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Background Catheter ablation of premature ventricular complexes from aortic sinus cusps (ASC‐PVC) is a complex procedure that conventionally requires coronary catheterization (CC) to localize coronary artery ostium (CAO). Little published information is available on the mapping and ablation with zero‐fluoroscopy (ZF) of ASC‐PVC. The aim of the study was to determine the efficacy and safety of ASC‐PVC ablation with a ZF approach guided by 3D intracardiac echocardiography integration in the electroanatomical mapping system (ICE 3D‐EAM). Methods This observational study included one patient cohort treated conventionally and another treated with ICE 3D‐EAM‐guided ZF ablation. Clinical, efficacy, and safety outcomes were evaluated acutely and at 3 months follow‐up. Results The study included 21 patients with ASC‐PVC: 10 in the ZF group (age 49 ± 16 years, 60% males) and 11 in the control group (age 47 ± 15 years, 27% males). Fluoroscopy was not required for any patient in the ZF group. Acute success was obtained in 80% of the ZF group vs 55% of the control group (P = .36). The recurrence rate was 30% in the ZF group vs 27% in the control group (P = 1). One nonsevere complication was observed in the ZF group (P = .48). Conclusions ZF catheter ablation of ASC‐PVC guided by ICE 3D‐EAM is feasible, effective, and safe., The graphical abstract shows the workflow for ZF ablation approach of ASC‐PVC using ICE 3D‐EAM. The key point is the ICE 3D‐EAM reconstruction which allows to assess the distance of the ablation catheter tip to CAO. Note that if the distance is at least >5 mm from earliest LVAT to CAO, the ablation is started. On the other hand, with a distance

Aim: To analyze the frequency and variables related to inappropriate rivaroxaban dosage in clinical practice and its impact on outcomes after 2 years. Materials & methods: Postauthorization, observational, multicenter study, in which atrial fibrillation patients, treated with rivaroxaban ≥6 months were included. Results: A total of 1421 patients (74.2 ± 9.7 years, CHA 2 DS 2 -VASc 3.5 ± 1.6) were included. Overall, 22.9% received rivaroxaban 15 mg. The proper dose of rivaroxaban was taken by 83.3% (9.7% underdosed, 7.0% overdosed). Older age and renal insufficiency were associated with inadequate rivaroxaban dosage. There was a trend toward higher all-cause mortality among underdosed patients (adjusted hazard ratio 1.39; 95% CI 0.75–2.58), and more bleedings in overdosed patients (2.29 vs 0.80 events/100 patient-years; p = 0.14). Conclusion: In clinical practice, rivaroxaban is properly dosed in most patients.

Supplementary data associated with this article can befound, in the online version, at https://doi.org/10.1016/j.medcli.2021.06.015, Introduction and purpose: Atrial fibrillation (AF) is common in patients admitted with severe COVID- 19. However, there is limited data about the management of chronic anticoagulation therapy in these patients. We assessed the anticoagulation and incidence of major cardiovascular events in hospitalized patients with AF and COVID-19. Methods: We retrospectively investigated all consecutive patients with AF admitted with COVID-19 between March and May 2020 in 9 Spanish hospitals. We selected a control group of non-AF patients consecutively admitted with COVID-19. We compared baseline characteristics, incidence of major bleed- ing, thrombotic events and mortality. We used propensity score matching (PSM) to minimize potential confounding variables, as well as a multivariate analysis to predict major bleeding and death. Results: 305 patients admitted with AF and COVID-19 were included. After PSM, 151 AF patients were matched with 151 control group patients. During admission, low-molecular-weight heparin was the principal anticoagulant and the incidence of major bleeding and mortality were higher in the AF group [16 (10.6%) vs 3 (2%), p = 0.003; 52 (34.4%) vs 35 (23.2%), p = 0.03, respectively]. The multivariate analysis showed the presence of AF as independent predictor of in-hospital major bleeding and mortality in COVID-19 patients. In AF group, a secondary multivariate analysis identified high levels of D-dimer as independent predictor of in-hospital major bleeding. Conclusions: AF patients admitted with COVID-19 represent a population at high risk for bleeding and mortality during admission. It seems advisable to individualize anticoagulation therapy during admission, considering patient specific bleeding and thrombotic risk., Antecedentes y objetivos: La fibrilación auricular (FA) es frecuente en pacientes ingresados por COVID-19 grave. Sin embargo, los datos sobre el manejo de la anticoagulación crónica en estos pacientes son escasos. Analizamos la anticoagulación y la incidencia de episodios cardiovasculares mayores en pacientes con FA ingresados por la COVID-19. Métodos: Retrospectivamente, se identificaron todos los pacientes con FA ingresados por la COVID-19 entre marzo y mayo de 2020, en 9 hospitales espa ̃noles. Se seleccionó un grupo control de pacientes ingresados consecutivamente por la COVID-19 sin FA. Se compararon las características basales, inci- dencia de hemorragias mayores, episodios trombóticos y mortalidad. Para reducir potenciales factores de confusión se realizó un emparejamiento por puntuación de propensión, así como un análisis multivariante para predecir hemorragia mayor y mortalidad. Resultados: Se incluyeron 305 pacientes con FA ingresados por la COVID-19. Tras el emparejamiento por puntuación de propensión, 151 pacientes con FA fueron emparejados con 151 controles. Durante el ingreso, la heparina de bajo peso molecular fue el principal anticoagulante y la incidencia de hemorragia mayor y mortalidad fue mayor en el grupo de FA (16[10,6%] vs. 3[2%], p = 0,003; 52[34,4%] vs. 35[23,2%], p = 0,03, respectivamente). El análisis multivariante demostró la presencia de FA como predictor indepen- diente de sangrados y mortalidad intrahospitalaria en los pacientes con la COVID-19. En el grupo de FA, un segundo análisis multivariante identificó valores elevados de dímero-D como predictor independiente de hemorragia mayor intrahospitalaria. Conclusiones: Los pacientes con FA ingresados por la COVID-19 representan una población de alto riesgo de sangrado y mortalidad durante el ingreso. Parece recomendable individualizar la anticoagulación durante el ingreso, considerando el riesgo específico de sangrado y trombosis.

