Ventricular Ectopy as a Predictor of Heart Failure and Death

Determining the recurrence rate of premature ventricular complexes and idiopathic ventricular tachycardia after radiofrequency catheter ablation with the help of designing a machine-learning model

Ventricular arrhythmias increase cardiovascular morbidity and mortality. Recurrent PVCs and IVT are generally considered benign in the absence of structural heart abnormalities. Artificial intelligence is a rapidly growing field. In recent years, medical professionals have shown great interest in the potential use of ML, an integral part of AI, in various disciplines, including diagnostic applications, decision-making, prognostic stratification, and solving complex pathophysiological aspects of diseases from these data at extraordinary complexity, scale, and acquisition rate. The aim of this study was to design an ML model to predict the probability of PVC and IVT recurrence after RF ablation. Data of patients were collected and manipulated using traditional analysis and various artificial intelligence models, namely MLP, Gradient Boosting Machines, Random Forest, and Logistic Regression. Hypertension, male sex, and the use of non-irrigate catheters were associated with less freedom from arrhythmia. All these results were obtained through traditional analytic methods, and according to AI, none of the variables had a clear effect on the recurrence of arrhythmia. Each AI model presents unique strengths and weaknesses, and further optimization and fine-tuning of these models are necessary to increase their clinical utility. By expanding the dataset, improved predictions can be fostered to ultimately increase the clinical utility of AI in predicting PVC erosion outcomes.

Cardiac magnetic resonance reveals concealed structural heart disease in patients with frequent premature ventricular contractions and normal echocardiography: A systematic review

Premature ventricular contractions (PVCs) are a common form of arrhythmic events, often representing an idiopathic and benign condition without further therapeutic interventions. However, in certain circumstances PVCs may represent the epiphenomenon of a concealed structural heart disease (SHD). Surface 12‑leads EKG and 24-h dynamic EKG are necessary to assess their main characteristics such as site of origin, frequency and complexity. Echocardiography represents the first-line imaging tool recommended to evaluate cardiac structures and function. Cardiac Magnetic Resonance (CMR) is recognized as a superior modality for detecting structural cardiac alterations, that might evade detection by conventional echocardiography. Moreover, in specific populations such as athletes, CMR may have a crucial role to exclude a concealed SHD and the risk of serious arrhythmic events during sport activity. Some clinical characteristics such as male sex, older age or family history of sudden cardiac death (SCD) or cardiomyopathy, and some electrocardiographic features of PVCs, in particular a right branch bundle block (RBBB) with superior/intermediate axis morphology, the reproducibility of VAs during exercise test (ET) or the evidence of complex ventricular arrhythmias, may warrant a CMR evaluation, due to the high probability of SHD. In this systematic review our objective was to provide an exhaustive overview on the role of CMR in detecting a concealed SHD in patients with high daily burden of PVCs and a normal echocardiographic evaluation, paving the way for a more extensive utilization of CMR in presence of certain high-risk clinical and/or EKG features identified during the diagnostic workup.

Systemic infarcts among patients with atrial fibrillation

BACKGROUND

The epidemiology of atrial fibrillation (AF)-associated thromboembolic complications outside of ischemic strokes has not been thoroughly elucidated.

OBJECTIVE

The aim of this study was to describe the epidemiology of AF-associated systemic infarcts and relevant interactions by sex and race/ethnicity.

METHODS

Using the Office of Statewide Health Planning and Development, we performed a longitudinal analysis of patients aged ≥18 years who received ambulatory surgery, emergency, or inpatient medical care in California between 2005 and 2015. We determined the distribution of infarct locations and risks of systemic infarcts for patients with AF. Interaction analyses by sex and race/ethnicity were conducted.

RESULTS

Of 1,321,694 patients with AF, the average annual rate of systemic infarct was 2.1% ± 0.18% compared with 0.56% ± 0.06% in the 22,944,488 patients without AF. The increased frequency of these infarcts was observed for every body area investigated. After adjustment for potential confounders and mediators, patients with AF experienced a 45% increased risk of a systemic infarct (hazard ratio, 1.45; 95% confidence interval, 1.44-1.47; P < .001). Women, Asians, Blacks, and Hispanics each exhibited a statistically significant heightened relative risk of systemic infarcts in the presence of AF.

CONCLUSION

AF increases the risk of infarcts throughout the body. Susceptibility to these systemic infarcts varies by sex and race/ethnicity in patterns similar to differential risks for stroke. The presence of a systemic infarct in the absence of a clear cause should raise suspicion for AF, and the potential benefits of AF prevention and anticoagulation should be considered beyond only infarcts to the brain.

Diagnostic reliability of monitoring for premature atrial and ventricular complexes

AIMS

Short-term ambulatory electrocardiogram (ECG) monitoring is often used to assess premature atrial complex (PAC) and premature ventricular complex (PVC) frequency, but the diagnostic reliability is unknown. The objective of this study was to study the day-to-day variability of PAC and PVC frequency.

METHODS AND RESULTS

We used 14-day full-disclosure mobile cardiac telemetry recordings without atrial fibrillation in 8245 US patients aged 17-103 years to calculate the diagnostic reliability of shorter ambulatory ECG recordings compared with 14-day averages. Over 14 days, 1853 patients had ≥500 PACs/day, 410 patients had ≥5000 PACs/day, and 197 patients had ≥10 000 PACs/day; 1640 patients had ≥500 PVCs/day, 354 patients had ≥5000 PVCs/day, and 175 patients had ≥10 000 PVCs/day. After 3 days, the estimated daily PAC frequency differed by ≥50% from the 14-day mean in 25% of patients; for PVCs, the corresponding duration was 7 days. Ten days of monitoring were needed to estimate PAC and PVC frequency within ±20% of the overall 14-day frequency in 80% of patients. For daily PAC and PVC frequencies ≥10 000, single-day estimation had a specificity of 99.3% [95% confidence interval (CI) 99.1-99.5] at a sensitivity of 76.6 (95% CI 70.1-80.4%) for PACs and a 99.6% (95% CI 99.4-99.7%) specificity at 79.4 (95% CI 72.7-85.2) sensitivity for PVCs. After 7 days, the sensitivity increased to 88.8% (95% CI 83.6-92.9) for PACs and 86.9% (95% CI 80.9-91.5%) for PVCs.

CONCLUSION

While there is substantial daily variability across most PAC and PVC levels, findings of ≥10 000 PACs or PVCs are highly specific and do not need to be confirmed with longer recordings.

Prevalence of frequent premature ventricular contractions and nonsustained ventricular tachycardia in older women screened for atrial fibrillation in the Women's Health Initiative

BACKGROUND

Frequent premature ventricular contractions (PVCs) and nonsustained ventricular tachycardia (NSVT) have been associated with cardiovascular disease and mortality. Their prevalence, especially in ambulatory populations, is understudied and limited by few female participants and the use of short-duration (24- to 48-hour) monitoring.

OBJECTIVE

The objective of this study was to report the prevalence of frequent PVCs and NSVT in a community-based population of women likely to undergo electrocardiogram (ECG) screening by sequential patch monitoring.

METHODS

Participants from the Women's Health Initiative Strong and Healthy (WHISH) trial with no history of atrial fibrillation (AF) but 5-year predicted risk of incident AF ≥5% by CHARGE-AF score were randomly selected to undergo screening with 7-day ECG patch monitors at baseline, 6 months, and 12 months. Recordings were reviewed for PVCs and NSVT (>5 beats); data were analyzed with multivariate regression models.

RESULTS

There were 1067 participants who underwent ECG screening at baseline, 866 at 6 months, and 777 at 12 months. Frequent PVCs were found on at least 1 patch from 4.3% of participants, and 1 or more episodes of NSVT were found in 12 (1.1%) women. PVC frequency directly correlated with CHARGE-AF score and NSVT on any patch. Detection of frequent PVCs increased with sequential monitoring.

