined in Tables 1 and 2 . View this table: Table 1 Classes of recommendations View this table: Table 2 Levels of evidence The experts of the writing panels have provided disclosure statements of all relationships they may have that might be perceived as real or potential sources of conflicts of interest. These disclosure forms are kept on file at the European Heart House, headquarters of the ESC. Any changes in conflict of interest that arise during the writing period must be notified to the ESC. The Task Force report received its entire financial support from …

EHRA Expert Consensus Statement on the management of cardiovascular implantable electronic devices in patients nearing end of life or requesting withdrawal of therapy

Abstract: The purpose of this Consensus Statement is to focus on implantable cardioverter-defibrillator (ICD) deactivation in patients with irreversible or terminal illness. This statement summarizes the opinions of the Task Force members, convened by the European Heart Rhythm Association (EHRA) and the Heart Rhythm Society (HRS), based on ethical and legal principles, as well as their own clinical, scientific, and technical experience. It is directed to all healthcare professionals who treat patients with implanted ICDs, nearing end of life, in order to improve the patient dying process. This statement is not intended to recommend or promote device deactivation. Rather, the ultimate judgement regarding this procedure must be made by the patient (or in special conditions by his/her legal representative) after careful communication about the deactivation's consequences, respecting his/her autonomy and clarifying that he/she has a legal and ethical right to refuse it. Obviously, the physician asked to deactivate the ICD and the industry representative asked to assist can conscientiously object to and refuse to perform device deactivation.

Antithrombotic management of atrial fibrillation patients presenting with acute coronary syndrome and/or undergoing coronary stenting: executive summary—a Consensus Document of the European Society of Cardiology Working Group on Thrombosis, endorsed by the European Heart Rhythm Association (EHRA) and the European Association of Percutaneous Cardiovascular Interventions (EAPCI)

Abstract: There remains uncertainty over optimal antithrombotic management strategy for patients with atrial fibrillation (AF) presenting with an acute coronary syndrome and/or undergoing percutaneous coronary intervention/stenting. Clinicians need to balance the risk of stroke and thromboembolism against the risk of recurrent cardiac ischaemia and/or stent thrombosis and the risk of bleeding. The full consensus document comprehensively reviews the published evidence and presents a consensus statement on a 'best practice' antithrombotic therapy guideline for the management of antithrombotic therapy in such AF patients. This executive summary highlights the main recommendations from the consensus document.

Constitutively active phosphatase inhibitor-1 improves cardiac contractility in young mice but is deleterious after catecholaminergic stress and with aging.

Abstract: Phosphatase inhibitor-1 (I-1) is a distal amplifier element of beta-adrenergic signaling that functions by preventing dephosphorylation of downstream targets. I-1 is downregulated in human failing hearts, while overexpression of a constitutively active mutant form (I-1c) reverses contractile dysfunction in mouse failing hearts, suggesting that I-1c may be a candidate for gene therapy. We generated mice with conditional cardiomyocyte-restricted expression of I-1c (referred to herein as dTGI-1c mice) on an I-1-deficient background. Young adult dTGI-1c mice exhibited enhanced cardiac contractility but exaggerated contractile dysfunction and ventricular dilation upon catecholamine infusion. Telemetric ECG recordings revealed typical catecholamine-induced ventricular tachycardia and sudden death. Doxycycline feeding switched off expression of cardiomyocyte-restricted I-1c and reversed all abnormalities. Hearts from dTGI-1c mice showed hyperphosphorylation of phospholamban and the ryanodine receptor, and this was associated with an increased number of catecholamine-induced Ca2+ sparks in isolated myocytes. Aged dTGI-1c mice spontaneously developed a cardiomyopathic phenotype. These data were confirmed in a second independent transgenic mouse line, expressing a full-length I-1 mutant that could not be phosphorylated and thereby inactivated by PKC-alpha (I-1S67A). In conclusion, conditional expression of I-1c or I-1S67A enhanced steady-state phosphorylation of 2 key Ca2+-regulating sarcoplasmic reticulum enzymes. This was associated with increased contractile function in young animals but also with arrhythmias and cardiomyopathy after adrenergic stress and with aging. These data should be considered in the development of novel therapies for heart failure.

