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Correction: Altered biophysical properties of the voltage-gated sodium channels in mouse atrial and ventricular cardiomyocytes

2017-09-11T08:33:04-07:00

O’Brien S, Holmes A, Parnell G, et al. 221 Altered biophysical properties of the voltage-gated sodium channels in mouse atrial and ventricular cardiomyocytes. Heart 2017;103:A143–A144.

The author name "Geroge Parnell", should have been spelled "George Parnell".




Heartbeat: Virtual histopathology after myocardial infarction

2017-09-11T08:33:03-07:00

Inflammation plays a key role in outcomes after myocardial infarction yet we have few tools to directly visualise the cellular inflammatory response in clinical practice. In this issue of Heart, Stirrat and colleagues1 performed repeated MRI studies in 31 patients after myocardial infarction using ultra-small-super-paramagnetic particles of iron oxide (USPIO) to visualise macrophages within the myocardium. In combination with other MRI imaging sequences, this approach provides a virtual histopathologic view of the myocardium. In the infarcted myocardial segment, USPIO uptake peaked at 2–3 days and resolved by 10–16 days whereas myocardial oedema peaked later (day 3 to 9) and persisted for over 3 months. (figure 1) As the authors suggest: "This imaging technique holds promise as a non-invasive method of assessing and monitoring myocardial cellular inflammation with potential application to diagnosis, risk stratification and assessment of novel anti-inflammatory therapeutic interventions."

Figure 1

Examples...




Enlarged left atrium, atrial fibrillation and adverse outcome in hypertrophic cardiomyopathy: is there a difference between apical and non-apical phenotype?

2017-09-11T08:33:03-07:00

Apical hypertrophic cardiomyopathy (HCM) was first described in 1976 by Sakamoto and colleagues as a novel cardiac condition characterised by a spade-shaped left ventricular cavity, apical hypertrophy and giant negative T waves.1 Contemporary reports of apical HCM describe it as a phenotypic variant of HCM in which hypertrophy is localised to the left ventricular apex with or without midsegment involvement. Apical HCM is observed worldwide, although it is traditionally reported more frequently in Asian countries (20%–40% of all HCMs) compared with Western countries (3%–11% of all HCMs). In general, patients with apical HCM exhibit mild symptoms and follow a more benign course with a lower mortality rate compared with other forms of HCM. However, numerous case reports and studies suggest considerable overlap between apical hypertrophy, midventricular obstruction and apical aneurysm. Further, our prior study and a report by Maron and colleagues demonstrated a largely unfavourable clinical course for...




Bicuspid aortic valves and intracranial aneurysms: more than an incidental coexistence?

2017-09-11T08:33:03-07:00

We read with great interest the manuscript by Egbe and coauthors from Mayo Clinic published in Heart.1 The authors focused on a clinically relevant manifestation of intracranial aneurysms (IAs) in patients diagnosed with a bicuspid aortic valve disease (BAV). A large institutional BAV cohort was retrospectively analysed while identifying those patients with BAV who had brain imaging with MRA. A total of 52 patients (7.7%) with IA were identified which were associated with seven adverse events during the follow-up (two aneurysm ruptures, four coil embolisations and three aneurysm enlargements >1 mm). Based on these findings, the authors stated an increased IA prevalence in patients with BAV, especially in those presenting with a concomitant aortic coarctation (ie, 12.9%). Furthermore, a clinically relevant association was revealed between proximal BAV-associated aortopathy and IA occurrence which may indicate a common pathophysiologic pathway in the aneurysm formation. Although the natural history of BAV-associated IA’s seems...




Visualising inflammation after myocardial infarction with the use of iron oxide nanoparticles

2017-09-11T08:33:03-07:00

Today, cardiovascular MRI (CMR) is widely used for diagnosis and therapeutic decision making in the setting of different cardiac diseases. CMR allows to analyse anatomical and functional parameters, and enables a non-invasive, accurate and repeatable assessment of changes in myocardial tissue. For example, contrast-enhanced CMR techniques such as late gadolinium enhancement (LGE) imaging enable an accurate, however, unspecific detection of myocardial damage, caused by myocardial infarction (MI). In addition, T2 and T2*-weighted CMR techniques allow to detect myocardial oedema as well as myocardial haemorrhage (in case of acute MI) and thereby provide additional information on infarct pathology and prediction of adverse outcome—at least in some cases.

