ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death)

Predictors of Sudden Cardiac Death in Doberman Pinschers with Dilated Cardiomyopathy

Background

Doberman Pinschers with dilated cardiomyopathy (DCM) are at high risk of sudden cardiac death (SCD). Risk factors for SCD are poorly defined.

Aim

To assess cardiac biomarkers, Holter‐ECG, echocardiographic variables and canine characteristics in a group of Doberman Pinschers with DCM dying of SCD and in a DCM control group to identify factors predicting SCD.

Methods/Animals

A longitudinal prospective study was performed in 95 Doberman Pinschers with DCM. Forty‐one dogs died within 3 months after the last cardiac examination (SCD‐group) and were compared to 54 Doberman Pinschers with DCM surviving 1 year after inclusion. Holter‐ECG, echocardiography, measurement of N‐terminal prohormone of brain‐natriuretic peptide (NT‐proBNP), and cardiac Troponin I (cTnI) concentrations were recorded for all dogs.

Results

Volume overload of the left ventricle (left ventricular end‐diastolic volume (LVEDV/BSA) > 91.3 mL/m²) was the single best variable to predict SCD. The probability of SCD increases 8.5‐fold (CI_0.95 = 0.8–35.3) for every 50 mL/m²‐unit increment in LVEDV/BSA. Ejection fraction (EF), left ventricular end‐systolic volume (LVESV/BSA) and NT‐proBNP were highly correlated with LVEDV/BSA (r = −0.63, 0.96, 0.86, respectively). Generated conditional inference trees (CTREEs) revealed that the presence of ventricular tachycardia (VT), increased concentration of cTnI, and the fastest rate (FR) of ventricular premature complexes (VPC) ≥260 beats per minute (bpm) are additional important variables to predict SCD.

Conclusion

Conditional inference trees provided in this study might be useful for risk assessment of SCD in Doberman Pinschers with DCM.

The Use of Implantable Cardioverter-defibrillators in the Prevention of Sudden Cardiac Death: A Focus on Congenital Heart Disease and Inherited Arrhythmia Syndromes

Some congenital heart diseases (CHDs) and inherited arrhythmia syndromes are associated with an increased risk of sudden cardiac death (SCD). Appropriate selection criteria for implantable cardioverter-defibrillator (ICD) implantation in these patients are poorly defined due to a paucity of data available from randomized clinical trials, leading to current guidelines relying more on non-randomized studies and expert opinions to make their recommendations. This review describes available evidence-based risk stratification methods for identifying patients at risk for SCD, as well as current guideline-driven management strategies for the use of ICDs in patients with CHD and inherited arrhythmia syndromes.

Multidisciplinary approach to cardiac and pulmonary vascular disease risk assessment in liver transplantation: An evaluation of the evidence and consensus recommendations

Liver transplant (LT) candidates today are older, have greater medical severity of illness, and have more cardiovascular comorbidities than ever before. In addition, there are specific cardiovascular responses in cirrhosis that can be detrimental to the LT candidate. Cirrhotic cardiomyopathy, a condition characterized by increased cardiac output and a reduced ventricular response to stress, is present in up to 30% of patients with cirrhosis, thus challenging perioperative management. Current noninvasive tests that assess for subclinical coronary and myocardial disease have low sensitivity, and altered hemodynamics during the LT surgery can unmask latent cardiovascular disease either intraoperatively or in the immediate postoperative period. Therefore, this review, assembled by a group of multidisciplinary experts in the field and endorsed by the American Society of Transplantation Liver and Intestine and Thoracic and Critical Care Communities of Practice, provides a critical assessment of the diagnosis of cardiac and pulmonary vascular disease and interventions aimed at managing these conditions in LT candidates. Key points and practice-based recommendations for the diagnosis and management of cardiac and pulmonary vascular disease in this population are provided to offer guidance for clinicians and identify gaps in knowledge for future investigations.

Sleep disturbance in patients with an implantable cardioverter defibrillator: Prevalence, predictors and impact on health status

Background:

Sleep disturbances are highly prevalent in patients with cardiac diseases and associated with poor health outcomes. However, little is known about sleep disturbance in patients with an implantable cardioverter defibrillator.

Aims:

We examined the prevalence and predictors of sleep disturbance and the impact on perceived health status in a Dutch cohort of implantable cardioverter defibrillator patients.

Methods:

Patients (n=195) enrolled in the Web-based distress program for implantable cardioverter defibrillator patients (WEBCARE) trial completed questionnaires at the time of implantable cardioverter defibrillator implantation, three, six and 12 months afterwards. Sleep disturbance was assessed with the corresponding item #3 of the Patient Health Questionnaire 9.

Results:

At baseline, 67% (n=130) reported sleep disturbance (cut off ≥1). One year later, the prevalence was 57% (n=112). Younger age (odds ratio=0.96, 95% confidence interval 0.92–0.99; p=0.012) and high negative affectivity/low social inhibition (odds ratio=4.47, 95% confidence interval 1.52–13.17; p=0.007) were associated with sleep disturbance at 12 months in adjusted analyses. Sleep disturbance was not associated with health status at 12 months. Charlson Comorbidity Index, anxiety, Type D personality and high negative affectivity/low social inhibition were associated with impaired health status at follow-up.

Conclusions:

Sleep disturbance was highly prevalent in patients with an implantable cardioverter defibrillator. Younger age and high negative affectivity predicted sleep disturbance 12 months post-implantation independent of other demographic, clinical, intervention and psychological covariates. Sleep disturbance was not associated with impaired health status at the 12-month follow-up.

