Israel Medical Association Journal

Background: Atrial fibrillation (AF) is the most common arrhythmia in adults and is associated with increased mortality and morbidity.

Objectives: To characterize patients diagnosed with AF in primary care clinics in southern Israel.

Methods: We conducted a cross-sectional study in 14 primary care clinics of the largest health insurance fund in Israel, reviewing the electronic medical records of adults aged ≥ 25 years diagnosed with AF. The prevalence, evaluation, antithrombotic treatment and treatments for rate control/rhythm control were analyzed.

Results: We retrieved the records of 995 patients with a diagnosis of AF; the prevalence of AF was 1.5% (2.5% aged ≥ 45 years). The patients’ mean age was 73.5 ± 1.4 years and 55.3% were female. Vitamin K antagonist (VKA) was prescribed for 591 patients (59%), of whom 8.5% had no international normalized ratio follow-up tests for at least 3 months before our review. Among patients in the VKA treatment group the risk for thromboembolic events was considered to be high, moderate and low in 22% (n=131), 66% (n=391) and 12% (n=69), respectively. Patients with a low Congestive Hypertension Age Diabetes Stroke (CHADS2) score (odds ratio = 0.555, 95% confidence interval 0.357–0.862) and patients who did not receive VKA (OR[1] = 0.601, 95% CI[2] 0.459–0.787) received significantly less rate-control treatment. Of the patients with a low CHADS2 score (< 1) 52.7% received VKA treatment, and 39.4% with a high CHADS2 score (≥ 3) did not receive VKA. A positive correlation between anticoagulation and rate or rhythm control was found.

Conclusions: The prevalence and age distribution of AF in southern Israel are similar to findings in the western world. Many of the patients did not receive appropriate antithrombotic prophylaxis.

Background: As the lowest natural site on earth (-415 meters), the Dead Sea is unique for its high pressure and oxygen tension in addition to the unparalleled combination of natural resources. Furthermore, its balneotherapeutic resorts have been reported to be beneficial for patients with various chronic diseases.

Objectives: To evaluate the safety, quality of life (QoL), exercise capacity, heart failure, and arrhythmia parameters in patients with systolic congestive heart failure (SCHF) and implantable cardioverter defibrillator (ICD) following descent and stay at the Dead Sea.

Methods: The study group comprised patients with SCHF, New York Heart Association functional class II-III after ICD implantation. The following parameters were tested at sea level one week prior to the descent, during a 4 day stay at the Dead Sea, and one week after return: blood pressure, O₂ saturation, ejection fraction (echocardiography), weight, B-type natriuretic peptide (BNP), arrhythmias, heart rate, heart rate variability (HRV), and QoL assessed by the Minnesota Living with Heart Failure questionnaire.

Results: We evaluated 19 patients, age 65.3 ± 9.6 years, of whom 16 (84%) were males and 18 (95%) had ICD-cardiac resynchronization therapy. The trip to and from and the stay at the Dead Sea were uneventful and well tolerated. The QoL score improved by 11 points, and the 6 minute walk increased by 63 meters (P < 0.001). BNP levels slightly increased with no statistical significance. The HRV decreased (P = 0.018). There were no significant changes in blood pressure, weight, O₂ saturation or ejection fraction.

Conclusions: Descent to, ascent from, and stay at the Dead Sea resort are safe and might be beneficial in some aspects for patients with sCHF and an ICD.
 

Background: Familial dysautonomia is a hereditary disease characterized by dysfunction of the sensory and autonomic nervous systems. Studies in patients with familial dysautonomia have shown that abnormal cardiac autonomic denervation might influence repolarization. Autonomic tone also affects atrial conduction parameters and P-wave dispersion, which are predictive of atrial fibrillation.

Objectives: To examine the possible association of familial dysautonomia with abnormal atrial conduction and P-wave dispersion.

Methods: The study population included 12 patients with familial dysautonomia and age and sex-matched control subjects. All participants underwent a 12-lead electrocardiogram under strict conditions. P-wave lengths and P-wave dispersion were computed from a randomly selected beat and an averaged beat using designated computer software.

Results: There were no statistically significant differences between the groups in minimal, maximal, and average P-wave duration or P-wave dispersion for a randomly selected beat. P-wave dispersion for an averaged beat was also similar. During 6 months follow-up, no supraventricular arrhythmias were documented in either group.