Introduction and objectives Atrioventricular block (AVB) in the presence of bradycardic drugs (BD) can be reversible, and pacemaker implantation is controversial. Our objective was to analyze the pacemaker implantation rate in the mid-term, after BD suspension, and to identify predictive factors. Methods We performed a cohort study that included patients attending the emergency department with high-grade AVB in the context of BD. We studied the persistence of AVB after BD discontinuation, recurrence in patients with AVB resolution, and the predictive variables associated with pacemaker requirement at 3 years. Results Of 127 patients included (age, 79 [71-83] years), BAV resolved in 60 (47.2%); among these patients, recurrence occurred during the 24-month median follow-up in 40 (66.6%). Pacemaker implantation was required in 107 patients (84.3%), despite BD discontinuation. On multivariable analysis, the variables associated with pacemaker need at 3 years were heart rate C I, 1.82-36.17), symptoms other than syncope (OR, 4.09; 95%CI, 1.18-14.13), and wide QRS (OR, 5.65; 95%CI, 1.77-18.04). Concomitant antiarrhythmic treatment was associated with AVB resolution (OR, 0.12; 95%CI, 0.02-0.66). Conclusions More than 80% of patients with AVB secondary to BD require pacemaker implantation despite drug discontinuation. Predictive variables were wide QRS, heart rate

BACKGROUND: Atrial fibrillation (AF) increases the risk of thromboembolism. We investigate the efficacy and safety of oral anticoagulation (OAC) therapy and explored the number needed to treat for net effect (NNTnet) of OAC in the Spanish cohort of the EURObservational Research Programme-AF (EORP-AF) Long-term General Registry. METHODS: The EORP-AF General Registry is a prospective, multicentre registry conducted in ESC countries, including consecutive AF patients. For the present analysis, we used the Spanish cohort, and the primary outcome was any thromboembolism (TE)/acute coronary syndrome (ACS)/cardiovascular death during the first year of follow-up. RESULTS: 729 AF patients were included (57.1% male, median age 75 [IQR 67-81] years, median CHA(2) DS(2) -VASc and HAS-BLED of 3 [IQR 2-5] and 2 [IQR 1-2], respectively). 548 (75.2%) patients received OAC alone (318 [43.6%] on VKAs and 230 [31.6%] on DOACs). After 1 year, the use of OAC alone showed lower rates of any TE/ACS/cardiovascular death (3.0%/year; p

Background: Arrhythmogenic cardiomyopathy (AC) is a life-threatening disease which predispose to malignant arrhythmias and sudden cardiac death (SCD) in the early stages of the disease. Risk stratification relies on the electrical, genetic, and imaging data. Our study aimed to investigate how myocardial deformation parameters may identify the subjects at risk of known predictors of major ventricular arrhythmias.Methods: A cohort of 45 subjects with definite or borderline diagnosis of AC was characterized using the advanced transthoracic echocardiography (TTE) and cardiac magnetic resonance (CMR) and divided into the groups according to the potential arrhythmic risk markers, such as non-sustained ventricular tachycardia (NSVT), late gadolinium enhancement (LGE), and genetic status. Layer-specific global longitudinal strain (GLS) by TTE 2D speckle tracking was compared in patients with and without these arrhythmic risk markers.Results: In this study, 23 (51.1%) patients were men with mean age of 43 ± 16 years. Next-generation sequencing identified a potential pathogenic mutation in 39 (86.7%) patients. Thirty-nine patients presented LGE (73.3%), mostly located at the subepicardial-to-mesocardial layers. A layer-specific-GLS analysis showed worse GLS values at the epicardial and mesocardial layers in the subjects with NSVT and LGE. The epicardial GLS values of −15.4 and −16.1% were the best cut-off values for identifying the individuals with NSVT and LGE, respectively, regardless of left ventricular ejection fraction (LVEF).Conclusions: The layer-specific GLS assessment identified the subjects with high-risk arrhythmic features in AC, such as NSVT and LGE. An epicardial GLS may emerge as a potential instrument for detecting the subjects at risk of SCD in AC.

An 81-year-old man with second-degree atrioventricular block was admitted to our centre for pacemaker implantation. Electroanatomic mapping and intracardiac echocardiography-guided left-bundle branch area pacing was performed, entirely without fluoroscopy. It is the first report to describe intracardiac echocardiography for guiding sheath movements into the heart. In conclusion, the combined use of intracardiac echocardiography and intracardiac navigation system allows us to perform left-bundle branch pacing without fluoroscopy.

Background Atrial fibrillation (AF) is the most common cardiac arrhythmia. Catheter ablation aims to restore sinus rhythm. However, relapses occur in up to 30% of patients. A Mediterranean diet (MedDiet) enriched with extra-virgin olive oil (EVOO) substantially reduced the incidence of AF in the PREDIMED trial. The PREDIMAR will test a similar intervention in secondary prevention. Methods PREDIMAR is a multicenter, randomized, single-blind trial testing the effect of a MedDiet enriched with EVOO to reduce tachyarrhythmia relapses after AF ablation. The primary outcome is the recurrence of any sustained atrial tachyarrhythmia after ablation (excluding those occurring only during the first 3 months after ablation). The target final sample size is 720 patients (360 per group) recruited from 4 Spanish hospitals. A remote intervention, maintained for 2 years, is delivered to the active intervention group including periodic phone calls by a dietitian and free provision of EVOO. The control group will receive delayed intervention after trial completion. Routine electrocardiogram (ECG) and Holter ECG are performed, and a portable cardiac rhythm monitoring device is provided to be worn by participants during 15 months. Results Recruitment started in March 2017. Up to July 2019, 609 patients were randomized (average inclusion rate: 5.3 patients/wk). Retention rates after 18 months are >94%. Conclusions If our hypothesis is confirmed, the utility of the MedDiet enriched with EVOO in slowing the progression of AF will be proven, preventing recurrences and potentially reducing complications.

