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Introduction: The need for transparency in financial relationships in the healthcare system, has culminated in Open Payments database, managed by the Center for Medicare and Medicaid Services (CMS). Since its inception in 2013, the trend in such payments to physicians practicing cardiac electrophysiology was not examined. Methods and Results: Payment information reported to CMS from January 2013 to December 2018 was obtained from the publicly available Open Payments data set using the online query tool. The data were analyzed by an individual provider and by state. An in‐depth analysis of payments in the year 2018 payments was performed. From 2014 to 2018, there was an 18% increase in the total number of payments reported from 88 877 payments in 2014 to 105 000 in 2018. Despite the increase in the total number of payments reported, the average payment steadily decreased over time, resulting in an overall reduction in the total amount of payments from 2014 to 2018 ($34.9 million to $28.2 million). Payments to the top 5% of individual recipients have also decreased over this time. In 2018, 2888 unique providers received reportable payments, a total of 105 000 payments, with a median payment amount of $1378 (interquartile range: $165–$5781). The majority of these payments were for food and beverage (82%) and travel/lodging (10%). The top five payers include Boston Scientific, Medtronic Vascular, Abbott Laboratories, Janssen Pharmaceuticals, and Biotronik. Conclusion: Among cardiac electrophysiologists, there is increased reporting of payments in the Open Payments program over time, with a notable decrease in the payment amount. [ABSTRACT FROM AUTHOR]

Background: Use of magnetic resonance imaging (MRI) brain is restricted in patients with cardiovascular implantable electronic devices (CIEDs). We proposed to determine whether mortality difference exists for patients with non-MRI-conditional CIEDs undergoing brain MRI compared with controls.Methods and Results: Retrospective analysis of prospectively collected data was performed to compare all-cause mortality in patients with CIEDs undergoing brain MRI (CIED-MRI) with 3 control groups matched for age, sex, imaging year, and type of CIED: (1) no CIED, brain MRI (no-CIED-MRI); (2) CIED, brain computerized tomography (CT) scan (CIED-CT); and (3) no CIED, brain CT (no-CIED-CT). The primary outcome was a significant difference (P<0.05) between estimated mortality rates. Secondary outcomes were changes in device function before and after brain MRI. The estimated all-cause mortality at 5 years for the CIED-MRI group [mean age (±SD), 68.2 years (15.3 years); 61.2% men] was not significantly different from patients who underwent CT with or without a device (CIED-CT group: hazard ratio, 0.814; 95% confidence interval, 0.593-1.117; P=0.2; no-CIED-CT group: hazard ratio, 1.149; 95% confidence interval, 0.818-1.613; P=0.4). There was a significant increase in mortality between CIED-MRI and no-CIED-MRI groups (hazard ratio, 1.463; 95% confidence interval, 1.019-2.099; P=0.04).Conclusions: Brain MRI in patients with CIEDs does not carry an increased mortality risk compared with brain CT and can be performed with adherence to appropriate procedural protocols. [ABSTRACT FROM AUTHOR]

Catheter Ablation for Atrial Arrhythmias in Patients With CA Background Cardiac amyloidosis (CA) is associated with increased atrial arrhythmias risk. The efficacy/safety of catheter-based ablation therapy in patients with CA has not been adequately assessed. Methods and Results All diagnosed CA patients who underwent atrial arrhythmia ablation therapy from 1995 to 2015 were reviewed. Arrhythmia recurrence, NYHA symptoms, and mortality were recorded. A total of 26 patients with CA and atrial arrhythmias were included; there were 7 light-chain (AL), 17 wild-type transthyretin (ATTRwt), and 2 mutated transthyretin (ATTRm) amyloidosis patients in total. Of which 13 underwent atrial arrhythmia ablation (CA-A) and 13 underwent AV nodal ablation (CA-AVN). In the CA-A group, there were: 3 with atrial fibrillation (AF); 6 with atrial flutter (AFL); 2 with AF/AFL; and 2 with atrial tachycardia (AT). One-year and 3-year recurrence-free survival were 75% and 60%, respectively. NYHA symptom improvement 6 months postablation was observed in both CA-A and CA-AVN groups: 7/10 (70%) and 4/8 (50%), respectively. Eleven patients with CA died (8 in CA-AVN group vs. 3 in CA-A group). Conclusions Catheter-based ablation for patients with CA appears to provide important symptomatic relief. However, mortality from the underlying disease remains a significant issue for the amyloid light-chain subtype. [ABSTRACT FROM AUTHOR]

