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Cadrin-Tourigny J, Bosman LP, Nozza A, Wang W, Tadros R, Bhonsale A, Bourfiss M, Fortier A, Lie ØH, Saguner AM, Svensson A, Andorin A, Tichnell C, Murray B, Zeppenfeld K, van den Berg MP, Asselbergs FW, Wilde AAM, Krahn AD, Talajic M, Rivard L, Chelko S, Zimmerman SL, Kamel IR, Crosson JE, Judge DP, Yap SC, van der Heijden JF, Tandri H, Jongbloed JDH, Guertin MC, van Tintelen JP, Platonov PG, Duru F, Haugaa KH, Khairy P, Hauer RNW, Calkins H, Te Riele ASJM, James CA. A new prediction model for ventricular arrhythmias in arrhythmogenic right ventricular cardiomyopathy. Eur Heart J 2020; 40:1850-1858. [PMID: 30915475 PMCID: PMC6568197 DOI: 10.1093/eurheartj/ehz103] [Citation(s) in RCA: 186] [Impact Index Per Article: 46.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 11/21/2018] [Accepted: 03/01/2019] [Indexed: 12/23/2022] Open
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Wilkoff BL, Boriani G, Mittal S, Poole JE, Kennergren C, Corey GR, Krahn AD, Schloss EJ, Gallastegui JL, Pickett RA, Evonich RF, Roark SF, Sorrentino DM, Sholevar DP, Cronin EM, Berman BJ, Riggio DW, Khan HH, Silver MT, Collier J, Eldadah Z, Holbrook R, Lande JD, Lexcen DR, Seshadri S, Tarakji KG. Cost-Effectiveness of an Antibacterial Envelope for Cardiac Implantable Electronic Device Infection Prevention in the US Healthcare System From the WRAP-IT Trial. Circ Arrhythm Electrophysiol 2020; 13:e008503. [PMID: 32915063 PMCID: PMC7566304 DOI: 10.1161/circep.120.008503] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Supplemental Digital Content is available in the text. In the WRAP-IT trial (Worldwide Randomized Antibiotic Envelope Infection Prevention), adjunctive use of an absorbable antibacterial envelope resulted in a 40% reduction of major cardiac implantable electronic device infection without increased risk of complication in 6983 patients undergoing cardiac implantable electronic device revision, replacement, upgrade, or initial cardiac resynchronization therapy defibrillator implant. There is limited information on the cost-effectiveness of this strategy. As a prespecified objective, we evaluated antibacterial envelope cost-effectiveness compared with standard-of-care infection prevention strategies in the US healthcare system.
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103
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Ng K, Titus EW, Lieve KV, Roston TM, Mazzanti A, Deiter FH, Denjoy I, Ingles J, Till J, Robyns T, Connors SP, Steinberg C, Abrams DJ, Pang B, Scheinman MM, Bos JM, Duffett SA, van der Werf C, Maltret A, Green MS, Rutberg J, Balaji S, Cadrin-Tourigny J, Orland KM, Knight LM, Brateng C, Wu J, Tang AS, Skanes AC, Manlucu J, Healey JS, January CT, Krahn AD, Collins KK, Maginot KR, Fischbach P, Etheridge SP, Eckhardt LL, Hamilton RM, Ackerman MJ, Noguer FRI, Semsarian C, Jura N, Leenhardt A, Gollob MH, Priori SG, Sanatani S, Wilde AAM, Deo RC, Roberts JD. An International Multicenter Evaluation of Inheritance Patterns, Arrhythmic Risks, and Underlying Mechanisms of CASQ2-Catecholaminergic Polymorphic Ventricular Tachycardia. Circulation 2020; 142:932-947. [PMID: 32693635 PMCID: PMC7484339 DOI: 10.1161/circulationaha.120.045723] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Genetic variants in calsequestrin-2 (CASQ2) cause an autosomal recessive form of catecholaminergic polymorphic ventricular tachycardia (CPVT), although isolated reports have identified arrhythmic phenotypes among heterozygotes. Improved insight into the inheritance patterns, arrhythmic risks, and molecular mechanisms of CASQ2-CPVT was sought through an international multicenter collaboration. METHODS Genotype-phenotype segregation in CASQ2-CPVT families was assessed, and the impact of genotype on arrhythmic risk was evaluated using Cox regression models. Putative dominant CASQ2 missense variants and the established recessive CASQ2-p.R33Q variant were evaluated using oligomerization assays and their locations mapped to a recent CASQ2 filament structure. RESULTS A total of 112 individuals, including 36 CPVT probands (24 homozygotes/compound heterozygotes and 12 heterozygotes) and 76 family members possessing at least 1 presumed pathogenic CASQ2 variant, were identified. Among CASQ2 homozygotes and compound heterozygotes, clinical penetrance was 97.1% and 26 of 34 (76.5%) individuals had experienced a potentially fatal arrhythmic event with a median age of onset of 7 years (95% CI, 6-11). Fifty-one of 66 CASQ2 heterozygous family members had undergone clinical evaluation, and 17 of 51 (33.3%) met diagnostic criteria for CPVT. Relative to CASQ2 heterozygotes, CASQ2 homozygote/compound heterozygote genotype status in probands was associated with a 3.2-fold (95% CI, 1.3-8.0; P=0.013) increased hazard of a composite of cardiac syncope, aborted cardiac arrest, and sudden cardiac death, but a 38.8-fold (95% CI, 5.6-269.1; P<0.001) increased hazard in genotype-positive family members. In vitro turbidity assays revealed that p.R33Q and all 6 candidate dominant CASQ2 missense variants evaluated exhibited filamentation defects, but only p.R33Q convincingly failed to dimerize. Structural analysis revealed that 3 of these 6 putative dominant negative missense variants localized to an electronegative pocket considered critical for back-to-back binding of dimers. CONCLUSIONS This international multicenter study of CASQ2-CPVT redefines its heritability and confirms that pathogenic heterozygous CASQ2 variants may manifest with a CPVT phenotype, indicating a need to clinically screen these individuals. A dominant mode of inheritance appears intrinsic to certain missense variants because of their location and function within the CASQ2 filament structure.
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Wood DA, Mahmud E, Thourani VH, Sathananthan J, Virani A, Poppas A, Harrington RA, Dearani JA, Swaminathan M, Russo AM, Blankstein R, Dorbala S, Carr J, Virani S, Gin K, Packard A, Dilsizian V, Légaré JF, Leipsic J, Webb JG, Krahn AD. Safe Reintroduction of Cardiovascular Services During the COVID-19 Pandemic: From the North American Society Leadership. Ann Thorac Surg 2020; 110:733-740. [PMID: 32380058 PMCID: PMC7198197 DOI: 10.1016/j.athoracsur.2020.04.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 04/27/2020] [Indexed: 11/30/2022]
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105
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Steinberg C, Cheung CC, Wan D, Sodhi A, Claros S, Staples JA, Philippon F, Laksman Z, Sarrazin JF, Bennett M, Plourde B, Deyell MW, Andrade JG, Roy K, Yeung-Lai-Wah JA, Molin F, Hawkins NM, Blier L, Nault I, O'Hara G, Krahn AD, Champagne J, Chakrabarti S. Driving Restrictions and Early Arrhythmias in Patients Receiving a Primary-Prevention Implantable Cardioverter-Defibrillator (DREAM-ICD) Study. Can J Cardiol 2020; 36:1269-1277. [PMID: 32474110 DOI: 10.1016/j.cjca.2020.05.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 05/19/2020] [Accepted: 05/20/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Current guidelines recommend 4 weeks of private driving restriction after implantation of a primary-prevention implantable cardioverter-defibrillator (ICD). These driving restrictions result in significant inconvenience and social implications. Advances in medical treatment and ICD programming have lowered the overall rate of device therapies. The objective of this study was to assess the incidence of ICD therapies at 30, 60, and 180 days after implantation. METHODS Driving Restrictions and Early Arrhythmias in Patients Receiving a Primary-Prevention Implantable Cardioverter-Defibrillator (DREAM-ICD) was a retrospective cohort study conducted at 2 Canadian university centres enrolling patients with new implantation of a primary-prevention ICD. Device programming was standardised according to current guidelines. A total of 803 patients were enrolled. RESULTS The cumulative rates of appropriate ICD therapies at 30, 60, and 180 days were 0.12%, 0.50%, and 0.75%, respectively. There was no syncope during the first 6 months. The median duration to the first appropriate ICD therapy was 208 (range 23-1109) days after implantation. The rate of inappropriate ICD therapies at 30 days was only 0.2%. Overall, < 13.6% of all appropriate ICD therapies occurred within the first 6 months after implantation. CONCLUSIONS The rate of appropriate ICD therapies within the first 30 days after device insertion is extremely low in contemporary primary prevention cohorts with guideline-concordant device programming. There was no increased risk for ventricular arrhythmia early after ICD insertion. The results of DREAM-ICD suggest the need for a revision of the existing driving restrictions for primary-prevention ICD recipients.
