Air pollution and out-of-hospital cardiac arrest risk: a 7-year study from a highly polluted area

AIMS

Globally, nearly 20% of cardiovascular disease deaths were attributable to air pollution. Out-of-hospital cardiac arrest (OHCA) represents a major public health problem; therefore, the identification of novel OHCA triggers is of crucial relevance. The aim of the study was to evaluate the association between air pollution (short-, mid-, and long-term exposures) and OHCA risk, during a 7-year period in a highly polluted urban area in northern Italy, with a high density of automated external defibrillators (AEDs).

METHODS AND RESULTS

Out-of-hospital cardiac arrests were prospectively collected from the 'Progetto Vita Database' between 1 January 2010 and 31 December 2017; day-by-day air pollution levels were extracted from the Environmental Protection Agency stations. Electrocardiograms of OHCA interventions were collected from the AED data cards. Day-by-day particulate matter (PM) 2.5 and 10, ozone (O3), carbon monoxide (CO), and nitrogen dioxide (NO2) levels were measured. A total of 880 OHCAs occurred in 748 days. A significant increase in OHCA risk with a progressive increase in PM2.5, PM10, CO, and NO2 levels was found. After adjustment for temperature and seasons, a 9% and 12% increase in OHCA risk for each 10 μg/m3 increase in PM10 (P < 0.0001) and PM2.5 (P < 0.0001) levels was found. Air pollutant levels were associated with both asystole and shockable rhythm risk, while no correlation was found with pulseless electrical activity.

CONCLUSION

Short- and mid-term exposures to PM2.5 and PM10 are independently associated with the risk of OHCA due to asystole or shockable rhythm.

Use of Oral Anticoagulants in Patients with Atrial Fibrillation: Preliminary Data from the Italian Atrial Fibrillation (ITALY-AF) Registry

BACKGROUND

Atrial fibrillation (AFIB), the most frequent cardiac arrhythmia, is a major risk factor for stroke, heart failure, and death. Because of the recent advances in AFIB management and the availability of new oral anticoagulants (OACs), there is a need for a systematic and predefined collection of contemporary data regarding its management and treatment.

METHODS

The objective of the ongoing ITALY-AFIB registry is to evaluate the long-term morbidity and mortality in patients with AFIB and to verify the implementation of the current guidelines for stroke prevention in these patients. The registry includes consecutive in- and out-patients with first diagnosed, paroxysmal, persistent, or permanent AFIB. In patients in sinus rhythm at entry, the qualifying episode of AFIB, confirmed by ECG diagnosis, had to have occurred within 1 year before entry. The clinical record form is web-based and accessible by personal keyword.

RESULTS

Enrolment into the registry started in the year 2013. In a current cohort of 2470 patients (mean age 75 ± 11 years, males 56%), the mean CHA2DS2-VASc score was 3.7 ± 1.8, and the mean HAS-BLED was 1.6 ± 0.9. There were no significant sex differences in the AFIB subtypes. At the end of the inclusion visit and after receiving knowledge of the web-based electronic estimate of risk for stroke and bleeding, the proportion of patients discharged with OACs was 80%. After exclusion of patients with first diagnosed AFIB (n = 397), the proportion of patients with prescription of OACs rose from 66% before the visit to 82% on discharge (p < 0.0001). Prescription of aspirin or other antiplatelet drugs fell from 18% before the visit to 10% on discharge (p < 0.0001).

CONCLUSIONS

A web-based management of AFIB with automated estimation of risk profiles appears to favorably affect adherence to AFIB guidelines, based on a high proportion of patients treated with OACs and a substantial decline in the use of antiplatelet drugs.

Anti-arrhythmic drugs in atrial fibrillation: tailor-made treatments

During the last decades, many improvements have been made regarding the treatment of atrial fibrillation in terms of risk prevention, anti-coagulation strategies, and gain in quality of life. Among those, anti-arrhythmic drugs (AADs) have progressively fallen behind and overtaken by technological aspects as devices as procedures are now the standards of care for many patients. But is this it? Are AADs doomed to be relegated to an obscure and rarely read paragraph of the European recommendations? Or could they be still employed safely and effectively? In the present paper, we will discuss contemporary evidence in order to define where AADs still play a pivotal role, how should AADs be used, and whether a tailored approach can be the way to propose the right treatment to the right patient.

HeartInsight: from SELENE HF to implementation in clinical practice

There is strong evidence that remote monitoring in cardiac implantable electronic devices can detect device malfunctions earlier than conventional monitoring and that it can be useful for detecting cardiac arrhythmias, while little data are available for an improved management of heart failure (HF). HeartInsight is a new remote monitoring algorithm developed and validated in the SELENE HF study that combines information from a diverse set of sensors integrated into one alert to detect worsening HF with promising accuracy. However, the shift from detecting technical issues or arrhythmia episodes to early predicting clinical events underscores the need to understand how to properly integrate these tools into the clinical workflow by defining an organizational model and shared guidelines for the management of HF alerts. Here, we critically discuss issues that will be raised by the implementation of this 'enhanced' remote monitoring approach to HF care in daily clinical practice.

Influence of obesity and overweight on the association between sleep-disordered breathing and atrial fibrillation: the DASAP-HF study

Background

The association between sleep apnea (SA) and atrial fibrillation (AF) has been well described. However, it remains unclear whether the association is causative or primarily dependent on shared comorbidities such as obesity. The Respiratory Disturbance Index (RDI) computed by an implantable cardioverter defibrillator (ICD) algorithm accurately identifies severe SA, whether central or obstructive in origin.

Purpose

In the present analysis we studied in patients with heart failure the contribution of obesity in the relationship between SA, measured by RDI, and AF.

Methods

Patients with ejection fraction ≤35% implanted with an ICD endowed with an algorithm (ApneaScan) that calculates the RDI each night, were enrolled and followed-up for 24 months. The weekly mean RDI value was considered, as calculated during the entire follow-up period. The endpoint was daily AF burden of ≥6 hours.

Results

164 patients (age 67±10 years, 75% male, ejection fraction 29±5%) had usable RDI values during the entire follow-up period. Body mass index (BMI) was &lt;25 kg/m2 in 62 patients (normal), 25.0–29.9 kg/m2 in 66 patients (overweight), ≥ 30 kg/m2 in 36 patients (obese). When compared with normal patients (31±11 episodes/h), the average RDI value calculated during the entire follow-up period did not differ in overweight patients (35±13 episodes/h, p=0.114), but was significantly higher in obese patients (39±12 episodes/h, p=0.002). During follow-up, AF burden ≥6 hours/day was documented in 48 (29%) patients (BMI ≥ versus &lt;25 kg/m2; HR: 1.47, 95% CI: 0.83–2.60, p=0.197; BMI ≥ versus &lt;30 kg/m2; HR: 0.98, 95% CI: 0.46–2.09, p=0.963). Based on the ROC curve analysis, average RDI ≥37 episodes/h maximized sensitivity and specificity for the prediction of AF (Area under the curve: 0.63, 95% CI: 0.55–0.70, p=0.011). Device-detected RDI ≥37 episodes/h was associated with the occurrence of AF on univariate analysis (HR: 3.88, 95% CI: 2.02–7.44, p&lt;0.001), as well as after correction for either BMI ≥25 kg/m2 (HR: 3.76, 95% CI: 1.94–7.26, p&lt;0.001), or BMI ≥30 kg/m2 (HR: 4.15, 95% CI: 2.15–8.04, p&lt;0.001).

Conclusions

In heart failure patients, we confirmed the association between ICD-detected SA and AF, an association that persisted independent of patient body habitus.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): The study is supported by a research grant from Boston Scientific

P369 BIOCIRCUIT®: A NEW SYSTEM FOR IMPROVING EXERCISE CAPACITY IN PATIENTS WITH CARDIOVASCULAR DISEASE

Introduction

Cardiovascular diseases is one of the most important public health problems; are among the main causes of morbidity, disability and mortality. Those who survive to an acute form become chronically ill with repercussions on the quality of life and on the economic and social costs. Secondary prevention through an intervention aimed to modify risk factors, in particular the sedentary lifestyle could be effective in the improvement of functional abilities. In this observational study carried out at the ABCardio company in Bologna (Italy), a personalized program of Physical Activity was performed through the innovative Biocircuit technology (Technogym®), on outpatients with a prevalent diagnosis of chronic ischemic heart disease.

Methods

We have analyzed 31 patients (M / F, 25/6) with a mean age of 61 years, and BMI of 26.4 kg / m2. Patients followed a two–month personalized physical activity program consisting in functional assessment at baseline (T0) and at the end of the program (T1) and of 2 weekly training sessions. Evaluation included: lower and upper limb isokinetic test to measure muscle strength, 500–meter moderate walking test to estimate maximum oxygen uptake (VO2max).

Results

The results obtained from the comparison between T0 and T1 in the 31 patients in study show significant improvements in the muscle strength of the lower limbs: Leg press +32.9 kg (p = 0.0003), Leg curl +11.8 kg (p &lt; 0.0001), Leg extension +15.8 kg (p = 0.0002); as well as in upper limb muscle strength: Low Row +10.5 kg (p = 0.0005), Chest press +5.7 kg (p = 0.0007), Shoulder press +6.2 kg (p = 0, 0005). Estimated VO2max was also significantly improved from 26.2 mL / kg / min (T0) to 36.3 mL / kg / min (T1), with a mean increase of 10.1 mL / kg / min (p = 0, 0001). No adverse events occurred during supervised training sessions.

Conclusions

The program, safe and well tolerated by the patients in study, has proved to be effective in increasing exercise capacity in terms of both muscle strength and aerobic capacity. This secondary prevention intervention can be considered useful in reducing residual cardiovascular risk as it induced a significant increase in VO2max.