Conclusions: We found that patients with familial dysautonomia had P-wave dispersion parameters not significantly different from those of controls. Further research is required to clarify the effects of dysautonomia on atrial conduction in familial dysautonomia.

Background: The predictive value of electrophysiologic studies depends on the aggressiveness of the programmed ventricular stimulation protocol.

Objectives: To assess if non-inducibility with an "aggressive" protocol of PVS[1] identifies post-infarction patients with low ejection fraction (EF[2] ≤ 30%) who may safely be treated without implantable cardioverter defibrillator.

Methods: We studied 154 patients during a 9 year period. Our aggressive PVS protocol included: a) stimulus current five times the diastolic threshold (≤ 3 mA) and b) repetition of double and triple extrastimulation at the shortest coupling intervals that capture the ventricle.

Results: Sustained ventricular tachyarrhythmias were induced in 116 patients (75.4%) and 112 (97%) of them received an ICD[3] (EPS[4]+/ICD+ group). Of the 38 non-inducible patients, 34 (89.5%) did not receive an ICD (EPS-/ICD- group). In comparison to the EPS+/ICD+ group, EPS-/ICD- group patients were older (69 ± 10 vs. 65 ± 10 years, P < 0.05), had a lower EF (23 ± 5% vs. 25 ± 5%,  P < 0.05) and a higher prevalence of left bundle branch block (45.5% vs. 20.2%, P < 0.005). Follow-up was longer for EPS+/ICD+ patients (40 ± 26 months) than for EPS-/ICD- patients (27 ± 22 months) (P = 0.011). Twelve EPS+/ICD+ patients (10.7%) and 5 EPS-/ICD- patients (14.7%) died during follow-up (P = 0.525). Kaplan-Meier survival curves did not show a significant difference between the two groups (P = 0.18).
Conclusions: The mortality rate in patients without inducible VTAs[5] using an aggressive PVS protocol and who did not undergo subsequent ICD implantation is not different from that of patients with inducible arrhythmias who received an ICD. Using this protocol, as many as one-fourth of primary prevention ICD implants could be spared without compromising patient prognosis

background: many electrophysiologists recommend implantable cardioverter defibrillators for patients with Brugada syndrome who are cardiac arrest survivors or presumed at high risk of sudden death (patients with syncope or a familial history of sudden death or those with inducible ventricular fibrillation at electrophysiologic study).

objectives: To assess the efficacy and complications of ICD therapy in patients with Brugada syndrome.

Methods: The indications, efficacy and complications of ICD therapy in all patient with Brugada syndrome who underwent ICD implantation in 12 Israeli centers between 1994 and 2007 were analyzed.

Results: there were 59 patients (53 males, 89.8%) with a mean age of 44.1 years. At diagnosis 42 patients (71.2%) were symptomatic while 17 (28.8%) were asymptomatic. The indications for ICD implantation were: a history of cardiac arrest (n=11, 18.6%), syncope (n=31, 52.5%), inducible VF in symptomatic patients (n=14, 23.7%), and a family history of sudden death (n=3, 0.5%). The overall inducibility rates of VF were 89.2% and 93.3% among the symptomatic and a symptomatic patients, respectively (P=NS). During a follow-up of 4-160 (45+-35) months, all patients (except one who died from cancer) are alive. Five patients (8.4%), all with a history of cardiac arrest, had appropriate ICD discharge. Conversely, none of the patients without prior cardiac arrest had appropriate device therapy during 39+-30 month follow-up. Complications were encountered in 19 patients (32%). Inappropriate shocks occurred in 16 (27.1%) due to lead failure/dislodgment (n=5), T wave oversensing (n=2), device failure (n=1), sinus tachycardia (n=4), and supraventricular tachycardia (n=4). One patient suffered a pneumothorax and another a brachial plexus injury during the implant procedure. One patient suffered a late (2 months) perforation of the right ventricle by the implanted lead. Eleven patients (18.6%) required a reintervention either for infection (n=1) or lead problems (n=10). Eight patients (13.5%) required psychiatric assistance due to complications related to the ICD (mostly inappropriate shocks in 7 patients).

Conclusions: In this Israeli population with Brugada syndrome treated with ICD, appropriate device therapy was limited to cardiac arrest survivors while none of the other patients including those with syncope and/or inducible VF suffered an arrhythmic event. The overall complication rate was high.