General Internal Medicine

Cardiac Electrophysiology

Questions discussed in this category

If a patient has potential arrhythmic-sounding syncope and a noninducible type 2 or 3 Brugada ECG pattern, have we excluded Brugada syndrome as the etiology for their syncope?

Should we then investigate for alternative syncopal etiologies before considering therapy (i.e. ICD implant)?

1 Answer available

How would you decide between conservative management vs. ILR or pacemaker for asymptomatic nocturnal bradycardia/pauses (as an example rates in the 30s, pauses ranging 4-12 seconds) in the absence of bradyarrhythmias during the day and ECG with normal intervals, and not otherwise on medications to slow down HR?

For additional context, work up with TTE and exercise stress testing have all been reassuring and normal.

2 Answers available

Based on most current research regarding the more widespread use of class IC antiarrhythmic drugs, what are your prescribing practices in patients with coronary artery disease?

To further elaborate, what level of obstruction with a normal stress test would be acceptable, and what would be too high risk? Would you consider an ...

1 Answer available

Can cardioversion be safely performed for recurrent atrial fibrillation in patients who have undergone left atrial appendage clipping during CABG, if they are not on chronic anticoagulation anymore?

1 Answer available

Is active cocaine or methamphetamine use a contraindication to implanting defibrillators?

2 Answers available

Where does dronedarone fall in your list of antiarrhythmics drugs to use in terms of efficacy and patient selection in contemporary management of atrial fibrillation?

1 Answer available

Would you initiate anti-arrhythmic drug therapy in patients who are asymptomatic and have normal LV function but with a PVC burden > 20 percent?

3 Answers available

Does the presence of diastolic dysfunction guide subsequent pharmacological, pacing and ablative therapies for atrial fibrillation?

If so, what diastolic parameters do you look at?

1 Answer available

For which stroke patients, if any, do you recommend implantable loop recorder for long-term cardiac monitoring and why?

It seems clear that longer monitoring yields more AF detected. What is less clear to me is whether all ILR-detected AF is relevant and merits anticoag...

4 Answers available

How do you manage patients with atrial fibrillation having a thromboembolic infarct despite being on adequate anticoagulation?

Would you recommend left atrial appendage occlusion with or without continuing anticoagulation? In light of Maarse et al., JAMA Neurology 2024.

3 Answers available

For how long would you hold anticoagulation before percutaneous left atrial appendage closure with Watchman or Amulet devices?

1 Answer available

For patients who have previously undergone MAZE ligation presenting with paroxysmal atrial fibrillation, how would you counsel them on the risk of stroke long-term when deciding whether or not to start or continue anticoagulation?

1 Answer available

When would you consider offering PVC ablation for otherwise healthy patients with preserved LV systolic function?

If PVC burden exceeded 10-15%, would you offer ablation in the absence of specific symptoms?

1 Answer available

Should presence of coronary artery calcifications on CT/CTA be considered as presence of vascular disease on CHA2DS2-VASc score?

1 Answer available

How do you identify the subset of heart failure patients who are likely to benefit from cardiac resynchronization therapy in the setting of an RBBB pattern?

1 Answer available

In light of the NOAH-AFNET6 and ARTESiA trials, how would you approach the decision regarding anticoagulation for patients with incidentally-detected AF <24 hrs on pacemakers/defibrillators?

How would you balance the stroke risk against the bleeding risk? And how would the AF burden play into your decision- would you treat 6 minutes of AF ...

1 Answer available

How do you determine which atrial fibrillation patients with a high thromboembolic risk and a contraindication for oral anticoagulation should undergo left atrial appendage occlusion?

Marcus et al., PMID 34775507

2 Answers available

What is your approach for de-escalation of antiarrhythmics for patients with a history of ventricular arrhythmias?

For example, for younger patients on amiodarone or those who wish to come off antiarrhythmics because of medication side effects.

1 Answer available

What criteria do you utilize in deciding when to treat or not treat frequent VPC’s?

2 Answers available

What is your preferred method for subclinical CAD screening prior to initiation of class IC antiarrhythmic drugs for atrial fibrillation?

2 Answers available

How soon following pacemaker implantation can patients safely undergo elective cardioversion?

