The surface electrocardiogram (ECG) can provide many clues to a patient’s underlying medical condition or tendency for arrhythmogenesis. An 80-year-old man with severe aortic stenosis and an implantable cardioverter-defibrillator (ICD) for advanced heart block presented with burping, chest discomfort and intermittent pounding sensations. His ECG showed atrial fibrillation with intermittent ventricular pacing at 60 bpm characterized by irregularly irregular rhythm, absent P waves, narrow intrinsic QRS complexes alternating with wide-paced beats (left bundle branch block [LBBB] morphology, superior axis) and visible pacing spikes. Device interrogation revealed ventricular tachycardia (VT) storm with multiple appropriate ICD shocks explaining his pounding sensations. This report highlights two key teaching points: recognizing atrial fibrillation during ventricular pacing—a frequently missed diagnosis affecting nearly half of patients with pacemakers—and managing VT storm to reduce shock burden. After device reprogramming and antiarrhythmic adjustment, the patient became asymptomatic.

Human ; Male ; Aged: 65-79 Yrs Old ; Thorax ; Teaching ; Tachycardia, Ventricular ; Electrocardiography ; Atrial Fibrillation ; Bundle-branch Block ; Constriction, Pathologic

INTRODUCTION: Radiofrequency catheter ablation (RFA) is an interventional cardiac electrophysiologic procedure that uses heat energy for definitive management of supraventricular tachycardias. It is a class I recommendation for chronic management of most supraventricular arrhythmias. No local data exist in the incidence hospitalization for SVT and utilization of RFA for this condition. The study aimed to obtain the prevalence of hospitalization of patients with supraventricular tachycardias where RFA is utilized, including the patients’ demographic profile, length of hospitalization, and mortality rate. METHODOLOGY: Philippine Health Insurance Corporation claims for hospitalization from January 1, 2017, to December 31, 2018, were reviewed. Data analysis was done using median and interquartile range for continuous data, and frequency and percentage distribution for categorical data. RESULTS: There were 1121 and 1149 claims for hospitalization for SVTs (atrial paroxysmal tachycardia, atrioventricular paroxysmal tachycardia, nodal paroxysmal tachycardia, and junctional tachycardia) in 2017 and 2018, respectively. This represents four hospitalization claims for SVT per 10,000 of the total PHIC claims. The majority of patients were female with median age of 52 years. Only 25 and 19 patients underwent radiofrequency ablation in 2017 and 2018, respectively. The majority of these patients were male and younger with a median age of 31 years. No mortality was recorded among patients admitted for catheter ablation. CONCLUSION In 2017 and 2018, hospitalization claims for SVT requiring catheter ablation were 0.04% (four hospitalization claims for SVT per 10,000 of the total claims) in both years. The majority of patients were admitted with pharmacologic therapy on discharge with very low utilization of radiofrequency ablation for long-term management.
Arrhythmias, Cardiac ; Tachycardia, Supraventricular ; Radiofrequency Ablation ; prevalence ; Hospitalization

BACKGROUND: Radiofrequency ablation (RFA) is the recommended treatment of choice for supraventricular tachycardia (SVT), whereas implantable cardioverter-defibrillator (ICD) is recommended for patients at high risk for sudden death due to ventricular tachycardia/fibrillation. Radiofrequency ablation has been proven to improve the quality of life of patients with SVT, whereas an ICD has been shown to reduce mortality among patients at risk for sudden cardiac death. Both procedures are expensive and usually beyond the reach of the average Filipino patient. OBJECTIVES: The objectives are to (1) determine the cost of hospitalization for cardiac arrhythmias that require RFA and cardioverter-defibrillator implantation in the Philippines, (2) propose revised Philippine Health Insurance Corporation (PhilHealth) benefit packages for both procedures, and (3) determine the budget impact of the proposed revised packages. METHODS: Hospitalization costs were obtained for both RFA and cardioverter-defibrillator implantation from two government tertiary care hospitals. A range of hospitalization costs involving possible lower and higher cost scenarios was estimated. Based on these estimates and the yearly number of arrhythmias that require these procedures, revised benefit packages for both RFA and cardioverter-defibrillator implantation were proposed to PhilHealth. The budget impact analysis for the first 3 and 5 years of implementation of these revised packages was subsequently calculated. RESULTS: The estimated hospitalization costs for RFA ranged from Philippine pesos (PHP) 248,485 to 310,480, whereas for cardioverter-defibrillator implantation, the costs ranged from PHP 509,122 to 581,940. These amounts are greatly disparate from the present PhilHealth coverages, which are PHP 9700 and 18,000 for RFA and cardioverter-defibrillator implantation, respectively. Based on these hospitalization costs, the proposed RFA benefit package is PHP 275,000 to 310,000, whereas for an ICD benefit package, PHP 513,000 to 576,000 is proposed. The incremental cost of more than PHP 300 million for RFA and more than PHP 700 million for an ICD is distributed for the next 3 or 5 years of implementation for these benefit packages, respectively. CONCLUSION The present PhilHealth case rates for both RFA and cardioverter-defibrillator implantation are greatly underestimated, which probably is the reason for their underutilization. There is a need to revise these case rates with due consideration of their actual hospitalization costs to lessen inequity in accessing these procedures.
Radiofrequency Ablation ; Defibrillators, Implantable