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Lakkireddy DR, Chung MK, Deering TF, Gopinathannair R, Albert CM, Epstein LM, Harding CV, Hurwitz JL, Jeffery CC, Krahn AD, Kusumoto FM, Lampert R, Mansour M, Natale A, Patton KK, Seiler A, Shah MJ, Wang PJ, Russo AM. Guidance for Rebooting Electrophysiology Through the COVID-19 Pandemic From the Heart Rhythm Society and the American Heart Association Electrocardiography and Arrhythmias Committee of the Council on Clinical Cardiology: Endorsed by the American College of Cardiology. JACC Clin Electrophysiol 2020; 6:1053-1066. [PMID: 32819525 PMCID: PMC7291987 DOI: 10.1016/j.jacep.2020.06.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Coronavirus disease 2019 (COVID-19) has presented substantial challenges to patient care and impacted health care delivery, including cardiac electrophysiology practice throughout the globe. Based upon the undetermined course and regional variability of the pandemic, there is uncertainty as to how and when to resume and deliver electrophysiology services for arrhythmia patients. This joint document from representatives of the Heart Rhythm Society, American Heart Association, and American College of Cardiology seeks to provide guidance for clinicians and institutions reestablishing safe electrophysiological care. To achieve this aim, we address regional and local COVID-19 disease status, the role of viral screening and serologic testing, return-to-work considerations for exposed or infected health care workers, risk stratification and management strategies based on COVID-19 disease burden, institutional preparedness for resumption of elective procedures, patient preparation and communication, prioritization of procedures, and development of outpatient and periprocedural care pathways.
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Sandhu RK, Raj SR, Thiruganasambandamoorthy V, Kaul P, Morillo CA, Krahn AD, Guzman JC, Sheldon RS, Banijamali HS, MacIntyre C, Manlucu J, Seifer C, Sivilotti M. Canadian Cardiovascular Society Clinical Practice Update on the Assessment and Management of Syncope. Can J Cardiol 2020; 36:1167-1177. [PMID: 32624296 DOI: 10.1016/j.cjca.2019.12.023] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 12/19/2019] [Accepted: 12/22/2019] [Indexed: 10/23/2022] Open
Abstract
Syncope is a symptom that occurs in multiple settings and has a variety of underlying causes, ranging from benign to life threatening. Determining the underlying diagnosis and prognosis can be challenging and often results in an unstructured approach to evaluation, which is ineffective and costly. In this first ever document, the Canadian Cardiovascular Society (CCS) provides a clinical practice update on the assessment and management of syncope. It highlights similarities and differences between the 2017 American College of Cardiology/American Heart Association/Heart Rhythm Society and the 2018 European Society of Cardiology guidelines, draws on new data following a thorough review of medical literature, and takes the best available evidence and clinical experience to provide clinical practice tips. Where appropriate, a focus on a Canadian perspective is emphasized in order to illuminate larger international issues. This document represents the consensus of a Canadian panel comprised of multidisciplinary experts on this topic with a mandate to formulate disease-specific advice. The primary writing panel wrote the document, followed by peer review from the secondary writing panel. The CCS Guidelines Committee reviewed and approved the statement. The practice tips represent the consensus opinion of the primary writing panel authors, endorsed by the CCS. The CCS clinical practice update on the assessment and management of syncope focuses on epidemiology, the initial evaluation including risk stratification and disposition from the emergency department, initial diagnostic work-up, management of vasovagal syncope and orthostatic hypotension, and syncope and driving.
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Botly LC, Martin-Rhee M, Kasiban A, Swartz RH, Mulvagh SL, Lindsay MP, Goia C, Smith EE, Hill MD, Field TS, Krahn AD, Oudit GY, Zieroth S, Yip CY. COVID-19 Pandemic: Global Impact and Potential Implications for Cardiovascular Disease in Canada. CJC Open 2020; 2:265-272. [PMID: 32691023 PMCID: PMC7275173 DOI: 10.1016/j.cjco.2020.06.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 06/03/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The literature indicates that cardiovascular disease (CVD; including stroke), older age, and availability of health care resources affect COVID-19 case fatality rates (CFRs). The cumulative effect of COVID-19 CFRs in global CVD populations and the extrapolated effect on access to health care services in the CVD population in Canada are not fully known. In this study we explored the relationships of factors that might affect COVID-19 CFRs and estimated the potential indirect effects of COVID-19 on Canadian health care resources. METHODS Country-level epidemiological data were analyzed to study the correlation, main effect, and interaction between COVID-19 CFRs and: (1) the proportion of the population with CVD; (2) the proportion of the population 65 years of age or older; and (3) the availability of essential health services as defined by the World Health Organization Universal Health Coverage index. For indirect implications on health care resources, estimates of the volume of postponed coronary artery bypass grafting, percutaneous coronary intervention, and valve surgeries in Ontario were calculated. RESULTS Positive correlations were found between COVID-19 CFRs and: (1) the proportion of the population with CVD (ρ = 0.40; P = 0.001); (2) the proportion of the population 65 years of age or older (ρ = 0.43; P = 0.0005); and (3) Universal Health Coverage index (ρ = 0.27; P = 0.03). For every 1% increase in the proportion of the population 65 years of age or older or proportion of the population with CVD, the COVID-19 CFR was 9% and 19% higher, respectively. Approximately 1252 procedures would be postponed monthly in Ontario because of current public health measures. CONCLUSIONS Countries with more prevalent CVD reported higher COVID-19 CFRs. Strain on health care resources is likely in Canada.
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Wood DA, Mahmud E, Thourani VH, Sathananthan J, Virani A, Poppas A, Harrington RA, Dearani JA, Swaminathan M, Russo AM, Blankstein R, Dorbala S, Carr J, Virani S, Gin K, Packard A, Dilsizian V, Légaré JF, Leipsic J, Webb JG, Krahn AD. Safe Reintroduction of Cardiovascular Services During the COVID-19 Pandemic: From the North American Society Leadership. J Am Coll Cardiol 2020; 75:3177-3183. [PMID: 32380033 PMCID: PMC7198172 DOI: 10.1016/j.jacc.2020.04.063] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 04/29/2020] [Indexed: 11/14/2022]
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Moulson N, Bewick D, Selway T, Harris J, Suskin N, Oh P, Coutinho T, Singh G, Chow CM, Clarke B, Cowan S, Fordyce CB, Fournier A, Gin K, Gupta A, Hardiman S, Jackson S, Lamarche Y, Lau B, Légaré JF, Leong-Poi H, Mansour S, Marelli A, Quraishi AUR, Roifman I, Ruel M, Sapp J, Small G, Turgeon R, Wood DA, Zieroth S, Virani S, Krahn AD. Cardiac Rehabilitation During the COVID-19 Era: Guidance on Implementing Virtual Care. Can J Cardiol 2020; 36:1317-1321. [PMID: 32553606 PMCID: PMC7293761 DOI: 10.1016/j.cjca.2020.06.006] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 06/07/2020] [Accepted: 06/08/2020] [Indexed: 02/04/2023] Open
Abstract
Cardiac rehabilitation programs across Canada have suspended in-person services as a result of large-scale physical distancing recommendations designed to flatten the COVID-19 pandemic curve. Virtual cardiac rehabilitation (VCR) offers an alternate mechanism of care delivery, capable of providing similar patient outcomes and safety profiles compared with centre-based programs. To minimize care gaps, all centres should consider developing and implementing a VCR program. The process of this rapid implementation, however, can be daunting. Centres should initially focus on the collation, utilization, and repurposing of existing resources, equipment, and technology. Once established, programs should then focus on ensuring that quality indicators are met and care processes are protocolized. This should be followed by the development of sustainable VCR solutions to account for care gaps that existed before COVID-19, and to improve cardiac rehabilitation delivery, moving forward. This article reviews the potential challenges and obstacles of this process and aims to provide pragmatic guidance to aid clinicians and administrators during this challenging time.
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Lakkireddy DR, Chung MK, Deering TF, Gopinathannair R, Albert CM, Epstein LM, Harding CV, Hurwitz JL, Jeffery CC, Krahn AD, Kusumoto FM, Lampert R, Mansour M, Natale A, Patton KK, Seiler A, Shah MJ, Wang PJ, Russo AM. Guidance for Rebooting Electrophysiology Through the COVID-19 Pandemic From the Heart Rhythm Society and the American Heart Association Electrocardiography and Arrhythmias Committee of the Council on Clinical Cardiology. Circ Arrhythm Electrophysiol 2020; 13:e008999. [PMID: 32530306 PMCID: PMC7368851 DOI: 10.1161/circep.120.008999] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Coronavirus disease 2019 (COVID-19) has presented substantial challenges to patient care and impacted healthcare delivery, including cardiac electrophysiology practice throughout the globe. Based upon the undetermined course and regional variability of the pandemic, there is uncertainty as to how and when to resume and deliver electrophysiology services for patients with arrhythmia. This joint document from representatives of the Heart Rhythm Society, American Heart Association, and American College of Cardiology seeks to provide guidance for clinicians and institutions reestablishing safe electrophysiological care. To achieve this aim, we address regional and local COVID-19 disease status, the role of viral screening and serological testing, return-to-work considerations for exposed or infected health care workers, risk stratification and management strategies based on COVID-19 disease burden, institutional preparedness for resumption of elective procedures, patient preparation and communication, prioritization of procedures, and development of outpatient and periprocedural care pathways.