Background Many patients with atrial fibrillation (AF) or atrial flutter (Aflutter) have concomitant sinus node dysfunction (SND). Ablation may result in injury to the sinus node complex or its blood supply resulting in sinus arrest and need for temporary pacing. We sought to characterize patients who develop acute SND (ASND) during/immediately after AF/Aflutter ablation. Methods We performed a retrospective analysis of AF/Aflutter ablation patients between January 1, 2010 and February 28, 2015 to characterize those who required temporary pacemaker (TPM) implantation due to ASND (sinus arrest, sinus bradycardia <40 beats/min, or junctional rhythm with hemodynamic compromise) following atrial ablation. Results Of 2,151 patients, eight patients (<0.5%) with ASND manifesting as sinus arrest (n = 2), severe sinus bradycardia (n = 2), and junctional rhythm with hemodynamic compromise (n = 4) were identified (all male, age 66 ± 9.9 years, 4/8 [50%] persistent AF). AF ablation was performed in four, atypical Aflutter in one, and AF/Aflutter in three patients. The ablation set consisted of: pulmonary vein (PV) isolation (n = 6), roof line ablation (n = 6), mitral annulus-left inferior PV line ablation (n = 5), left atrial appendage-mitral annulus ablation (n = 1), cavotricuspid isthmus ablation (n = 5), and isolation or ablation near the superior vena cava (SVC, n = 4). Patients with peri-SVC ablation were more likely to develop ASND (P = 0.03). All patients received TPM; six received permanent pacemaker before discharge, performed 3.5 days postablation (range 2-6 days). At 3-month device interrogation, all patients were atrially paced >50%. Conclusion ASND is a rare complication of atrial ablation. It may be more common when peri-SVC ablation is performed and may necessitate permanent pacemaker implantation. [ABSTRACT FROM AUTHOR]

The article focuses on the difficulty prediction of a transvenous lead extraction procedure. Topics discussed include lead extraction in congenital heart disease and pediatric patients, management, incidence and outcomes of the arteriovenous fistula complicating transvenous lead extraction and high-risk lead extraction using a hybrid approach.

Background: Approximately 12-21% of implantable cardioverter defibrillator (ICD) patients receive inappropriate shocks. We sought to determine the incidence and causes of noise/artifact and oversensing (NAO) resulting in ICD shocks. Methods: A random sample of 2,000 patients who received ICD and cardiac resynchronization therapy defibrillator shocks and were followed by a remote monitoring system was included. Seven electrophysiologists analyzed stored electrograms from the 5,279 shock episodes. Episodes were adjudicated as appropriate or inappropriate shocks. Results: Of the 5,248 shock episodes with complete adjudication, 1,570 (30%) were judged to be inappropriate shocks. Of these 1,570, 134 (8.5%) were a result of NAO. The 134 NAO episodes were determined to be due to external noise in 76 (57%), lead connector-related in 37 (28%), muscle noise in 11 (8%), oversensing of atrium in seven (5%), T-wave oversensing in two (2%), and other noise in one (1%). The ICD shock itself resulted in a marked decrease in the level of noise in 60 of 134 (45%) NAO episodes, and the magnitude of this effect varied with the type of NAO (58% for external noise, 35% for muscle, 27% for lead/connector, and 0% for oversensing; P = 0.03). There was no significant difference in NAO likelihood based on type of lead (integrated bipolar 89/1,802 vs dedicated bipolar 9/140, P = 0.67). Conclusions: External noise and lead/connector noise were the primary causes, while T-wave oversensing was the least common cause of NAO resulting in ICD shock. Noise/artifact decreased immediately after a shock in nearly half of episodes. The specific ICD lead type did not impact the likelihood of NAO. (PACE 2012;XX:1-7) [ABSTRACT FROM AUTHOR]

