Heart Rate Recovery After Exercise Is Associated With Arrhythmic Events in Patients With Catecholaminergic Polymorphic Ventricular Tachycardia

Prognosis and clinical management of asymptomatic family members with RYR2-mediated catecholaminergic polymorphic ventricular tachycardia: a review

Despite its low prevalence, the potential diagnosis of catecholaminergic polymorphic ventricular tachycardia (CPVT) should be at the forefront of a paediatric cardiologists mind in children with syncope during exercise or emotions. Over the years, the number of children with a genetic diagnosis of CPVT due to a (likely) pathogenic RYR2 variant early in life and prior to the onset of symptoms has increased due to cascade screening programmes. Limited guidance for this group of patients is currently available. Therefore, we aimed to summarise currently available literature for asymptomatic patients with a (likely) pathogenic RYR2 variant, particularly the history of CPVT and its genetic architecture, the currently available diagnostic tests and their limitations, and the development of a CPVT phenotype - both electrocardiographically and symptomatic - of affected family members. Their risk of arrhythmic events is presumably low and a phenotype seems to develop in the first two decades of life. Future research should focus on this group in particular, to better understand the development of a phenotype over time, and therefore, to be able to better guide clinical management - including the frequency of diagnostic tests, the timing of the initiation of drug therapy, and lifestyle recommendations.

Post-exercise heart rate variability recovery after 800-m endurance run load among Cameroonian adolescent's males

The 800-m (m) run is part of Physical Education classes in Cameroon, after which arrhythmias may occur during recovery. Hence, this study aimed at determining relationship between 800-m run loads on cardiac autonomic recovery among school adolescents. Forty-two male adolescents (aged [17 ​± ​1] years) performed 800-m. Post-exercise heart rate variability (HRV) was recorded during 5-min (min) (HRV5-min) and 15-min (HRV15-min) in time: Standard deviation of normal to normal (SDNN); Root mean square of successive differences (RMSSD) and frequency domain (LH: Low frequency, HF: High frequency, TP: Total power). Rating of Perceived Exertion (RPE) and blood lactate concentration (BLa) were measured after exercise. In HRV5-min, RPE was associated with SDNN (r ​= ​-0.44, p ​< ​0.01) and RMSSD (r ​= ​-0.38, p ​< ​0.05). BLa was correlated with SDNN (r ​= ​-0.38, p ​< ​0.05) and RMSSD (r ​= ​-0.56, p ​< ​0.001) in the time-domain, LF (r ​= ​-0.64, p ​< ​0.001), HF (r ​= ​-0.58, p ​< ​0.001) and TP (r ​= ​-0.61, p ​< ​0.001) in frequency-domain. Moreover, RPE was correlated with LF (r ​= ​-0.44, p ​< ​0.01), TP (r ​= ​-0.49, p ​< ​0.01) while exercise duration with HF (r ​= ​-0.38, p ​< ​0.05). In HRV15-min, BLa was correlated with RMSSD (r ​= ​-0.53, p ​< ​0.001) and SDNN (r ​= ​-0.68, p ​< ​0.001). RPE was negatively correlated SDNN (r ​= ​-0.53, p ​< ​0.01) and RMSSD (r ​= ​-0.44, p ​< ​0.01). BLa was associated with HF (r ​= ​-0.55, p ​< ​0.001), TP (r ​= ​-0.50, p ​< ​0.01) and RPE with LF (r ​= ​-0.51, p ​< ​0.01), HF (r ​= ​-0.50, p ​< ​0.01), TP (r ​= ​-0.49, p ​< ​0.01). In addition, exercise duration was negatively linked to HF (r ​= ​-0.36, p ​< ​0.05). This study outlined that in untrained adolescents an increase of 800-m loads is associated with a slow vagal indexes of HRV during the recovery.