CONCLUSION

In postmenopausal women at high risk for AF, frequent PVCs were relatively common (4.3%) and correlated with higher CHARGE-AF score. As strategies for AF screening continue to evolve, particularly in those individuals at high risk of AF, the prevalence of incidental ventricular arrhythmias is an important benchmark to guide clinical decision-making.

Premature ventricular complexes: Assessing burden density in a large national cohort to better define optimal ECG monitoring duration

BACKGROUND

Premature ventricular contraction (PVC) burden is a risk factor for heart failure and cardiovascular death in patients with structural heart disease. Long-term electrocardiographic monitoring can have a significant impact on PVC burden evaluation by further defining PVC distribution patterns.

OBJECTIVE

This study aimed to ascertain the optimal duration of electrocardiographic monitoring to characterize PVC burden and to understand clinical characteristics associated with frequent PVCs and nonsustained ventricular tachycardia in a large US cohort.

METHODS

Commercial data (iRhythm's Zio patch) from June 2011 to April 2022 were analyzed. Inclusion criteria were age >18 years, PVC burden ≥5%, and wear period ≥13 days. PVC burden cutoffs were determined on the basis of AHA/ACC/HRS guidelines for very frequent PVCs (10,000-20,000 during 24 hours). Patients were assigned to categories by PVC densities: low, <10%; moderate, 10% to <20%; and high, ≥20%. Mean measured error was assessed at baseline and daily until the wear period's end for overall PVC burden and different PVC densities.

RESULTS

Analysis of 106,705 patch monitors revealed a study population with mean age of 70.6 ± 14.6 years (33.6% female). PVC burden was higher in male patients and those >65 years of age. PVC burden mean error decreased from 2.9% at 24 hours to 1.3% at 7 days and 0.7% at 10 days. Number of ventricular tachycardia episodes per patient increased with increasing PVC burden (P < .0001).

CONCLUSION

Extending ambulatory monitoring beyond 24 hours to 7 days or more improves accuracy of assessing PVC burden. Ventricular tachycardia frequency and duration vary by initial PVC density, highlighting the need for prolonged cardiac monitoring.

Programmed Ventricular Stimulation: Risk Stratification and Guiding Antiarrhythmic Therapies

Electrophysiologic testing with programmed ventricular stimulation (PVS) has been utilized to induce ventricular tachycardia (VT), thereby improving risk stratification for patients with ischemic and nonischemic cardiomyopathies and determining the effectiveness of antiarrhythmic therapies, especially catheter ablation. A variety of procedural aspects can be modified during PVS in order to alter the sensitivity and specificity of the test including the addition of multiple baseline pacing cycle lengths, extrastimuli, and pacing locations. The definition of a positive result is also critically important, which has varied from exclusively sustained monomorphic VT (>30 seconds) to any ventricular arrhythmia regardless of morphology. In this review, we discuss the history of PVS and evaluate its role in sudden cardiac death risk stratification in a variety of patient populations. We propose an approach to future investigations that will capitalize on the unique ability to vary the sensitivity and specificity of this test. We then discuss the application of PVS during and following catheter ablation. The strategies that have been utilized to improve the efficacy of intraprocedural PVS are highlighted during a discussion of the limitations of this probabilistic strategy. The role of noninvasive programmed stimulation is also reviewed in predicting recurrent VT and informing management decisions including repeat ablations, modifications in antiarrhythmic drugs, and implantable cardioverter-defibrillator programming. Based on the available evidence and guidelines, we propose an approach to future investigations that will allow clinicians to optimize the use of PVS for risk stratification and assessment of therapeutic efficacy.

Functional-Molecular Mechanisms of Sympathetic-Parasympathetic Dysfunction in PVC-Induced Cardiomyopathy Revealed by Dual Stressor PVC-Exercise Challenge

BACKGROUND

The significance of autonomic dysfunction in premature ventricular contraction-induced cardiomyopathy (PVC-CM) remain unknown.

OBJECTIVE

Utilizing a novel "dual stressor" provocative challenge combining exercise with premature ventricular contraction (PVCs), the authors characterized the functional and molecular mechanisms of cardiac autonomic (cardiac autonomic nervous system) remodeling in a PVC-CM animal model.

METHODS

In 15 canines (8 experimental, 7 sham), we implanted pacemakers and neurotelemetry devices and subjected animals to 12 weeks of bigeminal PVCs to induce PVC-CM. Sympathetic nerve activity (SNA), vagal nerve activity (VNA), and heart rate were continuously recorded before, during, and after treadmill exercise challenge with and without PVCs, at baseline and after development of PVC-CM. Western blot and enzyme-linked immunosorbent assay were used to evaluate molecular markers of neural remodeling.

RESULTS

Exercise triggered an increase in both SNA and VNA followed by late VNA withdrawal. With PVCs, the degree of exercise-induced SNA augmentation was magnified, whereas late VNA withdrawal became blunted. After PVC-CM development, SNA was increased at rest but failed to adequately augment during exercise, especially with PVCs, coupled with impaired VNA and heart rate recovery after exercise. In the remodeled cardiac autonomic nervous system, there was widespread sympathetic hyperinnervation and elevated transcardiac norepinephrine levels but unchanged parasympathetic innervation, indicating sympathetic overload. However, cardiac nerve growth factor was paradoxically downregulated, suggesting an antineurotrophic counteradaptive response to PVC-triggered sympathetic overload.

CONCLUSIONS

Sympathetic overload, sympathetic dysfunction, and parasympathetic dysfunction in PVC-CM are unmasked by combined exercise and PVC challenge. Reduced cardiac neurotrophic factor might underlie the mechanisms of this dysfunction. Neuromodulation therapies to restore autonomic function could constitute a novel therapeutic approach for PVC-CM.

Real-world assessment of multipolar and point-by-point mapping for premature ventricular contraction ablation

AIMS

We aimed to assess the acute and midterm efficacy of premature ventricular contraction (PVC) ablation guided by multielectrode and point-by-point (PbP) mapping.

METHODS AND RESULTS

This is a retrospective, international multicentre study of consecutive patients referred for PVC ablation in 10 hospital centres from January 2017 to December 2021. Based on the mapping approach, two cohorts were identified: the 'Multipolar group', where a dedicated high-density mapping catheter was employed, and the 'PbP group', where mapping was performed with the ablation catheter. Procedural endpoints, safety, and acute (procedural) and midterm efficacies were assessed. Of the 698 patients included in this study, 592 received activation mapping [46% males, median age of 55 (41-65) years]-248 patients in the Multipolar group and 344 patients in the PbP group. A higher number of activation points [432 (217-843) vs. 95 (42-185), P < 0.001], reduced mapping time (40 ± 38 vs. 61 ± 50 min, P < 0.001), and shorter procedure time (124 ± 60 vs. 143 ± 63 min, P < 0.001) were reported in the Multipolar group. Both groups had high acute success rates (84.7% with Multipolar mapping vs. 81.3% with PbP mapping, P = 0.63), as well as midterm efficacy (83.4% vs. 77.4%, P = 0.08), with no significant differences in the risk of adverse events (6.0% vs. 3.5%, P = 0.24). However, for left-sided PVC ablation specifically, there was a higher midterm efficacy in the Multipolar group (80.7% vs. 69.5%, P = 0.04), with multipolar mapping being an independent predictor of success [adjusted OR = 2.231 (95% CI, 1.476-5.108), P = 0.02].

CONCLUSION

The acute and midterm efficacies of PVC ablation are high with both multipolar and PbP mapping, although the former allows for quicker procedures and may potentially improve the outcomes of left-sided PVC ablation.

Prevalence and predictors of mitral annular disjunction and ventricular ectopy in mitral valve prolapse

BACKGROUND

Mitral annular disjunction (MAD) is associated with ventricular arrhythmia in mitral valve prolapse (MVP). The proportional risk from MAD and other predictors of ventricular arrhythmia in MVP has not been well characterized.