Autonomic modulation and antiarrhythmic therapy in a model of long QT syndrome type 3

Abstract: Aims Clinical observations in patients with long QT syndrome carrying sodium channel mutations (LQT3) suggest that bradycardia caused by parasympathetic stimulation may provoke torsades de pointes (TdP). β-Adrenoceptor blockers appear less effective in LQT3 than in other forms of the disease. Methods and results We studied effects of autonomic modulation on arrhythmias in vivo and in vitro and quantified sympathetic innervation by autoradiography in heterozygous mice with a knock-in deletion (ΔKPQ) in the Scn5a gene coding for the cardiac sodium channel and increased late sodium current (LQT3 mice). Cholinergic stimulation by carbachol provoked bigemini and TdP in freely roaming LQT3 mice. No arrhythmias were provoked by physical stress, mental stress, isoproterenol, or atropine. In isolated, beating hearts, carbachol did not prolong action potentials per se , but caused bradycardia and rate-dependent action potential prolongation. The muscarinic inhibitor AFDX116 prevented effects of carbachol on heart rate and arrhythmias. β-Adrenoceptor stimulation suppressed arrhythmias, shortened rate-corrected action potential duration, increased rate, and minimized difference in late sodium current between genotypes. β-Adrenoceptor density was reduced in LQT3 hearts. Acute β-adrenoceptor blockade by esmolol, propranolol or chronic propranolol in vivo did not suppress arrhythmias. Chronic flecainide pre-treatment prevented arrhythmias (all P < 0.05). Conclusion Cholinergic stimulation provokes arrhythmias in this model of LQT3 by triggering bradycardia. β-Adrenoceptor density is reduced, and β-adrenoceptor blockade does not prevent arrhythmias. Sodium channel blockade and β-adrenoceptor stimulation suppress arrhythmias by shortening repolarization and minimizing difference in late sodium current.

Routine data from hospital information systems can support patient recruitment for clinical studies

Abstract: Background Delayed patient recruitment is a common problem in clinical studies. Hospital information systems (HIS) contain data items relevant for inclusion or exclusion criteria of these studies.P...

Guías de práctica clínica para el manejo de la fibrilación auricular

Abstract: Responsabilidad: Las Guias de Practica Clinica recogen la opinion de la ESC y se han elaborado tras una consideracion minuciosa de las evidencias disponibles en el momento en que fueron escritas. Se anima a los profesionales de la sanidad a que las tengan en plena consideracion cuando ejerzan su juicio clinico. No obstante, las Guias de Practica Clinica no deben invalidar la responsabilidad individual de los profesionales de la salud a la hora de tomar decisiones adecuadas a las circunstancias individuales de cada paciente, consultando con el propio paciente y, cuando sea necesario y pertinente, con su tutor o representante legal. Tambien es responsabilidad del profesional de la salud verificar las normas y los reglamentos que se aplican a los farmacos o dispositivos en el momento de la prescripcion. El contenido de las Guias de Practica Clinica de la Sociedad Europea de Cardiologia (ESC) ha sido publicado para uso exclusivamente personal y educacional. No esta autorizado su uso comercial. No se autoriza la traduccion o reproduccion en ningun formato de las Guias de la ESC ni de ninguna de sus partes sin un permiso escrito de la ESC. El permiso puede obtenerse enviando una solicitud por escrito a Oxford University Press, la empresa editorial de European Heart Journal y representante autorizada de la ESC para gestionar estos permisos. © The European Society of Cardiology 2010. Reservados todos los derechos. Para la solicitud de permisos, dirijase por correo electronico a: journals. permissions@oxfordjournals.org Los comentarios-anotaciones (*) incluidos en esta traduccion de la Guia han sido realizados por el Dr. Ignacio Fernandez Lozano (Madrid, Espana).

