Prognostic Implications of High-Degree Atrio-Ventricular Block in Patients with Acute Myocardial Infarction in the Contemporary Era

BACKGROUND

High-degree atrioventricular block (HAVB) is a known complication of ST-segment elevation myocardial infarction (STEMI). We aimed to determine the prevalence and prognostic impact of HAVB in a contemporary cohort of STEMI.

METHODS

Data were collected from the DIAMANTE registry that included STEMI patients admitted to our cardiac intensive care unit treated with urgent reperfusion. We studied the clinical characteristics and evolution in patients with and without HAVB at admission.

RESULTS

From 1109 consecutive patients, HAVB was documented in 95 (8.6%). The right coronary artery was the culprit vessel in 84 patients with HAVB (88.4%). The independent predictors of HAVB were: male sex (OR 1.9, 95% CI 1.2-2.9), age (OR 1.03, 95% CI 1.01-1.05), involvement of right coronary artery (OR 12.4, 95% CI 7.6-20.2), and creatinine value (OR 1.5, 95% CI 1.1-2.0). A transient percutaneous pacemaker was used in 37 patients with HAVB (38.9%). Patients with HAVB had higher mortality that patients without HAVB (15.8% vs. 4.1%, p < 0.001); however, in multivariate analysis, HAVB was not an independent predictor of in-hospital mortality.

CONCLUSIONS

HAVB was seen in 9% of STEMI patients and was particularly frequent in elderly males with renal failure. Patients with HAVB had a poor prognosis during hospitalization, but HAVB was not an independent predictor of in-hospital mortality.

Atrial myxoma surgery and p-wave remodeling

INTRODUCTION

Data regarding atrial electrocardiographic parameters in patients with atrial myxomas are scarce.

METHODS

We aimed to study atrial electrocardiographic features in patients with atrial myxomas, before and after surgery. We also analyze the incidence of atrial fibrillation during follow-up and its correlation with different P-wave indexes. 32 patients in sinus rhythm that underwent atrial myxoma surgery were included.

RESULTS

Mean age was 55.0±12.6 years and 18 (56.3%) were women. Ten patients had left atrial enlargement (31.3%). Only one myxoma was located in the right atrium. At baseline 7 cases of partial interatrial block (IAB) were detected (21.9%), two in the absence of left atrial enlargement. There were significant differences in atrial electrocardiographic indexes before and after surgery, including P-wave duration (108.9±17.9 ms vs. 93.0±12.4 ms; p < 0.001), partial IAB (21.9% vs 3.1%; p = 0.012) and duration of P-wave terminal force in lead V1 negativity (-0.6±0.3 vs -0.5±0.3 mm; p = 0.034). At a mean follow up of 10.0±5.5 years, 10 patients (31.3%) had experienced at least one episode of atrial fibrillation. Post-operative P-wave duration was associated with atrial fibrillation occurrence during follow-up (Hazard ratio: 0.90, 95% confidence interval: 0.83-0.98; p = 0.020).

CONCLUSIONS

Abnormalities in atrial electrocardiographic indexes are common in atrial myxomas and frequently improve after surgery. Post-operative P-wave duration is associated with atrial fibrillation occurrence during follow-up. This article is protected by copyright. All rights reserved.

Ticagrelor and Infection Risk in Patients with Coronary Artery Disease

BACKGROUND

Ticagrelor has a bactericidal effect in vitro, and clinical studies suggest a beneficial effect in infections. Our aim was to determine the incidence of infections in patients treated with 3 different P2Y12 receptor inhibitors.

METHODS

Retrospective registry in a cardiology department. Patients with coronary artery disease discharged on ticagrelor, prasugrel, or clopidogrel from March 2017 to June 2019 were included. The risk of infection was analyzed during the period of P2Y12 inhibitor treatment (12.4 ± 6.7 months).