OBJECTIVE

This study aimed to identify predictors of complex or frequent ventricular ectopy (cfVE) in MVP and to quantify risk of cfVE and mortality in MVP with MAD.

METHODS

We studied 632 adult patients with MVP on transthoracic echocardiography at the University of North Carolina Medical Center from 2016 to 2019 (median age, 64 [interquartile range, 52-74] years; 52.7% female; 16.3% African American). Resting and ambulatory electrocardiograms were used to identify cfVE.

RESULTS

MAD was present in 94 (14.9%) patients. Independent associations of MAD were bileaflet prolapse (odds ratio [95% CI], 4.25 [2.47-7.33]; P < .0001), myxomatous valve (2.17 [1.27-3.71]; P = .005), absence of hypertension (2.00 [1.21-3.32]; P = .007), electrocardiogram inferior or lateral lead T-wave inversion (2.07 [1.23-3.48]; P = .006), and female sex (1.99 [1.21-3.25]; P = .006). cfVE was frequent with MAD (39 [41.5%] vs 93 [17.3%] without; P < .0001). Independent cfVE predictors were MAD (hazard ratio [95% CI], 2.23 [1.47-3.36]; P = .0001), bileaflet prolapse (1.86 [1.25-2.76]; P = .002), heart failure (1.79 [1.16-2.77]; P = .009), lower left ventricular ejection fraction (0.14 [0.03-0.61]; P = .009), coronary artery disease (1.60 [1.05-2.43]; P = .03), and inferior or lateral lead T-wave inversion (1.51 [1.03-2.22]; P = .03). After a median of 40 (33-48) months, there was increased mortality with MAD (P = .04).

CONCLUSION

MAD in MVP is associated with bileaflet or myxomatous MVP, absence of hypertension, T-wave inversion, and female sex. There is increased cfVE and mortality with MAD, highlighting the need for closer follow-up of these patients.

Number of Premature Ventricular Complexes Predicts Long-Term Outcomes in Patients with Persistent Atrial Fibrillation

BACKGROUND

Premature ventricular complexes (PVCs) are common electrocardiographic abnormalities and may be a prognosticator in predicting mortality in patients with structurally normal hearts or chronic heart diseases. Whether PVC burden was associated with mortality in patients with chronic atrial fibrillation (AF) remained unknown. We investigated the prognostic value of PVC burden in patients with persistent AF.

METHODS

A retrospective analysis of 24 h Holter recordings of 1767 patients with persistent AF was conducted. Clinical characteristics, 24 h average heart rate (HR), and PVC measures, including 24 h PVC burden and the presence of consecutive PVCs (including any PVC couplet, triplet, or non-sustained ventricular tachycardia) were examined for the prediction of all-cause and cardiovascular mortality using the Cox proportional hazards model.

RESULTS

After a median follow-up time of 30 months, 286 (16%) patients died and 1481 (84%) patients survived. Multivariate analysis revealed that age, heart failure, stroke, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, beta-blocker, digoxin, oral anticoagulant use, and estimated glomerular filtration rate were significant baseline predictors of all-cause mortality and cardiovascular mortality. Twenty-four-hour PVC burden and the presence of consecutive PVCs were significantly associated with all-cause and cardiovascular mortality after adjusting for significant clinical factors. When compared to the first quartile of PVC burden (<0.003%/day), the highest quartile (>0.3%/day) was significantly associated with an increased risk of all-cause mortality (hazard ratio, 2.46; 95% CI, 1.77-3.42) and cardiovascular mortality (hazard ratio: 2.67; 95% CI, 1.76-4.06).

CONCLUSIONS

Twenty-four-hour PVC burden is independently associated with all-cause and cardiovascular mortality in patients with persistent AF.

2024 HRS expert consensus statement on arrhythmias in the athlete: Evaluation, treatment, and return to play

Youth and adult participation in sports continues to increase, and athletes may be diagnosed with potentially arrhythmogenic cardiac conditions. This international multidisciplinary document is intended to guide electrophysiologists, sports cardiologists, and associated health care team members in the diagnosis, treatment, and management of arrhythmic conditions in the athlete with the goal of facilitating return to sport and avoiding the harm caused by restriction. Expert, disease-specific risk assessment in the context of athlete symptoms and diagnoses is emphasized throughout the document. After appropriate risk assessment, management of arrhythmias geared toward return to play when possible is addressed. Other topics include shared decision-making and emergency action planning. The goal of this document is to provide evidence-based recommendations impacting all areas in the care of athletes with arrhythmic conditions. Areas in need of further study are also discussed.

Prognostic relevance of ventricular arrhythmias in surgical patients with gastrointestinal tumors

BACKGROUND

Individuals diagnosed with gastrointestinal tumors are at an increased risk of developing cardiovascular diseases. Among which, ventricular arrhythmia is a prevalent clinical concern. This suggests that ventricular arrhythmias may have predictive value in the prognosis of patients with gastrointestinal tumors.

AIM

To explore the prognostic value of ventricular arrhythmias in patients with gastrointestinal tumors receiving surgery.

METHODS

We retrospectively analyzed data from 130 patients undergoing gastrointestinal tumor resection. These patients were evaluated by a 24-h ambulatory electrocardiogram (ECG) at the Sixth Affiliated Hospital of Sun Yat-sen University from January 2018 to June 2020. Additionally, 41 general healthy age-matched and sex-matched controls were included. Patients were categorized into survival and non-survival groups. The primary endpoint was all-cause mortality, and secondary endpoints included major adverse cardiovascular events (MACEs).

RESULTS

Colorectal tumors comprised 90% of cases. Preoperative ambulatory ECG monitoring revealed that among the 130 patients with gastrointestinal tumors, 100 (76.92%) exhibited varying degrees of premature ventricular contractions (PVCs). Ten patients (7.69%) manifested non-sustained ventricular tachycardia (NSVT). The patients with gastrointestinal tumors exhibited higher PVCs compared to the healthy controls on both conventional ECG [27 (21.3) vs 1 (2.5), P = 0.012] and 24-h ambulatory ECG [14 (1.0, 405) vs 1 (0, 6.5), P < 0.001]. Non-survivors had a higher PVC count than survivors [150.50 (7.25, 1690.50) vs 9 (0, 229.25), P = 0.020]. During the follow-up period, 24 patients died and 11 patients experienced MACEs. Univariate analysis linked PVC > 35/24 h to all-cause mortality, and NSVT was associated with MACE. However, neither PVC burden nor NSVT independently predicted outcomes according to multivariate analysis.

CONCLUSION

Patients with gastrointestinal tumors exhibited elevated PVCs. PVCs > 35/24 h and NSVT detected by 24-h ambulatory ECG were prognostically significant but were not found to be independent predictors.

Class 1C Antiarrhythmics for Premature Ventricular Complex Suppression in Nonischemic Cardiomyopathy With Implantable Cardioverter-Defibrillators

BACKGROUND

Premature ventricular complexes (PVCs) are common and associated with worse outcomes in patients with heart failure. Class 1C antiarrhythmic drugs (AADs) effectively suppress PVCs, but guidelines currently restrict their use in structural heart disease.

OBJECTIVES

This study aimed to assess the safety and efficacy of class 1C AADs in patients with nonischemic cardiomyopathy (NICM) and implantable cardioverter-defibrillators (ICDs).

METHODS

All patients with NICM and an ICD treated with flecainide or propafenone at the Hospital of the University of Pennsylvania between 2014 and 2022 were identified. PVC burden, left ventricular ejection fraction (LVEF), and biventricular pacing percentage were compared before and during class 1C AAD treatment. Safety outcomes included sustained atrial and ventricular arrhythmias, heart failure admissions, and death.

RESULTS

We identified 34 patients, 23 receiving flecainide and 11 propafenone. Most patients (62%) had failed other AADs or catheter ablation (68%) prior to class 1C AAD initiation. PVC burden decreased from 20% ± 13% to 6% ± 7% (P < 0.001), LVEF increased from 33% ± 9% to 37% ± 10% (P = 0.01), and biventricular pacing percentage increased from 85% ± 9% to 93% ± 7% (P = 0.01). Sustained ventricular tachycardia (2 vs 9 patients) and admissions for decompensated heart failure (2 vs 3 patients) decreased compared with the 12 months prior to class 1C AAD initiation.