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112
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Lakkireddy DR, Chung MK, Deering TF, Gopinathannair R, Albert CM, Epstein LM, Harding CV, Hurwitz JL, Jeffery CC, Krahn AD, Kusumoto FM, Lampert R, Mansour M, Natale A, Patton KK, Seiler A, Shah MJ, Wang PJ, Russo AM. Guidance for rebooting electrophysiology through the COVID-19 pandemic from the Heart Rhythm Society and the American Heart Association Electrocardiography and Arrhythmias Committee of the Council on Clinical Cardiology: Endorsed by the American College of Cardiology. Heart Rhythm 2020; 17:e242-e254. [PMID: 32540298 PMCID: PMC7291964 DOI: 10.1016/j.hrthm.2020.06.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 06/09/2020] [Indexed: 01/12/2023]
Abstract
Coronavirus disease 2019 (COVID-19) has presented substantial challenges to patient care and impacted health care delivery, including cardiac electrophysiology practice throughout the globe. Based upon the undetermined course and regional variability of the pandemic, there is uncertainty as to how and when to resume and deliver electrophysiology services for arrhythmia patients. This joint document from representatives of the Heart Rhythm Society, American Heart Association, and American College of Cardiology seeks to provide guidance for clinicians and institutions reestablishing safe electrophysiological care. To achieve this aim, we address regional and local COVID-19 disease status, the role of viral screening and serologic testing, return-to-work considerations for exposed or infected health care workers, risk stratification and management strategies based on COVID-19 disease burden, institutional preparedness for resumption of elective procedures, patient preparation and communication, prioritization of procedures, and development of outpatient and periprocedural care pathways.
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Virani A, Singh G, Bewick D, Chow CM, Clarke B, Cowan S, Fordyce CB, Fournier A, Gin K, Gupta A, Hardiman S, Jackson S, Lamarche Y, Lau B, Légaré JF, Leong-Poi H, Mansour S, Marelli A, Quraishi A, Roifman I, Ruel M, John Sapp, Small G, Turgeon R, Wood DA, Zieroth S, Virani S, Krahn AD. Guiding Cardiac Care During the COVID-19 Pandemic: How Ethics Shapes Our Health System Response. Can J Cardiol 2020; 36:1313-1316. [PMID: 32505633 PMCID: PMC7270812 DOI: 10.1016/j.cjca.2020.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 05/27/2020] [Accepted: 06/02/2020] [Indexed: 12/01/2022] Open
Abstract
The COVID-19 pandemic has raised ethical questions for the cardiovascular leader and practitioner. Attention has been redirected from a system that focuses on individual patient benefit toward one that focuses on protecting society as a whole. Challenging resource allocation questions highlight the need for a clearly articulated ethics framework that integrates principled decision making into how different cardiovascular care services are prioritized. A practical application of the principles of harm minimisation, fairness, proportionality, respect, reciprocity, flexibility, and procedural justice is provided, and a model for prioritisation of the restoration of cardiovascular services is outlined. The prioritisation model may be used to determine how and when cardiovascular services should be continued or restored. There should be a focus on an iterative and responsive approach to broader health care system needs, such as other disease groups and local outbreaks.
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Lahrouchi N, Tadros R, Crotti L, Mizusawa Y, Postema PG, Beekman L, Walsh R, Hasegawa K, Barc J, Ernsting M, Turkowski KL, Mazzanti A, Beckmann BM, Shimamoto K, Diamant UB, Wijeyeratne YD, Kucho Y, Robyns T, Ishikawa T, Arbelo E, Christiansen M, Winbo A, Jabbari R, Lubitz SA, Steinfurt J, Rudic B, Loeys B, Shoemaker MB, Weeke PE, Pfeiffer R, Davies B, Andorin A, Hofman N, Dagradi F, Pedrazzini M, Tester DJ, Bos JM, Sarquella-Brugada G, Campuzano Ó, Platonov PG, Stallmeyer B, Zumhagen S, Nannenberg EA, Veldink JH, van den Berg LH, Al-Chalabi A, Shaw CE, Shaw PJ, Morrison KE, Andersen PM, Müller-Nurasyid M, Cusi D, Barlassina C, Galan P, Lathrop M, Munter M, Werge T, Ribasés M, Aung T, Khor CC, Ozaki M, Lichtner P, Meitinger T, van Tintelen JP, Hoedemaekers Y, Denjoy I, Leenhardt A, Napolitano C, Shimizu W, Schott JJ, Gourraud JB, Makiyama T, Ohno S, Itoh H, Krahn AD, Antzelevitch C, Roden DM, Saenen J, Borggrefe M, Odening KE, Ellinor PT, Tfelt-Hansen J, Skinner JR, van den Berg MP, Olesen MS, Brugada J, Brugada R, Makita N, Breckpot J, Yoshinaga M, Behr ER, Rydberg A, Aiba T, Kääb S, Priori SG, Guicheney P, Tan HL, Newton-Cheh C, Ackerman MJ, Schwartz PJ, Schulze-Bahr E, Probst V, Horie M, Wilde AA, Tanck MWT, Bezzina CR. Transethnic Genome-Wide Association Study Provides Insights in the Genetic Architecture and Heritability of Long QT Syndrome. Circulation 2020; 142:324-338. [PMID: 32429735 PMCID: PMC7382531 DOI: 10.1161/circulationaha.120.045956] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Supplemental Digital Content is available in the text. Long QT syndrome (LQTS) is a rare genetic disorder and a major preventable cause of sudden cardiac death in the young. A causal rare genetic variant with large effect size is identified in up to 80% of probands (genotype positive) and cascade family screening shows incomplete penetrance of genetic variants. Furthermore, a proportion of cases meeting diagnostic criteria for LQTS remain genetically elusive despite genetic testing of established genes (genotype negative). These observations raise the possibility that common genetic variants with small effect size contribute to the clinical picture of LQTS. This study aimed to characterize and quantify the contribution of common genetic variation to LQTS disease susceptibility.
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Wood DA, Mahmud E, Thourani VH, Sathananthan J, Virani A, Poppas A, Harrington RA, Dearani JA, Swaminathan M, Russo AM, Blankstein R, Dorbala S, Carr J, Virani S, Gin K, Packard A, Dilsizian V, Légaré JF, Leipsic J, Webb JG, Krahn AD. Safe Reintroduction of Cardiovascular Services During the COVID-19 Pandemic: From the North American Society Leadership. Can J Cardiol 2020; 36:971-976. [PMID: 32380228 PMCID: PMC7198201 DOI: 10.1016/j.cjca.2020.04.031] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 04/29/2020] [Indexed: 01/28/2023] Open
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Thiruganasambandamoorthy V, Sivilotti MLA, Le Sage N, Yan JW, Huang P, Hegdekar M, Mercier E, Mukarram M, Nemnom MJ, McRae AD, Rowe BH, Stiell IG, Wells GA, Krahn AD, Taljaard M. Multicenter Emergency Department Validation of the Canadian Syncope Risk Score. JAMA Intern Med 2020; 180:737-744. [PMID: 32202605 PMCID: PMC7091474 DOI: 10.1001/jamainternmed.2020.0288] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
IMPORTANCE The management of patients with syncope in the emergency department (ED) is challenging because no robust risk tool available has been recommended for clinical use. OBJECTIVE To validate the Canadian Syncope Risk Score (CSRS) in a new cohort of patients with syncope to determine its ability to predict 30-day serious outcomes not evident during index ED evaluation. DESIGN, SETTING, AND PARTICIPANTS This prospective multicenter cohort study conducted at 9 EDs across Canada included patients 16 years and older who presented to EDs within 24 hours of syncope. Patients were enrolled from March 2014 to April 2018. MAIN OUTCOMES AND MEASURES Baseline characteristics, CSRS predictors, and 30-day adjudicated serious outcomes, including arrhythmic (arrhythmias, interventions for arrhythmia, or unknown cause of death) and nonarrhythmic (myocardial infarction, structural heart disease, pulmonary embolism, or hemorrhage) serious outcomes, were collected. Calibration and discrimination characteristics for CSRS validation were calculated. RESULTS A total of 3819 patients were included (mean [SD] age 53.9 [22.8] years; 2088 [54.7%] female), of whom 139 (3.6%) experienced 30-day serious outcomes, including 13 patients (0.3%) who died. In the validation cohort, there were no differences between the predicted and observed risk, the calibration slope was 1.0, and the area under the receiver operating characteristic curve was 0.91 (95% CI, 0.88-0.93). The empirical probability of a 30-day serious outcome during validation was 3.64% (95% CI, 3.09%-4.28%) compared with the model-predicted probability of 3.17% (95% CI, 2.66%-3.77%; P = .26). The proportion of patients with 30-day serious outcomes increased from 3 of 1631 (0.3%) in the very-low-risk group to 40 of 78 (51.3%) in the very-high-risk group (Cochran-Armitage trend test P < .001). There was a similar significant increase in the serious outcome subtypes with increasing CSRS risk category. None of the very-low-risk and low-risk patients died or experienced ventricular arrhythmia. At a threshold score of -1 (2145 of 3819 patients), the CSRS sensitivity and specificity were 97.8% (95% CI, 93.8%-99.6%) and 44.3% (95% CI, 42.7%-45.9%), respectively. CONCLUSIONS AND RELEVANCE The CSRS was successfully validated and its use is recommended to guide ED management of patients when serious causes are not identified during index ED evaluation. Very-low-risk and low-risk patients can generally be discharged, while brief hospitalization can be considered for high-risk patients. We believe CSRS implementation has the potential to improve patient safety and health care efficiency.