RESULTS

A total of 250 patients were included (ticagrelor 91 [36.4%], prasugrel 89 [35.6%], clopidogrel 70 [28.0%]). Mean age was 61.0 ± 13.1 years, and 63 (25.2%) were women. The most common reason to use these drugs was ST-segment elevation acute myocardial infarction (STEMI) (152 patients - 60.8%). STEMI was the reason to use prasugrel in 84 patients (94.4%), ticagrelor in 44 (48.4%), and clopidogrel in 24 (34.3%), p < 0.001. An infection during follow-up was seen in 87 patients (34.8%), 23 treated with ticagrelor (25.3%), 30 with prasugrel (33.7%) and 34 with clopidogrel (48.6%), p = 0.009. Ticagrelor was independently associated with a lower likelihood of infection (Hazard Ratio [HR] 0.52, 95% confidence interval [CI] 0.28-0.95; p = 0.035) compared to prasugrel (HR 0.96, 95% CI 0.54-1.73; p = 0.909) and clopidogrel (HR = 1).

CONCLUSIONS

In patients admitted with coronary artery disease patients treated with ticagrelor had a lower frequency of infections during follow-up than those treated with other P2Y12 inhibitors. Further studies are necessary to clarify the bactericidal effect of ticagrelor in this context.

Rationale and design of the rigorous atrial analysis in advanced interatrial block (ARABIA) prospective study

BACKGROUND

Advanced interatrial block (IAB) is present in 10% of subjects ≥75 years and is associated with the risk of clinical events.

METHODS AND RESULTS

Prospective multicenter study that will include subjects ≥75 years without exclusion criteria (indication for anticoagulation, cardiac devices, severe valve disease, systolic dysfunction, moderate or severe cognitive impairment, poor echocardiographic window, non-sinus rhythm or partial IAB, stroke, and life expectancy <2 years). A total of 356 subjects, 178 patients with advanced IAB (exposed) and 178 matched individuals with normal P-wave (non-exposed) will be included. Electrocardiogram and advanced transthoracic echocardiography will be performed. Two substudies will include magnetic resonance imaging: cardiac (86 subjects, 43 exposed, and 43 non-exposed) and brain (86 subjects, 43 exposed, and 43 non-exposed). The follow-up will be 2 years. Our main objective is to determine the association of advanced IAB, P-wave duration, and atrial imaging parameters (I] atrial global longitudinal strain, II] maximal left atrial volume index, III] left atrial ejection fraction, IV] left atrial fibrosis - % total left atrial area V] inter- and intra-atrial asynchrony/dyssynchrony) with clinical events (atrial fibrillation, stroke, cognitive impairment, and mortality). The secondary objective is to assess the association of the P-wave duration with atrial imaging parameters and of both with cerebral microemboli in magnetic resonance imaging.

CONCLUSION

Our study will provide data regarding the association of advanced IAB, P-wave duration, and atrial imaging parameters with clinical events. We will also assess the association P-wave duration-atrial imaging parameters-cerebral microemboli.

Left atrial enlargement in competitive athletes and atrial electrophysiology

INTRODUCTION AND OBJECTIVES

There are scarce data on left atrial (LA) enlargement and electrophysiological features in athletes.

METHODS

Multicenter observational study in competitive athletes and controls. LA enlargement was defined as LA volume indexed to body surface area ≥ 34mL/m². We analyzed its relationship with atrial electrocardiography parameters.

RESULTS

We included 356 participants, 308 athletes (mean age: 36.4±11.6 years) and 48 controls (mean age: 49.3±16.1 years). Compared with controls, athletes had a higher mean LA volume index (29.8±8.6 vs 25.6±8.0mL/m², P=.006) and a higher prevalence of LA enlargement (113 [36.7%] vs 5 [10.4%], P <.001), but there were no relevant differences in P-wave duration (106.3±12.5ms vs 108.2±7.7ms; P=.31), the prevalence of interatrial block (40 [13.0%] vs 4 [8.3%]; P=.36), or morphology-voltage-P-wave duration score (1.8±0.84 vs 1.5±0.8; P=.71). Competitive training was independently associated with LA enlargement (OR, 14.7; 95%CI, 4.7-44.0; P <.001) but not with P-wave duration (OR, 1.02; 95%CI, 0.99-1.04), IAB (OR, 1.4; 95%CI, 0.7-3.1), or with morphology-voltage-P-wave duration score (OR, 1.4; 95%CI, 0.9-2.2).

