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Estimates of the prevalence of atrial fibrillation (AF) in heart failure (HF) originate from patients enrolled in clinical trials.To assess the prevalence and clinical correlates of AF among HF patients in everyday clinical practice from HF patients screened for the T-wave ALternans in Patients with Heart fAilure (ALPHA) study; to investigate the correlation between AF and functional status.Consecutive patients (N=3513) seen at nine Heart Failure Clinics were studied; 21.4% were in AF. AF prevalence was greater with increasing age (OR 1.04/year, p0.001) in non-ischaemic cardiomyopathy (OR 2.34, p0.001) and with increasing NYHA class (p0.0001). Multiple logistic regression predictors of AF were age70 years (OR 2.35), NYHA class II III or IV vs class I (OR 1.8, 4.4 and 3.1) and non-ischaemic cardiomyopathy (OR 3.2). A logistic model indicated that AF was associated with a 2.5 OR of being in NYHA class III-IV vs I-II while accounting for age, gender, left ventricular ejection fraction (LVEF), and aetiology of HF.The prevalence of AF in HF patients exceeds 20%, and increases with age and functional class. The presence of AF leads to a more severe NYHA class, indicating that AF contributes to the severity of heart failure.

ObjectivesThe aim of this study was to assess the prognostic value of T-wave alternans (TWA) in New York Heart Association (NYHA) functional class II/III patients with nonischemic cardiomyopathy and left ventricular ejection fraction (LVEF) ≤40%.BackgroundThere is a strong need to identify reliable risk stratifiers among heart failure candidates for implantable cardioverter-defibrillator (ICD) prophylaxis. T-wave alternans may identify low-risk subjects among post-myocardial infarction patients with depressed LVEF, but its predictive role in nonischemic cardiomyopathy is unclear.MethodsFour hundred forty-six patients were enrolled and followed up for 18 to 24 months. The primary end point was the combination of cardiac death + life-threatening arrhythmias; secondary end points were total mortality and the combination of arrhythmic death + life-threatening arrhythmias.ResultsPatients with abnormal TWA (65%) compared with normal TWA (35%) tests were older (60 ± 13 years vs. 57 ± 12 years), were more frequently in NYHA functional class III (22% vs. 19%), and had a modestly lower LVEF (29 ± 7% vs. 31 ± 7%). Primary end point rates in patients with abnormal and normal TWA tests were 6.5% (95% confidence interval [CI] 4.5% to 9.4%) and 1.6% (95% CI 0.6% to 4.4%), respectively. Unadjusted and adjusted hazard ratios were 4.0 (95% CI 1.4% to 11.4%; p = 0.002) and 3.2 (95% CI 1.1% to 9.2%; p = 0.013), respectively. Hazard ratios for total mortality and for arrhythmic death + life-threatening arrhythmias were 4.6 (p = 0.002) and 5.5 (p = 0.004), respectively; 18-month negative predictive values for the 3 end points ranged between 97.3% and 98.6%.ConclusionsAmong NYHA functional class II/III nonischemic cardiomyopathy patients, an abnormal TWA test is associated with a 4-fold higher risk of cardiac death and life-threatening arrhythmias. Patients with normal TWA tests have a very good prognosis and are likely to benefit little from ICD therapy.

Transient left ventricular apical ballooning, sometimes associated with intraventricular pressure gradient, is a condition simulating an acute myocardial infarction and may occur in patients presenting with chest pain, electrocardiographic changes and minimal myocardial enzyme release typically without coronary angiographic stenosis. It was originally described in the Japanese population and is often associated with cerebrovascular accidents, surgical procedures and emotional and physical stress. We report the case of a 65-year-old woman presenting with chest pain typical of myocardial ischemia, dyspnea, electrocardiographic abnormalities and signs of hemodynamic instability, occurring after a severe emotional stress. Echocardiography and contrast ventriculography showed normokinesis confined to the basal segments of the left ventricle, with a markedly decreased ejection fraction. Scintigraphy was suggestive of a large perfusion defect. The electrocardiographic abnormalities and dyskinesis persisted for many hours. Coronary angiography, performed in the acute phase, was completely normal. Five months later, the functional and electrocardiographic abnormalities had totally disappeared.

The atrial Fibrillation/flutter Italian REgistry (FIRE) study was designed to obtain updated information regarding the clinical characteristics of and medical approach to patients requiring urgent medical care for atrial fibrillation (AF) or atrial flutter in a nationwide and representative series of hospitals.4570 consecutive patients admitted to the emergency room for AF/atrial flutter were enrolled in 207 hospitals. Of these, 2838 (61.9%) were hospitalized (median 6 days, 43% in cardiology and 57% in internal medicine departments), and constitute the population of this study.AF/atrial flutter represented 1.5% of all emergency room admissions and 3.3% of all hospitalizations. The mean age was 70 +/- 12 years; 89.9% had AF and 10.1% atrial flutter. In 31% of the hospitalized patients no cardiac disease was present, and in 18% no disease (either cardiac or non-cardiac) could be detected. Predictors of no attempt of cardioversion (37.5% of patients) included: onset of AF48 hours, heart failure, increasing age, syncope, admission to a non-cardiology department, stroke or transient ischemic attack (TIA). Predictors of in-hospital mortality (2.2%) included: age, heart failure, diabetes, admission to a non-cardiology department, and stroke or TIA. Predictors of the absence of sinus rhythm at discharge (35.6% of patients) included: no attempt of cardioversion, heart failure, chronic anticoagulation, AF duration48 hours, increasing age, stroke or TIA, and admission to a non-cardiology department. Transesophageal echocardiography was performed in only 6% of patients.AF/atrial flutter represent a significant burden on the health care system with a higher than expected hospitalization rate from the emergency room. One out of three discharged patients is not in sinus rhythm. There is still a wide gap between evidence-based medicine and real practice in the treatment of patients with AF.

The authors report the case of 15-year-old girl with a history of palpitations and shortness of breath during exercise. The electrocardiogram showed ventricular preexcitation suggesting a Wolff-Parkinson-White syndrome with a posteroseptal accessory pathway. During the electrophysiological study a left posterospetal accessory pathway was identified and an orthodromic atrioventricular reentry tachycardia was reproducibly induced (cycle length 400 ms). After disappearance of the ventricular pre-excitation with radiofrequency ablation, a dual physiology of atrioventricular node condution was documented and a slow-fast atrioventricular nodal reentrant tachycardia was repeatedly induced. Upon induction, this tachycardia presented a proximal atrioventricular block with 2:1 condution converted to 1:1 condution with overdrive pacing from the proximal coronary sinus (cycle length 270 ms). Radiofrequency ablation of the slow pathway was performed with success. We discuss the need to suspect and seek different arrhythmogenic substracts of tachycardia in a single patient, the electrophysiologic conditions that could explain the inducibility of different arrhythmias in this case, and the controversy regarding ablation of more than one reentry circuit in a single procedure.