CONCLUSIONS

Class 1C AADs effectively suppressed PVCs in patients with NICM and ICDs, leading to increases in LVEF and biventricular pacing percentage. In this limited sample, their use was safe. Larger studies are needed to confirm the safety of this approach.

Reduced Ejection Fraction in Elite Endurance Athletes: Clinical and Genetic Overlap With Dilated Cardiomyopathy

BACKGROUND

Exercise-induced cardiac remodeling can be profound, resulting in clinical overlap with dilated cardiomyopathy, yet the significance of reduced ejection fraction (EF) in athletes is unclear. The aim is to assess the prevalence, clinical consequences, and genetic predisposition of reduced EF in athletes.

METHODS

Young endurance athletes were recruited from elite training programs and underwent comprehensive cardiac phenotyping and genetic testing. Those with reduced EF using cardiac magnetic resonance imaging (defined as left ventricular EF <50%, or right ventricular EF <45%, or both) were compared with athletes with normal EF. A validated polygenic risk score for indexed left ventricular end-systolic volume (LVESVi-PRS), previously associated with dilated cardiomyopathy, was assessed. Clinical events were recorded over a mean of 4.4 years.

RESULTS

Of the 281 elite endurance athletes (22±8 years, 79.7% male) undergoing comprehensive assessment, 44 of 281 (15.7%) had reduced left ventricular EF (N=12; 4.3%), right ventricular EF (N=14; 5.0%), or both (N=18; 6.4%). Reduced EF was associated with a higher burden of ventricular premature beats (13.6% versus 3.8% with >100 ventricular premature beats/24 h; P=0.008) and lower left ventricular global longitudinal strain (-17%±2% versus -19%±2%; P<0.001). Athletes with reduced EF had a higher mean LVESVi-PRS (0.57±0.13 versus 0.51±0.14; P=0.009) with athletes in the top decile of LVESVi-PRS having an 11-fold increase in the likelihood of reduced EF compared with those in the bottom decile (P=0.034). Male sex and higher LVESVi-PRS were the only significant predictors of reduced EF in a multivariate analysis that included age and fitness. During follow-up, no athletes developed symptomatic heart failure or arrhythmias. Two athletes died, 1 from trauma and 1 from sudden cardiac death, the latter having a reduced right ventricular EF and a LVESVi-PRS >95%.

CONCLUSIONS

Reduced EF occurs in approximately 1 in 6 elite endurance athletes and is related to genetic predisposition in addition to exercise training. Genetic and imaging markers may help identify endurance athletes in whom scrutiny about long-term clinical outcomes may be appropriate.

REGISTRATION

URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374976&isReview=true; Unique identifier: ACTRN12618000716268.

Predictors and possible mechanisms of premature ventricular contraction induced cardiomyopathy

Premature ventricular complexes (PVCs) are encountered frequently in clinical practice. While PVCs may have various causes, a small number of individuals with PVCs develop cardiomyopathy in the absence of other potential etiologies. When correctly identified, patients with PVC-incuded cardiomyopathy can have dramatic improvement of their cardiomyopathy with treatment of their PVCs. In this focused review, we discuss potential predictors of PVC-induced cardiomyopathy, including PVC frequency, PVC characteristics, and modifiable patient risk factors. We also review some proposed mechanisms of PVC-induced cardiomyopathy and conclude with future directions for research and clinical practice.

Prognostic implications of premature ventricular contractions and non-sustained ventricular tachycardia in light-chain cardiac amyloidosis

AIMS

Premature ventricular contractions (PVC) and non-sustained ventricular tachycardia (NSVT) are commonly observed in light chain cardiac amyloidosis (AL-CA), but their association with prognosis is still unclear. We aimed to evaluate the prognostic value of PVCs and NSVT in patients with moderate-to-advanced AL-CA.

METHODS AND RESULTS

We retrospectively included patients with AL-CA at modified 2004 Mayo stages II-IIIb between February 2014 and December 2020. Twenty-four-hour Holter recordings were assessed on admission. The outcomes included (i) new onset of adverse ventricular arrhythmia (VA) or sudden cardiac death (SCD) and (ii) cardiac death during follow-up. Of the 143 patients studied (60.41 ± 11.06 years, male 64.34%), 132 (92.31%) had presence of PVC, and 50 (34.97%) had NSVT on Holter. Twelve (8.4%) patients died in hospital and 131 patients were followed up (median 24.4 months), among whom 71 patients had cardiac death, and 15 underwent adverse VA/SCD. NSVT [hazard ratio (HR): 13.57, 95% confidence interval (CI): 3.06-60.18, P < 0.001], log-transformed PVC counts (HR: 1.46, 95%CI: 1.15-1.86, P = 0.002) and PVC burden (HR: 1.43 95%CI:1.14-1.80, P = 0.002) were predictive of new onset of adverse VA/SCD. The highest tertile of PVC counts (HR: 2.33, 95%CI: 1.27-4.28, P = 0.006) and PVC burden (HR: 2.58, 95%CI: 1.42-4.69, P = 0.002), rather than NSVT (HR: 1.16, 95%CI: 0.67-1.98, P = 0.603), was associated with cardiac death. Higher PVC counts/burden provided incremental value on modified 2004 Mayo stage in predicting cardiac death, with C index increasing from 0.681 to 0.712 and 0.717, respectively (P values <0.05).

CONCLUSION

PVC count, burden, and NSVT significantly correlated with adverse VA/SCD during follow-up in patients with AL-CA. Higher PVC counts/burdens added incremental value for predicting cardiac death.

2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional global data, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Efficacy and Safety of a Pharmaco-Invasive Strategy Using Half-Dose Recombinant Human Prourokinase in Patients with ST-Segment Elevation Myocardial Infarction During Hospitalization

This study investigated the efficacy and safety of pharmaco-invasive strategy with half-dose recombinant human prourokinase (PHDP) during hospitalization for patients with ST-segment elevation myocardial infarction (STEMI) to provide references for the treatment of STEMI. Patients with STEMI who fulfilled the inclusion and exclusion criteria and attended Chengde Central Hospital, Hebei Province, China, between September 3, 2019, and December 28, 2021, were included in this study. The experimental group received PHDP and the control group underwent primary percutaneous coronary intervention (PPCI). This study enrolled 150 patients with STEMI, 75 in the experimental group and 75 in the control group. Coronary angiography revealed successful thrombolysis in 64 (85.33%) patients. Compared with the control group, the experimental group had shorter first medical contact-reperfusion time (P < 0.001), less slow flow/no-reflow (P < 0.001), and a lower utilization rate of Tirofiban (P < 0.001). Validity endpoints: no statistically significant differences between the two groups. Safety endpoints: no statistically significant differences between bleeding and major adverse cardiovascular and cerebrovascular events (MACCEs), but the experimental group was more prone to arrhythmias (P = 0.040), particularly premature ventricular beats (PVB) (P = 0.008). In conclusion, the efficacy and safety of PHDP in the treatment of patients with STEMI were positive. Complete epicardial and myocardial reperfusion rates, risk for bleeding during hospitalization, and incidence of MACCEs were similar to those of the PPCI strategy. Although the PHDP group has a higher incidence of PVB, it does not increase the incidence of malignant arrhythmia. This study aimed to provide a new therapeutic strategy for the treatment of STEMI in hospitals without adequate PPCI resources condition.