CONCLUSIONS

LA enlargement is common in adult competitive athletes but is not accompanied by a significant modification in electrocardiographic parameters.

Clinical profile, anatomical features and long-term outcome of acute coronary syndromes in human immunodeficiency virus-infected patients

BACKGROUND

Long-term prognosis of acute coronary syndromes (ACS) in human immunodeficiency virus (HIV)-infected patients is unknown.

AIMS

To compare outcomes after ACS in HIV-infected and uninfected patients.

METHODS

Retrospective observational study. HIV cases were matched with two HIV-uninfected controls for age, sex and type of ACS.

RESULTS

In 92 HIV patients (mean age 51.3 ± 9.0 years, 7.6% women), the prevalence of cardiovascular risk factors was high (smoking 71.7%; hypertension 41.3%; diabetes 14.1%); dyslipidaemia was more frequent (53 (57.6%) vs 79 (42.9%), P = 0.02) and obesity less common (8 (8.7%) vs 41 (22.3%), P = 0.002) than in controls. Eighty-seven (94.6%) HIV patients had undetectable viral load and 85 (92.4%) were under anti-retroviral therapy. Multivessel disease was more common in HIV patients than in controls (44 (47.8%) vs 71 (39.1%); P = 0.05) as was Killip class 3-4 on admission (9 (9.8%) vs 6 (3.3%); P = 0.04). The rate of in-hospital mortality was similar in both groups (2%), and there were no significant differences in 3-year mortality (10.2% vs 5.7%; P = 0.27). Non-cardiovascular readmissions at 3 years were more frequent in HIV patients than in controls (36.5% vs 7.4%; P < 0.001). Multivariate analysis identified previous coronary artery disease as the strongest predictor of mortality in HIV patients (hazard ratio 4.7, 95% confidence interval 1.4-15.7, P = 0.01), whereas HIV infection was not associated with prognosis.

CONCLUSION

HIV patients with ACS had more frequent multivessel disease and heart failure than matched controls. However, in-hospital and long-term mortality was similar in both groups. Non-cardiovascular re-hospitalisations were more common in HIV patients.

Relation of Interatrial Block to Cognitive Impairment in Patients ≥ 70 Years of Age (From the CAMBIAD Case-control Study)

The association between atrial fibrillation, stroke, and interatrial block (IAB) (P-wave duration ≥120 ms) is well recognized, particularly in the case of advanced IAB. We aimed to assess the association of IAB with mild cognitive impairment. Advanced Characterization of Cognitive Impairment in Elderly with Interatrial Block was a case-control multicenter study, conducted in subjects aged ≥70 years in sinus rhythm without significant structural heart disease. Diagnosis of mild cognitive impairment was performed by an expert geriatrician, internist, or neurologist in the presence of changes in cognitive function (Mini Mental State Examination score 20 to 25) without established dementia. A total of 265 subjects were included. Mean age was 79.6 ± 6.3 years and 174 (65.7%) were women; there were 143 cases with mild cognitive impairment and 122 controls with normal cognitive function. Compared with controls, cases had longer P-wave duration (116.2 ± 13.8 ms vs 112.5 ± 13.3 ms, p = 0.028), higher prevalence of IAB (73 [51.0%] vs 38 [31.1%], p = 0.001), higher prevalence of advanced IAB (28 [19.6%] vs 10 [8.2%], p = 0.002), and higher MVP ECG risk score (2.7 ± 1.4 vs 2.2 ± 1.3, p = 0.004). IAB was independently associated with mild cognitive impairment, both for partial (odds ratio 2.0, 95% CI: 1.1 to 3.9) and advanced IAB (odds ratio 2.8, 95% CI: 1.1 to 6.7). In conclusion, in subjects aged ≥70 years without significant structural heart disease, IAB is independently associated with mild cognitive impairment. This association is stronger in the case of advanced IAB.