Regarding the initiation of timely and adequate therapy, diagnosis of myocardial inflammation in the early phase of heart disease—before the occurrence of structural changes in the myocardium—is crucial. Unfortunately, T2-weighted CMR techniques that promise to depict myocardial oedema as the first morphological change in the...




The role and clinical implications of diastolic dysfunction in aortic stenosis

2017-09-11T08:33:03-07:00

Diastolic dysfunction in aortic stenosis results primarily from left ventricular hypertrophy and myocardial fibrosis due to chronically elevated left ventricular systolic pressure. Currently, diastolic dysfunction does not have an explicit clinical role in management of patients with aortic stenosis. Studies have shown that improvement in diastolic dysfunction follows left ventricular remodelling after aortic valve replacement and that it occurs gradually or incompletely. Retrospective studies suggest that advanced grades of diastolic dysfunction at baseline are associated with increased mortality and adverse events even after aortic valve replacement. Recent studies have also associated myocardial fibrosis, a hallmark of diastolic dysfunction, with worse outcomes. In addition, these results were independent of the degree of aortic stenosis or valve replacement. Indirect evidence of the role of diastolic dysfunction in aortic stenosis also comes from paradoxical low-flow, low-gradient aortic stenosis, where disproportionate left ventricular hypertrophy leads to underfilling of the left ventricle, low-flow state and is associated with worse prognosis. Lastly, a limited number of studies suggest that worse diastolic dysfunction at baseline is detrimental in patients who develop aortic regurgitation after transcatheteraortic valve replacement, due to superimposition of volume overload on a stiff left ventricle. Current major limitations in our understanding of the prognostic role of diastolic dysfunction are the lack of universally accepted classification schemes, its dependence on dynamic loading conditions and the lack of larger prospective studies.




Carcinoid heart disease

2017-09-11T08:33:03-07:00

Rare neuroendocrine tumours (NETs) that most commonly arise in the gastrointestinal tract can lead to carcinoid syndrome and carcinoid heart disease. Patients with carcinoid syndrome present with vasomotor changes, hypermotility of the gastrointestinal system, hypotension and bronchospasm. Medical therapy for carcinoid syndrome, typically with somatostatin analogues, can help control symptoms, inhibit tumour progression and prolong survival. Carcinoid heart disease occurs in more than 50% of these patients and is the initial presentation of carcinoid syndrome in up to 20% of patients. Carcinoid heart disease has characteristic findings of plaque-like deposits composed of smooth muscle cells, myofibroblasts, extracellular matrix and an overlying endothelial layer which can lead to valve dysfunction. Valvular dysfunction can lead to oedema, ascites and right-sided heart failure. Medical therapy of carcinoid heart disease is limited to symptom control and palliation. Valve surgery for carcinoid heart disease should be considered for symptomatic patients with controlled metastatic carcinoid syndrome. A multidisciplinary approach is needed to guide optimal management.




Impact of atrial fibrillation on the clinical course of apical hypertrophic cardiomyopathy

2017-09-11T08:33:03-07:00

Background

Apical hypertrophic cardiomyopathy (ApHCM) is considered a ‘benign’ form of hypertrophic cardiomyopathy, with limited data on the long-term outcome. However, the clinical impact of atrial fibrillation (AF) in ApHCM is largely unknown. The hypothesis was that AF is common and has a prognostic implication in ApHCM.

Methods

The occurrence of AF and outcome was assessed in 306 consecutive patients with ApHCM (68% male, 62±11 years).

Results

AF occurred in 77 patients with ApHCM (prevalence, 25.2%; annual incidence, 4.6%/year) and was independently predicted by old age and large left atrium (>45 mm). Among 70 AF patients indicated with anticoagulation, 53 patients (76%) received warfarin. During a follow-up of 5.5±2.0 years, the patients with AF had a higher incidence of all-cause death, cardiovascular death and strokes (11.7% vs 1.3%, 6.5% vs 0.9% and 19.5% vs 2.6%, respectively, all p<0.05) than those without AF. When adjusted by the age and gender, those with AF still had an increased risk for all-cause death (HR 6.58; 95% CI 1.65–26.16, p=0.007) and strokes (HR 5.13; 95% CI 1.85 to 14.18, p=0.002). AF was detected before the time of stroke in 8 (53%) out of 15 patients with both AF and stroke. In addition, six out of eight patients were on anticoagulation at the time of stroke. The cause of death was a stroke in three (33%) out of nine patients with AF.

