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Saturday, August 31, 2019

ESC: Guidelines on management of fast heartbeat published

The European Society of Cardiology (ESC) Guidelines on supraventricular tachycardia are published online today in European Heart Journal,(1) and on the ESC website.(2) The document highlights how catheter ablation is revolutionising care for this group of common arrhythmias.
Supraventricular tachycardia (SVT) refers to a heart rate above 100 beats per minute (normal resting heart rate is 60 to 100). It occurs when there is a fault with the electric system that controls the heart’s rhythm. SVTs are frequent arrhythmias, with a prevalence of approximately 0.2% in the general population. Women have a risk of developing SVT that is two times greater than men, while people 65 years or older have more than five times the risk of developing SVT than younger people.
SVTs usually start and stop suddenly. They arise in the atria of the heart and the conduction system above the ventricles, and are rarely life-threatening in the acute phase, unlike arrhythmias from the ventricles. However, most SVTs, if left untreated, are lifelong conditions that affect the heart’s function, increase the risk of stroke, and affect quality of life. Symptoms include palpitations, fatigue, light-headedness, chest discomfort, shortness of breath, and altered consciousness.
The guidelines provide treatment recommendations for all types of SVTs. Drug therapies for SVT have not fundamentally changed since the previous guidelines were published in 2003.
But Professor Josep Brugada, Chairperson of the guidelines Task Force and professor of medicine, University of Barcelona, Spain, said: “We do have more data on the potential benefits and risks associated with several drugs, and we know how to use them in a safer way. In addition, some new antiarrhythmic drugs are available.”
Antiarrhythmic drugs are useful for acute episodes. For long-term treatment these drugs are of limited value due to relatively low efficacy and related side-effects.
The main change in clinical practice over the last 16 years is related to the availability of more efficient and safe invasive methods for eradication of the arrhythmia through catheter ablation. This therapy uses heat or freezing to destroy the heart tissue causing the arrhythmia.
Professor Demosthenes Katritsis, Chairperson of the guidelines Task Force and director of the 3rd Cardiology Department, Hygeia Hospital, Athens, Greece, said: “Catheter ablation techniques and technology have evolved in a way that we can now offer this treatment modality to most of our patients with SVT.”
SVT is linked with a higher risk of complications during pregnancy, and specific recommendations are provided for pregnant women. All antiarrhythmic drugs should be avoided, if possible, within the first trimester of pregnancy. However, if necessary, some drugs may be used with caution during that period.
“Pregnant women with persistent arrhythmias that do not respond to drugs, or for whom drug therapy is contraindicated or not desirable, can now be treated with catheter ablation using new techniques that avoid exposing themselves or their baby to harmful levels of radiation,” said Prof Katritsis.
What should people do if they experience a fast heartbeat? “Always seek medical help and advice if you have a fast heartbeat,” said Prof Brugada. “If SVT is suspected, you should undergo electrophysiology studies with a view to catheter ablation, since several of the underlying conditions may have serious long-term side effects and inadvertently affect your wellbeing. Prevention of recurrences depends on the particular type of SVT, so ask your doctor for advice. Catheter ablation is safe and cures most SVTs.”
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Authors: ESC Press Office
Mobile: +33 (0) 7 8531 2036
Email: press@escardio.org
Funding: None.
Disclosures: The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines.
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Some states, towns skeptical over proposed opioid settlement