Predictors of pacemaker dependency in patients implanted with a pacemaker after Transaortic valve replacement

Introduction and objectives

The development of complete AV block and the need for pacemaker implantation (PM) is the most frequent complication after Transaortic valve replacement (TAVR). In other PM clinical contexts, a higher percentage of ventricular stimulation has been associated with worse prognosis. The objective was to study the existence of predictors of PM dependence.

Methods

We identified 96 consecutive patients who had received a PM post-TAVR (all Core-Valve). We retrospectively analyzed this cohort with the aim of identifying predictors of a high and very high percentage of ventricular pacing (VP), PM dependency and survival.

Results

The mean age was 82.3 years, with a mean logistic EuroSCORE of 17.1, 53% were women and 12% of patients had LVEF < 50%. The indication was complete AV block in 40.5%, and LBBB in 59.5%. Mean survival was 62.7 months, IQR [54.4-71]. The only independent predictor of mortality was the pre-TAVR logistic Euro-SCORE (RR = 1,026, p = 0.033), but not LVEF < 50%, VP > 50%, VP > 85% or PM dependence. In 73 patients PM rhythm was documented at the end of follow-up. Of these, 14 (19.2%) were considered dependent, and 37 (50.7%) presented VP > 50%. The post-TAVR complete AV block recovery rate was 67.8%. In multivariate analysis, female sex (HR = 5.6, p = 0.005), and indication of complete AV block vs. LBBB (HR = 15.7, p = 0.017) were independently associated with PM dependency.

Conclusions

Female sex and indication due to complete AV block were independent predictors of PM dependency during follow up. In our series of patients with mostly normal LVEF, a high percentage of stimulation does not influence prognosis.

Young athletes' ECG: Incomplete right bundle branch block vs crista supraventricularis pattern

BACKGROUND

Incomplete right bundle branch block (IRBBB) is prevalent among athletes, but its etiology remains to be clearly elucidated and the commonly advocated mechanism, an intraventricular conduction delay, does not explain all cases. In the general population, an apparently similar phenomenon but with different pathophysiology and potential consequences, "crista supraventricularis pattern" (CSP, defined as QRS ≤ 100 ms, S wave <40 ms in I or V6 together with an RSR´ pattern in lead-V1) has been described. Yet, this manifestation has not been studied in athletes. Given that IRBBB can be associated with some serious conditions (including Brugada syndrome, arrhythmogenic cardiomyopathy, or atrial septal defects) the differentiation between IRBB and CSP could enhance the accuracy of the pre-participation screening (PPS). We thus aimed to determine the prevalence of CSP in young athletes.

METHODS

Observational study of standard 12-lead resting ECG in a cohort of children (5-16 years) attending a PPS program (August 2018-May 2019).

RESULTS

6,401 children (mean ± SD age 11.2 ± 2.9 years, 99.2% Caucasian, 93.8% male, 97.2% soccer players) were studied. We found CSP in 850 participants (prevalence = 13.3% [95% confidence interval 12.5-14.1]) whereas 553 (8.6%) had IRBBB. The proportion of athletes showing an S1S2S3 pattern was higher in those with CSP compared with the other QRS morphologies (P < .05).

CONCLUSIONS

CSP might have been overlooked in previous reports of sports PPS for children and misdiagnosed as IRBBB, as the proportion of the former condition was higher. Our findings might add useful information to improve the interpretation of the young athletes' ECG and thus the diagnostic value of PPS.