Association between implantable defibrillator-detected sleep apnea and atrial fibrillation: the DASAP-HF study

AIM

The Respiratory Disturbance Index (RDI) computed by an implantable cardioverter defibrillator (ICD) algorithm accurately identifies severe sleep apnea (SA). In the present analysis we tested the hypothesis that RDI could also predict AF burden.

METHODS

Patients with ejection fraction ≤35% implanted with an ICD were enrolled and followed-up for 24 months. One month after implantation, patients underwent a polysomnographic study. The weekly mean RDI value was considered, as calculated during the entire follow-up period and over a 1-week period preceding the sleep study. The endpoints were: daily AF burden of ≥5 minutes, ≥6 hours, ≥23 hours.

RESULTS

164 patients had usable RDI values during the entire follow-up period. Severe SA (RDI≥30 episodes/h) was diagnosed in 92 (56%) patients at the time of the sleep study. During follow-up, AF burden ≥5 minutes/day was documented in 70 (43%), ≥6 hours/day in 48 (29%), and ≥23 hours/day in 33 (20%) patients. Device-detected RDI≥30 episodes/h at the time of the polygraphy, as well as the polygraphy-measured apnea hypopnea index ≥30 episodes/h, were not associated with the occurrence of the endpoints, using a Cox regression model. However, using a time-dependent model, continuously measured weekly mean RDI≥30episodes/h was independently associated with AF burden ≥5 minutes/day (HR:2.13, 95%CI:1.24-3.65, p=0.006), ≥6 hours/day (HR:2.75, 95%CI:1.37-5.49, p=0.004), and ≥23 hours/day (HR:2.26, 95%CI:1.05-4.86, p=0.037).

CONCLUSIONS

In heart failure patients, ICD-diagnosed severe SA on follow-up data review identifies patients who are from two- to three-fold more likely to experience an AF episode, according to various thresholds of daily AF burden. This article is protected by copyright. All rights reserved.

The value of wearable cardioverter defibrillator in adult patients with recent myocardial infarction: Economic and clinical implications from a health technology assessment perspective

AIMS

Sudden cardiac death (SCD) causes high mortality and substantial societal burdens for healthcare systems (HSs). The risk of SCD is significantly increased in patients with reduced left ventricular ejection fraction after myocardial infarction (MI). Current guidelines recommend re-evaluation of cardioverter-defibrillator implantation 40 days post-MI, earliest. Medical therapy alone does not provide sufficient protection against SCD, especially in the first month post-MI, and needs time. Consequently, there is a gap in care of high-risk patients upon hospital discharge. The wearable cardioverter defibrillator (WCD) is a proven safe, effective therapy, which temporarily protects from SCD. Little information on WCD cost-effectiveness exists. We conducted this research to demonstrate the medical need of the device in the post-MI setting defining WCD cost-effectiveness.

METHODS & RESULTS

Based on a randomized clinical trials (RCTs) and Italian and international data, we developed a Markov-model comparing costs, patient survival, and quality-of-life, and calculated the Incremental Cost-Effectiveness Ratio (ICER) of a WCD vs. current standard of care in post-MI patients. The rather conservative base case analysis - based on the RCT intention-to-treat results - produced an ICER of €47,709 per Quality Adjusted Life Year (QALY) gained, which is far lower than the accepted threshold of €60,000 in the Italian National HS. The ICER per Life Year (LY) gained was €38,276.

CONCLUSION

WCD utilization in post-MI patients is clinically beneficial and cost-effective. While improving guideline directed patient care, the WCD can also contribute to a more efficient use of resources in the Italian HS, and potentially other HSs as well.

Determinants of worse prognosis in patients with cardiac resynchronization therapy defibrillators. Are ventricular arrhythmias an adjunctive risk factor?

AIMS

Cardiac resynchronization therapy (CRT) is indicated in patients with systolic heart failure (HF), severe left ventricle (LV) dysfunction and interventricular dyssynchrony.In prospective observational research, we aimed to evaluate whether CRT-induced LV reverse remodelling and occurrence of ventricular arrhythmias (VT/VF) independently contribute to prognosis in patients with CRT defibrillators (CRT-D).

METHODS

In 95 Italian cardiological centres, after a screening period of 6 months, patients were categorized according to VT/VF occurrence and CRT response, defined as LV end-systolic volume relative reduction >15% or LV ejection fraction absolute increase >5%. The main endpoint was death or HF hospitalizations.

RESULTS

Among 1308 CRT-D patients (80% male, mean age 66 years), at 6 months, follow-up 71% were identified as CRT responders and 12% experienced appropriate VT/VF detections. The main endpoint was significantly and independently associated with previous myocardial infarction, New York Heart Association Class, VT/VF occurrence and with CRT response. CRT nonresponder patients who suffered VT/VF in the screening period had a risk of death or HF hospitalizations [HR = 7.82, 95% confidence interval (CI) = 3.95-15.48] significantly (P < 0.001) higher than CRT responders without VT/VF occurrence. This risk is mitigated without VT/VF occurrence (HR = 3.47, 95% CI = 2.03-5.91, P < 0.001) or in case of CRT response (HR = 3.11, 95% CI = 1.44-6.72, P = 0.004).

CONCLUSION

Our data show that both CRT response and occurrence of VT/VF independently contribute to the risk of death or HF-related hospitalizations in CRT-D patients. Early VT/VF occurrence may be identified as a marker of disease severity than can be mitigated by CRT response both in terms of all-cause mortality and long-term VT/VF onset.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT00147290 and NCT00617175.

Implantable defibrillator-computed respiratory disturbance index predicts new-onset atrial fibrillation: the DASAP-HF study

Introduction

Sleep apnea (SA), as measured by polysomnography, is a risk factor for atrial fibrillation (AF). The DASAP-HF study previously demonstrated that the Respiratory Disturbance Index (RDI) computed by an implantable cardioverter defibrillator (ICD) algorithm accurately identifies severe SA, is associated with cardiovascular events, and independently predicts death.

Purpose

In the present analysis we tested the hypothesis that device-detected RDI could also predict AF burden.

Methods

Patients with left ventricular ejection fraction ≤35% implanted with an ICD were enrolled and followed-up for 24 months. One month after implantation, patients underwent a polysomnographic study. The weekly average RDI value was considered, as calculated by the algorithm during the entire follow-up period and over a 1 week period preceding the sleep study, and patients were stratified according to an RDI value ≥ or &lt;30 episodes/hour. The endpoints were: daily AF burden of ≥5 minutes, ≥6 hours, ≥23 hours.

Results

164 enrolled patients had usable RDI values during the entire follow-up period. Severe SA (RDI≥30 episodes/h) was diagnosed in 92 (56%) patients at the time of the polysomnographic study. During a median follow-up of 25 months, AF burden ≥5 minutes/day was documented in 70 (43%), ≥6 hours/day in 48 (29%), and ≥23 hours/day in 33 (20%) patients. Device-detected RDI≥30 episodes/h at the time of the polysomnographic study, as well as the polysomnography-measured apnea hypopnea index ≥30 episodes/h, were not associated with the occurrence of the endpoints, using a Cox regression model. However, using time-dependent Cox model continuously measured weekly average RDI≥30episodes/h was independently associated with AF burden ≥5 minutes/day (HR: 2.13, 95% CI: 1.24–3.65, p=0.006), ≥6 hours/day (HR: 2.75, 95% CI: 1.37–5.49, p=0.004), and ≥23 hours/day (HR: 2.26, 95% CI: 1.05–4.86, p=0.037), after correction for history of AF, left atrial diameter, and gender.

Conclusions

In heart failure patients implanted with an ICD, device-diagnosed severe SA is associated with a higher risk of AF. In particular, severe SA on follow-up data review identifies patients who are from two- to three-fold more likely to experience an AF episode, according to various thresholds of daily AF burden.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Promoted by the Italian Heart Rhythm Society (AIAC).Supported by a research grant from Boston Scientific.

Ventricular arrhythmias in athletes: Role of a comprehensive diagnostic workup

BACKGROUND

Ventricular arrhythmias (VAs) represent a critical issue with regard to sports eligibility assessment in athletes. The ideal diagnostic evaluation of competitive and leisure-time athletes with complex VAs has not been clearly defined.

OBJECTIVE

The purpose of this study was to assess the clinical implications of invasive electrophysiological assessments and endomyocardial biopsy (EMB) among athletes with VAs.

METHODS

We evaluated 227 consecutive athletes who presented to our institutions after being disqualified from participating in sports because of VAs. After noninvasive tests, electrophysiological study (EPS), electroanatomic mapping (EAM), and EAM- or cardiac magnetic resonance imaging-guided EMB was performed, following a prespecified protocol. Sports eligibility status was redefined at 6-month follow-up.

RESULTS

From our sample, 188 athletes (82.8%) underwent EAM and EPS, and 42 (15.2%) underwent EMB. A diagnosis of heart disease could be formulated in 30% of the study population (67/227; 95% confidence interval [CI] 0.24-0.36) after noninvasive tests; in 37% (83/227; 95% CI 31%-43%) after EPS and EAM; and in 45% (102/227; 95% CI 39%-51%) after EMB. In the subset of athletes undergoing EMB, invasive diagnostic workup allowed diagnostic reclassification of half of the athletes (n = 21 [50%]). Reclassification was particularly common among subjects without definitive findings after noninvasive evaluation (n = 23; 87% reclassified). History of syncope, abnormal echocardiogram, presence of late gadolinium enhancement, and abnormal EAM were linked to sports ineligibility at 6-month follow-up.

CONCLUSION

A comprehensive invasive workup provided additional diagnostic elements and could improve the sports eligibility assessment of athletes presenting with VAs. The extensive invasive evaluation presented could be especially helpful when noninvasive tests show unclear findings.

[Advances in the treatment of atrial fibrillation]

The management of atrial fibrillation (AF) has undergone tremendous changes over the last 50 years. Once thought as a mere consequence of rheumatic mitral stenosis, AF has surged to become a key clinical-electrocardiographic syndrome, with specific risk factors, a highly variable underlying substrate, and related complications, whose prevention requires an integrated holistic management plan. Throughout this article, we discuss major progresses in the fields of anticoagulation management, rhythm and rate control, and catheter ablation, aiming to provide a balanced oversight of what has been done, and a fresh perspective of what is yet to be accomplished by next generations of clinicians and researchers.