Conclusion

In patients with ApHCM, AF was common and was associated with a substantial risk for strokes and mortality suggesting that AF should be carefully managed in ApHCM.




The treatment of paroxysmal atrial fibrillation in UK primary care

2017-09-11T08:33:03-07:00

Objective

To determine whether patients with paroxysmal atrial fibrillation (AF) are less likely to be treated with anticoagulants than patients with persistent/permanent AF and to investigate trends in treatment between 2000 and 2015. UK and European guidelines recommend that anticoagulants are offered to all patients with AF at increased risk of stroke, irrespective of AF type.

Methods

Sixteen sequential cross-sectional analyses from 2000 to 2015 were carried out with index dates on 1st of May each year. The data source was primary care data from 648 practices across the UK contributing to The Health Improvement Network database. All patients with a diagnosis of AF aged ≥35 years and registered for at least 1 year were included. The main outcome measure was prescription of anticoagulant medication.

Results

The proportion of patients with AF with a diagnosis of paroxysmal AF increased from 7.4% (95% CI 7.0 to 7.8) in 2000 to 14.0% (95% CI 13.7 to 14.3) in 2015. Among patients with a CHADS2 score of ≥1, between 2000 and 2015 the proportion prescribed anticoagulants increased from 18.8% (95% CI 16.4 to 21.4) to 56.2% (95% CI 55.0 to 57.3) and from 34.2% (95% CI 33.3 to 35.0) to 69.4% (95% CI 68.9 to 69.8) in patients with paroxysmal and other (persistent/permanent) AF, respectively; RR for treatment of patients with paroxysmal AF compared with patients with other AF increased from 0.48 (95% CI 0.42 to 0.55) to 0.76 (95% CI 0.74 to 0.77). Adjusting for age, sex, Townsend score and presence or absence of contraindications had little effect on the results.

Conclusions

In 2000, eligible patients with paroxysmal AF were half as likely to be treated with anticoagulants as patients with other AF; this has improved over time, but in 2015, eligible patients with paroxysmal AF were still around 20% less likely to be prescribed anticoagulant medication.




Prevalence and predictors of intracranial aneurysms in patients with bicuspid aortic valve

2017-09-11T08:33:03-07:00

Objective

To determine the prevalence and outcomes of intracranial aneurysm (IA) in patients with bicuspid aortic valve (BAV).

Methods

Retrospective review of patients with BAV who underwent brain MR angiography at the Mayo Clinic from 1994 to 2013.

Results

There were 678 patients included in this study—mean age 57±13 years, men 480 (71%), mean follow-up 10±3 years (5913 patient-years). Coarctation of aorta (COA) was present in 154 (23%) patients.

There were 59 IAs identified in 52 of 678 patients (7.7%). IA was present in 20/154 patients (12.9%) with COA and 32/524 patients (5.7%) without COA (p<0.001). For the patients without COA, female gender and right–left cusp fusion were risks factors for IA in women after adjustment for all potential variables (HR 1.76, CI 1.31 to 2.68, p=0.03). There was no significant trend in the risk for IA across age tertiles: age ≤40 years versus 41–60 years (HR 1.19, p=0.34), and age 41–60 years versus 61–80 years (HR 1.06, p=0.56).

Among the 52 patients with IA, enlargement occurred in three patients (6%), rupture in two patients (4%) and four patients (8%) underwent coil embolisation. For the 626 patients without IA at baseline, no patient developed IA over 7±2 years of imaging follow-up.

Conclusions

BAV is associated with a higher prevalence of IA compared to the general population, and this risk is higher in patients with COA, right–left cusp fusion and female gender.




Long-term mortality and prehospital tirofiban treatment in patients with ST elevation myocardial infarction

2017-09-11T08:33:03-07:00

Objective

We undertook a subgroup analysis of the On-TIME 2 (Ongoing Tirofiban In Myocardial infarction Evaluation 2), a placebo-controlled, double-blind, randomised trial, in order to evaluate the association between N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels and long-term (5 years) mortality and to investigate the effect of prehospital tirofiban administration on mortality in relation to NT-proBNP levels.