Ivabradine in patients with inappropriate sinus tachycardia

Abstract: Inappropriate sinus tachycardia (IST) is characterized by paroxysmal tachycardia originating in the sinus nodal area. IST predominately affects young, female patients. Current antiarrhythmic drug treatment (s-blockers, calcium antagonists), frequently complicated by side effects, is often not successful. Ivabradine, approved for angina pectoris, selectively reduces heart rate by blocking the “funny current” in the sinus node. We therefore evaluated the effect of ivabradine in patients with symptomatic IST. Ten female patients (median age 32.5 years, range 12–57) suffering from symptomatic IST who had either failed (n = 8) or refused (n = 2) conventional therapy were analyzed. Symptoms included palpitations, pre-syncope, syncope, dyspnea, and exercise intolerance. After obtaining informed consent for individual off-label therapy, patients were treated with ivabradine (5–7.5 mg bid) in addition to beta-blocker therapy (n = 3) or as mono- therapy (n = 7). Therapy was monitored by 72-h Holter ECG and a symptoms questionnaire. Ivabradine significantly reduced maximum and mean heart rate (baseline, maximal heart rate 176 ± 45/min, mean heart rate 84 ± 11/min; ivabradine, maximal heart rate 137 ± 36/min, mean HR 74 ± 8/min, both p < 0.05, all values as mean ± SD). Minimum heart rate was not significantly changed. Three patients reported transient phosphene-like phenomena without discontinuation of ivabradine while on therapy. IST-associated symptoms were ameliorated (3 pts) or suppressed (5 pts) in all eight patients who could be contacted after a mean follow-up of 16 ± 9 months. Ivabradine appears effective and safe in patients with symptomatic inappropriate sinus tachycardia.

Cardiac overexpression of the human 5-HT4 receptor in mice

Abstract: Serotonin (5-HT) exerts pleiotropic effects in the human cardiovascular system. Some of the effects are thought to be mediated via 5-HT4 receptors, which are expressed in the human atrium and in ve...

Predictable and Less Predictable Unwanted Cardiac Drugs Effects: Individual Pre-Disposition and Transient Precipitating Factors

Abstract: In addition to their therapeutic effect, all drugs have unwanted effects For the purpose of this MiniReview, unwanted drug effects will be discussed as either predictable, dose-dependent effects, or as less predictable events which only occur in patients pre-disposed to unwanted drug reactions when confronted with specific situations While clinicians have long been using biomarkers to identify patients prone to less predictable unwanted drug effects, emerging data clearly suggest that such effects are often a consequence of interactions between drug effects, drug metabolism, an individual, at times genetically conferred pre-disposition to the interaction, and transient pre-disposing factors This paper describes general principles of predictable and less predictable unwanted drug effects and discusses the complex interplay of genetic and acquired pre-disposing and precipitating factors for such effects using the example of ventricular pro-dysrhythmia The latter, an important unwanted effect of many drugs, is a common yet not fully understood less predictable cardiac drug effect Understanding the mechanisms of ventricular pro-dysrhythmia may allow to predict this unwanted drug effect better, and to identify novel markers for such events in the future

Cardiological evaluation after cerebral ischaemia : Consensus statement of the Working Group Heart and Brain of the German Cardiac Society-Cardiovascular Research (DGK) and the German Stroke Society (DSG).

Abstract: The cardiological evaluation of patients with cerebral ischaemia is of great clinical importance because diseases of the heart and aorta represent important sources of embolism, because ischaemic stroke is an index event that can lead to the diagnosis of cardiovascular diseases and because the mortality and morbidity of stroke patients are determined by concomitant cardiac diseases. Despite the importance of cardiological examinations for patients with ischaemic strokes, the topic is only addressed by few prospective clinical studies. Therefore, this interdisciplinary consensus document was developed to summarise the available information and to make expert recommendations for the evaluation of cardiovascular risk markers, electrocardiographic examinations, echocardiography and the indications for further investigations of a cardiac disease.