Background: The increasing use of remote monitoring with the associated large retrievable databases provides a unique opportunity to analyze observations on implantable cardioverter-defibrillator (ICD) therapies. Adjudication of a large number of stored ICD electrograms (EGMs) presents a unique challenge. The ALTITUDE study group was designed to use the LATITUDE remote monitoring system to evaluate ICD patient outcomes across the United States. Methods and Results: Of 81,081 patients on remote monitoring, a random sample of 2,000 patients having 5,279 shock episodes was selected. The ALTITUDE EGM review committee was comprised of seven electrophysiologists from four institutions. An online EGM adjudication system was designed. Episodes were classified as appropriate (70% of shock episodes) or inappropriate ICD therapies (30%). Light's Kappa was used to assess agreement. Interobserver and intraobserver Kappa scores for dual-chamber ICDs were 0.84 (0.71-0.91) and 0.89 (0.82-0.95), consistent with substantial agreement. Interobserver and intraobserver Kappa scores for single-chamber ICDs were 0.61 (0.54-0.67) and 0.69 (0.59-0.79). The rhythm categories of 'nonsustained arrhythmia' and 'polymorphic and monomorphic ventricular tachycardia' resulted in the greatest degree of discordant adjudication between reviewers. Conclusions: This method of adjudication of a large volume of stored EGM data prior to device therapies will allow new observations in regards to device performance and has the potential to improve device programming and design. There was substantial interreviewer agreement for rhythm classification. Agreement was greater for dual-chamber compared to single-chamber devices, indicating the atrial lead adds diagnostic value in rhythm interpretation. (PACE 2011; 34:1003-1012) [ABSTRACT FROM AUTHOR]

Background: Recognition of rates and causes of hard, patient-centered outcomes of death and cerebrovascular events (CVEs) after heart rhythm disorder management (HRDM) procedures is an essential step for the development of quality improvement programs in electrophysiology laboratories. Our primary aim was to assess and characterize death and CVEs (stroke or transient ischemic attack) after HRDM procedures over a 17-year period.Methods: We performed a retrospective cohort study of all patients undergoing HRDM procedures between January 2000 and November 2016 at the Mayo Clinic. Patients from all 3 tertiary academic centers (Rochester, Phoenix, and Jacksonville) were included in the study. All in-hospital deaths and CVEs after HRDM procedures were identified and were further characterized as directly or indirectly related to the HRDM procedure. Subgroup analysis of death and CVE rates was performed for ablation, device implantation, electrophysiology study, lead extraction, and defibrillation threshold testing procedures.Results: A total of 48 913 patients (age, 65.7±6.6 years; 64% male) who underwent a total of 62 065 HRDM procedures were included in the study. The overall mortality and CVE rates in the cohort were 0.36% (95% confidence interval [CI], 0.31-0.42) and 0.12% (95% CI, 0.09-0.16), respectively. Patients undergoing lead extraction had the highest overall mortality rate at 1.9% (95% CI, 1.34-2.61) and CVE rate at 0.62% (95% CI, 0.32-1.07). Among patients undergoing HRDM procedures, 48% of deaths directly related to the HDRM procedure were among patients undergoing device implantation procedures. Overall, cardiac tamponade was the most frequent direct cause of death (40%), and infection was the most common indirect cause of death (29%). The overall 30-day mortality rate was 0.76%, with the highest being in lead extraction procedures (3.08%), followed by device implantation procedures (0.94%).Conclusions: Half of the deaths directly related to an HRDM procedure were among the patients undergoing device implantation procedures, with cardiac tamponade being the most common cause of death. This highlights the importance of the development of protocols for the quick identification and management of cardiac tamponade even in procedures typically believed to be lower risk such as device implantation. [ABSTRACT FROM AUTHOR]

The article presents a study which examines the frequency of arrhythmia in pregnancy over time. Analysis of data of pregnancy-related hospitalizations by arrhythmia, supraventricular tachycardia (SVT), and atrial fibrillation (AF) and ventricular arrhythmias from 2000 to 2012 is offered. Results highlight an increase in the frequency of arrhythmia in which the most frequent is AF.