OBJECTIVE To investigate the clinical outcomes of patients who underwent cardioversion compared with those who did not have cardioverson in a large dataset of patients with recent onset non-valvular atrial fibrillation. DESIGN Observational study using prospectively collected registry data (Global Anticoagulant Registry in the FIELD-AF-GARFIELD-AF). SETTING 1317 participating sites in 35 countries. PARTICIPANTS 52 057 patients aged 18 years and older with newly diagnosed atrial fibrillation (up to six weeks' duration) and at least one investigator determined stroke risk factor. MAIN OUTCOME MEASURES Comparisons were made between patients who received cardioversion and those who had no cardioversion at baseline, and between patients who received direct current cardioversion and those who had pharmacological cardioversion. Overlap propensity weighting with Cox proportional hazards models was used to evaluate the effect of cardioversion on clinical endpoints (all cause mortality, non-haemorrhagic stroke or systemic embolism, and major bleeding), adjusting for baseline risk and patient selection. RESULTS 44 201 patients were included in the analysis comparing cardioversion and no cardioversion, and of these, 6595 (14.9%) underwent cardioversion at baseline. The propensity score weighted hazard ratio for all cause mortality in the cardioversion group was 0.74 (95% confidence interval 0.63 to 0.86) from baseline to one year follow-up and 0.77 (0.64 to 0.93) from one year to two year follow-up. Of the 6595 patients who had cardioversion at baseline, 299 had a follow-up cardioversion more than 48 days after enrolment. 7175 patients were assessed in the analysis comparing type of cardioversion: 2427 (33.8%) received pharmacological cardioversion and 4748 (66.2%) had direct current cardioversion. During one year follow-up, event rates (per 100 patient years) for all cause mortality in patients who received direct current and pharmacological cardioversion were 1.36 (1.13 to 1.64) and 1.70 (1.35 to 2.14), respectively. OBJECTIVE To investigate the clinical outcomes of patients who underwent cardioversion compared with those who did not have cardioverson in a large dataset of patients with recent onset non-valvular atrial fibrillation. DESIGN Observational study using prospectively collected registry data (Global Anticoagulant Registry in the FIELD-AF-GARFIELD-AF). SETTING 1317 participating sites in 35 countries. PARTICIPANTS 52 057 patients aged 18 years and older with newly diagnosed atrial fibrillation (up to six weeks' duration) and at least one investigator determined stroke risk factor. MAIN OUTCOME MEASURES Comparisons were made between patients who received cardioversion and those who had no cardioversion at baseline, and between patients who received direct current cardioversion and those who had pharmacological cardioversion. Overlap propensity weighting with Cox proportional hazards models was used to evaluate the effect of cardioversion on clinical endpoints (all cause mortality, non-haemorrhagic stroke or systemic embolism, and major bleeding), adjusting for baseline risk and patient selection. RESULTS 44 201 patients were included in the analysis comparing cardioversion and no cardioversion, and of these, 6595 (14.9%) underwent cardioversion at baseline. The propensity score weighted hazard ratio for all cause mortality in the cardioversion group was 0.74 (95% confidence interval 0.63 to 0.86) from baseline to one year follow-up and 0.77 (0.64 to 0.93) from one year to two year follow-up. Of the 6595 patients who had cardioversion at baseline, 299 had a follow-up cardioversion more than 48 days after enrolment. 7175 patients were assessed in the analysis comparing type of cardioversion: 2427 (33.8%) received pharmacological cardioversion and 4748 (66.2%) had direct current cardioversion. During one year follow-up, event rates (per 100 patient years) for all cause mortality in patients who received direct current and pharmacological cardioversion were 1.36 (1.13 to 1.64) and 1.70 (1.35 to 2.14), respectively. CONCLUSION In this large dataset of patients with recent onset non-valvular atrial fibrillation, a small proportion were treated with cardioversion. Direct current cardioversion was performed twice as often as pharmacological cardioversion, and there appeared to be no major difference in outcome events for these two cardioversion modalities. For the overall cardioversion group, after adjustments for confounders, a significantly lower risk of mortality was found in patients who received early cardioversion compared with those who did not receive early cardioversion. STUDY REGISTRATION ClinicalTrials.gov NCT01090362.

Introduction: His-bundle pacing (HBP) and left bundle branch area pacing (LBBAP) are novel techniques that have demonstrated their efficacy in patients needing right ventricular pacing and in candidates for resynchronization therapy. The purpose of this study was to compare acute and short-term outcomes between HBP and LBBAP. Methods: Retrospective review of the success rate and change in QRS duration obtained by HBP and LBBAP in patients requiring anti-bradycardia pacing or cardiac resynchronization, evaluating the complications and pacing parameters at implantation and at 3 months. Results. The study included 90 procedures (46 HBP and 44 LBBAP) in 87 patients. Success was achieved in 77 procedures (85.6%): 37 (80.4%) in the HBP group and 40 (90.9%) in the LBBAP group (P = .23). Paced QRS duration was shorter in the LBBAP patients (109 ± 8 vs. 117 ± 19 ms; P

BACKGROUND Frequent premature ventricular complexes (PVCs) are common after a myocardial infarction (MI), but data on PVC ablation in this population are limited. OBJECTIVE The purpose of this study was to analyze data on PVC ablation in post-MI patients. METHODS Three hundred thirty-two patients with frequent PVCs and left ventricular (LV) dysfunction were prospectively studied. Data from 67 patients (20%; age 63 +/- 10 years; 65 men [93%]) with previous MI were compared with the remaining 265 patients. RESULTS PVCs in post-MI patients originate predominantly from the LV (92% LV vs 6% right ventricle [RV]; P

The treatment of patients with bifascicular block (BFB) and syncope in the absence of structural heart disease (SHD) is not well defined. The objective of our study is to compare pacemaker empirical implantation with the use of electrophysiological studies (EPS). This is a prospective cohort study that included 77 patients with unexplained cardiogenic syncope and BFB without structural heart disease between 1997 and 2012. Two groups: 36 patients received empirical pacemakers (Group A) and 41 underwent EPS (Group B) to guide their treatment. The incidence of syncope recurrence and atrioventricular block was lower in group A. Mortality and complication rates were similar between both groups. Multivariate analysis demonstrated a higher number of events (combined endpoint) in group B. Our study shows that treatment according to EPS does not improve the results of a treatment strategy based on empirical pacemaker.

A mechanical tricuspid valve makes it difficult to implant a transvenous endocardial lead in the right ventricle, necessitating pacing by alternative nonphysiological methods such as implanting an epicardial lead and pacing through the coronary sinus. Permanent His-bundle pacing is an increasingly

There is a consensus that patients with complete atrioventricular (AV) block accompanied by significant ventricular systolic dysfunction (before or after monoventricular pacing) benefit from cardiac resynchronization therapy (CRT). However, there are cases in which effective resynchronization is particularly difficult to achieve, generally owing to anatomic or vein-access problems. Up to now, the alternative therapy in these especially difficult cases has been the epicardial approach. We present His-bundle pacing (HBP) for the first time as a clinically effective alternative in a case that was complicated by dextrocardia and persistent right superior vena cava and required CRT because of systolic dysfunction in the presence of complete AV block.

