Postural Orthostatic Tachycardia Syndrome (POTS) is a variant of autonomic dysfunction (AD) defined by an increase in heart rate (HR) ≥ 30 bpm within 10 minutes (min) of a change from the supine to an upright position, in the absence of orthostatic hypotension. Many studies suggest that AD is common in active cancer patients and is associated with variable symptoms and decreased survival. Based on this evidence, we hypothesized that POTS can be associated with active cancer and might contribute to some of these patients’ symptoms and survival. Consecutive 220 active cancer patients aged 19–59 were enrolled. They were asked to lay flat for 5–10 min then to stand for 10 min without support. Total of 5 blood pressure (BP) and HR readings were taken (immediately before standing up then immediately after, and at 3, 6, and 10 min while standing). All patient’s symptoms were recorded. 213 patients were included. Age was 48 ± 8, 76

Introduction: Heart failure (HF) and atrial fibrillation (AF) are constantly linked together as predictors of a substantial increase in morbidity and mortality. In this study, we investigated the effects of atrial fibrillation in patients with heart failure. Methods: This study was a prospective observational multicenter national registry encompassing 21 health institutes in Jordan, comprising university hospitals, private hospitals, and private clinics. Patients visiting the cardiology clinic or inpatients admitted due to acute decompensated HF were included. The collected variables included age, sex, BMI, comorbidities, HDL, LDL, triglycerides, BNP, Sodium, potassium, hemoglobin, and creatinine. Results: Our study of 1571 patients showed significant differences between those with and without atrial fibrillation (AF). AF patients included more females (49.4% vs 34.0%), had a higher prevalence of hypertension (88.0% vs 78.5%), and were older (57.8% aged >= 70 years). Smoking rates were lower in patients with AF (22.3% vs 37.0%), while dyslipidemia was less common (54.5% vs 65.3%). Patients with AF also had more hospital admissions than those without AF (16% vs 11.6%). In addition, triglyceride levels were notably lower, hemoglobin levels were < 10 g/dL, and eGFR was reduced in patients with AF. In predicting death, the Random Forest Classifier had the highest accuracy (93.02%) and AUC (92.51%), whereas Logistic Regression had higher sensitivity (72.09%). Creatinine, Length of Hospital Stay, and other factors influenced the predictions, with creatinine levels being a strong predictor of patient outcomes. Conclusion: Atrial fibrillation patients were older and had a higher proportion of females compared than non-atrial fibrillation patients. Hypertension, a family history of premature coronary artery disease, and structural heart disease were notably higher in the atrial fibrillation group. Patients with atrial fibrillation had higher rates of hospital admissions than those without atrial fibrillation.

Introduction: Despite that trastuzumab (TZB) improves life expectancy and prognosis in patients with HER-2 positive breast cancer (BC), cardiotoxicity is a well-established complication. However, other potential cardiac complications of TZB such as pulmonary hypertension (PHTN) are poorly investigated. Aim: Evaluate the effect of TZB on pulmonary artery systolic pressure (PASP) and measure the predictors of developing elevated PASP. Methods: The medical records for all females who received TZB treatment for confirmed HER-2 positive BC at King Hussein Cancer Centre in Jordan between 2014 - 2019 who had a documented normal PASP of ≤35 mmHg before treatment were evaluated. Results: A total of 436 patients with a mean age of 53±11 years were included. The leading comorbidities were hypertension and diabetes mellitus affecting 26.2% and 15.4% of the patients, respectively. 15.6% of the study’s population were active smokers. Prior to initiating TZB, 22.3% had left ventricular hypertrophy (LVH), 14.3% had mild tricuspid valve regurgitation (TR), 11.5% had pericardial effusion, and 4.8% had mild aortic valve regurgitation (AR).Of alarming significance, 24.8% of the patients had their PASP increased after one year. Patients who developed elevated PASP tend to be older (56.9 vs 51.3, P<0.001), had baseline mild TR (26.3% vs 10.3%, P<0.001), LVH (39.4% vs 17.6%, P<0.001), and mild AR (9.1% vs 3.7%, P=0.031).Multivariate analysis showed that the only predictors of elevated PASP are TR at baseline (OR 3.9; 95% CI 1.58-6.17, P=0.001), and age (OR 1.04; 95% CI 1.01-1.06, P=0.005). However, baseline LVH (OR 1.79; 95% CI 0.98-3.26, P=0.057), number of the TZB cycles (OR 0.93; 95% 0.85-1.02, P=0.152), and the total dose of TZB (OR 1; 95% CI 1-1, P=0.284) were non-significant predictors. At 1 year follow up, the mean total cumulative dose of TZB was 6.8±1.8 grams that were given at a mean of 15±3 cycles. Moreover, major events (heart failure exacerbation, pulmonary embolism, and acute coronary syndrome) were recorded in 3.9% of the patients and death occurred in 4.1%. Conclusions: Trastuzumab demonstrated an increase in the PASP in a considerable portion of the patients at 1-year interval with this elevation being substantially concerning due to being highly indicative of PHTN.