Background The prognosis of left ventricular noncompaction (LVNC) remains elusive despite its recognition as a clinical entity for >30 years. We sought to identify clinical and imaging characteristics and risk factors for mortality in patients with LVNC. Methods and Results 339 adults with LVNC seen between 2000 and 2016 were identified. LVNC was defined as end-systolic noncompacted to compacted myocardial ratio >2 (Jenni criteria) and end-diastolic trough of trabeculation-to-epicardium (X):peak of trabeculation-to-epicardium (Y) ratio <0.5 (Chin criteria) by echocardiography; and end-diastolic noncompacted:compacted ratio >2.3 (Petersen criteria) by magnetic resonance imaging. Median age was 47.4 years, and 46% of patients were female. Left ventricular ejection fraction <50% was present in 57% of patients and isolated apical noncompaction in 48%. During a median follow-up of 6.3 years, 59 patients died. On multivariable Cox regression analysis, age (hazard ratio [HR] 1.04; 95% CI, 1.02-1.06), left ventricular ejection fraction <50% (HR, 2.37; 95% CI, 1.17-4.80), and noncompaction extending from the apex to the mid or basal segments (HR, 2.11; 95% CI, 1.21-3.68) were associated with all-cause mortality. Compared with the expected survival for age- and sex-matched US population, patients with LVNC had reduced overall survival ( P <0.001). However, patients with LVNC with preserved left ventricular ejection fraction and patients with isolated apical noncompaction had similar survival to the general population. Conclusions Overall survival is reduced in patients with LVNC compared with the expected survival of age- and sex-matched US population. However, survival rate in those with preserved left ventricular ejection fraction and isolated apical noncompaction was comparable with that of the general population.

Background: Prescription opioids are a major cause of the opioid epidemic. Despite the invasive nature of cardiac implantable electronic device (CIED) procedures, data on opioid prescription patterns after CIED procedures are lacking., Objective: The purpose of this study was to assess opioid prescribing patterns and the rates of new opioid refills (refills in previously opioid naïve patients) among patients undergoing CIED procedures., Methods: We performed a retrospective analysis of all patients undergoing CIED procedures from January 1, 2010, to March 30, 2018, at the Mayo Clinic (Minnesota, Arizona, and Florida). Procedures were categorized into new implant, generator change, device upgrade, lead revision or replacement, and subcutaneous implantable cardiac defibrillator (S-ICD) procedures. The rates of postoperative opioid prescription and new opioid refills were analyzed. Wilcoxon rank sum and χ 2 tests assessed variations., Results: A total of 16,517 patients (mean age 70 ± 15; 36% female) underwent CIED procedures. Opioids were prescribed to 20.2% of the patients, among whom 80% were opioid naïve. Among opioid naïve patients who received opioids, 9.4% (95% confidence interval [CI] 8.3%-10.5%) had subsequent opioid refills. The percentage of patients who received more than 200 oral morphine equivalents of prescription was 38.8% (95% CI 37.2%-40.5%). Temporal trends revealed increasing rates of any opioid prescription, peaking in 2015 at 25.9%, with subsequent downtrend to 14.6% in 2018 (P <.001)., Conclusion: Postoperative opioid prescription rate after CIED procedures was 20.2%, with most patients being opioid naïve. Among opioid naïve patients who received opioids, 9.4% had subsequent opioid refills. This finding suggests that perioperative pain management in CIED procedures warrants meticulous attention., (Copyright © 2019 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: Leadless cardiac pacing (LCP) has emerged as a new modality for permanent pacing. We sought to describe comparative outcomes between LCP and transvenous pacemakers., Methods: Patients receiving LCP (Micra [Medtronic, Minneapolis, MN, USA] and Nanostim [St. Jude Medical/Abbott Laboratories, Chicago, IL, USA]) between 2014 and 2017 at the Mayo Clinic Heart Rhythm Enterprise practice (Rochester, MN, USA; Jacksonville, FL, USA; and Scottsdale, AZ, USA) were identified. We identified 1:1 age- and sex-matched controls receiving single-chamber transvenous ventricular pacemakers (TVP). Statistical analyses were performed with JMP 13.0.0 (SAS, Institute Cary, NC, USA)., Results: Ninety patients underwent LCP implantation (73 Micra and 17 Nanostim) with a median follow-up duration of 62 (interquartile range 28-169) days. Both groups had 100% successful device implant rates. There were no differences in procedure-related major (0% vs 1%) or minor complications (8% vs 3%) in the LCP versus TVP groups (P > 0.05). Excluding Nanostim patients, there was a lower rate of device-related revision or extraction in the Micra versus TVP groups (0% vs 5%, P = 0.028). Device endocarditis was more common in the TVP group (0% vs 3%, P = 0.04). Estimated longevity was greater for the LCP group (median 12.0 vs 10.0 years, P < 0.0001). An increase in severity of tricuspid valve regurgitation (TR) by ≥2 grades occurred in none of the LCP patients, and in 19% of the TVP patients (P = 0.017)., Conclusion: There are no significant differences in procedural complications among patients receiving LCP versus TVP. The Micra group had lower rates of device-related revision/extraction compared to the TVP group. Patients with leadless pacemaker were less likely to develop endocarditis or worsening TR., (© 2019 Wiley Periodicals, Inc.)