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Sapp JL, Alqarawi W, MacIntyre CJ, Tadros R, Steinberg C, Roberts JD, Laksman Z, Healey JS, Krahn AD. Guidance on Minimizing Risk of Drug-Induced Ventricular Arrhythmia During Treatment of COVID-19: A Statement from the Canadian Heart Rhythm Society. Can J Cardiol 2020; 36:948-951. [PMID: 32299753 PMCID: PMC7195336 DOI: 10.1016/j.cjca.2020.04.003] [Citation(s) in RCA: 90] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 04/02/2020] [Indexed: 12/27/2022] Open
Abstract
The COVID-19 pandemic has led to efforts at rapid investigation and application of drugs which may improve prognosis but for which safety and efficacy are not yet established. This document attempts to provide reasonable guidance for the use of antimicrobials which have uncertain benefit but may increase risk of QT interval prolongation and ventricular proarrhythmia, notably, chloroquine, hydroxychloroquine, azithromycin, and lopinavir/ritonavir. During the pandemic, efforts to reduce spread and minimize effects on health care resources mandate minimization of unnecessary medical procedures and testing. We recommend that the risk of drug proarrhythmia be minimized by 1) discontinuing unnecessary medications that may also increase the QT interval, 2) identifying outpatients who are likely to be at low risk and do not need further testing (no history of prolonged QT interval, unexplained syncope, or family history of premature sudden cardiac death, no medications that may prolong the QT interval, and/or a previous known normal corrected QT interval [QTc]), and 3) performing baseline testing in hospitalized patients or those who may be at higher risk. If baseline electrocardiographic testing reveals a moderately prolonged QTc, optimization of medications and electrolytes may permit therapy. If the QTc is markedly prolonged, drugs that further prolong it should be avoided, or expert consultation may permit administration with mitigating precautions. These recommendations are made while there are no known effective treatments for COVID-19 and should be revisited when further data on efficacy and safety become available.
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Cheung CC, Davies B, Gibbs K, Laksman ZW, Krahn AD. Multilead QT Screening Is Necessary for QT Measurement: Implications for Management of Patients in the COVID-19 Era. JACC Clin Electrophysiol 2020; 6:878-880. [PMID: 32703574 PMCID: PMC7141442 DOI: 10.1016/j.jacep.2020.04.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 04/03/2020] [Accepted: 04/03/2020] [Indexed: 12/27/2022]
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Krahn AD, Birnie DH. A longer look at preventing cardiac device infection. Heart Rhythm 2020; 17:1123-1124. [PMID: 32165182 DOI: 10.1016/j.hrthm.2020.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 03/03/2020] [Indexed: 10/24/2022]
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Tarakji KG, Krahn AD, Poole J, Mittal S, Kennergren C, Corey GR, Biffi M, Korantzopoulos P, Dallaglio P, Lexcen D, Lande JD, Holbrook R, Wilkoff B. USE OF MACHINE LEARNING TECHNIQUES TO IDENTIFY RISK FACTORS FOR CARDIAC IMPLANTABLE ELECTRONIC DEVICE (CIED) INFECTION: LESSONS FROM THE WRAP-IT TRIAL. J Am Coll Cardiol 2020. [DOI: 10.1016/s0735-1097(20)30920-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Lieve KV, Dusi V, van der Werf C, Bos JM, Lane CM, Stokke MK, Roston TM, Djupsjöbacka A, Wada Y, Denjoy I, Bundgaard H, Noguer FRI, Semsarian C, Robyns T, Hofman N, Tanck MW, van den Berg MP, Kammeraad JA, Krahn AD, Clur SAB, Sacher F, Till J, Skinner JR, Tfelt-Hansen J, Probst V, Leenhardt A, Horie M, Swan H, Roberts JD, Sanatani S, Haugaa KH, Schwartz PJ, Ackerman MJ, Wilde AA. Heart Rate Recovery After Exercise Is Associated With Arrhythmic Events in Patients With Catecholaminergic Polymorphic Ventricular Tachycardia. Circ Arrhythm Electrophysiol 2020; 13:e007471. [DOI: 10.1161/circep.119.007471] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Risk stratification in catecholaminergic polymorphic ventricular tachycardia remains ill defined. Heart rate recovery (HRR) immediately after exercise is regulated by autonomic reflexes, particularly vagal tone, and may be associated with symptoms and ventricular arrhythmias in patients with catecholaminergic polymorphic ventricular tachycardia. Our objective was to evaluate whether HRR after maximal exercise on the exercise stress test (EST) is associated with symptoms and ventricular arrhythmias.
Methods:
In this retrospective observational study, we included patients ≤65 years of age with an EST without antiarrhythmic drugs who attained at least 80% of their age- and sex-predicted maximal HR. HRR in the recovery phase was calculated as the difference in heart rate (HR) at maximal exercise and at 1 minute in the recovery phase (ΔHRR1′).
Results:
We included 187 patients (median age, 36 years; 68 [36%] symptomatic before diagnosis). Pre-EST HR and maximal HR were equal among symptomatic and asymptomatic patients. Patients who were symptomatic before diagnosis had a greater ΔHRR1′ after maximal exercise (43 [interquartile range, 25–58] versus 25 [interquartile range, 19–34] beats/min;
P
<0.001). Corrected for age, sex, and relatedness, patients in the upper tertile for ΔHRR1′ had an odds ratio of 3.4 (95% CI, 1.6–7.4) of being symptomatic before diagnosis (
P
<0.001). In addition, ΔHRR1′ was higher in patients with complex ventricular arrhythmias at EST off antiarrhythmic drugs (33 [interquartile range, 22–48] versus 27 [interquartile range, 20–36] beats/min;
P
=0.01). After diagnosis, patients with a ΔHRR1′ in the upper tertile of its distribution had significantly more arrhythmic events as compared with patients in the other tertiles (
P
=0.045).
Conclusions:
Catecholaminergic polymorphic ventricular tachycardia patients with a larger HRR following exercise are more likely to be symptomatic and have complex ventricular arrhythmias during the first EST off antiarrhythmic drug.
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Cheung CC, Tadros R, Davies B, Krahn AD. Genetic Testing in Inherited Arrhythmias: Approach, Limitations, and Challenges. Can J Cardiol 2020; 36:584-587. [PMID: 32007350 DOI: 10.1016/j.cjca.2019.08.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 08/22/2019] [Accepted: 08/23/2019] [Indexed: 11/18/2022] Open
Abstract
Genetic testing is playing an ever-expanding role in cardiovascular care and is becoming part of the "toolkit" for the cardiovascular clinician. In patients with inherited arrhythmias, genetic testing can confirm a suspected diagnosis, establish a diagnosis in unexplained cases, and help facilitate cascade family screening. Many inherited arrhythmia syndromes are monogenic diseases arising from a single pathogenic variant involved in the structure and function of cardiac ion channels or structural proteins. As such, "arrhythmia gene panels" will often cast a wide net for such heritable diseases. However, challenges may arise when genetic testing results are ambiguous, or when genetic testing results (genotype) and clinical phenotypes do not match. In cases of "genotype-phenotype matching," genetic results complement the clinical phenotype and genetic testing can be used in diagnosis, family screening, and occasionally prognostication. It becomes more challenging when genetic results are negative or noncontributory and "contradict" the clinical phenotype. "Genotype mismatches" can also occur when genotype-positive patients have no clinical phenotype, or when genetic testing results point towards a completely different disease than the clinical phenotype. We discuss an approach to genetic testing and review the challenges that may arise when interpreting genetic testing results. Genetic testing has opened a wealth of opportunities in the diagnosis, management, and cascade screening of inherited arrhythmia syndromes, but has also opened a "Pandora's box" of challenges. Genetic results should be interpreted with caution and in a multidisciplinary clinic, with support from genetic counsellors and an expert with a focused interest in cardiovascular genetics.
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Isbister JC, Krahn AD, Semsarian C, Sy RW. Brugada Syndrome: Clinical Care Amidst Pathophysiological Uncertainty. Heart Lung Circ 2020; 29:538-546. [PMID: 31959551 DOI: 10.1016/j.hlc.2019.11.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 11/14/2019] [Accepted: 11/25/2019] [Indexed: 12/11/2022]
Abstract
Brugada syndrome (BrS) is a complex clinical entity with ongoing conjecture regarding its genetic basis, underlying pathophysiology, and clinical management. Within this paradigm of uncertainty, clinicians are faced with the challenge of caring for patients with this uncommon but potentially fatal condition. This article reviews the current understanding of BrS and highlights the "known unknowns" to reinforce the need for flexible clinical practice in parallel with ongoing scientific discovery.