Kardiologische Diagnostik nach zerebraler Ischämie

Abstract: DOI 10.1007/s00115-009-2901-3 Online publiziert: 24. Februar 2010 © Springer-Verlag 2010 U. Laufs1 · U.C. Hoppe2 · S. Rosenkranz2 · P. Kirchhof3 · M. Böhm1 · H.-C. Diener4 · M. Endres5 · M. Grond6 · W. Hacke7 · T. Meinertz8 · E.B. Ringelstein9 · J. Röther10 · M. Dichgans11 1 Klinik für Innere Medizin III, Kardiologie, Angiologie und internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg 2 Klinik III für Innere Medizin, Herzzentrum der Universität zu Köln 3 Medizinische Klinik und Poliklinik C, Universiätsklinkum Münster 4 Neurologische Klinik, Universitätsklinikum Essen 5 Klinik für Neurologie, Campus Mitte, Universitätsklinikum Charitè, Berlin 6 Klinik für Neurologie, Kreisklinikum Siegen 7 Neurologische Klinik, Universitätsklinik Heidelberg 8 Klinik und Poliklinik für Kardiologie/ Angiologie, Universitäres Herzzentrum Hamburg 9 Klinik und Poliklinik für Neurolgie, Universitäsklinikum Münster 10 Neurologische Klinik, Johannes-Wesling-Klinikum, Minden 11 Neurologische Klinik, Ludwig-Maximilians-Universität, Klinikum Großhadern, München

Ablation of atrial fibrillation: for whom and how?

Abstract: Atrial fibrillation (AF) is the most common sustained arrhythmia. Approximately seven million people suffer from AF in Europe, and it is likely that several more millions suffer from ‘silent’, undiagnosed AF.1 w1–w3 Once AF has manifested, it is usually a chronically progressing arrhythmia (figure 1A). The presence of AF, especially of long periods of the arrhythmia, causes pronounced electrical and structural alterations in the atria, thereby perpetuating AF and promoting its recurrence. In addition, chronic underlying comorbidities, a genetic predisposition to AF, and ‘natural’ ageing processes remodel the atria and contribute to the initiation and progression of AF (figure 1B). Figure 1 (A) ‘Natural’ time course of atrial fibrillation (AF) in a patient. Before the diagnosis of AF, most patients probably experience asymptomatic episodes of the arrhythmia. With the exception of rare patients with ‘true lone AF’, AF recurrences become longer and more frequent over time, and finally result in chronic forms of AF. The majority of patients progresses from persistent AF—that is, AF that is managed by rhythm control interventions—to long lasting persistent AF and finally permanent or accepted AF that is managed by rate control and antithrombotic therapy. Reproduced with permission from Kirchhof et al .1 (B) Different ‘vicious circles’ that contribute to AF. In addition to electrical triggers, often located in the pulmonary veins and the posterior left atrium (red circle), shortening of the atrial action potential can promote multiple wavelet reentry (blue circle), and structural remodelling of the atria contributes to conduction disturbances and electrical isolation of atrial myocardium (green circle). Furthermore, there is a bidirectional interaction between left ventricular dysfunction and atrial dysfunction (brown circle) in AF patients. Unfortunately, only a part of the atrial damage can be prevented by preventing AF (black pie piece), while other parts are due to other, often extracardiac …

Coincidence of paroxysmal supraventricular tachycardia and panic disorder: two case reports

Abstract: Panic disorder (PD) is characterised by sudden attacks of intense fear with somatic symptoms including palpitations and tachycardia. Reciprocally, palpitations caused by paroxysmal supraventricular tachycardia (PSVT) are commonly associated with anxiety and may therefore be misdiagnosed as PD. As demonstrated by two case reports, PSVT and PD can occur comorbidly in a chronological sequence, with PSVT possibly precipitating and maintaining PD via interoceptive processes or, alternatively, with PD increasing the risk for PSVT by elevating stress levels. As both PSVT and PD require different treatments, potentially helpful differential clinical diagnostic criteria are proposed.