The Influence of Lifestyle Factors on the Occurrence and Severity of Premature Ventricular Contractions: A Comprehensive Review

Premature ventricular contractions (PVC) are a type of ventricular arrhythmias, occurring as a result of formation or reentry of an abnormal impulse in the ventricular myocardium or in the Purkinje system. PVC occurs commonly in healthy individuals and is observed in 1%-4% of the population. Several lifestyle factors like stress levels, caffeine, drugs, alcohol, nicotine, sleep, and physical exercise have been implicated in increasing the risk. Caffeine and drugs precipitate heightened cardiac stimulation, precipitating PVCs. Excessive alcohol and nicotine disturb the electrical pathways resulting in PVCs. Higher rates of PVCs have been associated with obesity. Individuals with insomnia and increased stress levels are also at an increased risk due to an imbalance in the autonomic system. Exercise is known to induce PVCs, including in healthy, asymptomatic individuals. Modification of these factors can decrease PVC risk. This article aims to provide a comprehensive review of the effects of lifestyle factors on PVC.

Association between excess catecholamine synthesis and polymorphic premature ventricular contraction

BACKGROUND

The reasons for the etiology of premature ventricular contractions (PVCs) are not specifically known. Many patients are resistant to medical treatment, and a factor that would predict response to medical treatment cannot be identified. This study aims to investigate if a high catecholamine level results in polymorphic PVC.

METHODS

This study was obtained by prospective data registry analysis. A total of 100 patients, 50 from the PVC group, and 50 from the control group have been evaluated. The participants who were included in the patient group had a polymorphic PVC of 5% or more in their 24-h Holter evaluations. Metanephrine showing the level of adrenaline and normetanephrine, showing the level of noradrenaline levels have been measured from these urine samples.

RESULT

There was no difference between the two groups in terms of biochemical and essential characteristics. Normetanephrine level has been significantly higher in the PVC group compared to the control group (323.9 ± 208.9 μg to 129.25 ± 67.88 μg; p < 0.001). Similarly, metanephrine level has also been higher in the PVC group (124.75 ± 82.43 μg to 52.615 ± 36,54 μg; p < 0.001). A positive and moderate correlation has been identified between the number and ratio of PVC and the metanephrine and normetanephrine levels.

CONCLUSION

In this study, we found that the catecholamine levels were higher in the polymorphic PVC group than in the healthy volunteers. Also, an increase in the number and rate of PVC has been observed as the catecholamine levels increased.

CLINICAL TRIAL REGISTRATION

Urine Levels of Metanephrine and Normetanephrine in Patients With Frequent PVC; ClinicalTrials.gov number NCT03447002.

Mechanisms and Risk Factors for Premature Ventricular Contraction Induced Cardiomyopathy

Frequent premature ventricular contractions (PVCs) can cause a reversible form of cardiomyopathy in patients without structural heart disease. Because of the challenging nature of PVC-induced cardiomyopathy (PVICM), the mechanisms and risk factors for PVICM are still unclear. Based on the evidence from retrospective and observational studies, the risk factors for the development of PVICM, in addition to PVC exposure, include QRS duration, coupling interval and male sex. Based on animal models, abnormal calcium handling and cardiac remodeling may be the crucial mechanism underlying the development of cardiomyopathy. We have summarized the current knowledge on PVICM in this review. Understanding these mechanisms and risk factors is important for the diagnosis and management of this condition, which can lead to heart failure if left untreated.

Association Between Left Ventricular Scar and Ventricular Ectopy in People Living With and Without HIV

BACKGROUND

People living with HIV (PLWH) have greater risk for arrhythmic sudden death and heart failure than people without HIV (PWOH), though risk identifiers remain understudied. Higher ventricular ectopy (VE) burden reflects increased arrhythmic susceptibility and cardiomyopathy risk.

OBJECTIVES

The purpose of this study was to test if myocardial scar measured by late gadolinium-enhancement cardiovascular magnetic resonance (LGE-CMR) associates with VE by ambulatory electrocardiographic monitoring among PLWH and PWOH with risk factors for HIV, and if the association differs by HIV.

METHODS

Participants from 3 cohorts of PLWH and PWOH underwent electrocardiographic monitoring (median wear time 8.3 days) and CMR. Using multivariable regression, we assessed: 1) associations between scar metrics and VE, adjusting for demographics, HIV serostatus, substance use, cardiovascular risk factors, and left ventricular (LV) function/structure; and 2) effect measure modification by HIV.

RESULTS

Of 329 participants (median age 55 years, 30% women, 62% PLWH), 109 had LGE (62% PLWH). Ischemic or major nonischemic pattern LGE was associated with high VE burden (adjusted OR: 2.32, P = 0.004) and more PVCs/day (141% higher, P < 0.001). Among people with LGE, greater scar mass correlated with more PVCs/day (P = 0.028). Associations persisted after adjustment for LV function/structure and when excluding PLWH with HIV viremia and showed no effect measure modification by HIV.

CONCLUSIONS

Ischemic or major nonischemic pattern LGE and greater scar mass correlated with higher VE burden, independently of LV structure/function, HIV serostatus, and HIV viremia. The findings highlight specific scar characteristics common to PLWH and PWOH with risk factors for HIV that may portend higher risk for arrhythmias and heart failure.

An Early Indicator in Evaluating Cardiac Dysfunction Related to Premature Ventricular Complexes: Cardiorespiratory Capacity

Cardiac dysfunction induced by premature ventricular complexes (PVCs) is relatively controversial and challenging to detect in the early stage. In this observational study, we retrospectively analyzed the cardiopulmonary exercise test (CPET) data of 94 patients with frequent premature ventricular beats (47 males, 49.83 ± 13.63 years) and 98 participants (55 males, 50.84 ± 9.41 years) whose age and gender were matched with the patient with PVCs. The baseline information and routine echocardiography detection were recorded on admission. PVCs were diagnosed by 24 h Holter monitoring, and cardiorespiratory capacity was assessed using peak oxygen uptake (V'O2peak), anaerobic threshold (AT), and other CPET parameters with an individualized bicycle ramp protocol according to the predicted workload and exercise situation of each participant. There were no statistically significant differences in most baseline characteristics between the two groups. Indicators that reflect cardiopulmonary capacity, such as V'O2peak, AT, and ΔO2 pulse/Δwork rate(ΔV'O2/ΔWR), were all significantly lower in the PVC group (p = 0.031, 0.021, and 0.013, respectively) despite normal and nondiscriminatory left ventricular ejection fractions between the two groups. However, there was no statistically significant difference among subgroups based on the frequency of PVCs, which was <10,000 beats/24 h, 10,000-20,000 beats/24 h, and >20,000 beats/24 h. The cardiorespiratory capacity was lower in patients with frequent PVCs, indicating that CPET could detect early signs of impaired cardiac function induced by PVCs.

Mitral annular disjunction in surgical mitral valve prolapse: prevalence, characteristics and outcomes

BACKGROUND

There is a paucity of literature regarding outcomes of patients with mitral valve prolapse (MVP) and mitral annular disjunction (MAD) after mitral surgery, with many unanswered questions including the post-surgical persistence of MAD, effect of MAD on mitral valve reparability, and incidence of arrhythmia after mitral valve surgery. We aimed to examine the prevalence, imaging characteristics and clinical associations of mitral annular disjunction among patients undergoing mitral valve surgery for mitral valve prolapse, as well as outcomes after surgery including the persistence of MAD, arrhythmic events and excess mortality.

RESULTS

A retrospective analysis of 111 consecutive patients who underwent mitral valve surgery for MVP was performed. A total of 32 patients (28.8%) had MAD. Patients with MAD were younger (64 vs 67 yrs, p = 0.04), with lower rates of hypertension (21.9% vs 50.6%, p = 0.01) and hyperlipidaemia (25% vs 50.6%; p = 0.01) and were more likely to be female (43.8% vs 21.4%, p = 0.04) with myxomatous leaflets > 5mm (90.6% vs 15.2%, p =  < 0.01) and bileaflet prolapse (31.3% vs 10.1%, p = 0.02). Mitral valve repair was performed in 29/32 patients (90.6%) in the MAD positive group, and no patients had the persistence of MAD post-surgery. Post-operative ventricular arrhythmia was higher in the MAD positive group (28.13% vs 11.69%, p = 0.04) with no difference in mortality, 30-day hospital re-admission, or post-operative mitral regurgitation between patients with and without MAD over 3.91 years of follow up.