Prevalence of spontaneous Brugada ECG pattern recorded at standard intercostal leads: A meta-analysis

OBJECTIVE

Typical Brugada ECG pattern is the keystone in the diagnosis of Brugada syndrome. However, the exact prevalence remains unclear, especially in Asia. The present study was designed to systematically evaluate the prevalence of spontaneous Brugada ECG pattern recorded at standard leads.

METHODS

We searched the Medline, Embase and Chinese National Knowledge Infrastructure (CNKI) for studies of the prevalence of Brugada ECG pattern, published between Jan 1, 2003, and September 1, 2016. Pooled prevalence of type 1 and type 2-3 Brugada ECG pattern were estimated in a random-effects model, and group prevalence data by the characteristic of studies. Meta-regression analyses were performed to explore the potential sources of heterogeneity, and sensitivity analyses were conducted to assess the effect of each study on the overall prevalence.

RESULTS

Thirty-nine eligible studies involving 558,689 subjects were identified. Pooled prevalence of type 1 and 2-3 Brugada ECG pattern was 0.03% (95%CI, 0.01%-0.06%), and 0.42% (95%CI, 0.28%-0.59%), respectively. Regions, sample size, year of publication were the main source of heterogeneity. The prevalence of type 1 Brugada ECG pattern was higher in male, Asia, adult, patient, and fever subjects; but the relation between fever and type 2-3 Brugada ECG pattern was not significant. Sensitivity analysis showed that each study did not lonely affect the prevalence of type 1 and type 2-3 Brugada ECG pattern.

CONCLUSION

Brugada ECG pattern is not rare, especially preponderant in adult Asian males, and fever subjects. Clinical screening and further examination of Brugada syndrome in potential population need to be highlighted.

Electrocardiographic Markers of Appropriate Implantable Cardioverter-Defibrillator Therapy in Young People with Congenital Heart Diseases

Implantable cardioverter-defibrillators (ICDs) are increasingly utilized in patients with congenital heart disease (CHD). Prediction of the occurrence of shocks is important if improved patient selection is desired. The electrocardiogram (ECG) has been the first-line tool predicting the risk of sudden death, but data in CHD patients are lacking. We aim to evaluate the predictive value of electrocardiographic markers of appropriate therapy of ICD in young people with CHD. We conducted a prospective, longitudinal study, in twenty-six CHD patients (mean age 24.7 ± 5.3 years) who underwent first ICD implantation. Forty-two age- and diagnosis-matched controls were recruited. Twelve-lead ECG and 24 h Holter analysis were performed during a mean follow-up of 38.9 months. Data included heart rate, heart rate variability, QRS duration (QRSd), QTc interval and its dispersion, Tpeak-Tend (Tp-Te) interval and its dispersion, presence of fragmented QRS (fQRS), T wave alternans, atrial arrhythmias, and non-sustained ventricular tachycardia. Implant indication was primary prevention in ten cases (38.5%) and secondary prevention in 16 (61.5%). Overall, 17 subjects (65.3%) received at least one appropriate and effective ICD discharge. fQRS was present in 64.7% of cases with ICD therapy compared with patients without events or controls (p < 0.0001). Tp-e and Tp-e dispersion were significantly prolonged in patients with recurrences (113.5 and 37.2 ms) versus patients without ICD discharge (89.6 and 24.1 ms) or controls (72.4 and 19.3 ms) (p < 0.0001 and p < 0.0001, respectively). On univariate Cox regression analysis QRSd (hazard ratio: 1.19 per ms, p = 0.003), QTc dispersion (hazard ratio: 1.57 per ms, p = 0.002), fQRS (hazard ratio: 3.58 p < 0.0001), Tp-e (hazard ratio: 2.27 per ms, p < 0.0001), and Tp-e dispersion (hazard ratio: 4.15 per ms, p < 0.0001), emerged as strong predictors of outcome. On multivariate Cox analysis fQRS, Tp-e and Tp-e dispersion remained in the model. The presence of fQRS, and both Tp-e and Tp-e dispersion are useful ECG tools in daily clinical practice to identify CHD patients at risk for appropriate ICD therapy.

Role of Cardiac Imaging in Evaluating Risk for Sudden Cardiac Death

Sudden cardiac death (SCD) is a major cause of death from cardiovascular disease. Our ability to predict patients at the highest risk of developing lethal ventricular arrhythmias remains limited. Despite recent studies evaluating risk stratification tools, there is no optimal strategy. Cardiac imaging provides the opportunity to assess left ventricular ejection fraction, strain, fibrosis, and sympathetic innervation, all of which are pathophysiologically related to SCD risk. These modalities may play a role in the identification of vulnerable anatomic substrates that provide the pathophysiologic basis for SCD. Further studies are required to identify optimal imaging platform for risk assessment.

Heart Failure and Sudden Cardiac Death

The Centers for Diseases Control and Prevention estimates that 5.7 million adults in the United States suffer from heart failure and 1 in 9 deaths in 2009 cited heart failure as a contributing cause. Almost 50% of patients who are diagnosed with heart failure die within 5 years of diagnosis. Cardiovascular disease is a public health burden. The prognosis of patients with heart failure has improved significantly. However, the risk for death remains high. Managing sudden death risk and intervening appropriately with primary or secondary prevention strategies are of paramount importance.