Register und Studien des Deutschen Kompetenznetzes Vorhofflimmern (AFNET)

Abstract: The German Competence Network on Atrial Fibrillation (AFNET) is a national interdisciplinary research network funded by the Federal Ministry of Education and Research (BMBF). AFNET was initiated in 2003 and aims at improving treatment of atrial fibrillation (AF), the most frequent sustained cardiac arrhythmia. AFNET has established a nationwide patient registry on diagnostics, therapy, course and complications of AF in Germany. The data analyzed to date demonstrate that patients with AF are likely to have multiple co-morbidities, such as hypertension, valvular heart disease, coronary artery disease, diabetes mellitus and advanced age. Oral anticoagulation is provided to the majority of patients in accordance with the recommendations given by guidelines. Further areas of research deal with the optimal duration of antiarrhythmic therapy following electrical cardioversion of atrial fibrillation and the value of strategies to prevent arrhythmogenic changes, such as fibrosis in the atria, for prevention of further episodes of atrial fibrillation. Additional registry projects were established for patients with catheter-based interventional therapy of atrial fibrillation and surgical ablation to define success, complications and long term results of these recently developed procedures more clearly. Data and insights gathered from these projects were used to further develop standards of care in two international conferences.

An ultrasound view on the substrate for incident and recurrent atrial fibrillation in heart failure patients

Abstract: This editorial refers to 'Prediction of atrial fibrillation in patients with an implantable cardioverter-defibrillator and heart failure' by M. Bertini et al., published in this issue on page 1102―1111.

Abstract 11401: Electrophysiological Basis for Atrial Arrhythmia in a Long QT Syndrome Mouse Model

Abstract: Introduction: Long-QT syndromes (LQTSs) are known to cause ventricular tachyarrhythmias, but increasing evidence indicates they can also cause atrial fibrillation. Although atrial early afterdepolarizations (EADs) are a plausible cause, there are no published studies of cellular arrhythmia mechanisms at the atrial level in models of congenital LQTS. We therefore studied atrial-cellular electrophysiology in mice with an LQTS-3 SCN5A inactivation-impairing mutation (ΔKPQ) and matched littermate controls (WT). Methods: Late Na+ current (INaL) was measured with whole-cell patch-clamp. Transmembrane action potentials (APs) were recorded with floating microelectrodes from the epicardial side of the isolated left atrium, paced at 6 frequencies between 0.5 and 10 Hz, at 35°C (pH 7.4). Ranolazine (10 μM) was used as an INaL-blocker. Results: As expected, INaL was increased in atrial myocytes of ΔKPQ mice (Figure A). APs in ΔKPQ-mice were significantly prolonged over all frequencies. AP-duration (APD) prolongation ...

Cell-based therapy of the failing heart: a need to connect for proper electrical and contractile function

Abstract: This editorial refers to ‘Skeletal myoblast implants induce minor propagation delays, but do not promote arrhythmias in the normal swine heart’ by J. Moreno et al. , on page 1637 Despite clear improvements in acute therapy and chronic management, myocardial infarction remains a severe threat to cardiac function.1,2 In contrast to other organs, the heart has only limited regeneration capacity. Therefore, most of the cardiomyocytes that die in the process of acute myocardial ischaemia are replaced by dysfunctional scar tissue. In this context, regeneration of infarcted areas of the heart via application of progenitors/stem cells is a fascinating prospect. Clinical observations suggested a beneficial effect of injecting bone marrow-derived cells into coronary arteries3–5 or skeletal myoblasts into hearts during open heart surgery6,7 in survivors of myocardial infarction with heart failure, resulting in a high expectation that regeneration of the left ventricle could be instigated by such ‘regenerative therapy'. Subsequent larger trials found modest or no effects after intracoronary injection of bone marrow-derived cells.8–10 Furthermore, careful clinical follow-up of patients … *Corresponding author. Tel: +49 251 8345185; fax: +49 251 8347864, Email: kirchhp{at}uni-muenster.de