CONCLUSION

In this study of consecutive patients with MVP undergoing surgery, MAD was a common finding (almost 1 in 3). MAD does not compromise mitral valve surgical reparability, and both repair and replacement are effective at correcting disjunction. Our data suggest that concurrent MAD in MVP patients undergoing surgery has no significant effect on post surgical outcomes. Further research as to whether this patient cohort requires post-surgical arrhythmia monitoring is warranted.

Electrocardiographic Characteristics, Identification, and Management of Frequent Premature Ventricular Contractions

Premature ventricular complexes (PVCs) are frequently encountered in clinical practice. The association of PVCs with adverse cardiovascular outcomes is well established in the context of structural heart disease, yet not so much in the absence of structural heart disease. However, cardiac magnetic resonance (CMR) seems to contribute prognostically in the latter subgroup. PVC-induced myocardial dysfunction refers to the impairment of ventricular function due to PVCs and is mostly associated with a PVC burden > 10%. Surface 12-lead ECG has long been used to localize the anatomic site of origin and multiple algorithms have been developed to differentiate between right ventricular and left ventricular outflow tract (RVOT and LVOT, respectively) origin. Novel algorithms include alternative ECG lead configurations and, lately, sophisticated artificial intelligence methods have been utilized to determine the origins of outflow tract arrhythmias. The decision to therapeutically address PVCs should be made upon the presence of symptoms or the development of PVC-induced myocardial dysfunction. Therapeutic modalities include pharmacological therapy (I-C antiarrhythmic drugs and beta blockers), as well as catheter ablation, which has demonstrated superior efficacy and safety.

Identification of non-ischaemic fibrosis in male veteran endurance athletes, mechanisms and association with premature ventricular beats

Left ventricular fibrosis can be identified by late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) in some veteran athletes. We aimed to investigate prevalence of ventricular fibrosis in veteran athletes and associations with cardiac arrhythmia. 50 asymptomatic male endurance athletes were recruited. They underwent CMR imaging including volumetric analysis, bright blood (BB) and dark blood (DB) LGE, motion corrected (MOCO) quantitative stress and rest perfusion and T1/T2/extracellular volume mapping. Athletes underwent 12-lead electrocardiogram (ECG) and 24-h ECG. Myocardial fibrosis was identified in 24/50 (48%) athletes. All fibrosis was mid-myocardial in the basal-lateral left ventricular wall. Blood pressure was reduced in athletes without fibrosis compared to controls, but not athletes with fibrosis. Fibrotic areas had longer T2 time (44 ± 4 vs. 40 ± 2 ms, p < 0.0001) and lower rest myocardial blood flow (MBF, 0.5 ± 0.1 vs. 0.6 ± 0.1 ml/g/min, p < 0.0001). On 24-h ECG, athletes with fibrosis had greater burden of premature ventricular beats (0.3 ± 0.6 vs. 0.05 ± 0.2%, p = 0.03), with higher prevalence of ventricular couplets and triplets (33 vs. 8%, p = 0.02). In veteran endurance athletes, myocardial fibrosis is common and associated with an increased burden of ventricular ectopy. Possible mechanisms include inflammation and blood pressure. Further studies are needed to establish whether fibrosis increases risk of malignant arrhythmic events.

Impact of Premature Ventricular Complex (PVC) Burden on the Left Ventricle in the Structurally Normal Heart: Hemodynamic Alterations of Idiopathic PVC on Echocardiography

Background

Premature ventricular complex (PVC) without structural heart disease is mostly viewed as a benign arrhythmia. However, the high burden of PVC causes cardiomyopathy due to intraventricular dyssynchrony. The effects of ectopic contraction on left ventricular (LV) hemodynamics in the structurally normal heart are unclear.

Objectives

To examine the effect of PVC burden on LV dimension, LV systolic function, and intraventricular blood flow, and to determine whether ectopic ventricular contraction affects LV hemodynamics.

Methods

Patients aged ≥ 18 years with PVC ≥ 5% on Holter recording were enrolled and divided into groups G1 (5-10%), G2 (10-20%), and G3 (≥ 20%). We excluded patients with structural heart diseases, pacemakers, and LV systolic dysfunction [LV ejection fraction (LVEF) < 50%]. Clinical characteristics and routine transthoracic echocardiography parameters were compared.

Results

The end-systolic LV internal dimension increased according to the PVC burden from G1 to G3 (p = 0.001). LVEF was inversely associated with PVC burden from G1 to G3 (p = 0.002). The same pattern was seen for LV outflow tract (LVOT) maximal velocity (p = 0.005) and maximal pressure gradient (PG) (p = 0.005), LVOT velocity time integral (VTI) (p = 0.03) and LV stroke volume index (LVSI) (p = 0.008).

Conclusions

Systolic function and LV end-systolic dimension were inversely associated with PVC burden. Decreased LVOT flow velocity and PG were related to increased PVC burden. LVOT VTI and LVSI were smaller when the PVC burden exceeded 20%. These negative hemodynamic manifestations of idiopathic PVC were considerable even in structure normal hearts, hence the early elimination of PVC is strongly advised.

Pathophysiology and treatment of adults with arrhythmias in the emergency department, part 2: Ventricular and bradyarrhythmias

PURPOSE

This is the second article in a 2-part series reviewing the pathophysiology and treatment considerations for arrhythmias. Part 1 of the series discussed aspects related to treating atrial arrhythmias. Here in part 2, the pathophysiology of ventricular arrhythmias and bradyarrhythmias and current evidence on treatment approaches are reviewed.

SUMMARY

Ventricular arrhythmias can arise suddenly and are a common cause of sudden cardiac death. Several antiarrhythmics may be effective in management of ventricular arrhythmias, but there is robust evidence to support the use of only a few of these agents, and such evidence was largely derived from trials involving patients with out-of-hospital cardiac arrest. Bradyarrhythmias range from asymptomatic mild prolongation of nodal conduction to severe conduction delays and impending cardiac arrest. Vasopressors, chronotropes, and pacing strategies require careful attention and titration to minimize adverse effects and patient harm.

CONCLUSION

Ventricular arrhythmias and bradyarrhythmias can be consequential and require acute intervention. As experts in pharmacotherapy, acute care pharmacists can participate in providing high-level intervention by aiding in diagnostic workup and medication selection.

Subclinical Left Ventricular Dysfunction and Ventricular Arrhythmias in Older Adults With Normal Ejection Fraction

Background Premature ventricular contractions (PVCs) and nonsustained ventricular tachycardia (NSVT) are known to be associated with reduced left ventricular (LV) ejection fraction and adverse outcomes in patients with structural heart disease. The relationship between subclinical LV dysfunction and ventricular arrhythmias in the general population is not established. Methods and Results Participants in the SAFARIS (Subclinical Atrial Fibrillation and Risk of Ischemic Stroke) study with normal left ventricular ejection fraction (n=503; mean age 77 years, 63% women) underwent 14-day electrocardiographic monitoring and 2-dimensional echocardiography. Frequent PVCs were defined as PVCs >500 per 24 hours and NSVT as ≥4 consecutive ventricular ectopic beats. Reduced LV global longitudinal strain (GLS) was used as an indicator of subclinical LV dysfunction. Seventy-six participants (15.1%) had PVCs >500/d, 117 (23.3%) had NSVT episodes. LV GLS was significantly reduced in both frequent PVCs and NSVT groups (P<0.01). In multivariable analyses, lower LV GLS was associated with frequent PVCs (adjusted odds ratio [aOR], 1.19 [95% CI, 1.09-1.30 per unit reduction]; P<0.001) and NSVT (aOR, 1.09 [95% CI, 1.01-1.17]; P=0.036) independently of established risk factors and other echocardiographic parameters. Abnormal LV GLS (>-15.8%) carried a 2-fold increase in risk of ventricular arrhythmias (aOR, 2.18, P=0.029 for PVCs; aOR, 2.09, P=0.026 for NSVT). Conclusions PVCs and NSVT episodes were frequent in this community-based elderly cohort with normal left ventricular ejection fraction and were independently associated with lower LV GLS. The association between LV dysfunction and ventricular arrhythmias is present at an early, subclinical stage, an observation that carries possible preventative implications.