An offer from OxyContin maker Purdue Pharma and the Sackler family to settle some 2,000 lawsuits over their contribution to the national opioid crisis is receiving growing pushback from state and local officials who say the proposed deal doesn’t include enough money or accountability.
Connecticut Attorney General William Tong on Friday called for the company, which is headquartered in the state, to be forced out of the opioid business altogether.
“At a minimum, Connecticut demands that Purdue be broken up and shut down, and that its assets be liquidated,” Tong said in a statement.
He said he wants the controlling Sackler  to pay billions of dollars “they siphoned out of Purdue,” with the money going toward addiction research and treatment.
Massachusetts Attorney General Maura Healey said she wants any  to include more money than the $10 billion to $12 billion offered by Purdue and the $3 billion offered from the Sacklers, an amount that represents just a portion of the family’s fortune. Much of their money which appears to be overseas.
“We owe it to families in Massachusetts and across the country to hold Purdue and the Sacklers accountable, ensure that the evidence of what they did is made public, and make them pay for the damage they have caused,” Healey said in a statement.
The company and the family did not answer questions Friday about criticism of the settlement proposal, under which Purdue would file for bankruptcy and transform itself into a “public benefit trust corporation.” The trust’s profits from drug sales would go to the plaintiffs under the company’s settlement offer.
Purdue also has been considering filing for  on its own, an action that would upend the settlement talks involving state attorneys general and lawyers representing nearly  around the country.
Over the past few years, nearly every state and about 2,000 local and tribal governments have sued over the toll of the opioid epidemic. Purdue is a defendant in most of the lawsuits and members of the Sackler family are named in several, including lawsuits in Connecticut and Massachusetts.
The federal litigation is being overseen by a judge in Cleveland, who has been pushing for a national settlement before the first trial starts in October. That is proving difficult.
As details of Purdue’s settlement offer became public this week, some  said it wasn’t good enough.
In Delbarton, West Virginia, Mayor Elmer Spence’s son and nephew are two of the more than 400,000 people in the U.S. who have died from opioid overdoses since 2000. If Purdue’s offer of a settlement is accepted, the town would receive less than $50,000.
“That’s a drop in the bucket for what it’s really cost this community,” he said of a crisis that has driven up costs for police, ambulances and courts.
He said residents in the town of roughly 500 people have grown accustomed to losing loved ones: “I mean it’s really a slap in the face.”
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More vaping illnesses reported, many involving marijuana

Health officials are recommending people who vape consider avoiding e-cigarettes while they investigate more cases of a breathing ailment linked to the devices.
While the cause remains unclear, officials said Friday that many reports involve products that contain THC, the mind-altering substance in marijuana.
Officials from the Centers for Disease Control and Prevention said they are looking at 215 possible cases across 25 states. All the cases involve teens or adults who have used e-cigarettes or other vaping devices. Symptoms of the disease include coughing, shortness of breath, chest pain, fatigue, nausea and vomiting.
The CDC and Food and Drug Administration warned the public not to buy vaping products off the street. And officials recommended people concerned about the “consider refraining from using e-cigarette products.”
Health and Human Services Secretary Alex Azar said in a statement the government is “using every tool we have to get to the bottom of this deeply concerning outbreak.”
E-cigarettes generally heat a flavored nicotine solution into an inhalable aerosol. The products have been used in the U.S. for more than a decade and are generally considered safer than traditional cigarettes because they don’t create all the cancer-causing byproducts of burning tobacco.
But some vaping products have been found to contain other potentially harmful substances, including flavoring chemicals and oils used for vaping marijuana, experts say.
The mysterious illness underscores the complicated nature of the vaping market, which includes both government-regulated nicotine products and THC-based vape pens, which are considered illegal under federal law.
Eleven states and the District of Columbia allow marijuana for . THC-based products in these regulated markets are generally inspected for quality and safety, but there is a largely unregulated gray market.
On Thursday, top  in the Trump administration reiterated warnings against marijuana use by adolescents and pregnant women, emphasizing the increasing potency of the drug.
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ESC: Microbes may play a role in heart attack onset