Incidence and Clinical Impact of Right Ventricular Involvement (Biventricular Ballooning) in Takotsubo Syndrome: Results From the GEIST Registry

BACKGROUND

The short- and long-term prognosis of Takotsubo syndrome (TTS) presenting with right ventricular (RV) involvement remains poorly understood.

RESEARCH QUESTION

What is the incidence and clinical outcome of RV involvement in TTS?

STUDY DESIGN AND METHODS

This study analyzed 839 consecutive patients with TTS (758 female subjects and 81 male subjects) in a multicenter registry. RV involvement was defined as wall motion abnormality of the RV free wall, with or without apical involvement. The median long-term follow-up was 2.1 years (interquartile range, 0.3-4.5 years). The primary outcome was in-hospital and out-of-hospital all-cause mortality. The secondary end point was a composite of in-hospital death, thromboembolic events, cardiogenic shock, pulmonary edema, and malignant arrhythmias.

RESULTS

The incidence of RV involvement in TTS was 11% (n = 93). More often patients with RV involvement were male compared with patients without RV involvement (P = .02). There was a slight difference in the left ventricular ejection fraction measured in patients with RV involvement vs those patients with isolated left ventricular TTS (38 ± 10% vs 40 ± 10%; P = .03). No major differences in terms of comorbidities were observed between groups except regarding a history of cancer, which was significantly more prevalent in patients with TTS presenting with RV involvement (P = .03). Physical stressors were more prevalent in the RV group (P < .01), whereas emotional stressors were less prevalent (P < .01). Patients with RV involvement had a higher incidence of in-hospital cardiogenic shock (P = .02). The primary outcome (in- and out-of-hospital all-cause mortality) was observed in 12.8% of patients without RV involvement compared with 29% of patients with RV involvement. Although the in-hospital mortality rate was similar in both groups, a higher out-of-hospital all-cause mortality rate (log-rank test, P = .008) was observed in the RV involvement group. The Cox multivariable regression analysis showed that physical triggers were independent predictors of RV involvement.

INTERPRETATION

RV involvement defines a high-risk cohort of patients with TTS.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov; No.: NCT04361994; URL: www.clinicaltrials.gov.

Wearable Cardioverter Defibrillator (WCD) in Italy: results from the nationwide multicenter registry WEAR-ITA

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND

The Wearable Cardioverter Defibrillators (WCD) has been used extensively in Italy since 2015, following long years of experience in other countries. This technology provides temporary protection from Sudden Cardiac Death (SCD) for patients with an evolving risk profile that may not yet be eligible for an Implantable Cardioverter Defibrillator (ICD). Collecting national data on use of the device can help build a picture that will enable an understanding on how to use the WCD appropriately in the future.

PURPOSE

Our purpose has been to investigate WCD usage on a nationwide level. This is in terms of target population, average wear time, patient compliance, diagnosed and treated arrhythmic events and patient outcome once they stopped wearing the device.

METHODS

WEAR-ITA is a nationwide, multi-centre retrospective observational project. Patient data was retrospectively collected from the Italian hospitals that agreed to take part in the data collection for all patients fitted with a WCD between April 2015 to May 2018. All data refers to the range from the first day of wear until the end of use.

RESULTS

We collected data for 411 patients from 15 (75%) Italian regions. WCD use among the different regions was heterogeneous with a median of 0.5 (0.2-1.2) WCD wore/105 inhabitants. The mean age of the population was 55(±14) and the majority of patients were male (79%). Main WCD indication was non-ischemic cardiomyopathy with reduced ejection fraction (51%), ischemic etiology with severe systolic dysfunction (31%), uncertain or unidentified diagnosis (10%) that then revealed to be predominantly channelopathies or myocarditis and after ICD extraction (8%). Patients wore the WCD for a median of 59 (33-90) days and the median daily weartime was 23 (22,7-23,8) hours. In 15 patients (4%), the WCD recorded non sustained ventricular tachycardia (VT), 10  patients (2%) had hemodynamically well-tolerated sustained VT not needing a shock. 8 patients (2%) received effective appropriate shocks. Time to episodes were respectively 61 (14-61) days for non-sustained VT and 28 (19-70) days for VT/VF. 2 patients (0.5%) received inappropriate shocks for sinus tachycardia and atrial fibrillation (AF) respectively. WCD recorded new onset of supra ventricular tachycardia episodes in 12 patients (3%) and of atrial fibrillation (AF) in 7 patients (2%). 7 patients (2%) died while wearing WCD; none of them from SCD. At the end of the WCD use, 195 patients (47%) did not receive an ICD while 209 patients (51%)were implanted.

CONCLUSIONS

WCD is an effective therapy for the treatment of SCD with a very low complication rates. The indication and penetration in Italy is quite heterogeneous. The patient’s compliance is high over time. The incidence of appropriate shock is not negligible; only half of patients, who wore WCD, received an ICD. There is however still a requirement to conduct further randomized trials to understand which patients could most benefit from the use of WCD. Abstract Figure. Wereable Cardioverter Defibrillator

A Novel Non-Invasive Device for the Assessment of Central Venous Pressure in Hospital, Office and Home

Background

Venous congestion can be quantified by central venous pressure (CVP) and its monitoring is crucial to understand and follow the hemodynamic status of patients with cardio-respiratory diseases. The standard technique for CVP measurement is invasive, requiring the insertion of a catheter into a jugular vein, with potential complications. On the other hand, the current non-invasive methods, mainly based on ultrasounds, remain operator-dependent and are unsuitable for use in the home environment. In this paper, we will introduce a novel, non-invasive device for the hospital, office and home assessment of CVP.

Methods

After describing the measurement concept, we will report a preliminary experimental study enrolling 5 voluntary healthy subjects to evaluate the VenCoM measurements’ repeatability, and the system’s capability in measuring small elicited venous pressure variations (2 mmHg), as well as an induced venous hypertension within a pathological range (12÷20 mmHg).

Results

The experimental measurements showed a repeatability of ±1mmHg. The VenCoM device was able to reliably detect the elicited venous pressure variations and the simulated congestive status.

Discussion and Conclusion

The proposed non-invasive VenCoM device is able to provide a fast and repeatable CVP estimate, having a wide spectrum of potential clinical applications, including the monitoring of venous congestion in heart failure patients and in subjects with renal and hepatic dysfunction, as well as pulmonary hypertension (PH) that can be extended to pneumonia COVID-19 patients even after recovery. The device needs to be tested further on a large sample size of both healthy and pathological subjects, to systematically validate its reliability and impact in clinical setting.

Ventricular Fibrillation Recurrences in Successfully Shocked Out-of-Hospital Cardiac Arrests

Background and Objectives: The prognostic impact of ventricular fibrillation (VF) recurrences after a successful shock in out-of-hospital cardiac arrest (OOHCA) is still poorly understood, and some evidence suggests a potential pro-arrhythmic effect of chest compressions in this setting. In the present analysis, we looked at the short-term and long-term prognosis of VF recurrences in OOHCA. And their potential association with chest compressions. Materials and Methods: The Progetto Vita, prospectively collecting data on all resuscitation efforts in the Piacenza province (Italy), was used for the present analysis. From the 461 OOHCAs found in a shockable rhythm, only those with optimal ECG tracings and good audio recordings (160) were assessed. Rhythms other than VF post-shock were analyzed five seconds after shock delivery and survival to hospital admission, hospital discharge, and long-term survival data over a 14-year follow-up were collected. Results: Population mean age was 64.4 ± 16.9 years, and 31.9% of all patients were female. Mean time to EMS arrival was 5.9 ± 4.5 min. Short- and long-term survival without neurological impairment were higher in patients without VF recurrence when compared to patients with VF recurrence, independently from the pre-induction rhythm (p < 0.001). After shock delivery, VF recurrence was higher when chest compressions were resumed early after discharge and more vigorously. Conclusions: VF recurrences after a shock could worsen short and long-term survival. The potential pro-arrhythmic effect of chest compressions should be factored in when considering the real risks and benefits of this procedure.

"Pill in the Pocket" Antiarrhythmic Drugs for Orally Administered Pharmacologic Cardioversion of Atrial Fibrillation

The therapy of atrial fibrillation often involves the use of a rhythm control strategy, in which 1 or more antiarrhythmic drugs (AAD), ablative procedures, and/or hybrid approaches involving both of these options are utilized in an attempt to restore and maintain sinus rhythm. For chronic therapy, an AAD is taken daily. However, for patients with symptomatic but infrequent, acute, but nondestabilizing episodes, the use of an AAD only at the time of an episode that can quickly restore sinus rhythm, generally as an out-patient, without the burden of a daily drug regimen, may be better. This is called "pill-in-the-pocket" therapy. This manuscript reviews the "pill-in-the-pocket" concept, traces its development from its origins using quinidine, to its expansion using class IC AADs, to the more recent investigation of ranolazine for this purpose. Who should get it, what it involves, its efficacy rates and concerns are all discussed.

