ABSTRACT Background Exercise intolerance and poor quality of life remain challenges in HFpEF, driven by chronotropic incompetence and left atrial dysfunction. We evaluated whether rate‐adaptive/accelerated pacing (RAAP), targeting these mechanisms, improves hemodynamic, functional, and patient‐reported outcomes. Methods PubMed, Embase, and the Cochrane Library were searched. Outcomes included NT‐proBNP, Minnesota Living with Heart Failure Questionnaire (MLHFQ) score, 6‐min walk distance (6MWD), E/e', and E/A. Within‐group pre–post changes and comparisons with usual care were synthesized separately. Effects are reported as mean differences (MD) or odds ratios (OR) with 95% confidence intervals (CI). Results Eight reports involving 380 patients were included with myPACE overlap handled by one report per cohort per analysis. Within‐group, RAAP was associated with reductions in NT‐proBNP (MD −462.58 pg/mL; 95% CI −891.37 to −33.79), E/A (MD −1.01; −1.19 to −0.83), and E/e' (MD −3.18; −5.65 to −0.72), and improvements in 6MWD (MD +74.10 m; 36.34 to 111.86) and MLHFQ score (MD −17.40 points; −33.06 to −1.74). Compared with usual care, associations favored RAAP for NT‐proBNP (MD −108.51 pg/mL; −118.31 to −98.70), 6MWD (MD +73.36 m; 32.23 to 114.48), MLHFQ score (MD −16.52 points; −24.15 to −8.89), and AF burden (MD −6.13; −7.88 to −4.37). MACE also favored RAAP in an exploratory analysis (OR 0.47; 0.23 to 0.93), whereas peak VO 2 did not differ significantly. Conclusions RAAP was associated with favorable changes in hemodynamic and functional outcomes. These findings support further evaluation of individualized rate modulation in adequately powered randomized trials.
ABSTRACT Introduction Direct current cardioversion (DCCV) is a well‐established procedure for terminating various tachyarrhythmias. Recommendations for pre‐operative adjustment of atrioventricular nodal blocking agents (AVNBA) to minimize bradyarrhythmia are lacking. Methods We performed a retrospective analysis assessing safety and outcomes for our practice of holding AVNBA prior to DCCV. Adult patients with an elective DCCV from 10/01/2015 to 9/08/2023 were included and grouped into AVNBA held versus not held. Primary outcomes were perioperative bradyarrhythmia and 30 day bradyarrhythmia. Secondary outcomes included hypotension, 30 day tachyarrhythmia, ER visits, and other adverse events. Multilevel logistic regression models adjusted for demographics, comorbidities, and post‐discharge treatments were run. Results The study included 247 procedures (68% male, average age 70.6 years), with 150 (61%) in the AVNBA not held group and 97 (39%) in the AVNBA held group. At 30 day follow up, the AVNBA not held group had higher rates of recurrent tachyarrhythmia (39% vs. 25%, p = 0.019). After risk adjustment, antiarrhythmic drug use predicted perioperative (aOR = 4.46; 95% CI = 1.68–11.89) and 30 day bradyarrhythmia (aOR = 2.81; 95% CI = 1.30–6.09). AVNBA holding was not predictive of either outcome. After risk adjustment, AVNBA holding was not a significant predictor of 30 day tachyarrhythmia recurrence; baseline antiarrhythmic drug use was associated with lower odds of recurrence (aOR = 0.38; 95% CI = 0.19–0.76). Conclusions Holding AVNBA was not predictive of peri‐op or 30 day bradyarrhythmia after risk adjustment. Not holding AVNBA was associated with higher rates of recurrent tachyarrhythmia, but there was no association after risk adjustment. Our study reaffirms that elective DCCV is a safe and effective procedure, regardless of AVNBA holding status.
ABSTRACT Background Pulsed field ablation (PFA) is increasingly used for atrial fibrillation (AF), but device‐specific autonomic and respiratory reflex responses remain insufficiently characterized. We aimed to compare vagal responses and cough reflexes among three commercially available PFA systems across individual pulmonary veins and the posterior wall. Methods This retrospective single‐center study included 200 consecutive patients who underwent AF ablation with FARAPULSE ( n = 83), PULSESELECT ( n = 83), or VARIPULSE ( n = 34). Vagal response was operationally defined as bradyarrhythmia requiring temporary back‐up pacing during energy delivery. Cough reflex was assessed intraprocedurally at the left superior pulmonary vein (LSPV), left inferior pulmonary vein (LIPV), right superior pulmonary vein (RSPV), right inferior pulmonary vein (RIPV), and posterior wall. Results Baseline characteristics were generally similar among groups, although heart failure and diabetes mellitus (DM) differed significantly. Overall vagal response rates did not differ among FARAPULSE, PULSESELECT, and VARIPULSE (61.4%, 67.5%, and 58.8%, respectively; p = 0.596). In contrast, overall cough reflex rates differed significantly (75.9%, 91.6%, and 55.9%; p < 0.001), driven by consistently higher rates with PULSESELECT. On logistic regression, male sex, body mass index, and use of PULSESELECT versus FARAPULSE were independently associated with cough reflex. Conclusions Cough reflex was most frequent with PULSESELECT, whereas no significant difference in vagal response was observed among platforms. Recognizing these differences may improve procedural planning, sedation strategy, and prophylactic management during PFA.