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Roberts JD, Asaki SY, Mazzanti A, Bos JM, Tuleta I, Muir AR, Crotti L, Krahn AD, Kutyifa V, Shoemaker MB, Johnsrude CL, Aiba T, Marcondes L, Baban A, Udupa S, Dechert B, Fischbach P, Knight LM, Vittinghoff E, Kukavica D, Stallmeyer B, Giudicessi JR, Spazzolini C, Shimamoto K, Tadros R, Cadrin-Tourigny J, Duff HJ, Simpson CS, Roston TM, Wijeyeratne YD, El Hajjaji I, Yousif MD, Gula LJ, Leong-Sit P, Chavali N, Landstrom AP, Marcus GM, Dittmann S, Wilde AAM, Behr ER, Tfelt-Hansen J, Scheinman MM, Perez MV, Kaski JP, Gow RM, Drago F, Aziz PF, Abrams DJ, Gollob MH, Skinner JR, Shimizu W, Kaufman ES, Roden DM, Zareba W, Schwartz PJ, Schulze-Bahr E, Etheridge SP, Priori SG, Ackerman MJ. An International Multicenter Evaluation of Type 5 Long QT Syndrome: A Low Penetrant Primary Arrhythmic Condition. Circulation 2020; 141:429-439. [PMID: 31941373 DOI: 10.1161/circulationaha.119.043114] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Insight into type 5 long QT syndrome (LQT5) has been limited to case reports and small family series. Improved understanding of the clinical phenotype and genetic features associated with rare KCNE1 variants implicated in LQT5 was sought through an international multicenter collaboration. METHODS Patients with either presumed autosomal dominant LQT5 (N = 229) or the recessive Type 2 Jervell and Lange-Nielsen syndrome (N = 19) were enrolled from 22 genetic arrhythmia clinics and 4 registries from 9 countries. KCNE1 variants were evaluated for ECG penetrance (defined as QTc >460 ms on presenting ECG) and genotype-phenotype segregation. Multivariable Cox regression was used to compare the associations between clinical and genetic variables with a composite primary outcome of definite arrhythmic events, including appropriate implantable cardioverter-defibrillator shocks, aborted cardiac arrest, and sudden cardiac death. RESULTS A total of 32 distinct KCNE1 rare variants were identified in 89 probands and 140 genotype positive family members with presumed LQT5 and an additional 19 Type 2 Jervell and Lange-Nielsen syndrome patients. Among presumed LQT5 patients, the mean QTc on presenting ECG was significantly longer in probands (476.9±38.6 ms) compared with genotype positive family members (441.8±30.9 ms, P<0.001). ECG penetrance for heterozygous genotype positive family members was 20.7% (29/140). A definite arrhythmic event was experienced in 16.9% (15/89) of heterozygous probands in comparison with 1.4% (2/140) of family members (adjusted hazard ratio [HR] 11.6 [95% CI, 2.6-52.2]; P=0.001). Event incidence did not differ significantly for Type 2 Jervell and Lange-Nielsen syndrome patients relative to the overall heterozygous cohort (10.5% [2/19]; HR 1.7 [95% CI, 0.3-10.8], P=0.590). The cumulative prevalence of the 32 KCNE1 variants in the Genome Aggregation Database, which is a human database of exome and genome sequencing data from now over 140 000 individuals, was 238-fold greater than the anticipated prevalence of all LQT5 combined (0.238% vs 0.001%). CONCLUSIONS The present study suggests that putative/confirmed loss-of-function KCNE1 variants predispose to QT prolongation, however, the low ECG penetrance observed suggests they do not manifest clinically in the majority of individuals, aligning with the mild phenotype observed for Type 2 Jervell and Lange-Nielsen syndrome patients.
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Essebag V, Healey JS, Joza J, Nery PB, Kalfon E, Leiria TLL, Verma A, Ayala-Paredes F, Coutu B, Sumner GL, Becker G, Philippon F, Eikelboom J, Sandhu RK, Sapp J, Leather R, Yung D, Thibault B, Simpson CS, Ahmad K, Toal S, Sturmer M, Kavanagh K, Crystal E, Wells GA, Krahn AD, Birnie DH. Effect of Direct Oral Anticoagulants, Warfarin, and Antiplatelet Agents on Risk of Device Pocket Hematoma: Combined Analysis of BRUISE CONTROL 1 and 2. Circ Arrhythm Electrophysiol 2019; 12:e007545. [PMID: 31610718 DOI: 10.1161/circep.119.007545] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Oral anticoagulant use is common among patients undergoing pacemaker or defibrillator surgery. BRUISE CONTROL (Bridge or Continue Coumadin for Device Surgery Randomized Controlled Trial; NCT00800137) demonstrated that perioperative warfarin continuation reduced clinically significant hematomas (CSH) by 80% compared with heparin bridging (3.5% versus 16%). BRUISE-CONTROL-2 (NCT01675076) observed a similarly low risk of CSH when comparing continued versus interrupted direct oral anticoagulant (2.1% in both groups). Using patient level data from both trials, the current study aims to: (1) evaluate the effect of concomitant antiplatelet therapy on CSH, and (2) understand the relative risk of CSH in patients treated with direct oral anticoagulant versus continued warfarin. METHODS We analyzed 1343 patients included in BRUISE-CONTROL-1 and BRUISE-CONTROL-2. The primary outcome for both trials was CSH. There were 408 patients identified as having continued either a single or dual antiplatelet agent at the time of device surgery. RESULTS Antiplatelet use (versus nonuse) was associated with CSH in 9.8% versus 4.3% of patients (P<0.001), and remained a strong independent predictor after multivariable adjustment (odds ratio, 1.965; 95% CI, 1.202-3.213; P=0.0071). In multivariable analysis, adjusting for antiplatelet use, there was no significant difference in CSH observed between direct oral anticoagulant use compared with continued warfarin (odds ratio, 0.858; 95% CI, 0.375-1.963; P=0.717). CONCLUSIONS Concomitant antiplatelet therapy doubled the risk of CSH during device surgery. No difference in CSH was found between direct oral anticoagulant versus continued warfarin. In anticoagulated patients undergoing elective or semi-urgent device surgery, the patient specific benefit/risk of holding an antiplatelet should be carefully considered. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifiers: NCT00800137, NCT01675076.
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Thiruganasambandamoorthy V, Rowe BH, Sivilotti MLA, McRae AD, Arcot K, Nemnom MJ, Huang L, Mukarram M, Krahn AD, Wells GA, Taljaard M. Response by Thiruganasambandamoorthy et al to Letters Regarding Article, "Duration of Electrocardiographic Monitoring of Emergency Department Patients With Syncope". Circulation 2019; 140:e655-e656. [PMID: 31525105 DOI: 10.1161/circulationaha.119.041639] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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127
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Krahn AD, Longtin Y, Philippon F, Birnie DH, Manlucu J, Angaran P, Rinne C, Coutu B, Low RA, Essebag V, Morillo C, Redfearn D, Toal S, Becker G, Degrâce M, Thibault B, Crystal E, Tung S, LeMaitre J, Sultan O, Bennett M, Bashir J, Ayala-Paredes F, Gervais P, Rioux L, Hemels MEW, Bouwels LHR, van Vlies B, Wang J, Exner DV, Dorian P, Parkash R, Alings M, Connolly SJ. Prevention of Arrhythmia Device Infection Trial: The PADIT Trial. J Am Coll Cardiol 2019; 72:3098-3109. [PMID: 30545448 DOI: 10.1016/j.jacc.2018.09.068] [Citation(s) in RCA: 128] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 09/09/2018] [Accepted: 09/16/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Infection of implanted medical devices has catastrophic consequences. For cardiac rhythm devices, pre-procedural cefazolin is standard prophylaxis but does not protect against methicillin-resistant gram-positive organisms, which are common pathogens in device infections. OBJECTIVE This study tested the clinical effectiveness of incremental perioperative antibiotics to reduce device infection. METHODS The authors performed a cluster randomized crossover trial with 4 randomly assigned 6-month periods, during which centers used either conventional or incremental periprocedural antibiotics for all cardiac implantable electronic device procedures as standard procedure. Conventional treatment was pre-procedural cefazolin infusion. Incremental treatment was pre-procedural cefazolin plus vancomycin, intraprocedural bacitracin pocket wash, and 2-day post-procedural oral cephalexin. The primary outcome was 1-year hospitalization for device infection in the high-risk group, analyzed by hierarchical logistic regression modeling, adjusting for random cluster and cluster-period effects. RESULTS Device procedures were performed in 28 centers in 19,603 patients, of whom 12,842 were high risk. Infection occurred in 99 patients (1.03%) receiving conventional treatment, and in 78 (0.78%) receiving incremental treatment (odds ratio: 0.77; 95% confidence interval: 0.56 to 1.05; p = 0.10). In high-risk patients, hospitalization for infection occurred in 77 patients (1.23%) receiving conventional antibiotics and in 66 (1.01%) receiving incremental antibiotics (odds ratio: 0.82; 95% confidence interval: 0.59 to 1.15; p = 0.26). Subgroup analysis did not identify relevant patient or site characteristics with significant benefit from incremental therapy. CONCLUSIONS The cluster crossover design efficiently tested clinical effectiveness of incremental antibiotics to reduce device infection. Device infection rates were low. The observed difference in infection rates was not statistically significant. (Prevention of Arrhythmia Device Infection Trial [PADIT Pilot] [PADIT]; NCT01002911).