Introduction and objectives Nonischemic sudden cardiac death (SCD) is predominantly caused by cardiomyopathies and channelopathies. There are many diagnostic tests, including some complex techniques. Our aim was to analyze the diagnostic yield of a systematic diagnostic protocol in a specialized unit. Methods The study included 56 families with at least 1 index case of SCD (resuscitated or not). Survivors were studied with electrocardiogram, advanced cardiac imaging, exercise testing, familial study, genetic testing and, in some cases, pharmacological testing. Families with deceased probands were studied using the postmortem findings, familial evaluation, and molecular autopsy with next-generation sequencing (NGS). Results A positive diagnosis was obtained in 80.4% of the cases, with no differences between survivors and nonsurvivors ( P = .53). Cardiac channelopathies were more prevalent among survivors than nonsurvivors (66.6% vs 40%, P = .03). Among the 30 deceased probands, the definitive diagnosis was given by autopsy in 7. A diagnosis of cardiomyopathy tended to be associated with a higher event rate in the family. Genetic testing with NGS was performed in 42 index cases, with a positive result in 28 (66.6%), with no differences between survivors and nonsurvivors ( P = .21). Conclusions There is a strong likelihood of reaching a diagnosis in SCD after a rigorous protocol, with a more prevalent diagnosis of channelopathy among survivors and a worse familial prognosis in cardiomyopathies. Genetic testing with NGS is useful and its value is increasing with respect to the Sanger method.

Background The Prevention With Mediterranean Diet (PREDIMED) trial supported the effectiveness of a nutritional intervention conducted by a dietitian to prevent cardiovascular disease. However, the effect of a remote intervention to follow the Mediterranean diet has been less explored. Objective This study aims to assess the effectiveness of a remotely provided Mediterranean diet–based nutritional intervention in obtaining favorable dietary changes in the context of a secondary prevention trial of atrial fibrillation (AF). Methods The PREvention of recurrent arrhythmias with Mediterranean diet (PREDIMAR) study is a 2-year multicenter, randomized, controlled, single-blinded trial to assess the effect of the Mediterranean diet enriched with extra virgin olive oil (EVOO) on the prevention of atrial tachyarrhythmia recurrence after catheter ablation. Participants in sinus rhythm after ablation were randomly assigned to an intervention group (Mediterranean diet enriched with EVOO) or a control group (usual clinical care). The remote nutritional intervention included phone contacts (1 per 3 months) and web-based interventions with provision of dietary recommendations, and participants had access to a web page, a mobile app, and printed resources. The information is divided into 6 areas: Recommended foods, Menus, News and Online resources, Practical tips, Mediterranean diet classroom, and Your personal experience. At baseline and at 1-year and 2-year follow-up, the 14-item Mediterranean Diet Adherence Screener (MEDAS) questionnaire and a semiquantitative food frequency questionnaire were collected by a dietitian by phone. Results A total of 720 subjects were randomized (365 to the intervention group, 355 to the control group). Up to September 2020, 560 subjects completed the first year (560/574, retention rate 95.6%) and 304 completed the second year (304/322, retention rate 94.4%) of the intervention. After 24 months of follow-up, increased adherence to the Mediterranean diet was observed in both groups, but the improvement was significantly higher in the intervention group than in the control group (net between-group difference: 1.8 points in the MEDAS questionnaire (95% CI 1.4-2.2; P Conclusions The remote nutritional intervention using a website and phone calls seems to be effective in increasing adherence to the Mediterranean diet pattern among AF patients treated with catheter ablation. Trial Registration ClinicalTrials.gov NCT03053843; https://www.clinicaltrials.gov/ct2/show/NCT03053843

ObjectivesSARS-CoV-2 is a rapidly evolving pandemic causing great morbimortality. Medical therapy with hydroxicloroquine, azitromycin and protease inhibitors is being empirically used, with reported data of QTc interval prolongation. Our aim is to assess QT interval behaviour in a not critically ill and not monitored cohort of patients.DesignWe evaluated admitted and ambulatory patients with COVID-19 patients with 12 lead electrocardiogram at 48 hours after treatment initiation. Other clinical and analytical variables were collected. Statistical analysis was performed to assess the magnitude of the QT interval prolongation under treatment and to identify clinical, analytical and electrocardiographic risk markers of QT prolongation independent predictors.ResultsWe included 219 patients (mean age of 63.6 ± 17.4 years, 48.9% were women and 16.4% were outpatients. The median baseline QTc was 416 ms (IQR 404–433), and after treatment QTc was prolonged to 423 ms (405–438) (P < 0.001), with an average increase of 1.8%. Most of the patients presented a normal QTc under treatment, with only 31 cases (14,1 %) showing a QTc interval > 460 ms, and just one case with QTc > 500 ms. Advanced age, longer QTc basal at the basal ECG and lower potassium levels were independent predictors of QTc interval prolongation.ConclusionsAmbulatory and not critically ill patients with COVID-19 treated with hydroxychloroquine, azithromycin and/or antiretrovirals develop a significant, but not relevant, QT interval prolongation.What is already known about this subject?Treatment for COVID 19 with empirical drugs hydroxicloroquine, azitromycin and protease inhibitors affects ventricular repolarization by prolonging the QT interval in a variable degree basing upon heterogeneous studiesWhat does this study add?Not critically ill patients with COVID 19 develop a non relevant QT interval prolongation, leading to a modest arrhythmic risk increase, overall in patients with normal basal ECGHow might this impact on clinical practice?Our findings are significant as ECG monitoring of COVID 19 patients is costly and difficult. Ambulatory and stable patients with normal basal ECG might nor benefit from QT assessment afeter treatment initiation

Aims Arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) is a life-threatening entity with a highly heterogeneous genetic background. Cardiac magnetic resonance (CMR) imaging can identify fibrofatty scar by late gadolinium enhancement (LGE). Our aim is to investigate genotype–phenotype correlation in ARVC/D mutation carriers, focusing on CMR-LGE and myocardial fibrosis patterns. Methods and results A cohort of 44 genotyped patients, 33 with definite and 11 with borderline ARVC/D diagnosis, was characterized using CMR and divided into groups according to their genetic condition (desmosomal, non-desmosomal mutation, or negative). We collected information on cardiac volumes and function, as well as LGE pattern and extension. In addition, available ventricular myocardium samples from patients with pathogenic gene mutations were histopathologically analysed. Half of the patients were women, with a mean age of 41.6 ± 17.5 years. Next-generation sequencing identified a potential pathogenic mutation in 71.4% of the probands. The phenotype varied according to genetic status, with non-desmosomal male patients showing lower left ventricular (LV) systolic function. LV fibrosis was similar between groups, but distribution in non-desmosomal patients was frequently located at the posterolateral LV wall; a characteristic LV subepicardial circumferential LGE pattern was significantly associated with ARVC/D caused by desmin mutation. Histological analysis showed increased fibrillar connective tissue and intercellular space in all the samples. Conclusion Desmosomal and non-desmosomal mutation carriers showed different morphofunctional features but similar LV LGE presence. DES mutation carriers can be identified by a specific and extensive LV subepicardial circumferential LGE pattern. Further studies should investigate the specificity of LGE in ARVC/D.