Methods

A total of 984 patients with ST elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) were randomised to either in ambulance tirofiban or placebo. NT-proBNP levels were evaluated on admission before angiography (baseline) and 18–96 hours thereafter (post PCI).

Results

There were 918 (93.3%) patients with NT-proBNP values available at baseline and 865 (87.9%) post PCI. Patients with baseline NT-proBNP values above the median (137 pg/mL) had higher 30-day (5.1% vs 0.2%, p<0.001), 1-year (7.0% vs 0.7%, p<0.001) and 5-year (20.3% vs 4.9%, p<0.001) mortality as compared with patients with values below the median. Using multivariate Cox analysis, NT-proBNP above the median was an independent predictor for 5-year mortality (HR 2.73, 95% CI 1.47 to 5.06; p=0.002). Patients with values above the median who received early tirofiban treatment had significant lower mortality compared with patients treated with placebo at 30 days (2.7% vs 7.5%, p=0.021) and 1 year (4.5% vs 9.4%, p=0.043). At 5 years, a lower but non-significant mortality rate was maintained in the treatment group (18% vs 22.4%, p=0.265).

Conclusions

In patients with STEMI, baseline NT-proBNP level independently predicts long-term mortality. In patients with baseline NT-proBNP levels above the median, early prehospital treatment with tirofiban significantly reduced 30-day and 1-year mortality, suggesting that high-risk patients may derive particular benefit. This finding should be confirmed in other studies.

Trial registration number

ISRCTN06195297.




Effect of interleukin-6 inhibition on coronary microvascular and endothelial function in myocardial infarction

2017-09-11T08:33:03-07:00

Objective

Interleukin-6 (IL-6) is a driver of inflammation and associated endothelial cell activation in acute coronary syndromes. We evaluated the effect of the IL-6 receptor antagonist tocilizumab on coronary microvascular function and endothelial dysfunction measured by coronary flow reserve (CFR) and markers of endothelial cell activation in patients with non-ST-elevation myocardial infarction (NSTEMI).

Methods

This substudy was part of a two-centre, double-blind, randomised, placebo-controlled trial evaluating the effect of a single dose of tocilizumab in NSTEMI. Markers of endothelial cell activation (vascular cell adhesion molecule (VCAM)-1, intercellular adhesion molecule-1 and von Willebrand factor) were assessed in 117 patients. In 42 of these patients, 20 assigned to placebo and 22 to tocilizumab, we measured CFR. Blood samples were obtained at seven consecutive time points between day 1 and 3. CFR was measured by transthoracic echocardiography during hospitalisation and after 6 months.

Results

Tocilizumab did not affect CFR during hospitalisation (tocilizumab: 3.4±0.8 vs placebo: 3.3±1.2, p=0.80). CFR improved significantly in both groups at 6 months. Patients in the tocilizumab group had significantly higher area under the curve for VCAM-1 (median 622 vs 609 ng/mL/hour, tocilizumab and placebo respectively, p=0.003). There were inverse correlations between VCAM-1 and CFR in the placebo (hospitalisation: r=–0.74, p<0.01, 6 months: r=–0.59, p<0.01), but not in the tocilizumab group (hospitalisation: r=0.20, p=0.37, 6 months r=–0.28, p=0.20).

Conclusions

Tocilizumab did not affect CFR during hospitalisation or after 6 months. Tocilizumab increased VCAM-1 levels during hospitalisation, but this was not associated with reduced CFR in these patients.




Ferumoxytol-enhanced magnetic resonance imaging assessing inflammation after myocardial infarction

2017-09-11T08:33:03-07:00

Objectives

Macrophages play a central role in the cellular inflammatory response to myocardial infarction (MI) and predict subsequent clinical outcomes. We aimed to assess temporal changes in cellular inflammation and tissue oedema in patients with acute MI using ultrasmallsuperparamagnetic particles of iron oxide (USPIO)-enhanced MRI.

Methods

Thirty-one patients were recruited following acute MI and followed up for 3 months with repeated T2 and USPIO-enhanced T2*-mapping MRI. Regions of interest were categorised into infarct, peri-infarct and remote myocardial zones, and compared with control tissues.