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Mellor GJ, Panwar P, Lee AK, Steinberg C, Hathaway JA, Bartels K, Christian S, Balaji S, Roberts JD, Simpson CS, Boczek NJ, Tester DJ, Radbill AE, Mok NS, Hamilton RM, Kaufman ES, Eugenio PL, Weiss R, January C, McDaniel GM, Leather RA, Erickson C, Falik S, Behr ER, Wilde AAM, Sanatani S, Ackerman MJ, Van Petegem F, Krahn AD, Laksman Z. Type 8 long QT syndrome: pathogenic variants in CACNA1C-encoded Cav1.2 cluster in STAC protein binding site. Europace 2019; 21:1725-1732. [DOI: 10.1093/europace/euz215] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 07/18/2019] [Indexed: 11/12/2022] Open
Abstract
Abstract
Aims
Pathogenic gain-of-function variants in CACAN1C cause type-8 long QT syndrome (LQT8). We sought to describe the electrocardiographic features in LQT8 and utilize molecular modelling to gain mechanistic insights into its genetic culprits.
Methods and results
Rare variants in CACNA1C were identified from genetic testing laboratories. Treating physicians provided clinical information. Variant pathogenicity was independently assessed according to recent guidelines. Pathogenic (P) and likely pathogenic (LP) variants were mapped onto a 3D modelled structure of the Cav1.2 protein. Nine P/LP variants, identified in 23 patients from 19 families with non-syndromic LQTS were identified. Six variants, found in 79% of families, clustered to a 4-residue section in the cytosolic II–III loop region which forms a region capable of binding STAC SH3 domains. Therefore, variants may affect binding of SH3-domain containing proteins. Arrhythmic events occurred in similar proportions of patients with II–III loop variants and with other P/LP variants (53% vs. 48%, P = 0.41) despite shorter QTc intervals (477 ± 31 ms vs. 515 ± 37 ms, P = 0.03). A history of sudden death was reported only in families with II–III loop variants (60% vs. 0%, P = 0.03). The predominant T-wave morphology was a late peaking T wave with a steep descending limb. Exercise testing demonstrated QTc prolongation on standing and at 4 min recovery after exercise.
Conclusion
The majority of P/LP variants in patients with CACNA1C-mediated LQT8 cluster in an SH3-binding domain of the cytosolic II–III loop. This represents a ‘mutation hotspot’ in LQT8. A late-peaking T wave with a steep descending limb and QT prolongation on exercise are commonly seen.
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Rodés-Cabau J, Ellenbogen KA, Krahn AD, Latib A, Mack M, Mittal S, Muntané-Carol G, Nazif TM, Sondergaard L, Urena M, Windecker S, Philippon F. Management of Conduction Disturbances Associated With Transcatheter Aortic Valve Replacement. J Am Coll Cardiol 2019; 74:1086-1106. [DOI: 10.1016/j.jacc.2019.07.014] [Citation(s) in RCA: 171] [Impact Index Per Article: 34.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 07/05/2019] [Accepted: 07/07/2019] [Indexed: 12/12/2022]
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Shenasa M, Krahn AD. Antibiotic prophylaxis for cardiac implantable electronic devices: Is the jury out yet? Pacing Clin Electrophysiol 2019; 42:1079-1080. [DOI: 10.1111/pace.13743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 05/28/2019] [Indexed: 11/29/2022]
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Essebag V, AlTurki A, Proietti R, Healey JS, Wells GA, Verma A, Krahn AD, Simpson CS, Ayala-Paredes F, Coutu B, Leather R, Ahmad K, Toal S, Sapp J, Sturmer M, Kavanagh K, Crystal E, Leiria TL, Seifer C, Rinne C, Birnie D. Concomitant anti-platelet therapy in warfarin-treated patients undergoing cardiac rhythm device implantation: A secondary analysis of the BRUISE CONTROL trial. Int J Cardiol 2019; 288:87-93. [DOI: 10.1016/j.ijcard.2019.04.066] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 03/03/2019] [Accepted: 04/23/2019] [Indexed: 12/21/2022]
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Roston TM, Hart A, Krahn AD, Sanatani S. The challenge of implantable cardioverter-defibrillator programming and shock interpretation in treatment-refractory catecholaminergic polymorphic ventricular tachycardia. J Cardiovasc Med (Hagerstown) 2019; 20:569-571. [DOI: 10.2459/jcm.0000000000000814] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Janzen M, Cheung CC, Steinberg C, Lam PY, Krahn AD. Changes on the electrocardiogram in anorexia nervosa: A case control study. J Electrocardiol 2019; 56:64-69. [PMID: 31319227 DOI: 10.1016/j.jelectrocard.2019.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 07/02/2019] [Accepted: 07/07/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE Anorexia nervosa is a complex psychiatric condition with increased mortality. The electrocardiogram (ECG) may show repolarization changes which may associate with an increased risk of sudden death. Up to 80% of patients may be prescribed psychopharmacotherapies which alter the ECG, potentially compounding arrhythmic risk. This study aimed to describe and improve understanding of ECG changes in eating disorders and assess the effect of psychopharmacotherapies. METHODS Adolescent patients diagnosed with anorexia nervosa were reviewed. ECGs were reviewed by blinded expert reviewers, and repolarization parameters were compared to healthy controls. Patients on and off psychopharmacotherapies were compared. RESULTS Thirty-eight anorexia nervosa patients off psychopharmacotherapies were age matched to 53 healthy controls. Heart rate was lower in anorexia nervosa patients (56 vs. 74 bpm, p < 0.001). The absolute QT interval was longer in patients compared to controls (408 vs. 383 ms, p < 0.001), but the QTc by Hodges' formula was similar between groups (401 vs. 408 ms, p = 0.16). The prevalence of T-wave flattening and inversion was also similar between groups (13% vs. 4%, p = 0.12) and T-peak to T-end interval (Tpe) was shorter in patients compared to controls (p < 0.01). ECG parameters were similar between patients on and off psychopharmacotherapies aside from off-drug patients showing lower HR (56 vs. 65, p = 0.04). CONCLUSIONS Autonomic and repolarization changes are evident on the ECG of anorexia nervosa patients, though the QTc interval was in fact similar between groups. Changes in T-wave morphology and duration may be promising metrics of repolarization effects of anorexia nervosa.
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Roberts JD, Murphy NP, Hamilton RM, Lubbers ER, James CA, Kline CF, Gollob MH, Krahn AD, Sturm AC, Musa H, El-Refaey M, Koenig S, Aneq MÅ, Hoorntje ET, Graw SL, Davies RW, Rafiq MA, Koopmann TT, Aafaqi S, Fatah M, Chiasson DA, Taylor MR, Simmons SL, Han M, van Opbergen CJ, Wold LE, Sinagra G, Mittal K, Tichnell C, Murray B, Codima A, Nazer B, Nguyen DT, Marcus FI, Sobriera N, Lodder EM, van den Berg MP, Spears DA, Robinson JF, Ursell PC, Green AK, Skanes AC, Tang AS, Gardner MJ, Hegele RA, van Veen TA, Wilde AA, Healey JS, Janssen PM, Mestroni L, van Tintelen JP, Calkins H, Judge DP, Hund TJ, Scheinman MM, Mohler PJ. Ankyrin-B dysfunction predisposes to arrhythmogenic cardiomyopathy and is amenable to therapy. J Clin Invest 2019; 129:3171-3184. [PMID: 31264976 PMCID: PMC6668697 DOI: 10.1172/jci125538] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 05/14/2019] [Indexed: 01/11/2023] Open
Abstract
Arrhythmogenic cardiomyopathy (ACM) is an inherited arrhythmia syndrome characterized by severe structural and electrical cardiac phenotypes, including myocardial fibrofatty replacement and sudden cardiac death. Clinical management of ACM is largely palliative, owing to an absence of therapies that target its underlying pathophysiology, which stems partially from our limited insight into the condition. Following identification of deceased ACM probands possessing ANK2 rare variants and evidence of ankyrin-B loss of function on cardiac tissue analysis, an ANK2 mouse model was found to develop dramatic structural abnormalities reflective of human ACM, including biventricular dilation, reduced ejection fraction, cardiac fibrosis, and premature death. Desmosomal structure and function appeared preserved in diseased human and murine specimens in the presence of markedly abnormal β-catenin expression and patterning, leading to identification of a previously unknown interaction between ankyrin-B and β-catenin. A pharmacological activator of the WNT/β-catenin pathway, SB-216763, successfully prevented and partially reversed the murine ACM phenotypes. Our findings introduce what we believe to be a new pathway for ACM, a role of ankyrin-B in cardiac structure and signaling, a molecular link between ankyrin-B and β-catenin, and evidence for targeted activation of the WNT/β-catenin pathway as a potential treatment for this disease.