RYR2-ryanodinopathies: from calcium overload to calcium deficiency

The sarcoplasmatic reticulum (SR) cardiac ryanodine receptor/calcium release channel RyR2 is an essential regulator of cardiac excitation-contraction coupling and intracellular calcium homeostasis. Mutations of the RYR2 are the cause of rare, potentially lethal inherited arrhythmia disorders. Catecholaminergic polymorphic ventricular tachycardia (CPVT) was first described more than 20 years ago and is the most common and most extensively studied cardiac ryanodinopathy. Over time, other distinct inherited arrhythmia syndromes have been related to abnormal RyR2 function. In addition to CPVT, there are at least two other distinct RYR2-ryanodinopathies that differ mechanistically and phenotypically from CPVT: RYR2 exon-3 deletion syndrome and the recently identified calcium release deficiency syndrome (CRDS). The pathophysiology of the different cardiac ryanodinopathies is characterized by complex mechanisms resulting in excessive spontaneous SR calcium release or SR calcium release deficiency. While the vast majority of CPVT cases are related to gain-of-function variants of the RyR2 protein, the recently identified CRDS is linked to RyR2 loss-of-function variants. The increasing number of these cardiac 'ryanodinopathies' reflects the complexity of RYR2-related cardiogenetic disorders and represents an ongoing challenge for clinicians. This state-of-the-art review summarizes our contemporary understanding of RYR2-related inherited arrhythmia disorders and provides a systematic and comprehensive description of the distinct cardiac ryanodinopathies discussing clinical aspects and molecular insights. Accurate identification of the underlying type of cardiac ryanodinopathy is essential for the clinical management of affected patients and their families.

CatBoost-based improved detection of P-wave changes in sinus rhythm and tachycardia conditions: a lead selection study

Examining P-wave morphological changes in Electrocardiogram (ECG) is essential for characterizing atrial arrhythmias. However, standard 12-lead ECGsuffer from diagnostic redundancy due to low signal-to-noise ratio of P-waves. To address this issue, various optimal leads have been proposed for improved atrial activity recording, but the right selection among these leads is crucial for enhancing diagnostic efficacy. This study proposes an automated lead selection technique using the CatBoost machine learning (ML) model to improve the detection of P-wave changes among optimal bipolar leads under different heart rates. ECGs were obtained from healthy participants with a mean age of 25 ± 3.81 years (34% women), including 114 in sinus rhythm (SR) and 38 in sinus tachycardia (ST). The recordings were made using a newly designed atrial lead system (ALS), standard limb lead (SLL), modified limb lead (MLL), modified Lewis lead (LLM) and P-lead. P-wave features and Atrioventricular (AV) ratio were extracted for statistical analysis and ML classification. The optimum ML model was chosen to identify the best-performing optimal lead, which was selected based on the SLL metrics among different ML classifiers. CatBoost was found to outperform the other ML models in SLL-II with the highest accuracy and sensitivity of 0.82 and 0.90, respectively. The CatBoost model, amid other optimal leads, gave the best results for AL-I and AL-II (0.86 and 0.83 in accuracy and 0.91 and 0.93 in sensitivity). The developed CatBoost model selected AL-I and AL-II as the top two best-performing optimal leads for the enhanced acquisition of P-wave changes, which may be useful for diagnosing atrial arrhythmias.

Repeatability of ventricular arrhythmia characteristics on the exercise-stress test in RYR2-mediated catecholaminergic polymorphic ventricular tachycardia

AIMS

In catecholaminergic polymorphic ventricular tachycardia (CPVT), the exercise-stress test (EST) is the cornerstone for the diagnosis, risk stratification, and assessment of therapeutic efficacy, but its repeatability is unknown. We aimed to test the repeatability of ventricular arrhythmia characteristics on the EST in patients with CPVT.

METHODS AND RESULTS

EST-pairs (ESTs performed within 18 months between 2005 and 2021, on the same protocol, and without or on the exact same treatment) of patients with RYR2-mediated CPVT from two specialized centres were included. The primary endpoint was the repeatability of the maximum ventricular arrhythmia score [VAS: 0 for the absence of premature ventricular contractions (PVCs); 1 for isolated PVCs; 2 for bigeminal PVCs; 3 for couplets; and 4 for non-sustained ventricular tachycardia]. Secondary outcomes were the repeatability of the heart rate at the first PVC and the ΔVAS (the absolute difference in VAS between the EST-pairs). A total of 104 patients with 349 EST-pairs were included. The median duration between ESTs was 343 (interquartile range, 189-378) days. Sixty (17.2%) EST-pairs were off therapy. The repeatability of the VAS was moderate {Krippendorf α, 0.56 [95% confidence interval (CI), 0.48-0.64]}, and the repeatability of the heart rate at the first PVC was substantial [intra-class correlation coefficient, 0.78 (95% CI, 0.71-0.84)]. The use of medication was associated with a higher odds for a ΔVAS > 1 (odds ratio = 3.52; 95% CI, 2.46-4.57; P = 0.020).

CONCLUSION

The repeatability of ventricular arrhythmia characteristics was moderate to substantial. This underlines the need for multiple ESTs in CPVT patients and CPVT suspicious patients and it provides the framework for assessing the therapeutic efficacy of novel CPVT therapies.