SHOCKABLE VERSUS NONSHOCKABLE LIFE-THREATENING VENTRICULAR ARRHYTHMIAS USING DWT AND NONLINEAR FEATURES OF ECG SIGNALS

Shockable ventricular arrhythmias (VAs) such as ventricular tachycardia (VT) and ventricular fibrillation (VFib) are the life-threatening conditions requiring immediate attention. Cardiopulmonary resuscitation (CPR) and defibrillation are the significant immediate recommended treatments for these shockable arrhythmias to obtain the return of spontaneous circulation. However, accurate classification of these shockable VAs from nonshockable ones is the key step during defibrillation by automated external defibrillator (AED). Therefore, in this work, we have proposed a novel algorithm for an automated differentiation of shockable and nonshockable VAs from electrocardiogram (ECG) signal. The ECG signals are segmented into 5, 8 and 10[Formula: see text]s. These segmented ECGs are subjected to four levels of discrete wavelet transformation (DWT). Various nonlinear features such as approximate entropy ([Formula: see text], signal energy ([Formula: see text]), Fuzzy entropy ([Formula: see text]), Kolmogorov Sinai entropy ([Formula: see text], permutation entropy ([Formula: see text]), Renyi entropy ([Formula: see text]), sample entropy ([Formula: see text]), Shannon entropy ([Formula: see text]), Tsallis entropy ([Formula: see text]), wavelet entropy ([Formula: see text]), fractal dimension ([Formula: see text]), Kolmogorov complexity ([Formula: see text]), largest Lyapunov exponent ([Formula: see text]), recurrence quantification analysis (RQA) parameters ([Formula: see text]), Hurst exponent ([Formula: see text]), activity entropy ([Formula: see text]), Hjorth complexity ([Formula: see text]), Hjorth mobility ([Formula: see text]), modified multi scale entropy ([Formula: see text]) and higher order statistics (HOS) bispectrum ([Formula: see text]) are obtained from the DWT coefficients. Later, these features are subjected to sequential forward feature selection (SFS) method and selected features are then ranked using seven ranking methods namely, Bhattacharyya distance, entropy, Fuzzy maximum relevancy and minimum redundancy (mRMR), receiver operating characteristic (ROC), Student’s [Formula: see text]-test, Wilcoxon and ReliefF. These ranked features are supplied independently into the [Formula: see text]-Nearest Neighbor (kNN) classifier. Our proposed system achieved maximum accuracy, sensitivity and specificity of (i) 97.72%, 94.79% and 98.74% for 5[Formula: see text]s, (ii) 98.34%, 95.49% and 99.14% for 8[Formula: see text]s and (iii) 98.32%, 95.16% and 99.20% for 10[Formula: see text]s of ECG segments using only ten features. The integration of the proposed algorithm with ECG acquisition systems in the intensive care units (ICUs) can help the clinicians to decipher the shockable and nonshockable life-threatening arrhythmias accurately. Hence, doctors can use the CPR or AED immediately and increase the chance of survival during shockable life-threatening arrhythmia intervals.

Phenotype and Clinical Outcomes of Titin Cardiomyopathy

BACKGROUND

Improved understanding of dilated cardiomyopathy (DCM) due to titin truncation (TTNtv) may help guide patient stratification.

OBJECTIVES

The purpose of this study was to establish relationships among TTNtv genotype, cardiac phenotype, and outcomes in DCM.

METHODS

In this prospective, observational cohort study, DCM patients underwent clinical evaluation, late gadolinium enhancement cardiovascular magnetic resonance, TTN sequencing, and adjudicated follow-up blinded to genotype for the primary composite endpoint of cardiovascular death, and major arrhythmic and major heart failure events.

RESULTS

Of 716 subjects recruited (mean age 53.5 ± 14.3 years; 469 men [65.5%]; 577 [80.6%] New York Heart Association function class I/II), 83 (11.6%) had TTNtv. Patients with TTNtv were younger at enrollment (49.0 years vs. 54.1 years; p = 0.002) and had lower indexed left ventricular mass (5.1 g/m² reduction; p_adjusted = 0.03) compared with patients without TTNtv. There was no difference in biventricular ejection fraction between TTNtv^+/- groups. Overall, 78 of 604 patients (12.9%) met the primary endpoint (median follow-up 3.9 years; interquartile range: 2.0 to 5.8 years), including 9 of 71 patients with TTNtv (12.7%) and 69 of 533 (12.9%) without. There was no difference in the composite primary outcome of cardiovascular death, heart failure, or arrhythmic events, for patients with or without TTNtv (hazard ratio adjusted for primary endpoint: 0.92 [95% confidence interval: 0.45 to 1.87]; p = 0.82).

CONCLUSIONS

In this large, prospective, genotype-phenotype study of ambulatory DCM patients, we show that prognostic factors for all-cause DCM also predict outcome in TTNtv DCM, and that TTNtv DCM does not appear to be associated with worse medium-term prognosis.

Long-term outcome of catheter ablation and other form of therapy for electrical storm in patients with implantable cardioverter-defibrillators

PURPOSE

Radiofrequency catheter ablation (RFCA) for electrical storm (ES) has become a widely used therapeutic method. Its effectiveness in comparison to other forms of ES treatment is however uncertain.

METHODS

This single-centre retrospective study investigated the long-term clinical outcome after RFCA for ES and compared long-time effects of ablation to other forms of treatment. The study population consisted of 70 consecutive patients hospitalised between January 2010 and June 2015 due to ES. Patients were recruited for the study if the following criteria were fulfilled: first ES caused by ventricular tachycardia (VT) or ventricular fibrillation (VF), implanted cardioverter defibrillator or cardiac resynchronisation therapy device and left ventricular ejection fraction < 50%. The follow-up data on VT/ES recurrence was obtained from pacemaker/implanted cardioverter defibrillator memory. Data on all-cause mortality was collected during outpatient visits or by telephone contact.

