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Early or Delayed Cardioversion for Recent Onset AF

Pluymaekers et al report an open-label multicentre randomized clinical trial of early versus delayed onset cardioversion for recent onset atrial fibrillation.



Patients with recent-onset atrial fibrillation commonly undergo immediate restoration of sinus rhythm by pharmacologic or electrical cardioversion. However, whether immediate restoration of sinus rhythm is necessary is not known, since atrial fibrillation often terminates spontaneously.


In a multicenter, randomized, open-label, noninferiority trial, we randomly assigned patients with hemodynamically stable, recent-onset (<36 hours), symptomatic atrial fibrillation in the emergency department to be treated with a wait-and-see approach (delayed-cardioversion group) or early cardioversion. The wait-and-see approach involved initial treatment with rate-control medication only and delayed cardioversion if the atrial fibrillation did not resolve within 48 hours. The primary end point was the presence of sinus rhythm at 4 weeks. Noninferiority would be shown if the lower limit of the 95% confidence interval for the between-group difference in the primary end point in percentage points was more than −10.


The presence of sinus rhythm at 4 weeks occurred in 193 of 212 patients (91%) in
the delayed-cardioversion group and in 202 of 215 (94%) in the early-cardioversion group (between-group difference, −2.9 percentage points; 95% confidence interval [CI], −8.2 to 2.2; P=0.005 for noninferiority). In the delayed-cardioversion group, conversion to sinus rhythm within 48 hours occurred spontaneously in 150 of 218 patients (69%) and after delayed cardioversion in 61 patients (28%). In the early cardioversion group, conversion to sinus rhythm occurred spontaneously before the initiation of cardioversion in 36 of 219 patients (16%) and after cardioversion in 171 patients (78%). Among the patients who completed remote monitoring during 4 weeks of follow-up, a recurrence of atrial fibrillation occurred in 49 of 164 patients (30%) in the delayed- cardioversion group and in 50 of 171 (29%) in the earlycardioversion group. Within 4 weeks after randomization, cardiovascular complications occurred in 10 patients and 8 patients, respectively.


In patients presenting to the emergency department with recent-onset, symptomatic atrial fibrillation, a wait-and-see approach was noninferior to early cardioversion in achieving a return to sinus rhythm at 4 weeks.


Large Periprocedural Myocardial Infarction after PCI or CABG for left main disease: EXCEL trial

Ben-Yehuda et al report from the EXCEL trial on the impact of large periprocedural myocardial infarction on mortality in patients undergoing PCI or CABG for left main disease.


Cardiac Magnetic Resonance Imaging in MINOCA

Bhatia et al report the results of cardiac MRI in patients with troponin elevation and normal coronary arteries. ((




 Invasive angiography in the setting of
cardiac troponin elevation may reveal non-obstructive
coronary arteries leading to uncertainty in diagnosis.
Cardiac MR (CMR) may aid in diagnosis, however, the
spectrum of diagnostic findings in the patient presenting
with symptoms of cardiac ischaemia, elevated cardiac
biomarkers and a negative invasive coronary angiogram
is yet to be completely described.


We queried the Mayo Clinic, Rochester
inpatient record from 1 January 2000 to 31 December
2016 to identify patients who: (1) had an elevated
troponin T during admission, (2) underwent coronary
angiography within 30 days of troponin T elevation
which was considered negative for obstructive coronary
arterial disease and (3) underwent CMR within 30 days
of troponin T elevation. CMR diagnoses were classified
as either (1) myocarditis, (2) small area myocardial
infarction, (3) stress cardiomyopathy, (4) non-ischaemic
cardiomyopathy or (5) normal.


Of 215 patients, the spectrum of disease seen
on CMR was myocarditis (32%), small area infarction
(22%), non-ischaemic cardiomyopathy (20%) and stress
cardiomyopathy (9.3%).


 In the largest single-centre study assessing
the role of CMR in patients admitted with elevated
troponin T with a non-obstructive coronary disease on
an angiogram, small area infarction was seen in 22% of

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Radiation in Cardiology

Williams et al present a review of radiation in cardiology in <em>Education in Heart</em>.(


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Zero CT Calcium Score in Stable Chest Pain

Wang et al reports on the negative predictive value of zero CT calcium score. ( Open Heart 2019;6:e000945. doi:10.1136/openhrt-2018-000945)



To estimate the prevalence of non-calcified
coronary artery disease (CAD) in patients with suspected
stable angina and a zero coronary artery calcification
(CAC) score, and to assess the prognostic significance of a
zero CAC in these symptomatic patients.
Methods In this prospective cohort study, consecutive
patients with stable chest pain underwent CAC scoring
± CT coronary angiography (CTCA) as part of routine
clinical care at a single tertiary centre over 7 years. Major
adverse cardiac event (MACE) was defined as cardiac
death, non-fatal myocardial infarction and/or non-elective


A total of 915 of 1753 (52.2%) patients (mean
age 56.8 ± 12.0 years; 46.2% male) had a zero CAC
score. Of the 751 (82.1%) patients with a zero CAC in
whom CTCA was performed, 674 (89.7%) had normal
coronary arteries, 63 (8.4%) had non-calcified CAD with
< 50% stenosis and 14 (1.9%) had ≥ 50% stenosis in at
least one coronary artery. The negative predictive value
of a zero CAC for excluding a ≥ 50%CTCA stenosis was
98.1%. Over a median follow-up period of 2.2 years
(range 1.0–7.0 years), the absolute annualised rates of
MACE were as follows: zero CAC 1.9 per 1000 personyears and non-zero CAC 7.4 per 1000 person-years (HR
3.8, p = 0.009). However, after adjusting for age, gender
and cardiovascular risk factors using a multivariable Cox
proportional hazards model, there was no statistically
significant difference in the risk of MACE between the two
patient cohorts (p = 0.19). After adjusting for age, gender
and cardiovascular risk factors, the HR for all-cause
mortality among the zero CAC cohort vers non-zero CAC
was 2.1 (p = 0.27).


A zero CAC score in patients undergoing CT
scanning for suspected stable angina has a high negative
predictive value for the exclusion of obstructive CAD and is
associated with a good medium-term prognosis.

IVUS in Complex Percutaneous Coronary Intervention

Choi et al report on a prospective registry to compare outcomes for complex percutaneous coronary intervention between angiography and IVUS guided intervention.


Arrhythmogenic Cardiomyopathies: Diagnosis and Management

Protonotarios et al provide an excellent review of arrhythmogenic cardiomyopathies in Education in Heart (Protonotarios A, Elliott PM. Heart 2019;0:1–12. doi:10.1136/heartjnl-2017-311160).