Safety and efficacy of dronedarone from clinical trials to real-world evidence: implications for its use in atrial fibrillation

Efficacy and safety of dronedarone was shown in the ATHENA trial for paroxysmal or persistent atrial fibrillation (AF) patients. Further trials revealed safety concerns in patients with heart failure and permanent AF. This review summarizes insights from recent real-world studies and meta-analyses, including reports on efficacy, with focus on liver safety, mortality risk in patients with paroxysmal/persistent AF, and interactions of dronedarone with direct oral anticoagulants. Reports of rapidly progressing liver failure in dronedarone-prescribed patients in 2011 led to regulatory cautions about potential liver toxicity. Recent real-world evidence suggests dronedarone liver safety profile is similar to other antiarrhythmics and liver toxicity could be equally common with many Class III antiarrhythmics. Dronedarone safety concerns (increased mortality in patients with permanent AF) were raised based on randomized controlled trials (RCT) (ANDROMEDA and PALLAS), but comedication with digoxin may have increased the mortality rates in PALLAS, considering the dronedarone-digoxin pharmacokinetic (PK) interaction. Real-world data on apixaban-dronedarone interactions and edoxaban RCT observations suggest no significant safety risks for these drug combinations. Median trough plasma concentrations of dabigatran 110 mg during concomitant use with dronedarone are at acceptable levels, while PK data on the rivaroxaban-dronedarone interaction are unavailable. In RCTs and real-world studies, dronedarone significantly reduces AF burden and cardiovascular hospitalizations, and demonstrates a low risk for proarrhythmia in patients with paroxysmal or persistent AF. The concerns on liver safety must be balanced against the significant reduction in hospitalizations in patients with non-permanent AF and low risk for proarrhythmias following dronedarone treatment.

Device-Detected Atrial Fibrillation Before and After Hospitalisation for Noncardiac Surgery or Medical Illness: Insights From ASSERT

BACKGROUND

Atrial fibrillation (AF) is often detected during hospitalisation for surgery or medical illness and is often assumed to be due to the acute condition.

METHODS

The Asymptomatic Atrial Fibrillation and Stroke Evaluation in Pacemaker Patients and the Atrial Fibrillation Reduction Atrial Pacing Trial (ASSERT) study enrolled patients ≥ 65 years old without AF. Pacemakers or implantable cardioverter-defibrillators recorded device-detected AF. We identified participants who were hospitalised and compared the prevalence of AF before and after hospitalisation.

RESULTS

Among 2580 participants, 436 (16.9%) had a surgical or medical hospitalisation. In the 30 days following a first hospitalisation, 43 participants (9.9%, 95% confidence interval [CI] 7.2%-13.1%) had > 6 minutes of device-detected AF; 20 (4.6%, 95% CI 2.8%-7.0%) had > 6 hours. More participants had AF > 6 minutes in the 30 days following hospitalisation compared with the period 30-60 days before hospitalisation (9.9% vs 4.4%; P < 0.001). Similar results were observed for episodes > 6 hours (4.6% vs 2.3%, P = 0.03). Roughly half of participants with device-detected AF in the 30 days following hospitalisation had at least 1 episode of the same duration in the 6 months before (50% [95% CI 31.3%-68.7%] for > 6 min; 68.8% [95% CI 41.3%-89.0%] for > 6 h). Those with AF in the 30 days following hospitalisation were more likely to have had AF in the past (adjusted odds ratio [OR] 7.2, 95% CI 3.2-15.8 for > 6 min; adjusted OR 32.6, 95% CI 10.3-103.4 for > 6 h).

CONCLUSIONS

The prevalence of device-detected AF increases around the time of hospitalisation for noncardiac surgery or medical illness. About half of patients with AF around the time of hospitalisation previously had similar episodes.

Pharmacological therapy for the prevention of cardiovascular events in patients with myocardial infarction with non-obstructed coronary arteries (MINOCA): Insights from a multicentre national registry

AIMS

To assess the effect of pharmacological therapy on long-term prognosis of patients with MINOCA.

METHODS AND RESULTS

In this retrospective multicentre cohort study involving 9 Hub Hospitals across Italy we enrolled consecutive patients 18 years and older with diagnosis of MINOCA discharged from 1st March 2012 to 31st March 2018. Data on baseline characteristics and pharmacological therapy at discharge (ACEI/ARB, angiotensin-converting enzyme inhibitors/angiotensin receptor antagonists; ASA, acetylsalicylic acid; beta-blockers; CCB, calcium-channel blockers; DAPT, dual anti-platelet therapy; statins), were collected systematically. The primary endpoint (PE) of the study was a composite of all cause death or acute myocardial infarction or acute coronary syndrome or heart failure leading to hospitalization or stroke. A total of 621 patients were included (mean [SD] age 65.1 [13.9] years; 344 [55.4%] female), of whom 106 (17.1%) experienced PE, including 27 patients (4.3%) who died. Multivariable analysis, after correction for all baseline differences, showed a significant association between pharmacological therapy at discharge and an increased risk of PE for aspirin (HR[95%CI] = 2.47[1.05-5.78], adjusted p = 0.04), whereas beta-blockers were associated with a significant benefit (HR[95%CI] = 0.49 [0.31-0.79], adjusted p = 0.02).

CONCLUSION

The use of beta-blockers was significantly associated to a less frequent occurrence of adverse outcomes at long-term follow-up among patients with MINOCA, whereas ASA displayed a potentially harmful impact on prognosis. The findings in the study may be relevant for the design of future studies which should take into account possible heterogeneity among MINOCA patients.

Role of an extensive diagnostic work-up in the detection of concealed cardiomyopathies in athletes with premature ventricular complexes and implications for sports' eligibility assessment

Background

Premature ventricular complexes (PVCs) are a common clinical problem and a critical issue with regard to sports eligibility in sportsmen. Although PVCs can be considered a benign feature of the athlete's heart adaptive phenotype, they may also be the only clinical manifestation of a concealed cardiomyopathy, potentially heralding sudden cardiac death (SCD) during sports activity. The optimal diagnostic evaluation of athletes with PVCs is currently uncertain.

Purpose

To evaluate the diagnostic contribution and the implications for sports eligibility assessment of a thorough non-invasive and invasive work-up including electroanatomical mapping (EAM) and endomyocardial biopsy (EMB) in athletes with PVCs.

Methods

We conducted a prospective, single-arm, open-label double center study. All consecutive athletes presenting for evaluation at our institution after being disqualified from participating in sports due to PVCs were included in our study. These athletes underwent a baseline non-invasive diagnostic protocol with transthoracic echocardiogram and gadolinium enhanced cardiac magnetic resonance imaging (cMRI). Subsequently, an invasive diagnostic work-up was performed, including EPS with programmed electrical stimulation, EAM and EAM-guided EMB if deemed necessary. When clinically indicated, catheter ablation was performed. Sports eligibility status was re-assessed at six months' follow-up according to Italian sports medicine guidelines.

Results

After diagnostic evaluation, 20 subjects out of 107 (19%) had a diagnosis of heart disease, most commonly myocarditis (n=8), arrhythmogenic right ventricular cardiomyopathy (ARVC, n=7) or dilated cardiomyopathy (DCM, n=2). On multivariate logistic-regression analysis, QRS complex/T wave abnormalities on ECG (OR 23), non left bundle branch block and inferior axis PVC morphology (OR 13), echocardiogram abnormalities (OR 24) and low-voltage areas on EAM (OR 33) were significantly associated with diagnosis of a concealed cardiac disease. Nondiagnostic abnormalities on cMRI were common in this population of athletes, prevalently involving the right ventricle. EAM-guided EMB was performed in 12 subjects (11%) and catheter ablation in 56 (52.3%). After six months, 63 athletes (59%) were judged eligible to participate in competitive sports and 23 subjects (21%) were deemed eligible to participate in non-competitive sports.

Conclusions

Almost one fifth of sportsmen presenting with PVCs have a concealed heart disease, most commonly myocarditis or ARVC. Non-outflow tract PVCs' morphology and abnormalities on ECG, echocardiogram and EAM are predictive of structural heart disease's detection, whereas nondiagnostic findings on cMRI can be misleading in athletes. Invasive diagnostic tests, including EAM and EAM-guided EMB, play a critical role in case of diagnostic uncertainty. More than ¾ of subjects were judged eligible to participate in sports at 6 months' follow-up.

Funding Acknowledgement

Type of funding source: None

Impact of atrial fibrillation in critically ill patients admitted to a stepdown unit

BACKGROUND

Limited data are available on the clinical course of patients with history of atrial fibrillation (AF) when admitted in an intensive care environment. We aimed to describe the occurrence of major adverse events in AF patients admitted to a stepdown care unit (SDU) and to analyse clinical factors associated with outcomes, impact of dicumarolic oral anticoagulant (OAC) therapy impact and performance of clinical risk scores in this setting.

MATERIALS AND METHODS

Single-centre, observational retrospective analysis on a population of subjects with AF history admitted to a SDU. Therapeutic failure (composite of transfer to ICU or death) was considered the main study outcome. Occurrence of stroke and major bleeding (MH) was considered as secondary outcomes. The performance of clinical risk scores was evaluated.

RESULTS

A total of 1430 consecutive patients were enrolled. 194 (13.6%) reported the main outcome. Using multivariate logistic regression, age (odds ratio [OR]: 1.03, 95% confidence interval [CI]: 1.01-1.05), acute coronary syndrome (OR:3.10, 95% CI: 1.88-5.12), cardiogenic shock (OR:10.06, 95% CI: 5.37-18.84), septic shock (OR:5.19,95%CI:3.29-18.84), acute respiratory failure (OR:2.49, 95% CI: 1.67-3.64) and OAC use (OR: 1.61, 95% CI: 1.02-2.55) were independently associated with main outcome. OAC prescription was associated with stroke risk reduction and to both MH and main outcome risk increase. CHA₂ DS₂ -VASc (c-index: 0.545, P = .117 for stroke) and HAS-BLED (c-index:0.503, P = .900 for MH) did not significantly predict events occurrence.

CONCLUSIONS

In critically ill AF patients admitted to a SDU, adverse outcomes are highly prevalent. OAC use is associated to an increased risk of therapeutic failure, clinical scores seem unhelpful in predicting stroke and MH, suggesting a highly individualized approach in AF management in this setting.

ICD-detected respiratory disturbance index: accuracy for sleep apnea detection and prognostic value

Purpose

In patients affected by heart failure an association exists between sleep apnea (SA) measured by polysomnography and adverse outcome. Impedance-based implantable cardioverter defibrillator (ICD) algorithms have been designed to compute the Respiratory Disturbance Index (RDI) to identify severe SA. The purpose of the DASAP-HF study was to evaluate the accuracy of RDI for the prediction of severe SA, and investigate the prognostic value of device-detected RDI values.