RESULTS

Of the 70 patients enrolled, 28 (40%) were treated with RFCA (group A) and 42 (60%) received other forms of treatment for ES (group B). During a mean (±SD) 864 (629) days of follow-up, death occurred in 4 (14.3%) patients in the ablation group and in 16 (38.1%) patients treated with other methods [p = 0.03]. There was no significant between-group difference in VT/VF and ES recurrence. Statistical analysis revealed that the presence of cardiac resynchronisation therapy device during ES, stroke and/or transient ischaemic attack and lower baseline hematocrit level were the multivariate predictors of all-cause mortality.

CONCLUSIONS

In patients treated with RFCA for ES, all-cause mortality was significantly lower compared to the group treated with other methods.

Electrical Storm in Patients with Implantable Cardioverter-defibrillators: A Practical Overview

Electrical storm (ES) is an increasingly common medical emergency characterized by clustered episodes of sustained ventricular arrhythmias (VAs) that lead to repeated appropriate implantable cardioverter-defibrillator (ICD) therapies. A diagnosis of ES can be made with the occurrence of three or more sustained episodes of VAs, or of three or more appropriate ICD therapies within 24 hours in patients with implanted devices. ES is associated with poor outcomes in patients with structural heart disease, particularly those with severe left ventricular dysfunction. In large clinical trials involving patients with ICDs for primary and secondary prevention, ES appears to be a predictor of cardiac death, with notably higher rates of mortality soon after the event. ES management is challenging and requires special medical attention with accurate patient risk stratification and a multidisciplinary approach that includes the use of pharmacologic therapies such as antiarrhythmic drugs (AADs) and interventional approaches like catheter ablation, surgical ablation, or sympathetic neuromodulation. Initial management involves determining and addressing the underlying ischemia, any electrolyte imbalances, and/or other causative factors. Hemodynamic support needs to be considered in high-risk patients with unstable VAs or those with severe comorbidities such as low left ventricular ejection fraction, advanced New York Heart Association class, and/or chronic pulmonary disease. Following the acute phase of ES, treatment should shift towards maximizing therapeutic efforts to address heart failure, performing revascularization, and preventing subsequent VAs. In the present manuscript, we offer an overview of the most relevant clinical aspects of ES with regard to novel therapeutic strategies.

Management of Arrhythmias in Athletes: Atrial Fibrillation, Premature Ventricular Contractions, and Ventricular Tachycardia

OPINION STATEMENT

Management of atrial fibrillation, premature ventricular contractions, and ventricular tachycardia without underlying cardiac disease or arrhythmogenic conditions differs in athletes from the general population. Athletes tend to be younger, healthier individuals with few comorbidities. Therapies that work well in the general population may not be appropriate or preferable for athletes. Management strategies include deconditioning, pharmacologic therapy, such as rate control with β-blockers or non-dihydropyridine calcium channel blockers and rhythm control with class I or class III antiarrhythmic drugs, and catheter ablation. Deconditioning is not preferred by athletes because of lost playing time. Pharmacologic therapy is well tolerated among most individuals, but is not as favorable in athletes. Rate control medications can reduce performance and β-blockers, in particular, are prohibited in many sports. Antiarrhythmic drugs are preferred over rate control with athletes, but many, especially younger athletes, may not like the idea of long-term medical therapy. Catheter ablation has been proven to be safe and efficacious, may eliminate the need for long-term medical therapy, and is supported by the major societies (AHA, ACC, ESC).

Psychometric properties of HeartQoL, a core heart disease-specific health-related quality of life questionnaire, in Danish implantable cardioverter defibrillator recipients

Background

Patient-reported health-related quality of life is increasingly used as an outcome measure in clinical trials and as a performance measure to evaluate quality of care. The objective of this study was to assess the psychometric properties of the Danish HeartQoL questionnaire, a core heart disease-specific health-related quality of life questionnaire, in implantable cardioverter defibrillator recipients.

Design

This study involved cross-sectional and test-retest study designs.

Method

Implantable cardioverter defibrillator recipients in the cross-sectional study completed the HeartQoL, the Short-Form 36 Health Survey, and the Hospital Anxiety and Depression Scale. The HeartQoL structure, construct-related validity (convergent and discriminative) and reliability (internal consistency) were assessed. HeartQoL reproducibility (test-retest) was assessed in an independent sample of implantable cardioverter defibrillator recipients.

Results

Mokken scale analysis supported the bi-dimensional structure of HeartQoL among 358 implantable cardioverter defibrillator recipients. Convergent ( r > 0.72) and discriminative validity were confirmed. The HeartQoL scales demonstrated satisfactory internal consistency (Cronbach’s alpha > 0.90). Test-retest reliability (two weeks interval) was assessed in 89 implantable cardioverter defibrillator recipients and found to be acceptable for each scale (intra-class correlation > 0.90).

Conclusion

The Danish HeartQoL questionnaire demonstrated satisfactory key psychometric attributes of validity and reliability in this implantable cardioverter defibrillator population. This study adds support for the HeartQoL as a core heart-specific health-related quality of life questionnaire in a broad group of patients with heart disease including implantable cardioverter defibrillator recipients.