Microorganisms in the body may contribute to destabilisation of coronary plaques and subsequent heart attack, according to late breaking research presented today at ESC Congress 2019 together with the World Congress of Cardiology.
The study found that unlike gut bacteria, the bacteria in coronary plaques were pro-inflammatory. In addition, patients with  () had different bacteria in their guts compared to patients with stable angina.
Diet, smoking, pollution, age, and medications have a major impact on cell physiology, the immune system, and metabolism. Previous research indicates that these effects are mediated by microorganisms in the intestinal tract. This study investigated the contribution of the microbiota to the instability of coronary plaques.
The study enrolled 30 patients with acute coronary syndrome and ten patients with stable angina. The researchers isolated  from faeces samples. Coronary plaque bacteria were extracted from angioplasty balloons.
Comparison of microbiota in faeces and coronary plaques revealed a different composition in the two sites. While faecal bacteria had a heterogeneous composition, and a pronounced presence of Bacteroidetes and Firmicutes, coronary plaques primarily contained microbes with pro-inflammatory phenotypes belonging to Proteobacteria and Actinobacteria.
First author Eugenia Pisano, of the Catholic University of the Sacred Heart, Rome, Italy said: “This suggests a selective retention of pro-inflammatory bacteria in , which could provoke an inflammatory response and plaque rupture.”
The analyses also revealed differences in gut microbiota between the two groups of patients. Those with acute coronary syndrome had more Firmicutes, Fusobacteria and Actinobacteria, while Bacteroidetes and Proteobacteria were more abundant in those with stable angina.
Ms Pisano said: “We found a different make-up of the gut microbiome in acute and stable patients. The varying chemicals emitted by these  might affect plaque destabilisation and consequent heart attack. Studies are needed to examine whether these metabolites do influence plaque instability.”
She noted that to date, research has not convincingly shown that infections and the ensuing inflammation are directly involved in the process of plaque instability and  attack onset. As an example, antibiotics against Chlamydia Pneumoniae failed to reduce the risk of cardiac events.
But she said: “While this is a small study, the results are important because they regenerate the notion that, at least in a subset of patients, infectious triggers might play a direct role in plaque destabilisation. Further research will tell us if antibiotics can prevent cardiovascular events in certain patients.”
Ms Pisano concluded: “Microbiota in the gut and coronary plaque could have a pathogenetic function in the process of plaque destabilisation and might become a potential therapeutic target.”
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More information: The abstract “A different microbial signature in plaque and gut of patients presenting with ACS: a possible role for coronary instability” will be presented during the session Late Breaking Basic and Translational Science – Acute Coronary Syndromes and Heart failure on Saturday 31 August at 13:50 to 15:00 CEST in room Pristina – Village 3.
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Joint Commission sets maternal safety standards for hospital accreditation

Starting next July, the Joint Commission will require accredited hospitals to have 13 policies in place to help prevent the likelihood of hemorrhage and severe hypertension for pregnant patients.
The new standards, which will go into effect July 1, 2020, are in response to many hospitals adopting evidence-based practices to prevent maternal mortality due to hemorrhage and hypertension, two of the most common reasons for death in pregnant women.
“There has been a lot learned about what needs to be done to reduce maternal mortality rates,” said Dr. David Baker, executive vice president for healthcare quality evaluation at the Joint Commission. “We thought it was time to take those (best practices) and turn them into requirements to ensure that all hospitals try to follow them.”
The U.S. has a higher maternal mortality rate than other developed countries, with about 700 pregnancy-related deaths occurring each year, and 60% of those are preventable.
Hospitals’ compliance with the standards will be evaluated during Joint Commission accreditation surveys, which occur every three years.
The requirements were selected based on input from the Alliance for Innovation on Maternal Health and the California Maternal Quality Care Collaborative, which has been successful in reducing maternal mortality rates through evidence-based practices in the state.
Prior to finalizing the standards, the Joint Commission also visited hospitals throughout the U.S. to get their feedback. Baker said hospitals were overwhelmingly positive.
The American Hospital Association is also supportive of the new requirements.
“These standards play a vital role for pregnant and postpartum women, as well as their families,” Thomas Nickels, executive vice president of the AHA, wrote in a letter to the Joint Commission. “Maternal hemorrhage risk and severe hypertension/preeclampsia are two of the most common complications that occur in pregnant and postpartum women. Ensuring that hospitals and providers are trained and prepared to diagnose, manage and effectively treat such complications is critical.”
Some of the standards are providing education to all staff who treat pregnant and postpartum patients about the organization’s hemorrhage and hypertension procedures; conducting drills at least once per year to determine issues with ongoing quality improvement work and offering education to patients and their families about symptoms of postpartum hemorrhage and severe hypertension.
Baker said the Joint Commission attempted to select standards that all hospitals, no matter their resources, could comply with. For instance, the Joint Commission opted not to include a component of the safety bundles developed by the Alliance for Innovation on Maternal Health related to counting blood loss. Baker said there was concern that it would be too difficult for small hospitals to comply with.
“We see this as an ongoing process,” he said. “We want to make sure that all hospitals can meet these new requirements, but we will continue to look at what we can do as hospitals get more experience with these things. They might be able to do additional things in the future.”
In the coming months, the Joint Commission plans to host webinars with its accredited hospitals to explain the changes in more depth. Additionally, the Joint Commission is offering the Alliance for Innovation on Maternal Health and the California Maternal Quality Care Collaborative as resources for hospitals to successfully comply with the standards.
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Publicly insured more likely to drop off liver transplant waitlist, study finds