Background Acute ischemic stroke (Stroke) and transient ischemic attacks (TIA) are known complications in cancer patients and those with atrial fibrillation (AF). The role AF plays in Stroke/TIA in the setting of cancer is unclear. The purpose of this study was to assess the relationship between AF and Stroke/TIA in cancer patients. Methods We conducted a case-control study comparing all patients who developed Stroke/TIA from 2014 to 2019 following a cancer diagnosis at King Hussein Cancer Center (KHCC), matched to Stroke/TIA-free controls based on age, gender, and cancer site. Results Two hundred seventy-two patients were included (136 per group). The mean age was 63.95 ± 13.06 and 57% were females. The Stroke/TIA group had more AF at the time of event (14% vs. 4%, OR: 4.25, 95%-CI: 1.39 - 17.36) and had a larger proportion of death on study conclusion (OR: 9.4, 95%-CI: 3.74 - 23.64). On conditional logistic regression, patients in the Stroke/TIA group had higher odds of: AF (OR: 7.93, 95%-CI: 1.6 – 39.18), ischemic stroke before cancer diagnosis (OR: 9.18, 95%-CI: 2.66 – 31.74), being on active cancer treatment (OR: 3.11, 95%-CI: 1.46 – 6.62), dyslipidemia (OR: 3.78, 95%-CI: 1.32 – 10.82), and renal disease (OR: 4.25, 95%-CI: 1.55 – 11.63). On another conditional logistic regression model built to assess the role of the CHA 2 DS 2 -VASc score, a score of >=2 in males and >=3 in females significantly increased the risk of developing Stroke/TIA in cancer patients (OR: 2.45, 95%-CI: 1.08 - 5.58). Conclusion AF, previous ischemic stroke, active cancer treatment, dyslipidemia, and renal disease are independent risk factors for Stroke/TIA and a higher CHA 2 DS 2 -VASc score significantly increases the risk in cancer patients regardless of AF.

BACKGROUND QT prolongation is a risk factor for proarrhythmia when beginning antiarrhythmic drug therapy (AAD). However, there are no data regarding monitoring repolarization changes during a ventricular paced (VP) rhythm.OBJECTIVE The purpose of this study was to compare serial changes in corrected QT and JT intervals, during native conduction (NC) and VP rhythms when initiating Class III AADs.METHODS Twenty-two patients (73% men; mean age 65 t 11 years) with an implantable device and with <10% VP were monitored during AAD initiation (16 sotalol, 6 dofetilide). QTc and JTc were measured from ECGs obtained during NC and VP at baseline (pre-AAD) and then after each AAD dose.RESULTS During AAD Loading, mean QTc increased significantly during NC (431 7 28 ms to 463 7 33 ms, P =.002) but not with VP (520 t 48 ms to 538 7 45 ms, P =.07). Mean percent increase in peak QTc during NC was significantly greater than during VP (12 /s vs 7%, P =.003). In contrast, peak 3Tc during AAD loading was not significantly different between NC and VP (P =.67).CONCLUSION When initiating AAD, the change in QTc during VP does not correlate with the change in QTc during NC; thus, the VP QTc is inadequate for monitoring repolarization changes. However, VP 3Tc correlates well with 3Tc during NC. When initiating Class III AADs in patients with VP rhythms, the 3Tc, and not the QTc, interval is the useful marker for assessing repolarization. (C) 2014 Heart Rhythm Society. ALL rights reserved.