Aims Frequent premature ventricular complexes (PVCs) can induce or worsen left ventricular systolic dysfunction. We aimed to investigate the influence of the baseline QRS in the response after PVC ablation in patients with depressed left ventricular ejection fraction (LVEF). Methods and results Two hundred and fifteen [59 ± 13 years old, 152 (71%) men] consecutive patients with left ventricular (LV) systolic dysfunction and frequent PVCs referred for ablation were included and followed-up for 12 months. Echocardiographic response was defined as an improvement of at least five absolute points in LVEF. Clinical, electrocardiogram, and electrophysiological characteristics were analysed. Mean baseline QRS duration was 110 ms [97–140]. Premature ventricular complex burden significantly decreased after ablation from 23% [16–33] at baseline to 1% [0–8] at 12 months, P 130 ms. Conclusions In patients with LV systolic dysfunction, intrinsic QRS duration is inversely related to the probability and the degree of echocardiographic response after frequent PVC ablation. Patients with a QRS duration >130 ms at baseline have the poorer response after ablation.

Aims Ablation of frequent premature ventricular complexes (PVCs) improves left ventricular ejection fraction in patients with left ventricular (LV) systolic dysfunction. This study aims to evaluate the long-term hard outcomes and potential prognostic variables in this population. Methods and results Prospective multicentre study including 101 consecutive patients [56 ± 12 years old, 62 (61%) men] with LV systolic dysfunction and frequent PVCs who underwent PVC ablation before November 2015. The last evaluation performed was considered the long-term follow-up (LTFUP) evaluation. Mean follow-up was 34 ± 16 months (range 24–84 months). Ablation was successful in 95 (94%) patients. There was a significant reduction in the PVC burden from 21 ± 12% at baseline to 3.8 ± 6% at LTFUP, P Conclusion In patients with LV systolic dysfunction, ablation of frequent PVCs induces a significant improvement in functional, structural, and neurohormonal status, which persists at LTFUP. A sustained reduction in the baseline PVC burden is associated with a lower risk of cardiac mortality, cardiac transplantation, or hospitalization for heart failure during follow-up.

Short QT Syndrome (SQTS) is a very rare cardiac channelopathy that leads to an abbreviated QTc interval and sudden cardiac death (SCD). It is a genetically heterogeneous entity, with only 25 % of cases identified as having a pathogenic mutation in genes encoding mainly for plasma membrane ion

Premature ventricular complex (PVC) ablation has been shown to improve left ventricular ejection fraction (LVEF) and New York Heart Association functional class in patients with left ventricular dysfunction. Both are considered key variables in predicting risk of sudden cardiac death.The objective of this study was to assess whether ablation might remove the primary prevention (PP) implantable cardioverter-defibrillator (ICD) indication in patients with frequent PVC.Sixty-six consecutive patients with PP-ICD indication and frequent PVC [33 (50%) men; mean age 53 ± 13 years; 11 (17%) with ischemic heart disease] underwent PVC ablation. The ICD was withheld and the indication was reevaluated at 6 and 12 months.LVEF progressively improved from 28% ± 4% at baseline to 42% ± 12% at 12 months (P.001). New York Heart Association functional class improved from 2 patients with NYHA functional class I (3%) at baseline to 35 (53%) at 12 months (P.001). The brain natriuretic peptide level decreased from 246 ± 187 to 176 ± 380 pg/mL (P = .004). The PP-ICD indication was removed in 42 patients (64%) during follow-up, from 38 (92%) of them at 6 months, showing an independent association with baseline PVC burden and successful sustained ablation. In patients with successful sustained ablation, a cutoff value of 13% PVC burden had a sensitivity of 100% and a specificity of 93% (area under the curve 99%) for removing ICD indication postablation. No sudden cardiac deaths or malignant ventricular arrhythmias were observed.In patients with frequent PVC and PP-ICD indication, ablation improves LVEF and, in most cases, allows removal of the indication. Withholding the ICD and reevaluating within 6 months of ablation seems to be a safe and appropriate strategy.

Introduction and objectives To analyze the prognostic value of nocturnal hypoxaemia measured with portable nocturnal pulse-oximetry in patients hospitalized due to heart failure and its relation to mortality and hospital readmission. Methods We included 38 patients who were admitted consecutively to our unit with the diagnosis of decompensated heart failure. Pulse-oximetry was considered positive for hypoxaemia when more than 10 desaturations per hour were recorded during sleep. Follow-up was performed for 30.3 (standard deviation [SD] 14.2) months, the main objective being a combined endpoint of all-cause mortality and hospital readmission due to heart failure. Results The average age was 70.7 (SD 10.7) years, 63.3% were males. Pulse-oximetry was considered positive for hypoxaemia in 27 (71%) patients. Patients with positive pulse-oximetry had the most frequent endpoint (9.1% [1] vs. 61.5% [16], p = 0.003). After multivariate analysis, continuous nocturnal hypoxaemia was related to the combined endpoint (HR = 8.37, 1.19–68.4, p = 0.03). Discussion Patients hospitalized for heart failure and nocturnal hypoxaemia measured with portable pulse-oximeter have an increased risk of hospital readmission and death.