Twenty-five years of catheter ablation of ventricular tachycardia: a look back and a look forward

This article will discuss the past, present, and future of ventricular tachycardia ablation and the continuing contribution of the Europace journal as the platform for publication of milestone research papers in this field of ventricular tachycardia ablation.

Ventricular tachycardia risk prediction with an abbreviated duration mobile cardiac telemetry

Background

Ventricular tachycardia (VT) occurs intermittently, unpredictably, and has potentially lethal consequences.

Objective

Our aim was to derive a risk prediction model for VT episodes ≥10 beats detected on 30-day mobile cardiac telemetry based on the first 24 hours of the recording.

Methods

We included patients who were monitored for 2 to 30 days in the United States using full-disclosure mobile cardiac telemetry, without any VT episode ≥10 beats on the first full recording day. An elastic net prediction model was derived for the outcome of VT ≥10 beats on monitoring days 2 to 30. Potential predictors included age, sex, and electrocardiographic data from the first 24 hours: heart rate; premature atrial and ventricular complexes occurring as singlets, couplets, triplets, and runs; and the fastest rate for each event. The population was randomly split into training (70%) and testing (30%) samples.

Results

In a population of 19,781 patients (mean age 65.3 ± 17.1 years, 43.5% men), with a median recording time of 18.6 ± 9.6 days, 1510 patients had at least 1 VT ≥10 beats. The prediction model had good discrimination in the testing sample (area under the receiver-operating characteristic curve 0.7584, 95% confidence interval 0.7340-0.7829). A model excluding age and sex had an equally good discrimination (area under the receiver-operating characteristic curve 0.7579, 95% confidence interval 0.7332-0.7825). In the top quintile of the score, more than 1 in 5 patients had a VT ≥10 beats, while the bottom quintile had a 98.2% negative predictive value.

Conclusion

Our model can predict risk of VT ≥10 beats in the near term using variables derived from 24-hour electrocardiography, and could be used to triage patients to extended monitoring.

Management of Premature Ventricular Complexes in the Outpatient Setting

With an aging population and an explosion in ambulatory electrocardiographic monitoring, primary care clinicians will undoubtedly see an increase in patients presenting with premature ventricular complexes (PVCs), especially given how common they are in the general population. A sizable number of patients with PVCs are asymptomatic, and these PVCs have no significant clinical implications. In contrast, PVCs can predispose patients to or are a clinical marker of an underlying cardiomyopathy, heart failure, or sudden cardiac death. Such a dichotomy can create fear in dealing with PVCs in the outpatient setting, both in immediate situations and for surveillance and follow-up. In this review, we provide a comprehensive overview of the pathophysiologic basis of PVCs, appropriate diagnostic testing, management, and prognostic considerations necessary when faced with PVCs in the outpatient clinic. We also provide a simplistic approach to help guide the initial work-up of PVCs, basic treatment strategies, and indications of when to refer for cardiovascular specialty consultation to improve physician comfort and to enhance patient care.

The evolution of electrocardiographic abnormalities in the elderly with Chagas disease during 14 years of follow-up: The Bambui Cohort Study of Aging

BACKGROUND

The natural history of Chagas disease (ChD) in older ages is largely unknown, and it is a matter of controversy if the disease continues to progress in the elderly.

OBJECTIVE

To investigate the evolution of electrocardiographic abnormalities in T. cruzi chronically infected community-dwelling elderly compared to non-infected (NChD) subjects and how it affects this population's survival in a follow-up of 14 years.

METHODS AND RESULTS

A 12-lead ECG of each individual of the Bambui Cohort Study of Aging was obtained in 1997, 2002, and 2008, and the abnormalities were classified using the Minnesota Code. The influence of ChD on the ECG evolution was assessed by semi-competing risks considering a new ECG abnormality as the primary event and death as the terminal event. A Cox regression model to evaluate the population survival was conducted at a landmark point of 5.5 years. The individuals of both groups were compared according to the following categories: Normal, Maintained, New, and More by the development of ECG major abnormalities between 1997 and 2002. Among the participants, the ChD group had 557 individuals (median age: 68 years) and NChD group had 905 individuals (median age: 67 years). ChD was associated with a higher risk of development of a new ECG abnormality [HR: 2.89 (95% CI 2.28-3.67)]. The development of a new major ECG abnormality increases the risk of death ChD patients compared to those that maintain a normal ECG [HR: 1.93 (95% CI 1.02-3.65)].

CONCLUSION

ChD is still associated with a higher risk of progression to cardiomyopathy in the elderly. The occurrence of a new major ECG abnormality in ChD patients predicts a higher risk of death.

Catheter Ablation vs Antiarrhythmic Drug Therapy for Treatment of Premature Ventricular Complexes: A Systematic Review

There is variability in treatment modalities for premature ventricular complexes (PVCs), including use of antiarrhythmic drug (AAD) therapy or catheter ablation (CA). This study reviewed evidence comparing CA vs AADs for the treatment of PVCs. A systematic review was performed from the Medline, Embase, and Cochrane Library databases, as well as the Australian and New Zealand Clinical Trials Registry, U.S. National Library of Medicine ClinicalTrials database, and the European Union Clinical Trials Register. Five studies (1 randomized controlled trial) enrolling 1,113 patients (57.9% female) were analyzed. Four of five studies recruited mainly patients with outflow tract PVCs. There was significant heterogeneity in AAD choice. Electroanatomic mapping was used in 3 of 5 studies. No studies documented intracardiac echocardiography or contact force-sensing catheter use. Acute procedural endpoints varied (2 of 5 targeted elimination of all PVCs). All studies had significant potential for bias. CA seemed superior to AADs for PVC recurrence, frequency, and burden. One study reported long-term symptoms (CA superior). Quality of life or cost-effectiveness was not reported. Complication and adverse event rates were 0% to 5.6% for CA and 9.5% to 21% for AADs. Future randomized controlled trials will assess CA vs AADs for patients with PVCs without structural heart disease (ECTOPIA [Elimination of Ventricular Premature Beats with Catheter Ablation versus Optimal Antiarrhythmic Drug Treatment]), with impaired LVEF (PAPS [Prospective Assessment of Premature Ventricular Contractions Suppression in Cardiomyopathy] Pilot), and with structural heart disease (CAT-PVC [Catheter Ablation Versus Amiodarone for Therapy of Premature Ventricular Contractions in Patients With Structural Heart Disease]). In conclusion, CA seems to reduce recurrence, burden, and frequency of PVCs compared with AADs. There is a lack of data on patient- and health care-specific outcomes such as symptoms, quality of life, and cost-effectiveness. Several upcoming trials will offer important insights for management of PVCs.

Contemporary updates on ventricular arrhythmias: from mechanisms to management

Ventricular arrhythmias (VAs) are a group of heart rhythm disorders that can be life-threatening and cause significant morbidity. VA in the presence of structural heart disease (SHD) has distinct prognostic implications and requires a comprehensive and multifaceted approach for investigation and management. Early specialist referral should be considered for all patients with VA. Particular urgency is recommended in patients with syncope, nonsustained/sustained VA on Holter monitor and SHD on cardiac imaging because of the heightened risk of sudden cardiac death. Comprehensive phenotyping is recommended for most patients with VA, encompassing noninvasive cardiac functional testing, multimodality imaging and genetic testing in select circumstances. Management of idiopathic VA is guided heavily by symptom burden and the presence of ventricular systolic impairment. In SHD, guideline-directed heart failure therapy and device implantation are critical considerations. Whilst commonly used and well-established, antiarrhythmic drugs can be hampered by toxicity and failure of adequate arrhythmia control. Catheter ablation is increasingly being considered a feasible first-line alternative to medical therapy, where outcomes are influenced by disease aetiology and scar burden in SHD. Catheter ablation is associated with reduced arrhythmia recurrence and burden and improved quality of life at follow-up.