2 Answers available

In patients with concurrent, CAD and atrial fibrillation, more than 1 year post-PCI, the most recent AHA/ACC guidelines state that “oral anticoagulation monotherapy is recommended over the continuation of oral anticoagulant therapy and a single antiplatelet therapy.” If this individual undergoes surgery, the anticoagulant will be held. Would you then bridge with aspirin?

Joglar et al., PMID 38033089

1 Answer available

For patients who have undergone ablation for atrial fibrillation with elevated bleeding risk, what is your risk/benefit approach when deciding to continue oral anticoagulation long-term?

1 Answer available

What is your preferred method for subclinical CAD screening prior to initiation of class IA antiarrhythmic drugs for atrial fibrillation?

1 Answer available

What are the current clinical practices for TEE to guide cardioversion and anticoagulation duration post-cardioversion for Afib/flutter in patients following left atrial appendage closure?

4 Answers available

In what situations/patient population would you consider placing an implantable cardiac monitor in favor of external monitors for long-term dynamic monitoring of atrial fibrillation?

What are the real-life implications of the MONITOR-AF study to the routine management of AF?

1 Answer available

Given recent trials for the management of atrial fibrillation with an early ablation strategy (for example, EAST-AFNET 4, EARLY-AF, PROGRESSIVE-AF, STOP-AF), what is your approach to determining the appropriate timing for ablation in patients with atrial fibrillation?

And how do patient characteristics affect your decisions?

5 Answers available

When would you consider proceeding with antiarrhythmic drug load concurrently with DCCV as opposed to DCCV alone in patients with new-onset atrial fibrillation?

1 Answer available

In which situations do you preferentially use an MCOT in lieu of a standard event monitor?

1 Answer available

What is your approach to pacemaker lead thromboses in terms of threshold for lead extraction and initiation of systemic anticoagulation?

1 Answer available

Would you consider a primary prevention ICD in a patient with hypertrophic cardiomyopathy and non-sustained ventricular tachycardia, in the absence of any other high risk predictors for sudden cardiac death?

2 Answers available

What is your approach to risk stratification of asymptomatic patients with pre-excitation syndrome?

2 Answers available

How do you re-stratify patients with a primary prevention ICD in need of a generator change if their LVEF has improved to >40% and they have not previously required any device therapies?

1 Answer available

When would you consider implantable loop recorders for athletes with nonspecific complaints of palpitations/dizziness, without known history of arrhythmias?

1 Answer available

What is your preferred rate control agent for atrial fibrillation with rapid ventricular rate, and why?

1 Answer available

Would you empirically elective to anticoagulate patients with a remote (i.e. >10 year) history of paroxysmal atrial fibrillation presenting with newly diagnosed CVA, presumed cardioembolic in etiology, without any documented recurrence of AF?

3 Answers available

Papers discussed in this category

American heart journal, 2010-07

Cryptogenic Stroke and underlying Atrial Fibrillation (CRYSTAL AF): design and rationale.

Lancet, 2021 Aug 27

Implantable loop recorder detection of atrial fibrillation to prevent stroke (The LOOP Study): a randomised controlled trial.

J Am Coll Cardiol, 2019 Jan 28

2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society.

Stroke, 2019-06

Perioperative/Postoperative Atrial Fibrillation and Risk of Subsequent Stroke and/or Mortality.

Circulation, 2020 Dec 17

2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.

Herz, 2014 Dec

[The 2014 ESC guidelines on the diagnosis and management of hypertrophic cardiomyopathy : what is new?].

Journal of the American College of Cardiology, 2013-07-23

Treatment of obstructive sleep apnea reduces the risk of atrial fibrillation recurrence after catheter ablation.

N Engl J Med, 2018 Feb 01

Catheter Ablation for Atrial Fibrillation with Heart Failure.

Cardiovasc Drugs Ther, 2021 Sep 07

Is It Safe (and When) to Stop Oral Anticoagulation After Ablation for Atrial fibrillation? (Do We Have Enough Evidence to Solve the Dilemma?).

Circulation. Arrhythmia and electrophysiology, 2014-04

Guidelines for management of asymptomatic ventricular pre-excitation: brave new world or Pandora's box?