Methods

Patients with left ventricular ejection fraction ≤35% implanted with an ICD were enrolled and followed for 24 months. One month after implantation, patients underwent a polysomnographic study (PS) for assessing the apnea-hypopnea index (AHI). The average RDI value was calculated over a 1-week period preceding the sleep study and compared with the assessment of severe SA at PS (AHI ≥30 episodes/h). The endpoint was all-cause death after 24 months.

Results

224 out of 265 enrolled patients had usable RDI values. Patients characteristics: 79% male, 67±10 years, BMI 27±7kg/m2, ejection fraction 29±5%, 54% ischemic cardiomyopathy, 50% CRT-D. The mean AHI value at PS was 21±15 episodes/h. The mean RDI value recorded during the week preceding PS was 30±16 episodes/h. RDI values accurately identified severe SA diagnosed at PS (AUC 0.77; 95% CI 0.70–0.83; P=0.001). Based on the ROC curve analysis, RDI ≥29 episodes/h and AHI ≥17 episodes/h maximized sensitivity and specificity for the prediction of death. Both indexes were independently associated with all-cause death but, after correction for the other independent significant prognostic variables, RDI≥29episodes/h yielded stronger prediction (HR: 12.22, 95% CI:1.64–91.37, p=0.015) as compared to AHI ≥17episodes/h (HR: 4.14, 95% CI:1.17–14.66, p=0.028). Moreover, severe SA diagnosed at PS (AHI ≥30episodes/h) was not associated with death (HR: 1.20, 95% CI:0.3817–3.8266, p=0.761).

Conclusions

In heart failure patients indicated to ICD, severe SA was confirmed to be associated with survival. The ICD-measured RDI accurately identified severe SA detected at PS, and was associated with the risk of death at long-term.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Boston Scientific

Prognostic value of implantable defibrillator-computed respiratory disturbance index: The DASAP-HF study

BACKGROUND

Sleep apnea, as measured by polysomnography, is associated with adverse outcomes in heart failure. The DASAP-HF (Diagnosis and Treatment of Sleep Apnea in Patient With Heart Failure) study previously demonstrated that the respiratory disturbance index (RDI) computed by the ApneaScan algorithm (Boston Scientific) accurately identifies severe sleep apnea in implantable cardioverter-defibrillator (ICD) patients.

OBJECTIVE

The purpose of the long-term study phase was to assess the incidence of clinical events after 24 months and investigate the association with RDI values.

METHODS

Patients with left ventricular ejection fraction ≤35% implanted with an ICD were enrolled and followed-up for 24 months. The RDI calculated at 1 month after implantation was used to stratify patients (below or above 30 episodes/h). The endpoints were all-cause death and a combination of all-cause death or cardiovascular hospitalization.

RESULTS

Of the 265 enrolled patients, 224 had usable RDI values. Severe sleep apnea (RDI ≥30 episodes/h) was diagnosed in 115 patients (51%). These patients were more frequently male (84% vs 72%; P = .030) and had higher creatinine levels. During median follow-up of 25 months, 19 patients (8%) died. Cardiovascular hospitalizations were reported in 19 patients (8%). The risk of all-cause death was higher in patients with RDI ≥30 episodes/h (hazard ratio [HR] 3.33; 95% confidence interval [CI] 1.35-8.21; P = .023), as well as the risk of all-cause death or cardiovascular hospitalization (HR 1.94; 95% CI 1.01-3.76; P = .048). At multivariate analysis, independent predictors of death were RDI ≥30 episodes/h (HR 4.02; 95% CI 1.16-13.97; P = .029) and creatinine levels (HR 2.36; 95% CI 1.26-4.42; P = .008).

CONCLUSION

In heart failure patients implanted with an ICD, higher RDI values are associated with death and cardiovascular hospitalizations. Device-detected severe sleep apnea independently predicts death.

Clinical classification and the subclinical atrial fibrillation challenge: a position paper of the European Cardiac Arrhythmia Society

Symptomatic atrial fibrillation (AF) or clinical AF is associated with impaired quality of life, higher risk of stroke, heart failure, and increased mortality. Current clinical classification of AF is based on the duration of AF episodes and the recurrence over time. Appropriate management strategy should follow guidelines of Scientific Societies. The last decades have been marked by the advances in mechanism comprehension, better management of symptomatic AF, particularly regarding stroke prevention with the use of direct oral anticoagulants and a wider use of AF catheter or surgical ablations. The advent of new tools for detection of asymptomatic AF including continuous monitoring with implanted electronic devices and the use of implantable cardiac monitors and recently wearable devices or garments have identified what is called "subclinical AF" encompassing atrial high-rate episodes (AHREs). New concepts such as "AF burden" have resulted in new management challenges. Oral anticoagulation has proven to reduce substantially stroke risk in patients with symptomatic clinical AF but carries the risk of bleeding. Management of detected asymptomatic atrial arrhythmias and their relation to clinical AF and stroke risk is currently under evaluation. Based on a review of recent literature, the validity of current clinical classification has been reassessed and appropriate updates are proposed. Current evidence supporting the inclusion of subclinical AF within current clinical classification is discussed as well as the need for controlled trials which may provide responses to current therapeutic challenges particularly regarding the subsets of asymptomatic AF patients that might benefit from oral anticoagulation.

Procedural sedation for direct current cardioversion: a feasibility study between two management strategies in the emergency department

BACKGROUND

A cardiologist-only approach to procedural sedation with midazolam in the setting of elective cardioversion (DCC) for AF has already been proven as safe as sedation with propofol and anaesthesiologist assistance. No data exist regarding the safety of such a strategy during emergency procedures. The aim of this study is to compare the feasibility of sedation with midazolam, administered by a cardiologist, to an anaesthesiologist-assisted protocol with propofol in emergency DCC.

METHODS

Single centre, prospective, open blinded, randomized study including all consecutive patients admitted to the Emergency Department requiring urgent or emergency DCC. Patients were randomized in a 1:1 fashion to either propofol or midazolam treatment arm. Patients in the midazolam group were managed by the cardiologist only, while patients treated with propofol group underwent DCC with anaesthesiologist assistance.

RESULTS

Sixty-nine patients were enrolled and split into two groups. Eighteen patients (26.1%) experienced peri-procedural adverse events (bradycardia, severe hypotension and severe hypoxia), which were similar between the two groups and all successfully managed by the cardiologist. No deaths, stroke or need for invasive ventilation were registered. Patients treated with propofol experienced a greater decrease in systolic and diastolic blood pressure when compared with those treated with midazolam. As the procedure was shorter when midazolam was used, the median cost of urgent/emergency DCC with midazolam was estimated to be 129.0 € (1st-3rd quartiles 114.6-151.6) and 195.6 € (1st-3rd quartiles 147.3-726.7) with propofol (p < .001).

CONCLUSIONS

Procedural sedation with midazolam given by the cardiologist alone was feasible, well-tolerated and cost-effective in emergency DCC.

Incidence and Clinical Impact of Recurrent Takotsubo Syndrome: Results From the GEIST Registry

Background

Current literature only reports variable information from single‐center studies on the recurrence rate, the complications, and the outcome of patients with Takotsubo syndrome (TTS) experiencing recurrent TTS. Therefore, a detailed description of clinical characteristics, predictors, and the prognostic impact of patients with TTS and recurrences in a multicenter registry is needed.

Methods and Results

We analyzed 749 patients with TTS from 9 European centers being part of the international, multicenter GEIST (German Italian Stress Cardiomyopathy) Registry. Patients were divided into the recurrence group and the nonrecurrence group. The recurrence rate at a median follow‐up of 830 days (interquartile range, 118–1701 days) was 4%. Most recurrences were documented in the first 5 years after the index TTS episode. Up to 2 TTS recurrences were documented in 2 of 30 patients (6%). A variable ballooning pattern (n=6, 0.8%) with, in particular, involvement of the right ventricular occurred in 3 cases (0.4%) at the recurrence event. Except for the higher presence of arterial hypertension (86.7% versus 68.3%; P=0.03) in the recurrence group, no other baseline characteristics were different between groups. Observation of TTS complications during follow‐up, including stroke, thromboembolic events, in‐hospital death, and cardiogenic shock, revealed no significant differences between groups (P>0.05), except the higher presence of pulmonary edema in the recurrence group versus the nonrecurrence group (13.3% versus 4.9%; P=0.04).

Conclusions

The incidence of TTS recurrence is estimated to be 4% in this multicenter TTS registry. A variable TTS pattern at recurrence is common in up to 20% of recurrence cases.

Assessment of the German and Italian Stress Cardiomyopathy Score for Risk Stratification for In-hospital Complications in Patients With Takotsubo Syndrome

Importance

Takotsubo syndrome (TTS) is an acute, reversible heart failure syndrome featured by significant rates of in-hospital complications. There is a lack of data for risk stratification during hospitalization.

Objective

To derive a simple clinical score for risk prediction of in-hospital complications among patients with TTS.

Design, Setting, and Participants

In this prognostic study, 1007 consecutive patients were enrolled in the German and Italian Stress Cardiomyopathy (GEIST) registry from July 1, 2007, through December 31, 2017, and identified as the derivation cohort; 946 patients were enrolled in the Spanish Registry for Takotsubo Cardiomyopathy (RETAKO) as the external score validation. An admission risk score was developed using a stepwise multivariable regression analysis from 2 registries. Data analysis was performed from March 1, 2018, through July 31, 2018.

Main Outcomes and Measures

In-hospital complications were defined as death, pulmonary edema, need for invasive ventilation, and cardiogenic shock. Four variables were identified as independent predictors of in-hospital complications and were used for the score: male sex, history of neurologic disorder, right ventricular involvement, and left ventricular ejection fraction (LVEF).