Background: Stroke can be a devastating complication in patients with cardiovascular implantable electronic device (CIED) infection. Paradoxical septic embolism can occur in the presence of device leads and patent foramen ovale (PFO) via embolic dislodgment during transvenous lead removal (TLR)., Objective: The purpose of this study was to examine stroke and its associated factors in patients undergoing TLR for CIED infection., Methods: We performed a retrospective analysis of all patients undergoing TLR for CIED infection from January 1, 2000, to July 30, 2017, from all 3 tertiary referral centers at the Mayo Clinic (Rochester, Phoenix, and Jacksonville). The primary outcome was stroke and was further categorized into preprocedural and postprocedural stroke. Associated risk factors were analyzed., Results: A total of 774 patients (mean age 67.6 ± 14.9 years) underwent TLR for CIED infection. The stroke rate in this cohort was 1.9% (95% confidence interval [CI] 1.1%-3.2%). The preprocedural and postprocedural stroke rate was 0.9% (95% CI 0.4%-1.9%) and 1.0% (95% CI 0.4%-2.0%), respectively. PFOs were identified in 46.7% of patients with stroke and in 12.9% of patients without stroke, and were independently associated with stroke (P = .0002). This was especially in patients with right-sided vegetations with right-to-left shunting (odds ratio 6.4; 95% CI 1.3-31.0; P = .022)., Conclusion: In patients with CIED infection undergoing TLR, the presence of PFO, especially with right-sided vegetation with right-to-left shunting, was associated with an increased risk of stroke. This finding suggests that PFO screening before TLR warrants meticulous attention., (Copyright © 2018 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: Repaired congenital heart disease (rCHD) is strongly associated with ventricular tachycardia (VT) as an important late cause of morbidity and mortality. Ventricular reentry most commonly includes anatomic isthmuses created during the repair procedures., Objective: The purpose of this study was to analyze the long-term outcomes of catheter ablation, a commonly used standalone or adjunctive therapy, in a cohort of rCHD patients., Methods: A retrospective analysis of 21 consecutive patients with rCHD (45.0 ± 3.0 years, 71.4% male) undergoing ablation for VT was performed. The primary composite outcome was defined as in-hospital arrhythmic death, out-of-hospital sudden cardiac death, or appropriate implantable cardioverter-defibrillator therapy., Results: At initial electrophysiologic study, 14 patients (66.7%) had reentrant VT through an electroanatomic isthmus; the remaining 7 patients (33.3%) demonstrated focal VT. Isthmus-dependent reentry was identified as the mechanism for VT in 14 patients (66.7%), and conduction block was confirmed in 8 of these patients (57.1%). No patients with confirmed block developed VT recurrence. During long-term follow-up (33 ± 7 months), 20 of 21 patients (95.2%) had not reached the primary composite outcome. Three patients died of nonarrhythmic causes., Conclusion: Catheter-based VT ablation in patients with rCHD is associated with a low rate of VT recurrence. Focal VT was not uncommon in this cohort. If a reentrant mechanism is present, confirmation of conduction block across the isthmus is vital to prevent recurrence., (Copyright © 2016 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: There is significant practice variation in oral anticoagulation (OAC) use following catheter ablation for atrial fibrillation. It is not clear whether the risk of cardioembolism increases after discontinuation of OAC following catheter ablation., Methods and Results: We identified 6886 patients within a large national administrative claims database who underwent catheter ablation for atrial fibrillation between January 1, 2005, and September 30, 2014. We assessed the effect of time off of OAC by CHA2DS2-VASc score (after adjusting for other comorbidities) on risk of cardioembolism, using Cox proportional hazards models. There was an increase in the use of non-vitamin K OAC after ablation from 0% in 2005 to 69.8% in 2014. OAC discontinuation was high, with only 60.5% and 31.3% of patients remaining on OAC at 3 and 12 months, respectively. The rate of discontinuation was higher in low-risk patients (82% versus 62.5% at 12 months for CHA2DS2-VASc 0-1 versus ≥2, respectively; P<0.001). Stroke occurred in 1.4% of patients with CHA2DS2-VASc ≥2 and 0.3% of those with CHA2DS2-VASc 0 or 1 over the study follow-up. The risk of cardioembolism in the first 3 months after ablation was increased among those with any time off OAC (hazard ratio 8.06 [95% CI 1.53-42.3], P<0.05). The risk of cardioembolism beyond 3 months was increased with OAC discontinuation among high-risk patients (hazard ratio 2.48 [95% CI 1.11-5.52], P<0.05) but not low-risk patients., Conclusion: The overall risk of stroke in postablation patients is low; however, OAC discontinuation after ablation is common and is associated with increased risk of cardioembolism for all patients within the first 3 months and for high-risk patients in the long term. Continuing OAC for at least 3 months in all patients and indefinitely in high-risk patients appears to be the safest strategy., (© 2015 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)