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Wong EK, Bartels K, Hathaway J, Burns C, Yeates L, Semsarian C, Krahn AD, Virani A, Ingles J. Perceptions of genetic variant reclassification in patients with inherited cardiac disease. Eur J Hum Genet 2019; 27:1134-1142. [PMID: 30903112 PMCID: PMC6777462 DOI: 10.1038/s41431-019-0377-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 01/16/2019] [Accepted: 03/01/2019] [Indexed: 01/08/2023] Open
Abstract
Interpretation of sequence variants is an ongoing challenge and new approaches aim to increase stringency. The reclassification of variants has the potential to alter medical management and elicit psychosocial consequences for patients. The perspective of patients with an inherited cardiac disease and a clinically significant variant reclassification was explored through semi-structured phone interviews. Participants were recruited from two specialized multidisciplinary centers in Canada and Australia. Qualitative analysis was performed through a thematic analysis approach. Fifteen participants were interviewed, including 9 (60%) with an inherited cardiomyopathy and 6 (40%) with an inherited arrhythmia syndrome. Six (40%) patients had a classification upgrade, while 9 (60%) had a downgrade. Four major themes emerged: (1) reactions towards the reclassified variant; (2) impact on decision-making; (3) perception of the reclassification process; and (4) improvement of the reclassification process. Many patients adjusted to the reclassification, however some misunderstood the implications, impacting their responses and decision-making. In conclusion, careful discussion with patients about uncertainty and the potential for reclassification are crucial to ensure a deeper understanding of the outcome of genetic testing and impact on families.
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Towbin JA, McKenna WJ, Abrams DJ, Ackerman MJ, Calkins H, Darrieux FCC, Daubert JP, de Chillou C, DePasquale EC, Desai MY, Estes NAM, Hua W, Indik JH, Ingles J, James CA, John RM, Judge DP, Keegan R, Krahn AD, Link MS, Marcus FI, McLeod CJ, Mestroni L, Priori SG, Saffitz JE, Sanatani S, Shimizu W, van Tintelen JP, Wilde AAM, Zareba W. 2019 HRS expert consensus statement on evaluation, risk stratification, and management of arrhythmogenic cardiomyopathy. Heart Rhythm 2019; 16:e301-e372. [PMID: 31078652 DOI: 10.1016/j.hrthm.2019.05.007] [Citation(s) in RCA: 413] [Impact Index Per Article: 82.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Indexed: 02/08/2023]
Abstract
Arrhythmogenic cardiomyopathy (ACM) is an arrhythmogenic disorder of the myocardium not secondary to ischemic, hypertensive, or valvular heart disease. ACM incorporates a broad spectrum of genetic, systemic, infectious, and inflammatory disorders. This designation includes, but is not limited to, arrhythmogenic right/left ventricular cardiomyopathy, cardiac amyloidosis, sarcoidosis, Chagas disease, and left ventricular noncompaction. The ACM phenotype overlaps with other cardiomyopathies, particularly dilated cardiomyopathy with arrhythmia presentation that may be associated with ventricular dilatation and/or impaired systolic function. This expert consensus statement provides the clinician with guidance on evaluation and management of ACM and includes clinically relevant information on genetics and disease mechanisms. PICO questions were utilized to evaluate contemporary evidence and provide clinical guidance related to exercise in arrhythmogenic right ventricular cardiomyopathy. Recommendations were developed and approved by an expert writing group, after a systematic literature search with evidence tables, and discussion of their own clinical experience, to present the current knowledge in the field. Each recommendation is presented using the Class of Recommendation and Level of Evidence system formulated by the American College of Cardiology and the American Heart Association and is accompanied by references and explanatory text to provide essential context. The ongoing recognition of the genetic basis of ACM provides the opportunity to examine the diverse triggers and potential common pathway for the development of disease and arrhythmia.
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Vischer AS, Castelletti S, Syrris P, Bastiaenen R, Miles C, Akdis D, Denhaerynck K, Jacoby D, Saguner AM, Krahn AD, Behr ER, McKenna WJ, Pantazis A. Risk score for the exclusion of arrhythmic events in arrhythmogenic right ventricular cardiomyopathy at first presentation. Int J Cardiol 2019; 290:100-105. [PMID: 31104822 DOI: 10.1016/j.ijcard.2019.04.090] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 04/25/2019] [Accepted: 04/29/2019] [Indexed: 01/02/2023]
Abstract
AIMS Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a genetically determined heart muscle disorder associated with an increased risk of life-threatening arrhythmias in some patients. Risk stratification remains challenging. Therefore, we sought a non-invasive, easily applicable risk score to predict sustained ventricular arrhythmias in these patients. METHODS Cohort of Patients who fulfilled the 2010 ARVC task force criteria were consecutively recruited. Detailed clinical data were collected at baseline and during follow up. The clinical endpoint was a composite of recurrent sustained ventricular arrhythmias and hospitalization due to ventricular arrhythmias. Multivariable logistic regression was used to develop models to predict the arrhythmic risk. A cohort including patients from other registries in UK, Canada and Switzerland was used as a validation population. RESULTS One hundred and thirty-five patients were included of whom 35 patients (31.9%) reached the endpoint. A model consisting of filtered QRS duration on signal-averaged ECG, non-sustained VT (NSVT) on 24 h-ECG, and absence of negative T waves in lead aVR on 12‑lead surface ECG was able to predict arrhythmic events with a sensitivity of 81.8%, specificity of 84.0% and a negative predictive value of 95.5% at the first presentation of the disease. This risk score was validated in international ARVC registry patients. CONCLUSION A risk score consisting of a filtered QRS duration ≥117 ms, presence of NSVT on 24 h-ECG and absence of negative T waves in lead aVR was able to predict arrhythmic events at first presentation of the disease.
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Cheung CC, Mellor G, Deyell MW, Ensam B, Batchvarov V, Papadakis M, Roberts JD, Leather R, Sanatani S, Healey JS, Chauhan VS, Birnie DH, Champagne J, Angaran P, Klein GJ, Yee R, Simpson CS, Talajic M, Gardner M, Yeung-Lai-Wah JA, Chakrabarti S, Laksman ZW, Sharma S, Behr ER, Krahn AD. Comparison of Ajmaline and Procainamide Provocation Tests in the Diagnosis of Brugada Syndrome. JACC Clin Electrophysiol 2019; 5:504-512. [DOI: 10.1016/j.jacep.2019.01.026] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 01/02/2019] [Accepted: 01/31/2019] [Indexed: 01/20/2023]
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Thiruganasambandamoorthy V, Rowe BH, Sivilotti ML, McRae AD, Arcot K, Nemnom MJ, Huang L, Mukarram M, Krahn AD, Wells GA, Taljaard M. Duration of Electrocardiographic Monitoring of Emergency Department Patients With Syncope. Circulation 2019; 139:1396-1406. [DOI: 10.1161/circulationaha.118.036088] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Cheung CC, Davies B, Krahn AD. Letter by Cheung et al Regarding Article, “Concealed Arrhythmogenic Right Ventricular Cardiomyopathy in Sudden Unexplained Cardiac Death Events”. CIRCULATION-GENOMIC AND PRECISION MEDICINE 2019; 12:e002447. [DOI: 10.1161/circgen.118.002447] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Malhi N, Cheung CC, Deif B, Roberts JD, Gula LJ, Green MS, Pang B, Sultan O, Konieczny KM, Angaran P, Dorian P, Lashevsky I, Healey JS, Alak A, Tadros R, Andorin A, Steinberg C, Ayala-Paredes F, Simpson CS, Atallah J, Krahn AD. Challenge and Impact of Quinidine Access in Sudden Death Syndromes. JACC Clin Electrophysiol 2019; 5:376-382. [DOI: 10.1016/j.jacep.2018.10.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 10/11/2018] [Accepted: 10/15/2018] [Indexed: 11/24/2022]
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Laksman Z, Barichello S, Roston TM, Deyell MW, Krahn AD. Acute Management of Ventricular Arrhythmia in Patients With Suspected Inherited Heart Rhythm Disorders. JACC Clin Electrophysiol 2019; 5:267-283. [DOI: 10.1016/j.jacep.2019.02.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 02/02/2019] [Accepted: 02/03/2019] [Indexed: 02/08/2023]
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Cheung CC, Lieve KV, Roston TM, van der Ree MH, Deyell MW, Andrade JG, Laksman ZW, Nannenberg EA, Tadros R, Pang B, Rutberg J, Green MS, Conacher S, Seifer CM, Roberts JD, Steinberg C, Sanatani S, Wilde AA, Krahn AD. Pregnancy in Catecholaminergic Polymorphic Ventricular Tachycardia. JACC Clin Electrophysiol 2018; 5:387-394. [PMID: 30898243 DOI: 10.1016/j.jacep.2018.10.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 10/31/2018] [Accepted: 10/31/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVES This investigation was a retrospective study of catecholaminergic polymorphic ventricular tachycardia (CPVT) patients in Canada and the Netherlands to compare pregnancy, postpartum, and nonpregnant event rates. BACKGROUND CPVT is characterized by life-threatening arrhythmias during exertion or emotional stress. The arrhythmic risk in CPVT patients during pregnancy is unknown. METHODS Baseline demographics, genetics, treatment, and pregnancy complications were reviewed. Event rate calculations assumed a 40-week pregnancy and 24-week postpartum period. RESULTS Ninety-six CPVT patients had 228 pregnancies (median 2 pregnancies per patient; range: 1 to 10; total: 175.4 pregnant patient-years). The median age of CPVT diagnosis was 40.7 years (range: 12 to 84 years), with a median follow-up of 2.9 years (range: 0 to 20 years; total 448.1 patient-years). Most patients had pregnancies before CPVT diagnosis (82%). Pregnancy and postpartum cardiac events included syncope (5%) and an aborted cardiac arrest (1%), which occurred in patients who were not taking beta-blockers. Other complications included miscarriages (13%) and intrauterine growth restriction (1 case). There were 6 cardiac events (6%) during the nonpregnant period. The pregnancy and postpartum event rates were 1.71 and 2.85 events per 100 patient-years, respectively, and the combined event rate during the pregnancy and postpartum period was 2.14 events per 100 patient-years. These rates were not different from the nonpregnant event rate (1.46 events per 100 patient-years). CONCLUSIONS The combined pregnancy and postpartum arrhythmic risk in CPVT patients was not elevated compared with the nonpregnant period. Most patients had pregnancies before diagnosis, and all patients with events were not taking beta-blockers at the time of the event.