Association between interatrial block, left atrial fibrosis, and mechanical dyssynchrony: Electrocardiography-magnetic resonance imaging correlation

INTRODUCTION

Advanced interatrial block (IAB) on a 12-lead electrocardiogram (ECG) is a predictor of stroke, incident atrial fibrillation (AF), and AF recurrence after catheter ablation. The objective of this study was to determine which features of IAB structural remodeling is associated with left atrium (LA) magnetic resonance imaging structure and function.

METHODS/RESULTS

We included 152 consecutive patients (23% nonparoxysmal AF) who underwent preprocedural ECG and cardiac magnetic resonance (CMR) in sinus rhythm before catheter ablation of AF. IAB was defined as P-wave duration ≥120 ms, and was considered partial if P-wave was positive and advanced if P-wave had a biphasic morphology in inferior leads. From cine CMR and late gadolinium enhancement, we derived LA maximum and minimum volume indices, strain, LA fibrosis, and LA dyssynchrony. A total of 77 patients (50.7% paroxysmal) had normal P-wave, 52 (34.2%) partial IAB, and 23 (15.1%) advanced IAB. Patients with advanced IAB had significantly higher LA minimum volume index (25.7 vs 19.9 mL/m² , P = .010), more LA fibrosis (21.9% vs 13.1%, P = .020), and lower LA maximum strain rate (0.99 vs 1.18, P = .007) than those without. Advanced IAB was independently associated with LA (minimum [P = .032] and fibrosis [P = .009]). P-wave duration was also independently associated with LA fibrosis (β = .33; P = .049) and LA mechanical dyssynchrony (β = 2.01; P = .007).

CONCLUSION

Advanced IAB is associated with larger LA volumes, lower emptying fraction, and more fibrosis. Longer P-wave duration is also associated with more LA fibrosis and higher LA mechanical dyssynchrony.

Electrocardiogram and left atrial abnormality: Design of an observational study to clarify diagnostic criteria

Background

The criteria applied for diagnosis of left atrial (LA) abnormality using electrocardiogram (ECG) have high specificity but low sensitivity. In fact, some authors have suggested classifying P‐wave anomalies associated with LA abnormality and interatrial block as “atrial abnormalities.” The most widely known ECG criteria for LA abnormality include P‐wave duration, morphology and voltage of P wave in inferior leads, presence of P‐wave terminal force in V₁ (PtfV₁), and P‐wave axis and area. PtfV₁ has also been reported to vary according to misplacement of the V₁ and V₂ electrodes.

Methods

The objective of this observational cohort study is to determine the degree of correlation between ECG criteria for LA abnormality and left atrium volume and functionality, as determined by speckle tracking echocardiography. The study also aims to investigate the correlation between these echocardiographic parameters and PtfV₁ value by placing the V₁ and V₂ electrodes in the second, third, and fourth intercostal spaces.

Results and Conclusions

Our results could help to clarify whether the decrease in left atrial deformity, which is currently considered a surrogate target of fibrosis, correlates better with ECG criteria for LA abnormality than atrial volumes.

Circadian Rhythm of Deaths in a Cardiology Department: A Five-Year Analysis

BACKGROUND

Previous studies have described a circadian pattern of death from cardiovascular causes with a morning peak. Our aim is to describe the daytime oscillations in mortality in hospitalized patients with cardiovascular diseases.

METHODS

Our retrospective registry including all patients who died in the Cardiology Department, including the cardiac intensive care unit, Madrid, Spain.

RESULTS

From a total of 500 patients, time of death was registered in 373 (74.6%), which are the focus of our study; 354 (70.8%) died in the cardiac intensive care unit and 146 (29.2%) in the conventional ward. Mean age was 74.2 ± 13.1 years, and 239 (64.1%) were male. Cardiovascular causes were the leading cause of death (308 patients; 82.6%). Mortality followed a circadian biphasic pattern with a peak at dawn (00.00-05.59 a.m.: 104 patients [27.9%]) and in the afternoon (12.00-17.59 p.m.: 135 patients [36.2%]), irrespective of the cause of death. The peak of mortality occurred in the afternoon (12.00-17.59 p.m.) in the case of cardiovascular mortality (119 deaths [38.6%]) and in the evening (18.00-23.59 p.m.) for non-cardiovascular deaths (21 deaths [32.3%], p = 0.03). This pattern was present regardless from the place of death (conventional ward or cardiac intensive care unit) and also throughout the four seasons.