Background Empiric circumferential pulmonary vein isolation (CPVI) has become the therapy of choice for drug-refractory atrial fibrillation (AF). Although results are suboptimal, it is unknown whether mechanistically-based strategies targeting AF drivers are superior. Objectives This study sought to determine the efficacy and safety of localized high-frequency source ablation (HFSA) compared with CPVI in patients with drug-refractory AF. Methods This prospective, multicenter, single-blinded study of 232 patients (age 53 ± 10 years, 186 males) randomized those with paroxysmal AF (n = 115) to CPVI or HFSA-only (noninferiority design) and those with persistent AF (n = 117) to CPVI or a combined ablation approach (CPVI + HFSA, superiority design). The primary endpoint was freedom from AF at 6 months post-first ablation procedure. Secondary endpoints included freedom from atrial tachyarrhythmias (AT) at 6 and 12 months, periprocedural complications, overall adverse events, and quality of life. Results In paroxysmal AF, HFSA failed to achieve noninferiority at 6 months after a single procedure but, after redo procedures, was noninferior to CPVI at 12 months for freedom from AF and AF/AT. Serious adverse events were significantly reduced in the HFSA group versus CPVI patients (p = 0.02). In persistent AF, there were no significant differences between treatment groups for primary and secondary endpoints, but CPVI + HFSA trended toward more serious adverse events. Conclusions In paroxysmal AF, HFSA failed to achieve noninferiority at 6 months but was noninferior to CPVI at 1 year in achieving freedom of AF/AT and a lower incidence of severe adverse events. In persistent AF, CPVI + HFSA offered no incremental value. (Radiofrequency Ablation of Drivers of Atrial Fibrillation [RADAR-AF]; NCT00674401 )

BACKGROUND Frequent premature ventricular complexes (PVCs) can induce or worsen left ventricular (LV) systolic dysfunction. OBJECTIVE The purpose of this study was to identify the clinical pattern of patients having a "pure PVC-induced" cardiomyopathy at presentation. METHODS This prospective multicenter study included 155 consecutive patients (age 55612 years, 96 men [62%], 23% +/- 12% mean PVC burden) with LV dysfunction and frequent PVCs submitted for ablation and followed up for at least 12 months. Patients with a previously diagnosed structural heart disease (50 [32%]) and those without complete PVC abolition during follow-up who did not normalize LV ejection fraction (LVEF) (24 [15%]) were excluded from the analysis. RESULTS Of the remaining 81 patients, 41 (51%) had a successful sustained ablation, did not have normalized LVEF, and were classified as having PVC-worsened nonischemic cardiomyopathy, and 40 (49%) who had normalized LVEF were considered as having pure PVC-induced cardiomyopathy. The latter group had higher baseline PVC burden (27% +/- 12% vs 12% +/- 8%; P < .001), smaller LV end-diastolic diameter (58 +/- 5 mmvs 60 +/- 6 mm; P=.05), and shorter Kintrinsic QRS (105 +/- 12 vs 129 +/- 24 ms; P130 ms, baseline PVC burden 63 mm. CONCLUSION Almost half of patients with frequent PVCs and low LVEF of unknown origin normalize LVEF after sustained PVC abolition, and these patients can be identified before ablation.

Background Calmodulin 1, 2 and 3 (CALM) mutations have been found to cause cardiac arrest in children at a very early age. The underlying aetiology described is long QT syndrome (LQTS), catecholaminergic polymorphic ventricular tachycardia (CPVT) and idiopathic ventricular fibrillation (IVF). Little phenotypical data about CALM2 mutations is available. Objectives The aim of this paper is to describe the clinical manifestations of the Asn98Ser mutation in CALM2 in two unrelated children in southern Spain with apparently unexplained cardiac arrest/death. Methods Two unrelated children aged 4 and 7, who were born to healthy parents, were studied. Both presented with sudden cardiac arrest. The first was resuscitated after a VF episode, and the second died suddenly. In both cases the baseline QTc interval was within normal limits. Peripheral blood DNA was available to perform targeted gene sequencing. Results The surviving 4-year-old girl had a positive epinephrine test for LQTS, and polymorphic ventricular ectopic beats were seen on a previous 24-hour Holter recording from the deceased 7-year-old boy, suggestive of a possible underlying CPVT phenotype. A p.Asn98Ser mutation in CALM2 was detected in both cases. This affected a highly conserved across species residue, and the location in the protein was adjacent to critical calcium binding loops in the calmodulin carboxyl-terminal domain, predicting a high pathogenic effect. Conclusions Human calmodulin 2 mutation p.Asn98Ser is associated with sudden cardiac death in childhood with a variable clinical penetrance. Our results provide new phenotypical information about clinical behaviour of this mutation.

We have read with interest the article by Herman et al1 describing the prospective outcome of patients with unexplained cardiac arrest (UCA). Certainly, it seems that a high incidence of adverse events occurs in a short-period follow-up. We agree that an implantable cardioverter defibrillator (ICD) is mandatory irrespective of achieving a final diagnosis. The poorer prognosis in patients with structural abnormalities respect to those with primary electric disorders is an interesting finding and might be because of a high efficacy of medical treatment for some cardiac channelopathies. However, some other considerations need to be addressed. It is somewhat surprising that the same incidence of …

Introduction and objectives Sprint Fidelis defibrillation leads are prone to early failure. Most of the reported series come from a single institution. This paper describes the clinical experience in nine Spanish hospitals. Methods Clinical, implant, and follow-up data of all patients with a Sprint Fidelis lead were analyzed. All cases of lead failure were identified, medium-term lead survival was calculated, and possible predictors for lead failure were determined. Results In total, 378 leads in 376 patients were studied. The mean age (male 85.7%) was 64.9 ± 13.6 years. The majority of patients (59.8%) had ischemic heart disease. Mean left ventricular ejection fraction was 33.4% ± 14.5%. Left subclavian vein puncture was used in 74.8%. During a mean follow-up of 30.9 ± 14 months, 16 lead failures have occurred, with a lead survival of 96.1% at 36 months after implantation. Eleven of 16 lead failures were caused by failure of pace/sense conductors, 3 by defects in the high-voltage conductor, and 2 by defects in both types of conductors. A less depressed left ventricular ejection fraction was associated with an increased probability of lead failure (42.4% ± 16% vs. 33% ± 14.3%; P = .011). Three hospitals presented a rate of lead failure higher than 10%; the rate was less than 5% in the remaining 6 hospitals. Conclusions In this multicenter series of 378 leads, the 3-year estimated survival was higher than that reported in prior series. Clinical presentation of lead failures was similar to that reported previously. Left ventricular ejection fraction and hospital of implantation were variables associated to lead failure.