Results

Following a single dose, USPIO enhancement was detected in the myocardium until 24 hours (p<0.0001). Histology confirmed colocalisation of iron and macrophages within the infarcted, but not the non-infarcted, myocardium. Following repeated doses, USPIO uptake in the infarct zone peaked at days 2–3, and greater USPIO uptake was detected in the infarct zone compared with remote myocardium until days 10–16 (p<0.05). In contrast, T2-defined myocardial oedema peaked at days 3–9 and remained increased in the infarct zone throughout the 3-month follow-up period (p<0.01).

Conclusion

Myocardial macrophage activity can be detected using USPIO-enhanced MRI in the first 2 weeks following acute MI. This observed pattern of cellular inflammation is distinct, and provides complementary information to the more prolonged myocardial oedema detectable using T2 mapping. This imaging technique holds promise as a non-invasive method of assessing and monitoring myocardial cellular inflammation with potential application to diagnosis, risk stratification and assessment of novel anti-inflammatory therapeutic interventions.

Trial registration number

Trial registration number: 14663. Registered on UK Clinical Research Network (http://public.ukcrn.org.uk) and also ClinicalTrials.gov (https://clinicaltrials.gov/ct2/show/NCT02319278?term=DECIFER&rank=2).




Cardiovascular outcomes with an inhaled beta2-agonist/corticosteroid in patients with COPD at high cardiovascular risk

2017-09-11T08:33:03-07:00

Objectives

Cardiovascular disease (CVD) and chronic obstructive pulmonary disease (COPD) often coexist. We assessed the effect of inhaled COPD treatments on CVD outcomes and safety in patients with COPD and at heightened CVD risk.

Methods

The SUMMIT (Study to Understand Mortality and MorbidITy) was a multicentre, randomised, double-blind, placebo-controlled, event-driven trial in 16 485 patients with moderate COPD who had or were at high risk of CVD. Here, we assessed the prespecified secondary endpoint of time to first on-treatment composite CVD event (CVD death, myocardial infarction, stroke, unstable angina or transient ischaemic attack (TIA)) by Cox regression and by clinician-reported CVD adverse events across the four groups: once-daily inhaled placebo (n=4111), long-acting beta2-agonist (vilanterol (VI) 25 µg; n=4118), corticosteroid (fluticasone furoate (FF) 100 µg; n=4135) and combination therapy (FF/VI; n=4121).

Results

Participants were predominantly middle-aged (mean 65 (SD 8) years) men (75%) with overt CVD (66%). The composite CVD endpoint occurred in 688 patients (first event: sudden death (35%), acute coronary syndrome (37%) and stroke or TIA (23%), and was not reduced in any treatment group versus placebo: VI (HR 0.99, 95% CI 0.80 to 1.22), FF (HR 0.90, 95% CI 0.72 to 1.11) and their combination (HR 0.93, 95% CI 0.75 to 1.14). Outcomes were similar among all subgroups. Adverse events, including palpitations and arrhythmias, did not differ by treatment.

Conclusions

In patients with COPD with moderate airflow limitation and heightened CVD risk, treatment with inhaled VI, FF or their combination has an excellent safety profile and does not impact CVD outcomes.

Trial registration number

NCT01313676.




Pathophysiology, diagnosis and treatment of tachycardiomyopathy

2017-09-11T08:33:03-07:00

Learning objectives

  • Recognise the diagnosis of tachycardiomyopathy (TCMP)

  • Understand the pathophysiology

  • Determine treatment strategies to restore left ventricular function

  • The role of TCMP in non-responders to cardiac resynchronisation

  • Introduction

    Tachycardiomyopathies (TCMP) are an important cause of left ventricular (LV) dysfunction that should be recognised by physicians as they are potentially reversible and have a significant impact on morbidity and prognosis. They are classically defined as the reversible impairment of ventricular function induced by persistent arrhythmia. However, it is becoming increasingly evident that they can be induced by atrial and ventricular ectopy promoting dyssynchrony and indeed the term ‘arrhythmia-induced cardiomyopathy’ is emerging to describe the phenomenon.1 2 A more current proposed definition highlights aetiology: ‘Atrial and/or ventricular dysfunction—secondary to rapid and/or asynchronous/irregular myocardial contraction, partially or completely reversed after treatment of the causative arrhythmia’3 (figure 1). Two...