Sudden Cardiac Arrest in the Paediatric Population

Sudden cardiac arrest in the young is a rare event with a range of potential causes including cardiomyopathies, ion channelopathies, and autonomic nervous system dysfunction. Investigations into the cause involve a multidisciplinary team, including cardiologists, geneticists, and psychologists. In addition to a detailed medical history, family history and circumstances surrounding the event are important in determining the cause. Clinical investigations including an electrocardiogram are fundamental in diagnosis and should be interpreted cautiously because some children may have atypical presentations and an evolving phenotype. The potential for misdiagnosis exists that could lead to incorrect long-term management strategies. If an inherited condition is suspected, genetic testing of the patient and cascade screening of family members is recommended with genetic counselling and psychological support. Medical management is left to the treating physician acknowledging that a clear diagnosis cannot be made in approximately half of cases. Secondary prevention implantable defibrillators are widely deployed but can be associated with complications in young patients. A plan for safe return to activity is recommended along with a proper transition of care into adulthood. Broad screening of the general population for arrhythmia syndromes is not recommended; preventative measures include screening paediatric patients for risk factors by their primary care physician. Several milestone events or activities that take place in youth could be used as opportunities to promote safety. Further work into risk stratification of this paediatric population through patient registries and greater awareness of cardiopulmonary resuscitation and automated external defibrillator use in saving lives is warranted.

Aberrant autonomic pattern during the post-exercise recovery phase in long QT syndrome patients

OBJECTIVES

It is well-established that the autonomic nervous system (ANS) plays a central role in arrhythmogenesis. During and after exercise the ANS is particularly active, and since long QT syndrome (LQTS) patients have an increased risk of lethal arrhythmias during physical activity, it is important to investigate the autonomic function in these patients. In this study we investigate the ANS response during and after exercise in LQTS patients and healthy age and sex matched controls.

METHODS

Forty-four genotype-verified adult LQTS patients and forty-four healthy age- and sex-matched controls performed a submaximal bicycle exercise stress test. Heart rate recovery (HRR) and heart rate variability (HRV) were analyzed from registered electrocardiogram (ECG) and vector electrocardiogram (VCG) recordings collected throughout rest, exercise and in the post-exercise phase.

RESULTS

LQTS patients had a slower HRR than controls at 1- and 4-min post-exercise (p < 0.001). During the post-exercise phase, LQTS patients had a lower total power (p < 0.001), low frequency power (p < 0.001) and high frequency power (p < 0.001) than controls. In the same phase, LQTS patients off betablocker (BB) treatment showed a lower high frequency power (p = 0.01) and different low frequency/high frequency ratio (p = 0.003) when comparing with LQTS patients on BB treatment.

CONCLUSIONS

The parasympathetic effect on both HRR and HRV after exercise appears depressed in this LQTS patient cohort compared to healthy controls. This indicates an aberrant ANS response during the post-exercise phase which might be compensated by BB treatment. Our findings emphasize the importance of performing further investigations to identify the role of the ANS in LQTS arrhythmogenesis.

Burst Exercise Testing Can Unmask Arrhythmias in Patients With Incompletely Penetrant Catecholaminergic Polymorphic Ventricular Tachycardia

Catecholaminergic polymorphic ventricular tachycardia (CPVT) is characterized by cardiac arrest during sudden exertion. However, standard exercise stress testing (EST) lacks sensitivity, leading to misdiagnosis and undertreatment. After a nondiagnostic standard gradual EST, we report 6 patients who underwent a novel burst exercise test characterized by sudden high workload at the outset of testing. In 5 of 6 patients, the burst EST induced new and more complex arrhythmias versus standard EST, which compelled medication initiation in 3 patients. We postulate that this simple EST modification better mimics a typical CPVT triggering event and could improve diagnostic sensitivity and therapeutic decision making.

Autonomic cardiac innervation: impact on the evolution of arrhythmias in inherited cardiac arrhythmia syndromes

The autonomic nervous system (ANS) is an essential component of arrhythmogenicity, especially in the absence of structural heart disease and channelopathy. In this article, the authors review the role and characteristics of ANS in various channelopathies. Some of these, such as most long QT syndromes and catecholaminergic polymorphic ventricular tachycardia, are highly dependent on sympathetic activation, while parasympathetic tone is an important factor for arrhythmias in other channelopathies such as Brugada syndrome or early repolarisation syndrome. Recent advances highlighting the subtle role of ANS in channelopathies are presented here, demonstrating that all is far from being so simple and straightforward and revealing some paradoxical behaviours of channelopathies in relation to discrete ANS imbalance.