Cancer patients with public health insurance were more likely to drop off the waitlist for a liver transplant than patients with private insurance, according to a study published Friday in JAMA Network Open.
Among 705 patients with a common type of liver cancer waiting for a transplant at the University of California, San Francisco, 46.7% of patients with public insurance dropped off the waiting list over a seven-year study period.
That compared with 28.7% of patients insured by Kaiser Permanente and 33.8% by other private insurers despite similar tumor-related characteristics,according to the study. In total, 246 patients dropped off the wait-list during the period that lasted from Jan. 1, 2010 to Dec. 31, 2016.
“When we think about patients with liver cancer who are listed for transplants, we typically think about the main reasons they don’t make it to transplant being clinical characteristics,” explained study author Dr. Neil Mehta, an associate professor medicine at UCSF. “But this study suggested that even though patients in all the different insurance categories had similar clinical characteristics, they had very different rates of dropping off the waitlist, specifically patients with public insurance.”
Of the 705 patients in the study, about a quarter of patients dropped off the waiting list specifically because of tumor progression or death. That included 19.2% of patients in the sample with Kaiser Permanente insurance, 26.1% of patients with private insurance and 33.2% with public insurance.
The study found that 416 patients received liver transplants from deceased donors, including 65.6% of patients with Kaiser Permanente insurance, 63.1% with other private insurance and 44.2% with public insurance. Others may have gotten liver transplants from live donors or a center outside of the study.
Researchers speculated that socioeconomic factors were to blame for public insurance being associated with a higher risk of dropping off the waitlist. Patients on Medicaid were more likely to be poor and unemployed and lack stable housing and social support, which could impact the patient’s ability to attend follow up appointments, for example.
Mehta explained that to remain eligible for transplant, liver cancer patients must get imaging done every three months to make sure the tumor stays within transplant criteria. Organizations such as Kaiser Permanente have care coordination programs to help patients navigate the testing and challenges that come with being on the waitlist, while publicly insured patients may not have that benefit, he said.
“Our main hypothesis is that if we can actually improve healthcare coordination delivery for these patients, that can hopefully reduce these disparities,” Mehta said.
In an emailed statement, Dr. Joanna Ready, chair of the Kaiser Permanente Liver Transplant Advisory Board for Northern California, said Kaiser Permanente ensures patients with chronic conditions have timely access to care.
“For our liver transplant patients, we provide comprehensive pre- and post-transplant services, including nurse coordinators, physicians, and sub-specialty care, such as radiology, oncology, and cardiology. This ensures critical conditions such cancer are identified early and managed efficiently throughout the transplant journey,” she said.
Half of the patients in the study sample had Kaiser Permanente insurance because UCSF has a contract with Kaiser Permanente in Northern California, but that organization did not sponsor the study, Mehta said.
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Sanders proposes canceling $81 billion U.S. medical debt

U.S. presidential contender Bernie Sanders proposed a plan on Saturday to cancel $81 billion in existing past-due medical debt for Americans, but offered no details on how it would be financed.
Sanders, an independent U.S. senator from Vermont, said in a statement that under his plan, the government would negotiate and pay off past-due medical bills that have been reported to credit agencies. The proposal, he said, would also repeal some elements of the 2005 Bankruptcy reform bill and allow other existing and future medical debt to be discharged.
“In the United States of America, your financial life and future should not be destroyed because you or a member of your family gets sick,” said Sanders. “That is unacceptable. I am sick and tired of seeing over 500,000 Americans declare bankruptcy each year because they cannot pay off the outrageous cost of a medical emergency or a hospital stay.”
According to Sanders, medical debt is the leading cause of consumer bankruptcy, with more than half a million Americans filing due to medical expenses each year. He said the 2005 Bankruptcy reform bill made it difficult to discharge medical debt by imposing strict means tests and eliminated fundamental consumer protections for Americans.

“It also trapped families with medical debt in long-term poverty, mandated that they pay for credit counseling before filing for bankruptcy, and increased the need for expensive legal services when filing a case for medical bankruptcy,” the senator said.
Sanders is seeking the Democratic nomination, along with more than a dozen other candidates, for the right to challenge Republican President Donald Trump in November 2020.
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