Results

Of the 1007 patients enrolled in the GEIST registry, 107 (10.6%) were male, with mean (SD) age of 69.8 (11.4) years. Overall rate of in-hospital complications was 23.3% (235 of 1007) (death, 4.0%; pulmonary edema, 5.8%; invasive ventilation, 6.4%; and cardiogenic shock, 9.1%). The GEIST prognosis score was derived by providing 20 points each for male sex and history of neurologic disorders and 30 points for right ventricular involvement and then subtracting the value in percent of LVEF (decimal values between 0.15 and 0.70). Score accuracy on area under the receiver operating characteristic curve analysis was 0.71, with a negative predictive power of 87% with scores less than 20. External validation in the RETAKO population (124 [13.1%] male; mean [SD] age, 69.5 [14.9] years) revealed an area under the curve of 0.73 (P = .46 vs GEIST derivation cohort). Stratification into 3 risk groups (<20, 20-40, and >40 points) classified 316 patients (40.9%) as having low risk; 342 (44.3%) as having intermediate risk, and 114 (14.8%) as having high risk of complications. The observed in-hospital complication rates were 12.7% for low-risk patients, 23.4% for intermediate-risk patients, and 58.8% for high-risk patients (P < .001 for trend). After 2.6 years of follow-up, patients with in-hospital complications had significantly higher rates of mortality than those without complications (40% vs 10%, P = .01).

Conclusions and Relevance

The GEIST prognostic score may be useful in early risk stratification for TTS. High-risk patients with TTS may require an intensive care unit stay, and low-risk patients with TTS could be discharged within a few days. In-hospital complications in patients with TTS may be associated with increased risk of long-term mortality.

P428Cost-effectiveness of sedation for electrical cardioversion in the emergency department: a subanalysis of the Instead trial

BACKGROUND 

Direct current cardioversion (DCCV) represents the most widely used and effective method to restore sinus rhythm in patients with persistent AF. No specific guidelines or recommendations with regards to the most appropriate drug that should be used for procedural sedation have been described. Propofol is one of the most used drugs, however it should be administered only by personnel trained in advanced airway management. Midazolam has been described as a potential alternative.

PURPOSOSE 

The aim of our study was to assess the cost-effectiveness of procedural sedation with midazolam compared to the one with propofol for urgent/emergency DCCV in the emergency department. 

METHODS 

Single centre, prospective, open blinded, randomized study including 66 consecutive patients admitted to the emergency department requiring urgent or emergency DCCV for haemodynamic instability, chest pain or symptomatic palpitations. The enrolled patients were randomized in a 1:1 fashion into the propofol or midazolam group. With regards to the propofol group, the procedure was carried out with the assistance of the anaesthesiologist. In the midazolam group, both the procedural sedation and the cardioversion were carried out by the cardiologist alone. 

RESULTS 

Thirty-tree patients underwent procedural sedation with propofol and 33 with midazolam. Medical costs included expenses for personnel and related to possible procedural delays. The median medical cost was of 14.9 € for the midazolam group and 46.7 € for the propofol group (p&lt;.001) and was mainly driven by an increased delay and lack of coordination between the cardiologist and the anaesthesiologist. The median material cost in the midazolam group was higher than in the propofol one as the former implied the use of flumazenil (83.7 € vs. 78.8 €, p&lt;.001). Hospitalization costs included the cost related to monitoring time in the emergency department and possible costs derived by the admission to a medical ward. They added up to a median of 28.1 € in the midazolam group and 48.7 for the propofol group (p=.004) as most patients were discharged safely after a few hours. The total median cost of urgent/emergency DCCV with midazolam was estimated to be 126.2 € (1st-3rd quartiles 114.4-142.6) and 203.3 € (1st-3rd quartiles 149.3-734.8) with propofol (p&lt;.001). There was no significant difference in terms of adverse events. Sedation with midazolam was as safe, efficient and tolerated as sedation with propofol. Length of procedure was shorter when midazolam was used compared to propofol usage. Patients who underwent sedation with midazolam were safely discharged earlier.

CONCLUSIONS

Procedural sedation for electrical cardioversion in the emergency department is more cost-effective than sedation with propofol. By using midazolam we estimated that 77 € are saved for each DCCV. This is driven by the absence of another operator and the possibility of a quicker discharge given the use of flumazenil.

P1110Role of an extensive diagnostic work-up in the detection of concealed cardiomyopathies in athletes with complex ventricular arrhythmias and implications for sports" eligibility assessment

Background

ventricular Arrhythmias (VAs) are a common clinical problem and a critical issue with regards to sports" eligibility in athletes. Although VAs can be considered a benign feature of the athlete’s heart adaptive phenotype, they may also be the only clinical manifestation of a concealed cardiomyopathy, potentially heralding sudden cardiac death (SCD) during sports activity.

Purpose

to evaluate the diagnostic contribution and the implications for sports eligibility assessment of a thorough non-invasive and invasive work-up including electrophysiology study (EPS), electroanatomical mapping (EAM) and endomyocardial biopsy (EMB) in athletes with complex VAs and to derive a multiparametric risk score in order to easily predict structural heart diseases’ diagnosis.

Methods

we conducted a prospective, single-arm, open-label single center, observational study. All consecutive athletes presenting for evaluation at our institution after being disqualified from participating in sports due to complex VAs were enrolled. The athletes underwent a baseline non-invasive diagnostic protocol with transthoracic echocardiogram and gadolinium enhanced cardiac magnetic resonance imaging (cMRI). Subsequently EPS, EAM and EAM-guided EMB were performed if deemed necessary. Sports eligibility status was re-assessed at 6 months’ follow-up. A multivariable logistic regression model was built, considering cMRI as the gold standard exam.

Results

after diagnostic evaluation, 55 subjects (26.4%) had a diagnosis of heart disease, most commonly myocarditis (n = 27) and arrhythmogenic right ventricular cardiomyopathy (ARVC, n = 16). After 6 months, 100 athletes (48.1%) were judged eligible to participate in competitive sports and 46 subjects (22.1%) were deemed eligible to participate in non-competitive sports. On multivariable logistic-regression analysis, abnormalities on ECG (OR 5.3) or on echocardiogram (OR 3.7), sustained VA inducibility on EPS (OR 17.7) and low-voltage areas on EAM (OR 7.7) proved all predictive of concealed structural heart diseases’ diagnosis. We derived two simple risk scores: a 40-points risk score and an 8-points risk score (obtained by weighing each variable according to the regression model’s ORs). Both these risk scores’ performance proved very good (AUC = 0.856 for the 40-points score and AUC = 0.852 for the 8-points score, figure 1).

Conclusions

approximately 1/4 of athletes presenting with complex VAs have a concealed heart disease, most commonly myocarditis or ARVC. ECG, echocardiogram and EAM abnormalities and sustained VAs inducibility on EPS are predictive of structural heart diseases’ detection. Therefore, these diagnostic tests should be routinely included in the evaluation of athletes with complex VAs. A risk score including the results of these tests can greatly help in the prediction of concealed structural heart diseases’ diagnosis. More than 2/3 of subjects were judged eligible to participate in sports at 6 months’ follow-up.

Abstract Figure 1. ROC curves for diagnosis

P531Cardiac resynchronization therapy in patients with permanent atrial fibrillation: insights from the HMEA database

Funding Acknowledgements

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Background/Introduction: The benefits of cardiac resynchronization therapy with defibrillator (CRT-D) in heart failure are well established. However, a gap of evidence is still present for patients with permanent atrial fibrillation (perm-AF)

Purpose

To investigate outcomes of CRT-D patients with perm-AF in terms of appropriate shock for ventricular arrhythmia and all-cause mortality in a long-term time horizon. 

Methods

We used the Home Monitoring Expert Alliance (HMEA) database, a nationwide data repository of daily remote monitoring transmissions. The episodes with delivered shock were adjudicated by a board of 3 electrophysiologists.

Results

Among 1226 CRT-D patients (mean age 71.2 ± 10.0 years; 75.5% males), 276 (22.5%) had perm-AF at device implantation. These patients had more frequently rate responsive function (19.7% vs 64.1%) and higher basic rate (median value 60 bpm vs 70 bpm) as compared to all other patients (p &lt; 0.001). The CRT pacing percentage calculated over the first 2 months was slightly lower for perm-AF patients (median value 96.0% vs 98.8%, p &lt; 0.001).

At 5-year appropriate shock incidence was 34.2% (95% confidence interval [CI], 25.1%-45.3%) for perm-AF and 19.9% (15.6%-25.1%) for all other patients. All-cause mortality was 27.7% (17.7%-41.8%) for perm-AF and 15.6% (12.2%-19.9%) for all other patients. 

The age- and sex-adjusted hazard ratio between perm-AF and all other patients was 1.81 (95% CI: 1.25-2.64, p = 0.002) for appropriate shock and 0.92 (95% CI: 0.57-1.50, p = 0.748) for all-cause mortality.

Conclusion

Although a higher incidence of appropriate shock, perm-AF at the time of CRT-D implantation was not associated with increased long-term mortality,

Abstract Figure. Appropriate shock and mortality

P431Flecainide or propafenone oral bolus to facilitate electrical cardioversion of persistent atrial fibrillation

Background

 electrical cardioversion (ECV) of atrial fibrillation (AF) is a pivotal component of the rhythm control approach. Although ECV is safe and effective in the majority of patients, approximately one patient out of ten experiences an early or very early recurrence. In order to improve ECV’s success rate, oral or intravenous amiodarone pre-treatment is commonly prescribed and followed by a second ECV attempt. However, due to the long time needed to achieve therapeutic levels and the high risk of phlebitis, faster and safer strategies to facilitate ECV are highly needed.

Purpose

 to evaluate whether the administration of a flecainide or propafenone oral bolus followed by ECV would prove effective and safe in facilitating conversion to sinus rhythm in patients with persistent AF and a prior ECV failure.