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Roston TM, Jones K, Hawkins NM, Bos JM, Schwartz PJ, Perry F, Ackerman MJ, Laksman ZW, Kaul P, Lieve KV, Atallah J, Krahn AD, Sanatani S. Implantable cardioverter-defibrillator use in catecholaminergic polymorphic ventricular tachycardia: A systematic review. Heart Rhythm 2018; 15:1791-1799. [DOI: 10.1016/j.hrthm.2018.06.046] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Indexed: 11/25/2022]
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Baruteau AE, Kyndt F, Behr ER, Vink AS, Lachaud M, Joong A, Schott JJ, Horie M, Denjoy I, Crotti L, Shimizu W, Bos JM, Stephenson EA, Wong L, Abrams DJ, Davis AM, Winbo A, Dubin AM, Sanatani S, Liberman L, Kaski JP, Rudic B, Kwok SY, Rieubland C, Tfelt-Hansen J, Van Hare GF, Guyomarc’h-Delasalle B, Blom NA, Wijeyeratne YD, Gourraud JB, Le Marec H, Ozawa J, Fressart V, Lupoglazoff JM, Dagradi F, Spazzolini C, Aiba T, Tester DJ, Zahavich LA, Beauséjour-Ladouceur V, Jadhav M, Skinner JR, Franciosi S, Krahn AD, Abdelsayed M, Ruben PC, Yung TC, Ackerman MJ, Wilde AA, Schwartz PJ, Probst V. SCN5A mutations in 442 neonates and children: genotype–phenotype correlation and identification of higher-risk subgroups. Eur Heart J 2018; 39:2879-2887. [DOI: 10.1093/eurheartj/ehy412] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 07/01/2018] [Indexed: 01/20/2023] Open
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Brunham LR, Lynch K, English A, Sutherland R, Weng J, Cho R, Wong GC, Anis AH, Francis GA, Khan NA, McManus B, Wood D, Walley KR, Leipsic J, Humphries KH, Hoens A, Krahn AD, John Mancini GB, Pimstone S. The design and rationale of SAVE BC: The Study to Avoid CardioVascular Events in British Columbia. Clin Cardiol 2018; 41:888-895. [PMID: 29635745 DOI: 10.1002/clc.22959] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 03/20/2018] [Accepted: 03/30/2018] [Indexed: 11/05/2022] Open
Abstract
Atherosclerotic cardiovascular disease (ASCVD) is highly heritable, particularly when it occurs at a young age. The screening of individuals with premature ASCVD, although often recommended, is not routinely performed. Strategies to address this gap in care are essential. We designed the Study to Avoid CardioVascular Events in British Columbia (SAVE BC) as a prospective, observational study of individuals with a new diagnosis of very premature ASCVD (defined as age ≤ 50 years in males and age ≤ 55 years in females) and their first-degree relatives (FDRs) and spouses. FDRs and spouses will undergo screening for cardiovascular (CV) risk factors and subclinical ASCVD using a structured screening algorithm. All subjects will be followed longitudinally for ≥10 years. The overall goal of SAVE BC is to evaluate the yield of a structured screening program for identifying individuals at risk of premature ASCVD. The primary objectives of SAVE BC are to identify and follow index cases with very premature ASCVD and their FDRs and to determine the diagnostic yield of a structured screening program for these individuals. We will collect data on CV risk factors, medication use, CV events, and healthcare costs in these individuals. SAVE BC will provide insight regarding approaches to identify individuals at risk for premature ASCVD with implications for prevention and treatment in this population.
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Cheung CC, Krahn AD, Andrade JG. The Emerging Role of Wearable Technologies in Detection of Arrhythmia. Can J Cardiol 2018; 34:1083-1087. [PMID: 30049358 DOI: 10.1016/j.cjca.2018.05.003] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 04/26/2018] [Accepted: 05/02/2018] [Indexed: 11/18/2022] Open
Abstract
Over the past decade, there has been an explosion of consumer devices for the purposes of health and fitness tracking. The wearable technology market, composed of devices that monitor physiological parameters, such as heart rate and sleep pattern, is anticipated to grow to 929 million connected devices in 2021. These devices encompass wristbands, glasses, in-ear monitors, or electronic shirts, with varying capacity to monitor heart rate, heart rhythm, blood pressure, physical activity, respiratory rate, blood glucose, and sleep patterns. For heart-rate monitoring, most wearable devices use photoplethysmography (PPG) technology, meaning they are inherently less accurate than conventional electrocardiography monitoring techniques (reference standard). However, a growing body of evidence suggests that these technologies can be harnessed to facilitate arrhythmia detection in the appropriate context. Studies evaluating PPG-based wearables in conjunction with machine-learning algorithms have shown promise in detection of such arrhythmias, as atrial fibrillation. Limitations of wearable technologies include their accuracy and accessibility and the clinical implications of wearable-detected arrhythmias. Despite this, wearable technologies represent an important frontier in health evaluation. Future wearables will benefit from improved reliability and accuracy, collect additional health and fitness parameters, support management of chronic disease, and provide real-time connectivity and feedback that may supplant conventional medical monitoring. Wearables have the potential to become truly disruptive in our health care sector, with large segments of the population soon to have readily available health data that the physician must interpret.
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Malhi N, Hawkins NM, Andrade JG, Krahn AD, Deyell MW. Catheter ablation of atrial fibrillation in heart failure with reduced ejection fraction. J Cardiovasc Electrophysiol 2018; 29:1049-1058. [DOI: 10.1111/jce.13497] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 03/20/2018] [Accepted: 03/30/2018] [Indexed: 12/13/2022]
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Bennett MT, Leader N, Sapp J, Parkash R, Gardner M, Healey JS, Thibault B, Sterns L, Essebag V, Birnie D, Sivakumaran S, Nery P, Andrade JG, Krahn AD, Tang A. Differentiating Ventricular From Supraventricular Arrhythmias Using the Postpacing Interval After Failed Antitachycardia Pacing. Circ Arrhythm Electrophysiol 2018; 11:e005921. [PMID: 29618476 DOI: 10.1161/circep.117.005921] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 02/05/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Implantable cardioverter defibrillator arrhythmia discrimination algorithms often are unable to discriminate ventricular from supraventricular arrhythmias. We sought to evaluate whether the response to antitachycardia pacing (ATP) in patients with an implantable cardioverter defibrillator could further discriminate ventricular from supraventricular arrhythmias in patients receiving ATP. METHODS AND RESULTS All episodes of ventricular or supraventricular tachycardia where ATP was delivered in patients enrolled in RAFT (Cardiac-Resynchronization Therapy for Mild-to-Moderate Heart Failure Trial) were included. RAFT randomized 1798 patients with New York Heart Association class II/III heart failure, left ventricular ejection fraction ≤30%, and QRS duration of ≥120 ms to a implantable cardioverter defibrillator±cardiac resynchronization therapy. The tachycardia cycle lengths (TCLs) before and after the delivery of ATP and the postpacing intervals were assessed. Overall, 10 916 ATP attempts were reviewed for 8150 tachycardia episodes in 924 patients. After excluding tachycardias where ATP terminated the episode or where the specific mechanism of the tachycardia was uncertain, we analyzed 3676 ATP attempts delivered for 2046 tachycardia episodes in 541 patients. A shorter difference between postpacing interval and TCL (PPI-TCL) was more likely to be associated with ventricular tachycardia than with supraventricular tachyarrhythmia (138.1±104.2 versus 277.4±126.9 ms; p<0.001). Analysis of the receiver operator curve for the PPI-TCL revealed an area under the curve of 0.803 (p<0.001; 95% confidence interval, 0.784-0.822). The majority of tachycardias with a PPI-TCL >360 ms were supraventricular with a PPI-TCL value of ≤360 ms having a sensitivity of 97.4% and specificity of 28.3% for ventricular tachycardia. CONCLUSIONS The ATP response, specifically the PPI-TCL, can further discriminate ventricular from supraventricular arrhythmias in patients with implantable cardioverter defibrillators when the currently available discriminators fail. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT00251251.
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Janzen ML, Malhi N, Laksman ZWM, Puyat J, Krahn AD, Hawkins NM. The QT Interval in Anorexia Nervosa: A Meta-Analysis. JACC Clin Electrophysiol 2018; 4:839-841. [PMID: 29929679 DOI: 10.1016/j.jacep.2018.01.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 01/29/2018] [Accepted: 01/31/2018] [Indexed: 11/17/2022]
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