Representation of cardiovascular magnetic resonance in the AHA / ACC guidelines

BACKGROUND

Whereas evidence supporting the diagnostic value of cardiovascular magnetic resonance (CMR) has increased, there exists significant worldwide variability in the clinical utilization of CMR. A recent study demonstrated that CMR is represented in the majority of European Society for Cardiology (ESC) guidelines, with a large number of specific recommendations in particular regarding coronary artery disease. To further investigate the gap between the evidence and clinical use of CMR, this study analyzed the role of CMR in the guidelines of the American College of Cardiology (ACC) and American Heart Association (AHA).

METHODS

Twenty-four AHA/ACC original guidelines, updates and new editions, published between 2006 and 2017, were screened for the terms "magnetic", "MRI", "CMR", "MR" and "imaging". Non-cardiovascular MR examinations were excluded. All CMR-related paragraphs and specific recommendations for CMR including the level of evidence (A, B, C) and the class of recommendation (I, IIa, IIb, III) were extracted.

RESULTS

Twelve of the 24 guidelines (50.0%) contain specific recommendations regarding CMR. Four guidelines (16.7%) mention CMR in the text only, and 8 (33.3%) do not mention CMR. The 12 guidelines with recommendations for CMR contain in total 65 specific recommendations (31 class-I, 23 class-IIa, 6 class-IIb, 5 class-III). Most recommendations have evidence level C (44/65; 67.7%), followed by level B (21/65; 32.3%). There are no level A recommendations. 22/65 recommendations refer to vascular imaging, 17 to congenital heart disease, 8 to cardiomyopathies, 8 to myocardial stress testing, 5 to left and right ventricular function, 3 to viability, and 2 to valvular heart disease.

CONCLUSIONS

CMR is represented in two thirds of the AHA/ACC guidelines, which contain a number of specific recommendations for the use of CMR. In a simplified comparison with the ESC guidelines, CMR is less represented in the AHA/ACC guidelines in particular in the field of coronary artery disease.

Spanish Implantable Cardioverter-defibrillator Registry. 13th Official Report of the Spanish Society of Cardiology Electrophysiology and Arrhythmias Section (2016)

INTRODUCTION AND OBJECTIVES

To report the findings of the Spanish Implantable Cardioverter-defibrillator Registry for 2016 compiled by the Electrophysiology and Arrhythmias Section of the Spanish Society of Cardiology.

METHODS

Prospective data were voluntarily recorded on a data collection form and send to the Spanish Society of Cardiology by each implantation team.

RESULTS

Overall, 5673 device implantations were reported, representing 85% of the estimated total number of implantations. The reported implantation rate was 122 per million population and the estimated total implantation rate was 143 per million. The proportion of first implantations was 66.8%. Data were received from 177 hospitals (8 more than in 2015). Most implantable cardioverter-defibrillator recipients were men (81.9%). The mean age was 62.7 ± 13.4 years. Most patients had severe or moderate-to-severe ventricular dysfunction and were in New York Heart Association functional class II. The most frequent underlying cardiac condition was ischemic heart disease, followed by dilated cardiomyopathy. Indications for primary prevention accounted for 62% of first implantations. Overall, 81.2% of devices were implanted by cardiac electrophysiologists.

CONCLUSIONS

The 2016 Spanish Implantable Cardioverter-defibrillator Registry includes information on 85% of the devices implanted in Spain. The total number of device implantations increased in comparison with the last few years. The percentage of implantations for primary prevention also increased in comparison with the previous year.

2017 Comprehensive Update of the Canadian Cardiovascular Society Guidelines for the Management of Heart Failure

Since the inception of the Canadian Cardiovascular Society heart failure (HF) guidelines in 2006, much has changed in the care for patients with HF. Over the past decade, the HF Guidelines Committee has published regular updates. However, because of the major changes that have occurred, the Guidelines Committee believes that a comprehensive reassessment of the HF management recommendations is presently needed, with a view to producing a full and complete set of updated guidelines. The primary and secondary Canadian Cardiovascular Society HF panel members as well as external experts have reviewed clinically relevant literature to provide guidance for the practicing clinician. The 2017 HF guidelines provide updated guidance on the diagnosis and management (self-care, pharmacologic, nonpharmacologic, device, and referral) that should aid in day-to-day decisions for caring for patients with HF. Among specific issues covered are risk scores, the differences in management for HF with preserved vs reduced ejection fraction, exercise and rehabilitation, implantable devices, revascularization, right ventricular dysfunction, anemia, and iron deficiency, cardiorenal syndrome, sleep apnea, cardiomyopathies, HF in pregnancy, cardio-oncology, and myocarditis. We devoted attention to strategies and treatments to prevent HF, to the organization of HF care, comorbidity management, as well as practical issues around the timing of referral and follow-up care. Recognition and treatment of advanced HF is another important aspect of this update, including how to select advanced therapies as well as end of life considerations. Finally, we acknowledge the remaining gaps in evidence that need to be filled by future research.

[Sexual activity in implantable cardioverter defibrillator patients included in cardiac rehabilitation]

OBJECTIVES

To analyse the effects of a Cardiac Rehabilitation Program (CRP) on quality of life and sexual activity levels in patients with implantable cardioverter defibrillators (ICD).

METHOD

A total of 25 patients (22 men and 3 women) were included in a study that consisted of the analysis of any defibrillator discharges, their repercussion on the couple, and the effects of CRP on physical and psychological aspects, and on sexual activity (SA).