Methods

we conducted a prospective, open-label, single center observational study. The case group was formed by patients with persistent AF and a prior ECV failure receiving flecainide or propafenone oral bolus (at the same doses used for the "pill-in-the-pocket" approach) followed by a second ECV attempt 3 hours after drug ingestion. For comparison, we selected patients with a prior ECV failure that underwent amiodarone-facilitated ECV. Before ECV, amiodarone was either administered orally for at least 1 month or intravenously for 24 hours. The primary outcome was conversion to sinus rhythm, defined as sinus rhythm persisting for at least 12 hours after ECV.

Results

patient’s characteristics were well balanced in the 3 groups, apart from slightly lower left ventricular ejection fraction values in the amiodarone groups. The day after ECV failure, 29 patients received oral flecainide at a 200 mg (n = 15) or at a 300 mg (n = 14) dose and one patient received oral propafenone at a 600 mg dose before undergoing a second ECV attempt. In nine patients, amiodarone was given intravenously for 24 hours. Amiodarone was prescribed orally to 22 patients for a median of seven weeks at an average daily dose of 241.4 mg. In the flecainide/propafenone group, one patient converted to sinus rhythm one hour after drug ingestion; among the other 29 subjects, the second ECV was effective in 23 (cumulative effectiveness: 80.0%). In the intravenous amiodarone group, 2 patients converted to sinus rhythm during drug infusion; among the other 7, the second ECV proved effective in 4 (cumulative effectiveness: 66.7%). In the oral amiodarone group, ECV was successful in 17 patients (77.3%). When comparing the three groups, the primary outcome occurred in a similar proportion of patients (Chi-squared test: p = 0.34; Fisher’s exact test: p = 0.24). Serious adverse events were not reported.

Conclusions

flecainide or propafenone oral bolus quickly facilitated conversion to sinus rhythm in the vast majority of patients with persistent AF and a prior ECV failure with a low inherent risk of adverse events. Flecainide effectiveness proved similar to intravenous or oral amiodarone.

74Subclinical atrial fibrillation before and after acute medical illness or noncardiac surgery: insights from ASSERT

OnBehalf

ASSERT Investigators

Background

Atrial fibrillation (AF) is frequently detected perioperatively or during acute medical illness. It is unclear if such AF is reversible and unlikely to recur, or is a manifestation of paroxysmal AF.

Objective

To compare the prevalence of pacemaker-detected, subclinical AF (atrial rate &gt;190 bpm) before and after hospitalization for noncardiac surgery or medical illness in patients without a history of clinical AF.

Methods

ASSERT enrolled patients who were &gt;65 years old and had hypertension but no known AF. Pacemakers and defibrillators recorded episodes of subclinical AF. We identified participants who were hospitalized for noncardiac surgery or medical illness, and created heart rhythm profiles, centred on the day of hospitalization. We compared the prevalence of subclinical AF before and after hospitalization. We blanked the 30 days before hospitalization, because of uncertainty in defining the precise onset of illness.

Results

Among 2580 patients, 436 had a documented surgical or medical hospitalization. In the 30 days following a first hospitalization, 43 patients (9.9%) had &gt;1 episode of &gt;6 minutes of subclinical AF; 20 (4.6%) had &gt;6 hours and 13 (3%) had &gt;24 hours.

A higher proportion of patients had &gt;1 episode of subclinical AF &gt;6 minutes in the 30 days following a first surgical or medical hospitalization, as compared to the period between 30 and 60 days before hospitalization (9.9% versus 4.4%, P &lt; 0.001). There was no significant difference when comparing 0-90 days after hospitalization to 30-120 days before (13.7% versus 10.6%, P = 0.1). Similar results were observed for the same comparisons with episodes &gt;6 hours (4.6% versus 2.3%, P = 0.03 and 5.9% versus 5.6%, P = 0.8, respectively).

The majority of patients with subclinical AF in the 30 days following hospitalization had at least one episode of subclinical AF of the same duration in the 6 months prior (50% for episodes &gt;6 minutes; 69% for &gt;6 hours and 60% for &gt;24 hours). Those who did have subclinical AF in the 30 days following hospitalization were more likely to have had subclinical AF in the past 6 months than those who did not (OR 7.2 95%CI 3.2-15.8 for episodes &gt;6 minutes; OR 32.6, 95%CI 10.3-103.4 for &gt;6 hours and OR 36.3 95%CI 9.0-146.0 for &gt;24 hours).

Conclusions

The prevalence of subclinical AF increased following hospitalization for noncardiac surgery or medical illness.  However, most patients with subclinical AF following hospitalization had previously experienced similar episodes, particularly those with longer episodes of subclinical AF.

Subclinical progression of systemic sclerosis-related cardiomyopathy

AIMS

Cardiac involvement in patients with systemic sclerosis (SSc) is frequent and represents a negative prognostic factor. Recent studies have described subclinical heart involvement of both the right ventricle (RV) and left ventricle (LV) via speckle-tracking-derived global longitudinal strain (GLS). It is currently unknown if SSc-related cardiomyopathy progresses through time. Our aim was to assess the progression of subclinical cardiac involvement in patients with SSc via speckle-tracking-derived GLS.

METHODS

This was a prospective longitudinal study enrolling 72 consecutive patients with a diagnosis of SSc and no structural heart disease nor pulmonary hypertension. A standard echocardiographic exam and GLS calculations were performed at baseline and at follow-up.

RESULTS

Traditional echocardiographic parameters did not differ from baseline to 20-month follow-up. LV GLS, despite being already impaired at baseline, worsened significantly during follow-up (from -19.8 ± 3.5% to -18.7 ± 3.5%, p = .034). RV GLS impairment progressed through the follow-up period (from -20.9 ± 6.1% to -18.7 ± 5.4%, p = .013). The impairment was more pronounced for the endocardial layers of both LV (from -22.5 ± 3.9% to -21.4 ± 3.9%, p = .041) and RV (-24.2 ± 6.2% to -20.6 ± 5.9%, p = .001). A 1% worsening in RV GLS was associated with an 18% increased risk of all-cause death or major cardiovascular event (p = .03) and with a 55% increased risk of pulmonary hypertension (p = .043).

CONCLUSION

SSC-related cardiomyopathy progresses over time and can be detected by speckle-tracking GLS. The highest progression towards reduced deformation was registered for the endocardial layers, which supports the hypothesis that microvascular dysfunction is the main determinant of heart involvement in SSc patients and starts well before overt pulmonary hypertension.

Prospective evaluation of the multisensor HeartLogic algorithm for heart failure monitoring

Background

The HeartLogic algorithm measures data from multiple implantable cardioverter‐defibrillator‐based sensors and combines them into a single index. The associated alert has proved to be a sensitive and timely predictor of impending heart failure (HF) decompensation.

Hypothesis

We describe a multicenter experience of remote HF management by means of HeartLogic and appraise the value of an alert‐based follow‐up strategy.

Methods

The alert was activated in 104 patients. All patients were followed up according to a standardized protocol that included remote data reviews and patient phone contacts every month and at the time of alerts. In‐office examinations were performed every 6 months or when deemed necessary.

Results

During a median follow‐up of 13 (10–16) months, the overall number of HF hospitalizations was 16 (rate 0.15 hospitalizations/patient‐year) and 100 alerts were reported in 53 patients. Sixty alerts were judged clinically meaningful, and were associated with multiple HF‐related conditions. In 48 of the 60 alerts, the clinician was not previously aware of the condition. Of these 48 alerts, 43 triggered clinical actions. The rate of alerts judged nonclinically meaningful was 0.37/patient‐year, and the rate of hospitalizations not associated with an alert was 0.05/patient‐year. Centers performed remote follow‐up assessments of 1113 scheduled monthly transmissions (10.3/patient‐year) and 100 alerts (0.93/patient‐year). Monthly remote data review allowed to detect 11 (1%) HF events requiring clinical actions (vs 43% actionable alerts, P < .001).

Conclusions

HeartLogic allowed relevant HF‐related clinical conditions to be identified remotely and enabled effective clinical actions to be taken; the rates of unexplained alerts and undetected HF events were low. An alert‐based management strategy seemed more efficient than a scheduled monthly remote follow‐up scheme.

Atrial signal amplitude predicts atrial high-rate episodes in implantable cardioverter defibrillator patients: Insights from a large database of remote monitoring transmissions

BACKGROUND

Parameters measured during implantable cardioverter defibrillator (ICD) implant also depend on bioelectrical properties of the myocardium. We aimed to explore their potential association with clinical outcomes in patients with single/dual-chamber ICD and cardiac resynchronization therapy defibrillator (CRT-D).

METHODS

In the framework of the Home Monitoring Expert Alliance, baseline electrical parameters for all implanted leads were compared by the occurrence of all-cause mortality, adjudicated ventricular arrhythmia (VA), and atrial high-rate episode lasting ≥24 hours (24 h AHRE).

RESULTS

In a cohort of 2976 patients (58.1% ICD) with a median follow-up of 25 months, event rates were 3.1/100 patient-years for all-cause mortality, 18.1/100 patient-years for VA, and 9.3/100 patient-years for 24 h AHRE. At univariate analysis, baseline shock impedance was consistently lower in groups with events than without, with a 40 Ω cutoff that better identified high-risk patients. However, at multivariable analysis, the adjusted-hazard ratios (HRs) lost statistical significance for any endpoint. Baseline atrial sensing amplitude during sinus rhythm was lower in patients with 24 h AHRE than in those without (2.45 [IQR: 1.65-3.85] vs 3.51 [IQR: 2.37-4.67] mV, P < .01). The adjusted HR for 24 h AHRE in patients with atrial sensing >1.5 mV vs those with values ≤1.5 mV was 0.52 (95% CI: 0.33-0.83), P = .006.

