Letter by Chhabra and Spodick Regarding Article, “Influence of Steroid Therapy on the Incidence of Pericarditis and Atrial Fibrillation After Percutaneous Epicardial Mapping and Ablation for Ventricular Tachycardia” by Dyrda et al
2014; Lippincott Williams & Wilkins; Volume: 7; Issue: 5 Linguagem: Inglês
10.1161/circep.114.002063
ISSN1941-3149
AutoresLovely Chhabra, David H. Spodick,
Tópico(s)Cardiac pacing and defibrillation studies
ResumoHomeCirculation: Arrhythmia and ElectrophysiologyVol. 7, No. 5Letter by Chhabra and Spodick Regarding Article, "Influence of Steroid Therapy on the Incidence of Pericarditis and Atrial Fibrillation After Percutaneous Epicardial Mapping and Ablation for Ventricular Tachycardia" by Dyrda et al Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by Chhabra and Spodick Regarding Article, "Influence of Steroid Therapy on the Incidence of Pericarditis and Atrial Fibrillation After Percutaneous Epicardial Mapping and Ablation for Ventricular Tachycardia" by Dyrda et al Lovely Chhabra, MD David H. Spodick, MD, DSc Lovely ChhabraLovely Chhabra Department of Cardiovascular Medicine, Hartford Hospital, University of Connecticut School of Medicine, Hartford, CT David H. SpodickDavid H. Spodick Department of Cardiovascular Medicine, Saint Vincent Hospital, University of Massachusetts Medical School, Worcester, MA Originally published1 Oct 2014https://doi.org/10.1161/CIRCEP.114.002063Circulation: Arrhythmia and Electrophysiology. 2014;7:991Dydra et al compared the efficacy of 3 different therapeutic approaches (no-steroids, systemic-steroids, and intrapericardial-steroids) on the incidence of postprocedure atrial fibrillation (PPAF) and pericarditis in patients undergoing epicardial ventricular tachycardia ablation.1 They reported significantly decreased incidence of pericarditic chest pain in patients treated with intrapericardial steroids. Though the results are potentially interesting, the retrospective study design significantly limits the evaluation efficacy of these different strategies. The authors defined pericarditis on the basis of only 2 criteria: pleuritic chest pain and pericarditic ECG changes; however, they have not incorporated the other 2 standard diagnostic criteria namely echocardiographic evidence of new pericardial effusion or the presence of a pericardial rub. This raises a significant potential for selection bias.2 For instance, any pleuritic chest pain at the postoperative site itself may have been mistakenly considered as pericarditic pain.The authors have cited our work, suggesting an increased incidence of AF in pericarditis; however, it is worth emphasizing that pericarditis itself is not strongly arrhythmogenic unless an underlying substrate for PPAF is present, for example, ventricular disease or dysfunction, aging, or underlying left atrial abnormality.3 A previous study on epicardial ventricular tachycardia ablation reported an increased incidence of PPAF; however, it was in the setting of increased incidence of other clinical factors like RV puncture and increased procedure length, thus suggesting that the presence of pericarditis may be incidental rather than causative.4 Also, on the other hand, the previous largest study on epicardial ventricular tachycardia ablation did not report PPAF as a problem.5It is surprising that the use of NSAIDs was the lowest (24%) in the group who did not receive any form of steroid therapy, despite having the highest incidence of pericarditis (55%). This probably represents a limitation of the retrospective study design because one would otherwise expect a higher incidence of NSAID use in such population for treating pericarditis. The study results also do not account for the future recurrences of pericarditis. This may be an important consideration as steroids are known for providing prompt symptomatic relief at the cost of increased future recurrences (a phenomenon well-known in idiopathic pericarditis).Colchicine has recently been shown to offer significant reduction in the incidence of PPAF after atrial fibrillation ablation and postpericardiotomy (COPPS trial). Colchicine thus perhaps could be an effective alternate therapy for reducing PPAF in epicardial ventricular tachycardia ablation with low potential risk for future recurrences, though this would require investigation in a controlled clinical trial. The authors have not compared atrial fibrillation incidence in patients treated with no therapy versus treated with steroids, but do report an increased atrial fibrillation incidence associated with pericarditic ECG changes. A subanalysis would be helpful to determine if PPAF incidence was affected because of a direct anti-inflammatory effect of steroids or rather because of a decreased incidence of clinical pericarditis (irrespective of ECG changes). Also, it would be ideal to tease out the effect of beta blockers and alternate antiarrhythmic therapies on the PPAF incidence as patients treated with steroids were more likely to receive antiarrhythmic drugs.Lovely Chhabra, MDDepartment of Cardiovascular MedicineHartford HospitalUniversity of Connecticut School of MedicineHartford, CTDavid H. Spodick, MD, DScDepartment of Cardiovascular MedicineSaint Vincent HospitalUniversity of Massachusetts Medical SchoolWorcester, MADisclosuresDr Spodick receives royalties from his textbook, The Pericardium: A Comprehensive Textbook (Fundamental and Clinical Cardiology), Marcel Dekker, New York, 1997.References1. Dyrda K, Piers SR, van Huls van Taxis CF, Schalij MJ, Zeppenfeld K. Influence of steroid therapy on the incidence of pericarditis and atrial fibrillation following percutaneous epicardial mapping and ablation for ventricular tachycardia.Circ Arrhythm Electrophysiol. 2014; 7:671–676.LinkGoogle Scholar2. Chhabra L, Chaubey VK, Spodick DH. Diagnostic criteria for acute pericarditis need closer attention.Pacing Clin Electrophysiol. 2014; 37:658.CrossrefMedlineGoogle Scholar3. Spodick DH. Arrhythmias during acute pericarditis. A prospective study of 100 consecutive cases.JAMA. 1976; 235:39–41.CrossrefMedlineGoogle Scholar4. Mahapatra S, LaPar DJ, Bhamidipati CM, McDaniel G, Kamath S, Bunch TJ, Ailawadi G. Incidence, risk factors, and consequences of new-onset atrial fibrillation following epicardial ablation for ventricular tachycardia.Europace. 2011; 13:548–554.CrossrefMedlineGoogle Scholar5. Sacher F, Roberts-Thomson K, Maury P, Tedrow U, Nault I, Steven D, Hocini M, Koplan B, Leroux L, Derval N, Seiler J, Wright MJ, Epstein L, Haissaguerre M, Jais P, Stevenson WG. Epicardial ventricular tachycardia ablation a multicenter safety study.J Am Coll Cardiol. 2010; 55:2366–2372.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited ByChhabra L and Spodick D (2015) Letter by Chhabra and Spodick Regarding Article, "Clinical Profile and Influences on Outcomes in Patients Hospitalized for Acute Pericarditis", Circulation, 132:7, (e126-e126), Online publication date: 18-Aug-2015.Dyrda K, Piers S, van Huls van Taxis C, Schalij M and Zeppenfeld K (2014) Response to Letter by Chhabra and Spodick Regarding Article, "Influence of Steroid Therapy on the Incidence of Pericarditis and Atrial Fibrillation Following Percutaneous Epicardial Mapping and Ablation for Ventricular Tachycardia" by Dyrda et al, Circulation: Arrhythmia and Electrophysiology, 7:5, (992-992), Online publication date: 1-Oct-2014. October 2014Vol 7, Issue 5 Advertisement Article InformationMetrics © 2014 American Heart Association, Inc.https://doi.org/10.1161/CIRCEP.114.002063PMID: 25336374 Originally publishedOctober 1, 2014 PDF download Advertisement SubjectsArrhythmiasElectrophysiology
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