BackgroundThere are a variety of periprocedural anticoagulation strategies for atrial fibrillation (AF) ablation, including the use of dabigatran. It is unclear which strategy is superior.ObjectiveTo compare the safety and efficacy of anticoagulation with uninterrupted warfarin, dabigatran, and warfarin with heparin bridging in patients undergoing ablation of AF at four experienced centers.Methods and ResultsIn this retrospective analysis, 882 patients (mean age: 61 ± 11 years) underwent ablation of AF using uninterrupted warfarin (n = 276), dabigatran (n = 374), or warfarin with heparin bridging (n = 232) for periprocedural anticoagulation. The rate of total complications was 23/276 (8.3%) in the uninterrupted warfarin group, 30/374 (8.0%) in the dabigatran group, and 29/232 (12.5%) in the bridged group (P = 0.15). Major complications were more frequent in the uninterrupted warfarin group 12/276 (4.3%) compared with 3/374 (0.8%) in dabigatran and 6/232 (2.6%) in the bridged group (P = 0.01). The most common major complication was the need for transfusion or occurrence of major bleeding. Minor complications did not differ among the three groups. On multivariate analysis, female gender (odds ratio [OR] 1.93, confidence interval [CI] 1.16–3.19, P = 0.011), bridging heparin (OR 2.13, CI 1.100–3.941, P = 0.016), use of triple antithrombotic therapy (OR 1.77, CI 1.05–2.98, P = 0.033), and prior myocardial infarction (OR 2.40, CI 1.01–5.67, P = 0.046) independently predicted total complications.ConclusionsWhen comparing the use of uninterrupted warfarin, dabigatran, and warfarin with heparin bridging in patients undergoing catheter ablation of AF, dabigatran was not associated with increased risk, major complications were more common in the uninterrupted warfarin group, and after adjustment, warfarin with bridging increased total complications.

Background—For ablation of atrial fibrillation, it is unclear how baseline international normalized ratio (INR) affects the dosing of unfractionated heparin (UFH). Methods and Results—A retrospective review of 170 consecutive patients undergoing atrial fibrillation ablation with baseline activated clotting time (ACT) and INR values was performed. Patients were grouped according to INR <2.0 (G<2; n=129) and INR ≥2.0 (G≥2; n=41). Clinical variables, UFH doses, and ACT values were recorded. An equation was derived to calculate the first bolus of UFH required to achieve an ACT ≥300 seconds, and this was subsequently assessed in 168 patients. For the initial 170 patients, the baseline INR (2.47±0.31 versus 1.53±0.31) and ACT (185±26 versus 153±30 seconds) were significantly greater in G≥2 (P<0.001). The amount of UFH to achieve the first ACT ≥300 seconds was significantly higher for G<2 versus G≥2 (9701±2390 versus 8268±2366 U; P=0.0001). Baseline INR, ACT, and weight were predictors of the UFH dosage to achieve an ACT ≥300 seconds. An equation derived to achieve an ACT ≥300 seconds after a single bolus of UFH met this end point in 160 of 168 patients (95%). Conclusions—Baseline INR and ACT, in addition to weight, are the only predictors of UFH dosage needed to achieve an ACT ≥300 seconds. A derived equation predicted the UFH dosage to achieve an ACT ≥300 seconds.

We report the case of a patient who had recurrent atypical atrial flutter (AFL) despite aggressive medical therapy status following surgical correction of a partial anomalous left pulmonary venous return to the coronary sinus (PAPVR). The surgery opened the roof of the coronary sinus (CS) to the left atrium (LA) to ensure a large communication between the CS and the LA, closed the CS ostium and atrial septal defect (ASD) with a pericardial patch, and undertook right pulmonary vein isolation with cryoenergy. The patient was brought to the electrophysiology (EP) laboratory, and transeptal (TS) puncture was performed through the ASD patch followed by successful mapping and ablation of the AFL circuit between the anterior superior mitral valve annulus and the right inferior pulmonary vein (PV) os.