CONCLUSIONS

Although lower baseline shock impedance was observed in patients with events, the association lost statistical significance at multivariable analysis. Conversely, low sinus rhythm atrial sensing (≤1.5 mV) measured with standard transvenous leads could identify subjects at high risk of atrial arrhythmia.

The role of physical activity in individuals with cardiovascular risk factors: an opinion paper from Italian Society of Cardiology-Emilia Romagna-Marche and SIC-Sport

: Regular physical activity is a cornerstone in the prevention and treatment of atherosclerotic cardiovascular disease (CVD) due to its positive effects in reducing several cardiovascular risk factors. Current guidelines on CVD suggest for healthy adults to perform at least 150 min/week of moderate intensity or 75 min/week of vigorous intensity aerobic physical activity. The current review explores the effects of physical activity on some risk factors, specifically: diabetes, dyslipidemia, hypertension and hyperuricemia. Physical activity induces an improvement in insulin sensitivity and in glucose control independently of weight loss, which may further contribute to ameliorate both diabetes-associated defects. The benefits of adherence to physical activity have recently proven to extend beyond surrogate markers of metabolic syndrome and diabetes by reducing hard endpoints such as mortality. In recent years, obesity has greatly increased in all countries. Weight losses in these patients have been associated with improvements in many cardiometabolic risk factors. Strategies against obesity included caloric restriction, however greater results have been obtained with association of diet and physical activity. Similarly, the beneficial effect of training on blood pressure via its action on sympathetic activity and on other factors such as improvement of endothelial function and reduction of oxidative stress can have played a role in preventing hypertension development in active subjects. The main international guidelines on prevention of CVD suggest to encourage and to increase physical activity to improve lipid pattern, hypertension and others cardiovascular risk factor. An active action is required to the National Society of Cardiology together with the Italian Society of Sports Cardiology to improve the prescription of organized physical activity in patients with CVD and/or cardiovascular risk factors.

Is delayed cardioversion the better approach in recent-onset atrial fibrillation? No

Symptomatic atrial fibrillation (AF) is a common cause of emergency department (ED) referrals. In case of hemodynamic stability, the choice to either perform early cardioversion (pharmacologic or electrical) or to prescribe rate-lowering drugs and differ any attempts to restore sinus rhythm (i.e., wait-and-see approach) has been widely debated. Results of the recent Rate Control versus Electrical Cardioversion Trial 7-Acute Cardioversion versus Wait and See (RACE 7 ACWAS) have been considered a strong argument in favor of the wait-and-see approach. In this debate, we discuss several issues that would support early cardioversion, ranging from patients' satisfaction and costs to concerns about safety. Furthermore, the wait-and-see approach may translate into a missed opportunity to encourage widespread use of a "pill-in-the-pocket" home treatment: this underused option could allow rapid solving of many AF episodes, potentially avoiding future ED referrals. Our opinion is that a delayed cardioversion may introduce unneeded complications in the straightforward management of a common clinical problem. Therefore, early cardioversion should continue to be the preferred option because of its proven efficacy, safety and convenience.

3079Subclinical progression of biventricular cardiomyopathy in patients with systemic sclerosis

Background

Systemic sclerosis (SSc) is a progressive autoimmune disease which has been proven to affect the heart. While it is widely known that the disease can cause pulmonary artery hypertension and therefore secondary right heart impairment, new studies have detected a subclinical heart involvement of both the left and right ventricles. The similar changes in myocardial deformation of both chambers assessed by speckle tracking imaging are consistent with the definition of SSc-related cardiomyopathy as a standalone entity with peculiar characteristics.

Purpose

The aim of the present study is to describe the progression of myocardial deformation as assessed through speckle tracking in patients with SSc and no pulmonary hypertension.

Methods

Prospective, longitudinal study on 48 patients affected by SSc. Patients with a history of heart failure, known structural heart disease, atrial fibrillation, and pulmonary hypertension were excluded. For every patient, standard echocardiographical and speckle-tracking derived variables for the systolic and diastolic function of the left ventricle (LV) and right ventricle (RV) were acquired at baseline and after 15±6 months.

Results

While common parameters of systolic function (Simpons's left ventricular ejection fraction, right ventricular fractional area change, TAPSE, tricuspidal S') did not change during follow-up, mean global longitudinal strain (GLS) significantly worsened for both left (from −19.1%±4.2% to −17.2%±5.0%) and right ventricle (from −17.9%±5.2% to −15.9%±4.8%) over 15 months. The increased impairment seen in SSc patients was homogeneous across endocardial layers (LV: from −21.8%±4.8% to −18.8%±5.2%; RV: from −20.6%±4.5% to −19.4%±4.9%), midventricular layers (LV: from −19.2%±4.5% to −17.7%±4.9%; RV: from −17.7%±4.7% to −16.7%±4.6%) and epicardial layers (LV: from −16.3%±4.7% to −16.0%±4.3%; RV: from −15.4%±5.0% to −14.6%±4.1%), as well as across myocardial segments (Figure 1). No difference in progression rate was seen between the diffuse and limited version of SSc, nor between different serotypes.

Figure 1

Conclusions

While traditional echocardiographical parameters are useless in order to follow the natural history of SSc-related cardiomyopathy during its early stages, GLS impairment progresses during a 15-month follow-up and involves similarly both the left and right ventricle. Whether, how, and how much the altered myocardial deformation contributes to the incidence of pulmonary arterial hypertension in these patients is still to be assessed.

Acknowledgement/Funding

Marche Polytechnic University

P2875Comparison between ejection fraction, global longitudinal strain, mechanical dispersion and delta contraction duration in predicting first and subsequent arrhythmic events in ICD patients

Background

According to current guidelines, left ventricular ejection fraction (LVEF) is currently the most important parameter for primary prevention of sudden cardiac death in patients with structural heart disease. Unfortunately, LVEF has low sensitivity in detecting arrhythmic events and presents a significant intra- and inter-operator variability. For these reasons, alternative predictors in patients with structural heart disease are being sought. Among those, speckle-tracking derived parameters such as global longitudinal strain (GLS), mechanical dispersion (MD), and delta contraction duration (DCD) have been proposed as better alternatives.

Purpose

To assess speckle-tracking derived parameters as predictors of first and subsequent arrhythmic events in implantable cardioverter-defibrillator (ICD) patients with structural heart disease, and to compare their performance with LVEF.

Methods

Prospective, observational study enrolling all consecutive patients with structural heart disease admitted for an ICD implant. Patients not followed by a home-monitoring system were excluded. 2D speckle-tracking analysis was used to derive GLS, MD, and DCD of all patients at enrolment. Home monitoring was checked weekly in order to detect all ventricular arrhythmias (VA) and ICD therapies. A recurrent-event statistical approach (Prentice, Williams, and Peterson model) was applied in order to evaluate subsequent events after the first ones.

Results

Two-hundred-and-three patients were consecutively enrolled and followed-up for a median follow-up of 2.2 years. Kaplan-Meier curves showed an increased risk of ATP or shock (Log-rank p=0.003) and VAs (Log-rank p=0.001) associated with lower quartiles of GLS (Figure 1). An impaired GLS was independently associated with an increased risk for the first ICD therapy (HR 1.94; 95% CI 1.30–2.91; p=0.001), and for the first VA (HR 1.42; 95% CI 1.01–1.98; p=0.04). GLS impairment was not significantly associated with an increased risk of recurrent ICD therapies or VAs. LVEF, MD and DCD were not associated with an increased risk of first, second and third ICD therapy or VA.

Conclusions

Impaired GLS is associated with an increased risk of VAs and appropriate ICD therapies in a consecutive, “real-world”, unselected population of remote-monitored patients with structural heart disease, although it does not seem reliable in predicting further arrhythmic event after the first one. LVEF, MD, and DCD do not predict first or subsequent arrhythmic events in ICD patients with structural heart disease.

Acknowledgement/Funding

Marche Polytechnic University

Are Atrial High-Rate Episodes Associated With Increased Risk of Ventricular Arrhythmias and Mortality?

OBJECTIVES

This study evaluated the temporal association between atrial high-rate episodes (AHREs) and sustained ventricular arrhythmias (VAs) in a remotely monitored cohort with implantable cardioverter-defibrillators (ICD) with and/or without cardiac resynchronization therapy with a defibrillator (CRT-D).

BACKGROUND

Clinical relevance of AHREs in terms of VA rate and survival has not been outlined yet.

METHODS

This study analyzed data of patients with ICDs and CRT-Ds from the nationwide Home Monitoring Expert Alliance network. The cohort included 2,435 patients with a median follow-up of 25 months (interquartile range: 13 to 42 months) and age 70 years (range 61 to 77 years); 19.7% were women, 51.4% had coronary artery disease, and 45.2% had a CRT-D. There were 3,410 appropriate VA episodes; 498 (14.6%) were preceded by AHREs within 48 h; in 85.5% of this group, AHREs were still ongoing at episode onset.

RESULTS

In a longitudinal analysis, the odds ratios (ORs) of experiencing any VA in a 30-day interval with AHREs versus intervals without AHREs were 2.35 (95% confidence interval [CI]: 1.86 to 2.97; p < 0.001) for ventricular tachycardia (VT), 3.06 (95% CI: 2.35 to 3.99; p < 0.001) for fast VT, 1.84 (95% CI: 1.36 to 2.48; p < 0.001) for self-extinguishing ventricular fibrillation (VF), and 2.31 (95% CI: 1.17 to 4.57; p = 0.01) for VF. ORs decreased with increasing AHRE burden. Patients with AHREs 48 h before VAs were more likely to experience VA recurrences (adjusted hazard ratio [HR]: 1.78; 95% CI: 1.41 to 2.24; p < 0.001) and had higher overall mortality (HR: 2.67; 95% CI: 1.68 to 4.23; p < 0.001).

CONCLUSIONS

AHREs were not uncommon 48 h before VAs, which tended to be distributed around intervals with AHREs. Temporal connection between AHREs and VAs was a marker of increased risk of VA recurrence and a poorer prognosis.