CONCLUSIONS

Mortality in hospitalized patients with cardiovascular diseases follows a circadian biphasic pattern.

Prognostic Implications of Influenza Virus Infection in a Cardiac Intensive Care Unit: Potential Impact of a Screening Program

Objectives: Our goal was to determine the presentation and prognosis of influenza in an intensive cardiac care unit and to analyze the impact of an active surveillance program in the diagnosis. Methods: We performed a prospective registry during the flu season in a coronary unit. In the first phase, no systematic screening was performed. Systematic influenza A and B detection was performed in a second phase for all patients admitted. Results: From 227 patients, we identified 17 (7.5%) with influenza. Influenza patients were more likely to have a non-ischemic cause of admission (14 patients [82.4%] vs. 48 patients [40.3%], p = 0.002), fever (8 patients [47.1%] vs. 3 patients [2.6%], p < 0.001), and respiratory failure (7 patients [41.2%] vs. 8 patients [7%], p = 0.001). Influenza infection was an independent predictor of mortality (odds ratio 12.0, 95% confidence interval 1.9–13.6, p < 0.001). The incidence of influenza was 6.6% (6 patients) when no active screening was performed and 7.9% (11 patients) when systematic detection was performed (p = 0.005). The time to diagnosis was shorter in the systematic screening phase (0.92 ± 1.6 vs. 5.2 ± 3.8 days, p = 0.01). Conclusions: Influenza affects approximately 8% of patients admitted to an intensive cardiac care unit during the flu season, with a high mortality rate. An active surveillance program improves early detection.

Clinical characteristics of patients with sustained ventricular arrhythmias after sacubitril/valsartan initiation

Our aim was to describe the clinical profile of patients presenting sustained ventricular arrhythmias after sacubitril/valsartan (SV) initiation. All cases of sustained ventricular arrhythmias in patients receiving SV were consecutively recorded in two centers. Nineteen patients had sustained ventricular arrhythmias after SV. All were men and were previously receiving angiotensin-converting enzyme inhibitors, or angiotensin II receptor blockers before SV initiation. Fifteen patients (78.9%) had electrical stability in the previous 6 months. Nine patients (47.4%) initiated SV at the lowest available dose (24/26 mg). Globally, in all but five patients alive at discharge, SV was discontinued after the event. Six patients presented new arrhythmic events after discontinuation of SV. Two deaths and three heart transplants occurred (one due to heart failure and the other two due to persistent ventricular arrhythmias). All patients had a high arrhythmic risk, and 17 (89.5%) had an implanted cardioverter defibrillator. No specific triggers for the arrhythmic event were found. Male sex and previous episodes of ventricular arrhythmias could be associated with an increased risk of sustained ventricular tachycardia after SV initiation. Discontinuation of the drug might be an additional approach to enable a better control of ventricular arrhythmias in some patients.

Prognostic of Interatrial Block after an Acute ST-Segment Elevation Myocardial Infarction

BACKGROUND

The influence of interatrial block (IAB) in the prognosis after an acute ST-segment elevation myocardial infarction (STEMI) is unknown.

OBJECTIVES

To assess the prognostic impact of IAB after an acute STEMI regarding long-term mortality, development of atrial fibrillation, and stroke.