Background: The efficacy of shock in converting different ventricular tachyarrhythmias has not been well characterized in a large natural-practice setting., Objective: To determine shock success rate by energy and ventricular rhythm in a large cohort of patients with implantable cardioverter-defibrillators., Methods: Two thousand patients with 5279 shock episodes were randomly sampled for analysis from the LATITUDE remote monitoring system. Within an episode, the rhythm preceding therapy (shock or antitachycardia pacing [ATP]) was adjudicated. Patients who died after unsuccessful implantable cardioverter-defibrillator shocks did not transmit final remote monitoring data and were not included in the study., Results: Of 3677 shock episodes for ventricular tachyarrhythmia, 2679 were treated with shock initially and were classified as monomorphic ventricular tachycardia ( n = 1544), polymorphic/monomorphic ventricular tachycardia (n = 371), or ventricular fibrillation (n = 764). The success rate after the first, second, and final shock averaged 90.3%, 96.4%, and 99.8%, respectively. After unsuccessful initial ATP (n = 998), the first, second, and final shock was successful in 84.8%, 92.9%, and 100% of the episodes. The success rate after the first or second shock was significantly lower after failed ATP compared to shock as first therapy (both P<.001). Among episodes treated initially with shock, the success rate for monomorphic ventricular tachycardia (89.2%) when treated with energy level ≤ 20 J was significantly higher than that for ventricular fibrillation (80.8%) (P = .04). The level of shock energy was a significant predictor of the success of the first shock (odds ratio 1.16; 95% confidence interval 1.03-1.30; P = .013)., Conclusions: The success rate of first shock as first therapy is approximately 90%, but was lower after failed ATP. Programming a higher level of energy after ATP is suggested., (Copyright © 2013. Published by Elsevier Inc.)