Congenital long QT syndrome is mainly caused by mutations in the KCNQ1, KCNH2 and SCN5A genes. The aim of this study was to investigate the prevalence of mutations in these three genes in patients with long QT syndrome or idiopathic ventricular fibrillation seen at our center. The study included nine patients with long QT syndrome and four with idiopathic ventricular fibrillation. The first-degree relatives of genotype-positive probands were also investigated. Missense mutations were found in seven patients with long QT syndrome and two with idiopathic ventricular fibrillation. Overall, 71.4% of mutations were in KCNH2 and 28.6% were in SCN5A. No mutations in KCNQ1 were found. Only two mutations had been previously observed. Mutations were also found in six of the 19 relatives studied. In conclusion, our initial experience shows that genetic testing had a high sensitivity for diagnosing long QT syndrome. Mutations were found most frequently in the KCNH2 gene.

ObjectiveThis study aims to evaluate the influence of myocardial scar after premature ventricular complexes (PVC) ablation in patients with left ventricular (LV) dysfunction.Methods70 consecutive patients (58±11 years, 58 (83%) men, 23% (18–32) mean PVC burden) with LV dysfunction and frequent PVCs submitted for ablation were included. A late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) was performed prior to the ablation and a quantitative and qualitative analysis of the scar was done.ResultsLeft ventricular ejection fraction progressively improved from 34.3%±9% at baseline to 44.4%±12% at 12 months (pConclusionsPresence of myocardial scar modulates, but does not preclude, the probability of response to PVC ablation in patients with LV dysfunction.

Introduction and objectives The aim was to investigate the clinical practice of using antiarrhythmic drugs after electrical cardioversion in patients without structural heart disease and their effect on the maintenance of sinus rhythm. Methods In total, 528 patients with persistent atrial fibrillation but without significant structural heart disease who underwent successful electrical cardioversion at 96 Spanish hospitals were followed up for 1 year. Patients were assessed at 1, 3, 6, and 12 months. The use and effectiveness of antiarrhythmic drugs for preventing the recurrence of persistent atrial fibrillation was evaluated. Results Some 80% of patients were receiving antiarrhythmic drugs at discharge, most frequently amiodarone. No specific clinical factor was associated with greater use of antiarrhythmics. Overall, 37% of patients were in sinus rhythm at all follow-up assessments. At the 1-year assessment, 59% of patients who remained in sinus rhythm were still taking antiarrhythmic drugs. Multivariate Cox regression analysis identified weight (hazard ratio [HR]=1.01 per kg; P =.04) and no antiarrhythmic treatment (HR=1.59; P =.001) as being independently associated with the recurrence of persistent atrial fibrillation. Amiodarone tended to be better than other antiarrhythmic drugs. Conclusions In routine clinical practice, the large majority of patients without structural heart disease received antiarrhythmic drugs, most frequently amiodarone, after successful electrical cardioversion. Drug use was the principal factor associated with the maintenance of sinus rhythm at 1 year.

Aims To describe atrial fibrillation (AF) management in member countries of the European Society of Cardiology (ESC) and to verify cardiology practices against guidelines. Methods and results Among 182 hospitals in 35 countries, 5333 ambulant and hospitalized AF patients were enrolled, in 2003 and 2004. AF was primary or secondary diagnosis, and was confirmed on ECG in the preceding 12 months. Clinical type of AF was reported to be first detected in 978, paroxysmal in 1517, persistent in 1167, and permanent in 1547 patients. Concomitant diseases were present in 90% of all patients, causing risk factors for stroke to be also highly prevalent (86%). As many as 69% of patients were symptomatic at the time of the survey; among asymptomatic patients, 54% were previously experienced symptoms. Oral anticoagulation was prescribed in 67 and 49% of eligible and ineligible patients, respectively. A rhythm control strategy was applied in 67% of currently symptomatic patients and in 44% of patients who never experienced symptoms. Conclusion This survey provides a unique snapshot of current AF management in ESC member countries. Discordance between guidelines and practice was found regarding several issues on stroke prevention and antiarrhythmic therapy.

Left ventricular systolic dysfunction related to ventricular arrhythmias is a relatively poorly understood entity. To increase our knowledge base, we describe 5 patients in whom the link between ventricular dysfunction and ventricular arrhythmia was unequivocally established. All patients had repetitive monomorphic ventricular arrhythmias and left ventricular systolic dysfunction (ejection fraction ≤40% and end-diastolic size ≥55 mm). The arrhythmogenic source was identified by electrophysiological study (right ventricle in 2 patients, left ventricle in 2, and left sinus of Valsalva in one), and was eliminated in all patients by radiofrequency catheter ablation. At 7±2 months post-ablation, large improvements were seen in left ventricular function and remodeling (ejection fraction ≥50% and end-diastolic size ≤51 mm in all cases), with no recurrence of arrhythmia during followup (10-69 months). This finding confirms that recurring ventricular arrhythmias can induce left ventricular dysfunction which may be reversible after ablation.

The purpose of this study was to determine whether administration of adenosine 5'-triphosphate (ATP; 20-40 mg) after successful ablation of accessory pathway (AP) with manifest preexcitation is useful for detecting residual conduction and predicting early recurrences.The reported incidence of recurrence of AP conduction after an initially successful procedure is 5% to 10%. Little information on the variables related to early recurrence has been reported.We prospectively used 108 ATP tests on 100 consecutive patients (66 men, mean age 36 +/- 15 years) with manifest preexcitation. Five minutes after successful ablation, intravenous boluses of ATP at increasing doses were injected until the target effect of second- or third-degree AV block or AP conduction was observed.The effect of ATP was AV block (negative test) in 82 cases (76%), conduction over previously ablated AP (positive test) in 9 cases (8.3%), and no achievement of target effect (nondiagnostic test) in 17 cases (15.7%). Thirteen early recurrences were observed in 12 patients. In all 9 (100%) patients with positive ATP test and in 4 (4.9%) of the 82 patients with negative ATP test, conduction over the AP recurred (relative risk 20; 95% confidence interval 8-53; P.000001). The diagnostic accuracy of the test (analyzing the target effect) was 95%, sensitivity 69%, specificity 100%, and positive and negative predictive values 100% and 95%, respectively.ATP administration after successful ablation of APs has a high predictive value for early recurrence and may help optimize the duration of the ablation procedure.