    Cardiovascular highlights from non-cardiology journals

    2017-09-11T08:33:03-07:00

    Levosimendan for hemodynamic support after cardiac surgery

    Left ventricular dysfunction following cardiac surgery remains a significant perioperative challenge, one often treated with inotropic support, however practice patterns vary widely and there are few outcome data to support a standardised practice. Levosimendan represents a newer class of ‘inodilators’, calcium sensitizers, thought to improve cardiac output without increasing myocardial oxygen consumption. In the Levosimendan to Reduce Mortality in High Risk Cardiac Surgery Patients (CHEETAH) randomised trial, 506 patients with a preoperative ejection fraction <25%, a preoperative need for intraaortic balloon pump (IABP) support, or post-operative need for support with IABP or high-dose inotropes within 24 hours of cardiopulmonary bypass were randomised 1:1 to receive either levosimendan infusion or placebo plus standard medical therapy in a double-blinded fashion. The primary outcome of the study was 30 day mortality. No difference in the primary outcome was found between the levosimendan group (12.9% mortality) and the...




    Palpitations in a 72-year-old woman

    2017-09-11T08:33:03-07:00

    Clinical introduction

    A 72-year-old woman presented with an 8-year history of palpitations occurring every few weeks. They were sudden in onset, were associated with dizziness and could last for up to 2 hours. She was prescribed bisoprolol which reduced the frequency of events but did not abolish them. Baseline ECG and echocardiography were normal. She was referred for electrophysiological study. Despite initial difficulties, diagnostic catheters were placed in the right ventricular (RV) apex and in the coronary sinus (CS) via the right internal jugular vein and superior vena cava (SVC) (figure 1A). A narrow complex tachycardia was easily induced, and ablation was then delivered during tachycardia with the ablation catheter positioned as shown in (figure 1A). This terminated tachycardia 4 s after onset of energy delivery and on follow-up she has remained asymptomatic. She later underwent a CT scan (figure 1B,C; online ).

    Figure 1

    (A) Fluoroscopy of catheter placement. (B) Sagittal contrast-enhanced CT image. (C) Axial contrast-enhanced CT.

    Question

    What anatomical abnormality caused difficulty in catheter placement during the procedure?

  • Azygous continuation of the inferior vena cava (IVC)

  • Giant Eustachian valve

  • Dextrocardia

  • Renal tumour compressing IVC




  • Mechanical prosthetic heart valves (MPHV) in pregnancy are associated with a high risk of maternal and fetal morbidity and mortality

    2017-09-11T08:33:03-07:00

    We read with interest the paper by Bhagra et al1 and wish to add further information from two recent publications which emphasise their key points that ‘pregnancy in women with mechanical heart valves is high risk’ and that ‘a multidisciplinary team approach to the management of pregnant women with Prosthetic Heart Valves is necessary to ensure optimal outcomes.’

    A recent prospective observational national study of women in the UK with pregnancies between February 2013 and January 2015, estimated the incidence of mechanical prosthetic heart valves (MPHVs) in pregnancy to be 3.7 per 100 000 and described high rates of maternal mortality (9%), serious maternal morbidity (41%) and poor fetal outcomes (47% of the cohort and 35% of those reaching the third trimester).2 These complication rates are higher than previously described in the literature. This may be because the validated methodology resulted in less reporting bias; or because of variation...




    Moderate sedation in cardiac electrophysiology laboratory: a retrospective safety analysis

    2017-09-11T08:33:04-07:00

    Sawhney et al reported that nurse-led, physician-directed moderate sedation during cardiac electrophysiology procedures is safe.1 All of the patients undergoing cardiac electrophysiological (EP) procedures and cardiac implantable electronic device (CIED) implantation during the last 12 years were moderately sedated. Since this study is a retrospective study, we could not comprehend why all patients were sedated despite the fact that routine sedation during all cardiac EP procedures and all CIED implantation is not recommended.

    Moreover, as mentioned in the article, sedation is a continuum and it is not always possible to predict how individual patients will respond. Therefore, a gradual increase of doses of the sedatives during sedation may be needed, which may possibly increase the procedure duration. Did authors ascertain any prolongation of the procedures due to sedative administration?

    Furthermore, sedation may diminish arrhythmia induction during EP procedures, particularly in patients with catecholamine-sensitive ventricular tachycardias.2...