Circulation. Arrhythmia and electrophysiology, 2015-12

Long-Term Natural History of Adult Wolff-Parkinson-White Syndrome Patients Treated With and Without Catheter Ablation.

Heart Rhythm, 2020 Jun 01

Loss of ventricular preexcitation during noninvasive testing does not exclude high-risk accessory pathways: A multicenter study of WPW in children.

J Geriatr Cardiol, 2017 Oct

Reversal of Wolff-Parkinson-White Syndrome induced dilated cardiomyopathy via resynchronization and subsequent accessory pathway ablation.

Journal of the American College of Cardiology, 2014-09-09

Reply: Ejection fraction may improve but the scar still exists! The risk may be lower but not zero.

J Am Coll Cardiol, 2014 Apr 09

Appropriateness of primary prevention implantable cardioverter-defibrillators at the time of generator replacement: are indications still met?

Heart rhythm, 2020 Jul 25

Clinical significance of myocardial scar in patients with frequent premature ventricular complexes undergoing catheter ablation.

JACC. Clinical electrophysiology, 2022 Apr 28

Short-Coupled Idiopathic Ventricular Fibrillation: A Literature Review With Extended Follow-Up.

The New England journal of medicine, 2011-09-15

Apixaban versus warfarin in patients with atrial fibrillation.

The New England journal of medicine, 2011 Aug 10

Rivaroxaban versus warfarin in nonvalvular atrial fibrillation.

The New England journal of medicine, 2009 Aug 30

Dabigatran versus warfarin in patients with atrial fibrillation.

Circulation, 2011 Jul 25

Mobile thrombus on device leads in patients undergoing ablation: identification, incidence, location, and association with increased pulmonary artery systolic pressure.

Circulation, 2020 Apr 27

Evaluation and Management of Premature Ventricular Complexes.

Indian pacing and electrophysiology journal, 2019 Feb 26

Late elimination of challenging idiopathic ventricular arrhythmias originating from left ventricular summit by anatomical ablation.

Heart rhythm O2, 2021 Feb 26

Empiric ablation of asymptomatic PVCs when there is greater than 20% burden but normal left ventricular function-An argument in support of catheter ablation.

Heart rhythm O2, 2021 Feb 26

Empiric catheter ablation of premature ventricular contractions when there is a >20% burden in an asymptomatic patient with normal left ventricular size and function-An argument for a conservative, do-less approach.

European heart journal, 2017-05-01

Duration of device-detected subclinical atrial fibrillation and occurrence of stroke in ASSERT.

Heart rhythm, 2019-01

Identification of paroxysmal atrial fibrillation subtypes in over 13,000 individuals.

Pacing and clinical electrophysiology : PACE, 2019-07

Reactive atrial-based antitachycardia pacing therapy reduces atrial tachyarrhythmias.

The New England journal of medicine, 2023 Aug 25

Anticoagulation with Edoxaban in Patients with Atrial High-Rate Episodes.

Heart rhythm, 2015 Apr 11

New-generation atrial antitachycardia pacing (Reactive ATP) is associated with reduced risk of persistent or permanent atrial fibrillation in patients with bradycardia: Results from the MINERVA randomized multicenter international trial.

Circulation, 2023 Nov 30

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.

The New England journal of medicine, 2023 Nov 12

Apixaban for Stroke Prevention in Subclinical Atrial Fibrillation.

Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology, 2012 Mar

Review of atrial fibrillation outcome trials of oral anticoagulant and antiplatelet agents.

The New England journal of medicine, 1991-03-21

Mortality and morbidity in patients receiving encainide, flecainide, or placebo. The Cardiac Arrhythmia Suppression Trial.

Journal of interventional cardiac electrophysiology : an international journal of arrhythmias and pacing, 2022 Apr 02

Propafenone use in coronary artery disease patients undergoing atrial fibrillation ablation.

Journal of clinical medicine, 2021 Apr 02

Flecainide How and When: A Practical Guide in Supraventricular Arrhythmias.

The New England journal of medicine, 2021 May 15

Left Atrial Appendage Occlusion during Cardiac Surgery to Prevent Stroke.

Journal of the American Heart Association, 2023 May 15

Left Atrial Appendage Occlusion During Cardiac Surgery: A 75-Year-Old Journey.

Circulation, 2019-08-20