Background and Aims: Western studies have shown that TIMI (Thrombolysis In Myocardial Infarction) risk scores predict adverse events in patients with non ST-elevation acute coronary syndrome (NSTEACS) and ST-elevation myocardial infarction (STEMI). Whether this also applies to Jordanian patients is largely unknown. Materials and Methods: We prospectively followed up 656 patients with ACS for total mortality, combined events of death, nonfatal MI or urgent coronary revascularization up to one year after admission. Results: Of the whole group, 472 patients (72%) had NSTEACS, and 184 patients (28%) had STEMI. Among NSTEACS patients, 31.0% had a low risk score (total points 0 - 2 of 7), 43.5% had an intermediate risk score (total points 3 - 4), and 25.5% had a high risk score (total points 5 - 7). In-hospital mortality was not different in the respective risk score groups (1.4%, 0.5%, and 3.4%, p = 0.123). At 1 year, mortality was significantly higher in the high risk score group (12.8%) compared with the intermediate (4%) and low (1.4%) risk groups (p = 0.001). Among STEMI patients, 58.6% had a low risk score (total points 0 - 3 of 13 - 14), 31.0% had a low intermediate risk score (total points 4 - 6), 8.0% had a high intermediate score (total points 7 - 9), and 2.4% had a high risk score (total points > 10). In-hospital mortality rate was significantly higher in the two intermediate risk score groups (7.4%, 14.3%, respectively) and the high risk score group (50%) compared with the low risk score group (1.0%, p = 0.001). The high risk and the two intermediate risk groups also had higher one-year mortality (75%, 28.6% and 16.7%, respectively) than the low risk group (3.9%, p = 0.001). Similarly, composite events occurred at a significantly higher rate in patients with high risk scores than intermediate or low risk scores among NSTEACS and STEMI patients. Conclusions: In Jordanian ACS patients, high TIMI risk scores were associated with a high risk of cardiovascular events. Such patients are candidates for early aggressive therapeutic strategies.

Western studies have shown that diabetes mellitus and other glucometabolic states are highly prevalent among patients with Acute Coronary Syndrome (ACS), and are associated with worse adverse cardiovascular outcome. Whether this also applies to Middle Eastern patients is largely unknown. We studied the prevalence of glucometabolic states (known diabetes, newly diagnosed diabetes, impaired fasting glucose (IFG), and no diabetes) in 656 ACS patients, who were followed up prospectively for total mortality, and composite events of death, readmission for myocardial infarction, or urgent coronary revascularization for 1 year after admission. Of the whole group, 291 (44.6%) were known diabetics, 69 (10.6%) had newly diagnosed diabetes, 86 (13.2%) had impaired fasting glucose, and 206 (31.6%) were nondiabetics. The overall in-hospital mortality rate was 2.6%, and was not significantly different between the four groups. At 1 year; overall mortality was 7.2%, and was significantly higher ( p = 0.002) among diabetics (newly diagnosed; 17.1%, and known diabetics; 7.8%) compared with patients who had IFG (3.4%) and nondiabetics (4.4%). Composite events at 6 months was significantly higher ( p = 0.016) in known diabetics (14.7%), compared with newly diagnosed diabetics (7.1%), IFG (9.2%) and nondiabetics (6.3%). At 1 year, composite events occurred in 15.9% of the whole group, and was significantly higher ( p = 0.049) in known diabetics (20.1%), compared with newly diagnosed diabetics (10%), IFG (11.5%) and nondiabetics (13.6%). In Middle Eastern ACS patients, 70% have abnormal glucometabolic states. Newly diagnosed diabetics and known diabetics have higher risk of cardiovascular events than patients with impaired fasting glucose and nondiabetics after 1 year of admission.