Unexplained cardiac arrest (UCA) can be caused by low-penetrance genetic disorders. The aim of this cross-sectional study is to assess the usefulness of a new diagnostic protocol: Thirty-five patients were recruited from 9 Spanish centers. Electrocardiogram, echocardiogram, and coronary catheterization were used to rule out electrical or structural heart disease in all subjects. Patients underwent pharmacologic tests with epinephrine and flecainide, followed by assessment of family members using electrocardiogram and echocardiogram, and next-generation genetic sequencing to analyze 126 genes if all the other test results were negative. A firm diagnosis of channelopathy required phenotypic proof of the condition in unmasking tests, the presence of a pathogenic variant consistent with the phenotype observed, and/or co-segregation of the mutation found in a family member's phenotype. A firm diagnosis was made in 18 cases. The diagnoses were 7 Brugada syndrome, 5 catecholaminergic polymorphic ventricular tachycardia, 3 long QT syndrome, 2 early repolarization syndrome, and 1 short QT syndrome. Pharmacologic testing was the most frequent method of diagnosis. In 5 cases, the diagnosis was made based on positive genetic testing without phenotypic alterations. In conclusion, this sequential diagnostic protocol allows diagnoses to be made in approximately half of the UCA cases. These diagnoses are low clinical penetrance channelopathies. If interpreted carefully, genetic tests can be a useful tool for diagnosing UCA without a phenotype. (C) 2015 Elsevier Inc. All rights reserved.

Background — In patients with syncope and structural heart disease, syncope is suspected to be attributable to a primary cardiac arrhythmia, but little is known of its mechanism when electrophysiologic study is unremarkable. Methods and Results — We applied an implantable loop recorder in 35 patients with overt heart disease at risk of ventricular arrhythmia, because these were patients with previous myocardial infarction or cardiomyopathy with depressed ejection fraction or nonsustained ventricular tachycardia in whom an electrophysiologic study was unremarkable. During a follow-up of 3 to 15 months, syncope recurred in 6 patients (17%) after a mean of 6±5 months; in 3 patients, the mechanism of syncope was bradycardia with long pauses (sudden-onset AV block in 2 cases and sinus arrest in 1 case); in 1 patient, there was stable sinus tachycardia; and in 2 patients, who had chronic atrial fibrillation, there was an increase in ventricular rate. A total of 23 episodes of presyncope were documented in 8 patients (23%): no rhythm variation or mild tachycardia in 12 cases, paroxysmal atrial fibrillation or atrial tachycardia in 10 cases, and sustained ventricular tachycardia in 1 case. No patient died during the study period nor suffered from injury attributable to syncopal relapse. Conclusions — The patients with unexplained syncope, structural heart disease, and negative electrophysiologic study had a favorable medium-term outcome with no case of death and a low recurrence rate of syncope without related injury. The mechanism of syncope was heterogeneous, and ventricular tachyarrhythmia was unlikely.

Study objectives: To evaluate the benefit of sinus rhythm (SR) restoration in patients with chronic controlled atrial fibrillation (AF) and left ventricular systolic dysfunction (LVSD). Design: Prospective case-control study on the short-term outcome (6 to 9 months) of clinical and echocardiographic variables following attempted cardioversion. Setting: Outpatient clinic of a university hospital. Patients: Fifteen men and 5 women, ranging in age from 40 to 76 years, who had chronic controlled (mean [6 SD] ventricular rate, 82 6 10 beats/min) AF and left ventricular fractional shortening (LVFS) of < 28% at baseline. Control was provided by retrospective paired echocardiographic examinations of six AF patients, plus the study cases with potentially unsuccessful cardioversion or early recurrence of AF. Interventions: Attempt to restore SR with amiodarone or electrical countershock. Measurements and results: Conversion was attained in 17 patients, but AF recurred early in 4 patients, 3 of whom had proven ischemic LVSD. In the 13 patients with sustained SR, LVFS increased from 20 6 4% to 31 6 6% (p < 0.0001). In contrast, no changes were detected in the control group (n 5 13). This improvement was paralleled by decreases in left ventricular (LV) end-diastolic dimension (from 55 6 7t o 516 6 mm; p 5 0.014), LV mass (from 181 6 28 to 159 6 37 g; p 5 0.015), and left atrial diameter (from 45 6 9m m to 426 7; p 5 0.003). A marked decrease in heart rate (from 82 6 9t o 646 5 beats/min; p < 0.0001) and a reduction in New York Heart Association functional class (from 2.3 6 0.9 to 1.2 6 0.4; p 5 0.0007) also were observed in patients with sustained SR but not among subjects in the control group. Conclusions: Even when adequate control of the ventricular rate has been achieved, the LV function of patients with chronic AF greatly improves after restoration and maintenance of SR. (CHEST 2001; 120:132‐138) dysfunction Abbreviations: ACE 5 angiotensin-converting enzyme; AF 5 atrial fibrillation; LA 5 left atrium; LV 5 left ventricle, ventricular; LVEDD 5 left ventricular end-diastolic dimension; LVFS 5 left ventricular fractional shortening; LVM 5 left ventricular mass; LVS 5 left ventricular systolic; LVSD 5 left ventricular systolic dysfunction; SR 5 sinus rhythm

Aims To evaluate the efficacy and safety of a single loading oral dose of propafenone in the interruption of recent-onset atrial fibrillation. Methods After a complete medical history, physical examination, 12-lead ECG, chest X-ray, and routine biochemical laboratory testing, 55 consecutive patients with recent-onset atrial fibrillation were randomized double-blind in the emergency department for the administration of either a single oral dose (450 to 750 mg) of propafenone (29 cases) or a placebo (26 cases). After the 24-h observation period, comprehensive echocardiographic examination was performed. Results The groups were homogeneous as regards biological, clinical and echocardiographic characteristics. Two hours after treatment, 12 patients (41%) on propafenone but only two (8%) on placebo had converted to sinus rhythm ( P =0·005). This striking difference was maintained 6 h after treatment (65 vs 31%; P =0·015) but lessened at 12 h (69% vs 42%; P =0·060) and was insignificant at the end of the 24-h treatment period (79% vs 73%; P =0·752). Apart from hypotension, transient in three cases and sustained in one whose later echocardiographic examination demonstrated left systolic ventricular dysfunction, propafenone was well tolerated. Conclusions Although there is no significant difference in the rates of conversion 24 h after treatment, propafenone works faster than placebo in achieving sinus rhythm. This rapid action of oral propafenone can be useful to solve quickly the clinical problems of a high proportion of patients arriving at the emergency department with acute atrial fibrillation.