RESULTS

The mean age of the patients was 55years (22 to 79). Initially, fear for device discharges was present in all patients. On arrival, 14 patients (56%) did not have any SA: 2 with ages of 69 and 79years; one woman due to severe anxiety; an alcoholic man, and 10 because the ICD had been implanted less than 1 month before. Nine men and two women had restarted SA: 5 of them 5-52months after the implantation, and the other 6, 30days after implantation of the ICD while attending the CRP. At the end of the study, 21 patients had regained SA. Two men had clinical signs of depression and anxiety, with one requiring specialised treatment. Functional capacity improved significantly, 6.5±3.0METs at the beginning of the program and 9.2±3.3METs at the end, with a P<.005. There was only one inappropriate discharge.

CONCLUSIONS

Discharges caused by newest devices have dropped significantly. This fact, together with the action of CRP at physical, psychological, and informative levels, makes it possible to control the dysfunctions in the quality of life and sexuality in patients.

De Novo FGF12 (Fibroblast Growth Factor 12) Functional Variation Is Potentially Associated With Idiopathic Ventricular Tachycardia

Background

Idiopathic ventricular tachycardia (VT) is a type of cardiac arrhythmia occurring in structurally normal hearts. The heritability of idiopathic VT remains to be clarified, and numerous genetic factors responsible for development of idiopathic VT are as yet unclear. Variations in FGF12 (fibroblast growth factor 12), which is expressed in the human ventricle and modulates the cardiac Na⁺ channel Na_V1.5, may play an important role in the genetic pathogenesis of VT.

Methods and Results

We tested the hypothesis that genetic variations in FGF12 are associated with VT in 2 independent Chinese cohorts and resequenced all the exons and exon–intron boundaries and the 5′ and 3′ untranslated regions of FGF12 in 320 unrelated participants with idiopathic VT. For population‐based case–control association studies, we chose 3 single‐nucleotide polymorphisms—rs1460922, rs4687326, and rs2686464—which included all the exons of FGF12. The results showed that the single‐nucleotide polymorphism rs1460922 in FGF12 was significantly associated with VT after adjusting for covariates of sex and age in 2 independent Chinese populations: adjusted P=0.015 (odds ratio: 1.54 [95% CI, 1.09–2.19]) in the discovery sample, adjusted P=0.018 (odds ratio: 1.64 [95% CI, 1.09–2.48]) in the replication sample, and adjusted P=2.52E‐04 (odds ratio: 1.59 [95% CI, 1.24–2.03]) in the combined sample. After resequencing all amino acid coding regions and untranslated regions of FGF12, 5 rare variations were identified. The result of western blotting revealed that a de novo functional variation, p.P211Q (1.84% of 163 patients with right ventricular outflow tract VT), could downregulate FGF12 expression significantly.

Conclusions

In this study, we observed that rs1460922 of FGF12 was significantly associated with VT and identified that a de novo variation of FGF12 may be an important genetic risk factor for the pathogenesis of VT.

Cardiac Abnormalities in Adult Patients With Polymyositis or Dermatomyositis as Assessed by Noninvasive Modalities

OBJECTIVE

Cardiac events are a major cause of death in patients with idiopathic inflammatory myopathies. The study objective was in a controlled setting to describe cardiac abnormalities by noninvasive methods in a cohort of patients with polymyositis (PM) or dermatomyositis (DM) and to identify predictors for cardiac dysfunction.

METHODS

In a cross-sectional study, 76 patients with PM/DM and 48 matched healthy controls (HCs) were assessed by serum levels of cardiac troponin I, electrocardiography, Holter monitoring, echocardiography with tissue Doppler imaging, and quantitative cardiac (99m) Tc-pyrophosphate ((99m) Tc-PYP) scintigraphy.

RESULTS

Compared to HCs, patients with PM/DM more frequently had left ventricular diastolic dysfunction (LVDD) (12% versus 0%; P = 0.02) and longer QRS and QT intervals (P = 0.007 and P < 0.0001, respectively). In multivariate analysis, factors associated with LVDD were age (P = 0.001), disease duration (P = 0.004), presence of myositis-specific or -associated autoantibodies (P = 0.05), and high cardiac (99m) Tc-PYP uptake (P = 0.006). In multivariate analysis of the pooled data for patients and HCs, a diagnosis of PM/DM (P < 0.0001) was associated with LVDD.

CONCLUSION

Patients with PM or DM had an increased prevalence of cardiac abnormalities compared to HCs. LVDD was a common occurrence in PM/DM patients and correlated to disease duration. In addition, the association of LVDD with myositis-specific or -associated autoantibodies and high cardiac (99m) Tc-PYP uptake supports the notion of underlying autoimmunity and myocardial inflammation in patients with PM/DM.

Arrhythmogenic Right Ventricular Cardiomyopathy: Clinical Course and Predictors of Arrhythmic Risk

BACKGROUND

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a leading cause of sudden cardiac death, but its progression over time and predictors of arrhythmias are still being defined.

OBJECTIVES

This study sought to describe the clinical course of ARVC and occurrence of life-threatening arrhythmic events (LAE) and cardiovascular mortality; identify risk factors associated with increased LAE risk; and define the response to therapy.

METHODS

We determined the clinical course of 301 consecutive patients with ARVC using the Kaplan-Meier method adjusted to avoid the bias of delayed entry. Predictors of LAE over 5.8 years of follow-up were determined with Cox multivariable analysis. Treatment efficacy was assessed comparing LAE rates during matched time intervals.

