Comments on: Better living through electricity?

By: CardioNP

CardioNP — Thu, 16 Dec 2004 04:24:50 +0000

We discussed the “pill-in-the-pocket” article during cardio journal club this week. Consensus was that it was not that impressive. It was a very limited group of patients that were eligible for inclusion – approached that of including only those with lone afib. There was no placebo arm – they state that other studies had shown the effectiveness of propafenone or flecainide, so placebo comparison was not needed. This I think reduces the rigor of the study.

Also, there was no objective data to show that the patient was truly in afib when they had “palpitations”. No use of event recorders or implantable loop recorders to show that the perceived palpitations were in fact afib. In patients with new onset afib, it may self terminate, so it is quite possible the “palpitations” would have stopped without popping the pill in the pocket. I believe that a placebo arm would have been useful despite their claims of efficacy for propafenone and flecainide.

Most patients with afib do not meet their inclusion criteria, so I hope that practitioners do not implement this approach in patients dissimilar to those in the study. Additionally, many episodes of afib are asymptomatic, so the patients could have been having many more events than realized.

By: mjmd

mjmd — Tue, 14 Dec 2004 18:41:22 +0000

The corresponding author of this article, Dr. Pierre Jais, has emailed me this reply:

I would like to thank you for your comments and interesting web site.

I just would like to emphasize that the baseline echographic EF was acquired just after the ablation procedure, in sinus rhythm, to overcome the limititation you pointed out.

Best regards.

Pierre Jais

I went back to the article, to see if I had misunderstood or misstated the methods. The description of the echocardiographic determination of ejection fraction at baseline is as follows:

Patients were routinely admitted two days before the ablation procedure for baseline evaluation. Treatment with oral anticoagulants, taken by all the patients, was stopped on admission, and treatment with all antiarrhythmic drugs, except amiodarone, was stopped for an appropriate period before ablation. Heart rate and rhythm were monitored with the use of 48-hour ambulatory electrocardiography. Transesophageal echocardiography was performed to rule out atrial thrombi, and transthoracic echocardiography was performed to evaluate cardiac structure and function. Echocardiographic measurement of the left ventricular ejection fraction was standardized with the use of Simpson’s biplane method for all patients during the initial hospitalization and subsequent visits.

From the above description, I don’t think it was unreasonable to assume that the initial EF was determined while the patients were still in atrial fibrillation.

Thus, the author’s reply represents a significant clarification.

By: Mad House Madman

Mad House Madman — Fri, 03 Dec 2004 17:03:54 +0000

This article points to an interesting future for arrhythmia cardiologists. The new bill approving ICD’s for all patients with EF<35% is about to come into effect this January. As if they won’t be busy enough. This study points to a superiority of ablation over rate control for atrial fibrillation. Get to know your favorite arrhythmia specialist, you’ll be calling them, often.
Love your site by the way. Ever since I started reading it I’ve come across so much more intelligent in the eyes of my commish. Will add you to my links as soon as I can.