John Mandrola


July 01, 2014

On the way home from medical meetings it has been my habit to review the abstract book (and now e-book) for "little" studies I may have missed. The fine print can be fun. As in . . . "Yeah, that makes sense," or, "Yes, yes, I have seen that, too."

Your eye is drawn to posters for various reasons. Sometimes it's obvious the study was well done and a publication is forthcoming; sometimes it's a quirky approach to a problem, and sometimes you like the message being sent—by those who submitted and those who accepted the abstract. In the everyday practice of medicine, it's not just the big clinical trials that inform; it's also the real-world experience of colleagues.

There were many of these sorts of studies in the CardioStim 2014 book. Here is a completely, utterly biased "Top 10" list of interesting posters. For added fun and writing practice, I will keep the commentary down to (almost) Twitter length.

The Way We Think About AF Is Changing

First, AF doesn't just happen. And, second, AF is increasingly recognized as a manifestation of atrial cardiomyopathy, not necessarily the reverse. Dutch researchers used their 446-patient series to compare young- vs old-onset AF[1]. They found young-onset AF associated with a high prevalence of comorbidities, and true lone AF was rare. These findings have big implications for treatment. #Lifestyle

NOAC Drugs Before AF Ablation

Stanford researchers did transesophageal echocardiography (TEE) on 179 patients before AF ablation and analyzed three groups: warfarin (n=33), rivaroxaban (Xarelto, Bayer Pharma/Janssen Pharmaceuticals) (n=33), and dabigatran (Pradaxa, Boehringer Ingelheim) (n=98)[2]. They found no left atrial appendage (LAA) clots in the warfarin or rivaroxaban group but two patients in the dabigatran group had clot. Yes, these are limited data, but it is something I have seen: LAA clots with dabigatran but not with rivaroxaban.

Once-Daily Rivaroxaban Has Been Surprisingly Successful for Stroke Prevention

Perhaps this is because rivaroxaban also acts on endothelial thrombomodulin (TM), a membrane protein important for anticoagulant effects. Japanese researchers found that TM concentration with administration of rivaroxaban differed from warfarin, and this may be related to a different and additional anticoagulant action[3]. #Maybe

Cardioversion With Dabigatran

Does cardioversion with dabigatran make you nervous? It does me. Here is a Latvian study of 898 patients (mean CHA2DS2-VASc=3.1) who had cardioversion[4]. They compared 481 patients pretreated with dabigatran with 387 patients on warfarin and found no differences in embolic events (dabigatran=0.1% vs warfarin=0.7%) The rate of thrombus on TEE was also similar.

I'm Worried About Lead Extraction (Two Abstracts)

How often does a roofer recommend not fixing a roof? This analogy applies to the recent industry-fueled expansion of lead extraction. I worry because "do no harm" should drive the decision making around this procedure.

Danish researchers reported their 13-year experience of 279 extraction procedures, in which major complications, including two deaths, occurred in 1.4% of patients[5]. Most important, though, was that the indication for removal was infection (not just because we bought a new laser) in 85%. Good on them.

Pisa, Italy, seems to be the worldwide capital of lead extraction[6]. This group routinely updates their large experience at heart meetings. Their CardioStim 2014 report included 3834 attempted lead removals. Success with "manual traction" or "mechanical dilation" was achieved in more than 90% of patients. One is left to wonder how they do all this without a laser.

The Blind Spot of Heart-Failure Treatment

As in much of medicine these days, the glitter of new drugs, sensors, and devices obscures the obvious: exercise is still an excellent treatment. With near-infrared spectroscopy, University of Georgia researchers reported lower mitochondrial capacity in ICD patients[7]. We learn in seventh-grade biology that the mitochondria are the powerhouse of the cell. Why do we forget this in medical training?

IV Lidocaine Is Like an Old Necktie

One way to age healthcare workers is their reaction when you suggest using rapid onset/offset pure sodium-channel blockade to treat ventricular tachycardia. Young people look bewildered: "What drug?" In a sign of the times, CardioStim reviewers accepted a small Japanese study in which lidocaine proved rather effective at terminating refractory ventricular arrhythmias, either alone or in combination with amiodarone[8].

Can You Do My Ablation Through a Radial Approach, Please?

Up to now, the answer has been no. Mexican researchers, however, reported a series of 24 patients who had successful (and efficient) ablation of their left-sided accessory pathways via a transradial approach[9]. This one is limited in scope but nifty nonetheless.

Fear Permeates Hospital Culture, yet QT Prolongation Gets Little Notice

Caregivers have grown more fearful of making errors on billing sheets than they are about prescribing dangerous drugs. UK researchers studied a group of 234 inpatients who were prescribed a QT-prolonging drug[10]. One in three patients developed QT prolongation, but rarely was it recognized. Be afraid of the QT interval, please. This should be one problem EMR could help with.

The Challenge of Finding the Sweet Spot of ICD Benefit

It cannot be said enough: ICDs prevent only arrhythmic death. French researchers applied the Goldenberg et al risk score[11] to a series of 2398 patients implanted with an ICD for primary prevention[12]. They found both cardiac nonarrhythmic mortality and noncardiovascular mortality dramatically increased along the strata of that score, while the rate of appropriate shocks remained constant at 6.5% to 7.7%. #SeePeopleNotEFs

That's it for CardioStim 2014.



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