RESULTS

A first LAE occurred in 1.5 per 100 person-years between birth and age 20 years, in 4.0 per 100 person-years between ages 21 and 40 years, and in 2.4 per 100 person-years between ages 41 and 60 years. Cumulative probability of a first LAE at follow-up was 14% at 5 years, 23% at 10 years, and 30% at 15 years. Higher risk of LAE was predicted by atrial fibrillation (hazard ratio [HR]: 4.38; p = 0.002), syncope (HR: 3.36; p < 0.001), participation in strenuous exercise after the diagnosis (HR: 2.98; p = 0.028), hemodynamically tolerated sustained monomorphic ventricular tachycardia (HR: 2.19; p = 0.023), and male sex (HR: 2.49; p = 0.012). No difference was observed in the occurrence of LAE before and after treatment with amiodarone, beta-blockers, sotalol, or ablation. A total of 81 patients received an implantable cardioverter-defibrillator, 34 were successfully defibrillated.

CONCLUSIONS

The high risk of life-threatening arrhythmias in patients with ARVC spans from adolescence to advanced age, reaching its peak between ages 21 and 40 years. Atrial fibrillation, syncope, participation in strenuous exercise after the diagnosis of ARVC, hemodynamically tolerated sustained monomorphic ventricular tachycardia, and male sex predicted lethal arrhythmias at follow-up. The lack of efficacy of antiarrhythmic therapy and the life-saving role of the implantable cardioverter-defibrillator highlight the importance of risk stratification for patient management.

Management of ventricular tachycardia storm in patients with structural heart disease

Electrical storm (ES) is a medical emergency characterized by repetitive episodes of sustained ventricular arrhythmias (VAs) in a limited amount of time (at least 3 within a 24-h period) leading to repeated appropriate implantable cardioverter defibrillator therapies. The occurrence of ES represents a major turning point in the natural history of patients with structural heart disease being associated with poor short- and long-term survival particularly in those with compromised left ventricular ejection fraction (LVEF) that can develop hemodynamic decompensation and multi-organ failure. Management of ES is challenging with limited available evidence coming from small retrospective series and a substantial lack of randomized-controlled trials. In general, a multidisciplinary approach including medical therapies such as anti-arrhythmic drugs, sedation, as well as interventional approaches like catheter ablation, may be required. Accurate patient risk stratification at admission for ES is pivotal and should take into account hemodynamic tolerability of VAs as well as comorbidities like low LVEF, advanced NYHA class and chronic pulmonary disease. In high risk patients, prophylactic mechanical circulatory support with left ventricular assistance devices or extracorporeal membrane oxygenation should be considered as bridge to ablation and recovery. In the present manuscript we review the available strategies for management of ES and the evidence supporting them.

[Algorithm for the management of patients with stable coronary artery disease and high-grade ventricular arrhythmias]

The paper gives an original algorithm for the management of patients with stable coronary artery disease, preserved/moderately reduced left ventricular systolic function, and high-grade ventricular arrhythmias from the first registration of the latter to the choice of treatment policy. Great attention is paid to the assessment of a private clinical case, by determining the nature of arrhythmias, and to the involvement of autonomic regulation in the genesis of ventricular arrhythmias. The importance of topical diagnosis of ventricular arrhythmias and identification of psychological disorders is emphasized. Diagnostic problems are solved in a step-by-step fashion using up-to-date techniques. The key point of the algorithm proposed is to prevent sudden cardiac death.

Plasma Ceramides, Mediterranean Diet, and Incident Cardiovascular Disease in the PREDIMED Trial (Prevención con Dieta Mediterránea)

BACKGROUND

Although in vitro studies and investigations in animal models and small clinical populations have suggested that ceramides may represent an intermediate link between overnutrition and certain pathological mechanisms underlying cardiovascular disease (CVD), no prospective studies have investigated the association between plasma ceramides and risk of CVD.

METHODS

The study population consisted of 980 participants from the PREDIMED trial (Prevención con Dieta Mediterránea), including 230 incident cases of CVD and 787 randomly selected participants at baseline (including 37 overlapping cases) followed for ≤7.4 years. Participants were randomized to a Mediterranean diet supplemented with extra virgin olive oil, a Mediterranean diet supplemented with nuts, or a control diet. Plasma ceramide concentrations were measured on a liquid chromatography tandem mass spectrometry metabolomics platform. The primary outcome was a composite of nonfatal acute myocardial infarction, nonfatal stroke, or cardiovascular death. Hazard ratios were estimated with weighted Cox regression models using Barlow weights to account for the case-cohort design.

RESULTS

The multivariable hazard ratios (HR) and 95% confidence intervals (CIs) comparing the extreme quartiles of plasma concentrations of C16:0, C22:0, C24:0, and C24:1 ceramides were 2.39 (1.49-3.83, Ptrend<0.001), 1.91 (1.21-3.01, Ptrend=0.003), 1.97 (1.21-3.20, Ptrend=0.004), and 1.73 (1.09-2.74, Ptrend=0.011), respectively. The ceramide score, calculated as a weighted sum of concentrations of four ceramides, was associated with a 2.18-fold higher risk of CVD across extreme quartiles (HR, 2.18; 95% CI, 1.36-3.49; Ptrend<0.001). The association between baseline ceramide score and incident CVD varied significantly by treatment groups (Pinteraction=0.010). Participants with a higher ceramide score and assigned to either of the 2 active intervention arms of the trial showed similar CVD risk to those with a lower ceramide score, whereas participants with a higher ceramide score and assigned to the control arm presented significantly higher CVD risk. Changes in ceramide concentration were not significantly different between Mediterranean diet and control groups during the first year of follow-up.