Objective: To determine the opinions of medical professionals, legal professionals, and patients regarding the withdrawal of implantable cardioverter-defibrillator (ICD) and pacemaker therapy at the end of life., Participants and Methods: A survey regarding 5 cases that focused on withdrawal of ICD or pacemaker therapy at the end of life was constructed and sent to 5270 medical professionals, legal professionals, and patients. The survey was administered from March 1, 2008, to March 1, 2009., Results: Of the 5270 recipients of the survey, 658 (12%) responded. In a terminally ill patient requesting that his ICD be turned off, most legal professionals (90% [63/70]), medical professionals (98% [330/336]), and patients (85% [200/236]) agreed the ICD should be turned off. Most legal professionals (89%), medical professionals (87%), and patients (79%) also considered withdrawal of pacemaker therapy in a non-pacemaker-dependent patient appropriate. However, significantly more legal (81%) than medical professionals (58%; P<.001) or patients (68%, P=.02) agreed with turning off a pacemaker in the pacemaker-dependent patient. A similar number of legal professionals thought turning off a device was legal regardless of whether it was an ICD or pacemaker (45% vs 38%; P=.50). However, medical professionals were more likely to perceive turning off an ICD as legal than turning off a pacemaker (85% vs 41%; P<.001)., Conclusion: Most respondents thought device therapy should be withdrawn if the patient requested its withdrawal at the end of life. However, opinions of medical professionals and patients tended to be dependent on the type of device, with turning off ICDs being perceived as more acceptable than turning off pacemakers, whereas legal professionals tended to perceive all devices as similar. Thus, education and discussion regarding managing devices at the end of life are important when having end-of-life discussions and making end-of-life decisions to better understand patients' perceptions and expectations.

Atrial fibrillation (AF) is the most common rhythm disturbance seen in clinical practice. Evidence emerged that suggested inflammation was associated with risk of AF. Helicobacter pylori causes gastric and esophageal inflammation, as well as systemic and vascular inflammation. These local and systemic inflammatory effects may increase the risk of AF. Study patients were consecutive patients who underwent angiography for suspicion of coronary artery disease. Patients' AF status was determined by a search of hospital discharge summaries for diagnostic International Classification of Diseases, Ninth Revision codes for AF, assessment of previous electrocardiograms at the index and previous admissions to LDS Hospital (Salt Lake City, Utah), and search of the electrocardiographic database of LDS Hospital. In addition to routine laboratory studies, serum was analyzed to determine H pylori serostatus and index C-reactive protein (CRP) level. A total of 943 patients with known AF status were studied. Those with AF tended to be older (70.9 +/- 9.5 vs 63.9 +/- 10.7 years; p <0.001) and had a higher prevalence of congestive heart failure (28% vs 11%; p <0.001). In addition, patients with AF were more likely to be seropositive for H pylori in comparison to the seronegative group (65% vs 55%; p = 0.049). Mean CRP was similar between those with and without AF (2.2 +/- 2.7 vs 2.3 +/- 2.4 mg/dl; p = 0.79). There was no apparent association between H pylori serostatus and CRP. Multivariate predictors of AF included age (hazard ratio [HR] 1.07 per year, 95% confidence interval [CI] 1.04 to 1.10, p <0.0001) and heart failure (HR 2.87, 95% CI 1.59 to 5.18, p <0.0001). H pylori added to the model was marginally associated with AF (HR 1.53, 95% CI 0.95 to 2.47, p = 0.08) when not accounting for age. However, younger patients (<50 years) who were H pylori seropositive had a higher relative risk of AF (8%) versus those who were seronegative (0%). In comparison, older patients seropositive for H pylori had only a modest increased risk of AF (17.5% vs 15.4%; p = 0.11). In conclusion, these data showed a general association of H pylori and AF in patients with multiple cardiovascular risk factors. The association did not persist after accounting for other risk factors. Although older age was highly associated with AF risk in this population, H pylori was additive across 3 distinct age groups, with the highest risk conveyed in the younger cohort.