METHODS

Registry of 972 consecutive patients with STEMI and sinus rhythm at discharge, with a long-term follow-up (49.6 ± 24.9 months). P wave duration was analyzed using digital calipers, and patients were divided into three groups: normal P wave duration (<120 ms), partial IAB (pIAB) (P wave ≥120 ms and positive in inferior leads), and advanced IAB (aIAB) (P wave ≥120 ms plus biphasic [positive/negative] morphology in inferior leads).

RESULTS

Mean age was 62.6 ± 13.5 years. A total of 708 patients had normal P wave (72.8%), 207 pIAB (21.3%), and 57 aIAB (5.9%). Patients with aIAB were older (mean age 73 years) than the rest (62 years in the other two groups, p < 0.001). They also had a higher rate of hypertension (70 vs. 55% in pIAB and 49% in normal P wave, p = 0.006) and higher all-cause mortality (26.3 vs. 12.6% in pIAB and 10.3% in normal P wave, p = 0.001). However, multivariable analysis did not show an independent association between IAB and prognosis.

CONCLUSION

About a quarter of patients discharged in sinus rhythm after an acute STEMI have IAB. Patients with aIAB have a poor prognosis, although this is explained mainly by the association of aIAB with age and other variables.

Seasonality in Mortality in a Cardiology Department: A Five-Year Analysis in 500 Patients

BACKGROUND

Previous studies have indicated that cardiovascular mortality follows a seasonal trend. The aim of this work was to determine the evolution of mortality throughout the year in a cardiology department.

METHODS

All admissions and deaths occurring in our Cardiology Department over a 5-year period (2013-2017) were recorded retrospectively.

RESULTS

From a total of 17,829 hospital admissions, 500 patients died (2.8%, 0.3 patients/day). The mean age of deceased patients was 74.2 ± 13.1 years, and 186 (37.2%) were women. Mortality ranged from 0.17 deaths/day in August to 0.40 deaths/day in February (p = 0.03), and from 0.20 deaths/day in summer to 0.36 deaths/day in winter (p = 0.001). There was also a trend towards a variation in hospitalizations, with a peak in January (10.5 admissions/day) and the lowest figure in August (7.0 admissions/day), p = 0.047. We found no significant seasonal trend regarding mortality rate with respect to the number of hospital admissions (p = 0.89). The most common cause of death was refractory heart failure (267 patients [65.8%]). A noncardiac cause of death was observed in 134 patients (26.8%).

CONCLUSIONS

In a cardiology department, there are twice as many deaths in winter as in summer. Hospitalizations also tend to be more frequent in winter than in summer.

Ventricular Arrhythmic Storm after Initiating Sacubitril/Valsartan

Objectives: Sacubitril/valsartan was approved recently for the treatment of patients with heart failure and reduced ejection fraction. We present 6 cases of ventricular arrhythmia, that occurred shortly after sacubitril/valsartan initiation, that required drug withdrawal. Other potential triggering factors of electrical storm were ruled out and, from the arrhythmic perspective, all of the patients were stable in the previous year. Our aim is to describe the possible association of sacubitril/valsartan with arrhythmic storm. Methods: This was an observational monocentric study performed in the first 7 months of sacubitril/valsartan commercialization in Spain (October 2016). All patients were included in the SUMA (Sacubitril/Varsartan Usado Ambulatoriamente en Madrid [Sacubitril/Valsartan Used in Outpatients in Madrid]) registry. Patients were consecutively enrolled on the day they started the drug. Ventricular arrhythmic storm was defined as ≥2 episodes of sustained ventricular arrhythmia or defibrillator therapy application in 24 h. Results: From 108 patients who received the drug, 6 presented with ventricular arrhythmic storm (5.6%). Baseline characteristics were similar in the patients with and without ventricular arrhythmic storm. The total number of days that sacubitril/valsartan was administered to each patient was 5, 6, 44 (8 since titration), 84, 93, and 136 (105 since titration), respectively. Conclusions: Our data are not enough to infer a cause-and-effect relationship. Further investigations regarding a potential proarrhythmic effect of sacubitril/valsartan are probably needed.