We report the case of a 28-year-old woman with ostium secundum atrial septal defect, mitral stenosis and a persistent left superior vena cava, who developed heart failure at age 17 and was admitted at different institutions for shortness of breath. The patient had one complicated pregnancy at age 25 in which she presented with worsening heart failure. She was able to deliver her baby via spontaneous vaginal delivery under epidural anesthesia, but had to stay admitted for an additional 3 weeks. Two-dimensional echocardiogram with doppler studies showed an ostium secundum atrial septal defect, severe rheumatic mitral stenosis (Mitral Valve Area = 0.60 cm2 by planimetry and 0.90 cm2 by pressure half-time), severe tricuspid regurgitation, mild aortic regurgitation, pulmonary regurgitation with severe pulmonary hypertension, and a dilated coronary sinus. During bubble contrast study, micro-bubbles from the agitated saline appeared initially in the coronary sinus before appearing in the right sided chambers, suggesting the presence of a persistent left superior vena cava. Cardiac magnetic resonance imaging confirmed the initial echocardiographic findings. Cardiac catheterization and venography confirmed the presence of a persistent left superior vena cava which was draining into a markedly dilated coronary sinus, a severe mitral stenosis (MVA=0.86 cm2), an atrial septal defect with a left-to-right shunt (Qp:Qs = 2:1), and severe pulmonary hypertension. The combination of an atrial septal defect and mitral stenosis is rare, with an incidence ranging from 0.6 to 4% among those with congenital disease. The incidence of the combination of the three lesions - ASD, mitral stenosis and persistent left superior vena cava - is unknown. Since the pulmonary vascular disease was still reversible based on the hemodynamic studies, the plan was to have the patient undergo mitral valve replacement, tricuspid valve annuloplasty, and patch closure of the atrial septal defect. Before any surgical procedure could be done however, the patient succumbed to heart failure.
Human ; Female ; Adult ; Infant ; Anesthesia, Epidural ; Aortic Valve Insufficiency ; Cardiac Catheterization ; Coronary Sinus ; Dyspnea ; Echocardiography ; Heart Failure ; Heart Septal Defects, Atrial ; Hemodynamics ; Hypertension, Pulmonary ; Incidence ; Infant ; Magnetic Resonance Imaging ; Mitral Valve ; Mitral Valve Stenosis ; Phlebography ; Pulmonary Valve Insufficiency ; Tricuspid Valve ; Tricuspid Valve Insufficiency ; Vascular Diseases

RESEARCH DESIGN AND METHODS: A systematic literature search through March 20, 2009 was conducted to identify randomized, placebo-controlled trials of statins that report data on the incidence of new-onset diabetes mellitus. Incidence of new-onset DM was treated as a dichotomous variable. Weighted averages were reported as relative risks (RR) with associated 95% confidence intervals (CI). A random-effects model was used.

RESULTS: Six prospective, randomized, placebocontrolled trials (n=57,593) were identified. Upon metaanalysis, the use of statins did not significantly increase the risk nor prevent the development of new-onset DM (relative risk 1.06; 95% confidence interval 0.93-1.22). Moderate statistical heterogeneity was observed in this analysis (I2=58%, Q statistic p=0.04) arising from pravastatinÊs tendency towards a reduction in risk of developing diabetes and the other statins showing an increase in risk. There was also no significant impact on the incidence of new-onset DM with either high- or low-dose statin use (RR 1.13, 95% CI 0.95 to 1.35 for low-dose statin; RR 1.02, 95% CI 0.84 to 1.25 for high-dose statin).

CONCLUSIONS: Statins as a class did not demonstrate a statistically significant positive or negative impact on a patientÊs risk of developing new-onset DM. Randomized controlled trials of statin therapy with incidence of newonset DM as a primary outcome are required to definitely determine its impact on the development of DM. The mechanisms by which these statins affect glucose metabolism also need to be studied further. However, the beneficial effects of statins in decreasing major vascular events and vascular mortality far outweigh the risks of any adverse effects of statin therapy on glucose metabolism.

Gastroparesis ; Diabetes Insipidus ; Glucose Intolerance

BACKGROUND: Vitamin E is a widely available drug widely marketed for alleged cardiovascular benefits. However, recent randomized trials do not show consistent risk reductions in cardiovascular outcomes. A meta-analysis conducted three years ago concluded no benefit in high-risk patients, and that further research on it be abandoned. We felt the need to update this study since there continue to be studies with conflicting findings.OBJECTIVE: This meta-analysis aims to update the investigation on whether vitamin E in high-risk patients causes significant risk reductions in non-fatal myocardial infarction, stroke, cardiovascular death, and all-cause mortality.METHODS: A computerized search of Medline was done using the online PubMed system. Randomized, controlled trials involving high-risk patients including a vitamin E treatment arm and a non-supplemental arm that tested for the specified cardiovascular outcomes were reviewed and appraised independently by three investigators. After quality appraisal and validity assessment, data from the Vitamin E treatment arm and placebo/non-supplementation arm were extrapolated from each study and entered into RevMan 4.2.3. Odds ratios were determined and plotted using a random effects model.RESULTS: Eight randomized controlled trials were included in the study. There were no significant reductions in all-cause mortality (OR=1.02, 95 percent CI 0.98-1.07), cardiovascular death (OR=1.00, 95 percent CI 0.95-1.06) or stroke events (OR=0.97, 95 percent CI 0.89-1.07), or. non-fatal myocardial infarction (OR 0.93, 95 percent CI 0.83-1.04).; Moreover, for non-fatal MI outcomes, statistical heterogeneity was present (Chi2 13.46, p = 0.004, I2 77.7 percent).CONCLUSION: We found no significant reduction in risk for cardiovascular outcomes with Vitamin E supplementation in high-risk patients. We conclude that Vitamin E should not be routinely recommended for high-risk patients.
Vitamin E ; Tocopherol ; Alpha Tocopherol ; Antioxidants ; Stroke ; Myocardial Infarction