CONCLUSIONS

Our study documented a novel positive association between baseline plasma ceramide concentrations and incident CVD. In addition, a Mediterranean dietary intervention may mitigate potential deleterious effects of elevated plasma ceramide concentrations on CVD.

CLINICAL TRIAL REGISTRATION

URL: http://www.isrctn.com. Unique identifier: ISRCTN35739639.

Brugada Syndrome:Risk Stratification And Management

The Brugada syndrome (BrS) is an arrhythmogenic disease associated with an increased risk of ventricular fibrillation and sudden cardiac death. The risk stratification and management of BrS patients, particularly of asymptomatic ones, still remains challenging. A previous history of aborted sudden cardiac death or arrhythmic syncope in the presence of spontaneous type 1 ECG pattern of BrS phenotype appear to be the most reliable predictors of future arrhythmic events. Several other ECG parameters have been proposed for risk stratification. Among these ECG markers, QRS-fragmentation appears very promising. Although the value of electrophysiological study still remains controversial, it appears to add important information on risk stratification, particularly when incorporated in multiparametric scores in combination with other known risk factors. The present review article provides an update on the pathophysiology, risk stratification and management of patients with BrS.

Autoimmune channelopathies as a novel mechanism in cardiac arrhythmias

Cardiac arrhythmias confer a considerable burden of morbidity and mortality in industrialized countries. Although coronary artery disease and heart failure are the prevalent causes of cardiac arrest, in 5-15% of patients, structural abnormalities at autopsy are absent. In a proportion of these patients, mutations in genes encoding cardiac ion channels are documented (inherited channelopathies), but, to date, the molecular autopsy is negative in nearly 70% of patients. Emerging evidence indicates that autoimmunity is involved in the pathogenesis of cardiac arrhythmias. In particular, several arrhythmogenic autoantibodies targeting specific calcium, potassium, or sodium channels in the heart have been identified. Experimental and clinical studies demonstrate that these autoantibodies can promote conduction disturbances and life-threatening tachyarrhythmias by inducing substantial electrophysiological changes. In this Review, we propose the term 'autoimmune cardiac channelopathies' to define this novel pathogenic mechanism of cardiac arrhythmias, which could be more frequent and clinically relevant than previously appreciated. Indeed, pathogenic autoantibodies against ion channels are detectable not only in patients with manifest autoimmune disease, but also in apparently healthy individuals, which suggests a causal role in some cases of unexplained arrhythmias and cardiac arrest. Considering this possibility and performing specific testing in patients with 'idiopathic' rhythm disturbances could create novel treatment opportunities.

Clinical risk profile score predicts all cause mortality but not implantable cardioverter defibrillator intervention rate in a large unselected cohort of patients with congestive heart failure

BACKGROUND

Primary prophylactic implantable cardioverter defibrillator (ICD) therapy is indicated for patients with reduced left ventricular ejection fraction (LVEF). We aimed to determine if preoperative clinical risk profiling can predict long-term benefit, and if clinical risk scores can be applied and improved in a patient cohort outside the clinical trial setting.

METHODS

Using registry data, 789 patients with reduced LVEF who received ICDs for primary prevention during 2006-2011 were identified (age 64 ± 11 years, 82% men, 63% ischemic etiology, 52% cardiac resynchronization therapy with defibrillator). The patients were divided into three risk groups, based on the presence of baseline clinical risk factors (age >70, QRS duration >120 ms, New York Heart Association class III-IV, atrial fibrillation history, or creatinine >106 μmol/L). Endpoints were all-cause mortality and survival free of adequate ICD therapy.

RESULTS

Mean follow-up was 39 ± 18 months. Annual mortality was 7.6%, and increased with risk group (p < .001). Rates of appropriate antitachycardia pacing and shock therapy were not statistically different between the groups, and ranged from 11%-16% and 6%-14%, respectively. By combining the previous risk score with data on diabetes, a better independent prediction of mortality was achieved; mortality rates then ranged from 11% (low-risk) to 46% (high-risk) (p < .0001).

CONCLUSIONS

Implantable cardioverter defibrillator therapies occur across the spectrum of comorbidities in a population with systolic heart failure. However, all-cause mortality is considerably higher in the group of patients with accumulated risk factors, and using the proposed scoring system can be helpful for the evaluation and risk stratification of the patient prior to making a decision for a primary prophylactic ICD implantation.

A classic case of arrhythmogenic right ventricular cardiomyopathy (ARVC) and literature review

Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) is a relatively under-recognized hereditary cardiomyopathy. It is characterized pathologically by fibro-fatty infiltration of right ventricular (RV) myocardium and clinically by consequences of RV electrical instability. Timely intervention with device therapy and pharmacotherapy may help reduce the risk of arrhythmic events or sudden cardiac death. Here, we describe a classic case of a young adult with ARVC and a brief literature review. The patient presented with exertional palpitations and ARVC was suspected after his routine electrocardiogram (EKG) revealed symmetric T wave inversions and possible epsilon waves in right precordial leads. Subsequent work up showed fatty infiltration of RV myocardium on cardiac magnetic resonance imaging and inducible ventricular tachycardia from the right ventricle during electrophysiologic study. Those findings confirmed the diagnosis of ARVC and warranted treatment with implantable cardioverter defibrillator. It is always exciting to encounter rare pathological entities with classic clinical findings, especially when they present as a diagnostic challenge.We were able to provide correct diagnosis and management, thereby preventing the potentially lethal consequences. Therefore, it is important to recognize the possible EKG findings of ARVC and to know when to pursue further investigations and to implement therapies.