Relationship between epicardial adipose tissue measured by computed tomography and premature ventricular complexes originating from different sites

AIMS

This study aims to explore the association between the features of epicardial adipose tissue (EAT) in different zones and premature ventricular complexes (PVCs) originating from different sites by computed tomography (CT).

METHODS AND RESULTS

A total of 136 patients who underwent radiofrequency ablation for PVCs were incorporated in this study. One hundred and thirty-six matched controls were included in this study using the case-control method (1:1 matching). PVCs were classified into four subgroups: (1) right ventricular outflow tract (RVOT-PVCs), (2) non-RVOT of the right ventricle (RV-PVCs), (3) left ventricular outflow tract (LVOT-PVCs), and (4) non-LVOT of the left ventricle (LV-PVCs). The volume and density of EAT were quantified by CT. Patients with PVCs had a significantly higher volume and lower density of EAT than the controls (P < 0.001). The LVOT-PVCs and LV-PVCs had a higher left ventricle periventricular EAT volume (LV-EATv) proportion (P < 0.05). The right ventricle periventricular EAT volume (RV-EATv) proportion was higher in ROVT-PVCs and LVOT-PVCs (P < 0.05). RVOT-PVC patients had a higher volume ratio and a smaller density differential (P < 0.05). Patients with LVOT-PVCs had a lower volume ratio and the LV-PVCs showed a greater density differential (P < 0.05).

CONCLUSION

Higher volume and lower density of EAT were significantly associated with frequent PVCs. The RVOT-PVC patients had a higher volume ratio and a smaller density differential. The LVOT-PVCs had a lower volume ratio and the LV-PVCs showed a greater density differential. These suggest a link between EAT structural properties and PVCs and a potential role for regional EAT in the development of PVCs.

Acute Effects of Coffee Consumption on Health among Ambulatory Adults

BACKGROUND

Coffee is one of the most commonly consumed beverages in the world, but the acute health effects of coffee consumption remain uncertain.

METHODS

We conducted a prospective, randomized, case-crossover trial to examine the effects of caffeinated coffee on cardiac ectopy and arrhythmias, daily step counts, sleep minutes, and serum glucose levels. A total of 100 adults were fitted with a continuously recording electrocardiogram device, a wrist-worn accelerometer, and a continuous glucose monitor. Participants downloaded a smartphone application to collect geolocation data. We used daily text messages, sent over a period of 14 days, to randomly instruct participants to consume caffeinated coffee or avoid caffeine. The primary outcome was the mean number of daily premature atrial contractions. Adherence to the randomization assignment was assessed with the use of real-time indicators recorded by the participants, daily surveys, reimbursements for date-stamped receipts for coffee purchases, and virtual monitoring (geofencing) of coffee-shop visits.

RESULTS

The mean (±SD) age of the participants was 39±13 years; 51% were women, and 51% were non-Hispanic White. Adherence to the random assignments was assessed to be high. The consumption of caffeinated coffee was associated with 58 daily premature atrial contractions as compared with 53 daily events on days when caffeine was avoided (rate ratio, 1.09; 95% confidence interval [CI], 0.98 to 1.20; P = 0.10). The consumption of caffeinated coffee as compared with no caffeine consumption was associated with 154 and 102 daily premature ventricular contractions, respectively (rate ratio, 1.51; 95% CI, 1.18 to 1.94); 10,646 and 9665 daily steps (mean difference, 1058; 95% CI, 441 to 1675); 397 and 432 minutes of nightly sleep (mean difference, 36; 95% CI, 25 to 47); and serum glucose levels of 95 mg per deciliter and 96 mg per deciliter (mean difference, -0.41; 95% CI, -5.42 to 4.60).

CONCLUSIONS

In this randomized trial, the consumption of caffeinated coffee did not result in significantly more daily premature atrial contractions than the avoidance of caffeine. (Funded by the University of California, San Francisco, and the National Institutes of Health; CRAVE ClinicalTrials.gov number, NCT03671759.).

High Burden of Premature Ventricular Complex Increases the Risk of New-Onset Atrial Fibrillation

Background High burden of premature ventricular complex (PVC) leads to increased cardiovascular mortality. A recent nationwide population-based study demonstrated that PVC is associated with an increased risk of atrial fibrillation (AF). However, the relationship between PVC burden and new-onset AF has not been investigated. The purpose of the study is to elucidate whether PVC burden is associated with new-onset AF. Methods and Results We designed a single-center, retrospective, large population-based cohort study to evaluate the role of PVC burden and new-onset AF in Taiwan. Patients who were AF naïve with PVC were divided into the low burden group (<1000/day) and moderate-to-high burden group (≥1000/day) based on the 24-h Holter ECG report. New-onset AF was defined as a new or first detectable event of either a persistent or paroxysmal AF. A total of 16 030 patients who were AF naïve and underwent 24-h Holter ECG monitoring were enrolled in this study, with a mean follow-up time of 973 days. A propensity score-matched analysis demonstrated that the moderate-to-high burden PVC group had a higher risk of developing new-onset AF than that of the low burden PVC group (4.91% versus 2.73%, P<0.001). Multivariate Cox regression analysis showed that moderate-to-high burden of PVC is an independent risk factor for new-onset AF. The Kaplan-Meier analysis demonstrated that patients with moderate-to-high PVC burden were associated with higher risk of new-onset AF (log-rank P<0.001). Conclusions PVC burden is associated with new-onset AF. Patients with moderate-to-high PVC burden are at a higher risk of new-onset AF. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03877614.

Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Temporal and Spatial Changes of Proarrhythmic Substrate in Premature Ventricular Contraction-Induced Cardiomyopathy

BACKGROUND

The changes in proarrhythmic substrates and malignant ventricular arrhythmia mechanisms caused by premature ventricular contraction-induced cardiomyopathy (PVCCM) remain unclear.

OBJECTIVES

The goal of this study was to establish the electrophysiological mechanism of how high-load PVC causes malignant arrhythmia.

METHODS

Thirteen swine were exposed to 50% paced PVC from the right ventricular apex for 12 weeks (PVCCM, n = 6) and no pacing for 12 weeks (control, n = 7). Cardiac function was quantified biweekly with echocardiography. Computed tomography scans and electrophysiological examinations were performed monthly to dynamically evaluate the changes in the cardiac structure and the arrhythmogenic substrate.

RESULTS

The decreases in the cardiac function and ventricular enlargement in the PVCCM group were significant after 12 weeks of PVC stimulation compared with the control group (P < 0.001). Electrophysiological examination found that the ventricular effective refractory period dispersion (0.071 ± 0.008), area of the low-voltage zone (9.41 ± 1.55 cm2), and malignant ventricular arrhythmia inducibility (33.3%) of the PVCCM group increased significantly at week 8 after pacing (P < 0.001 vs the control group); these changes slowed down after 8 weeks. Moreover, the distribution of the low-voltage zone presented obvious spatial heterogeneity, especially in the anterior wall of the right ventricle, accompanied by delayed activation in the sinus rhythm (67 ± 13 milliseconds). Consistently, the proportion of ventricular fibrosis- and expression-related proteins were significantly increased in the PVCCM group (P < 0.001), especially in the right ventricle. Moreover, proteomic analysis confirmed the spatial profile of these fibrotic changes in the PVCCM group.

CONCLUSIONS

High-burden PVC can cause significant temporal and spatial heterogeneity changes in proarrhythmic substrates, which are potentially related to the upregulation of calcium signaling caused by asynchronous activation.

Left and Right PVC-Induced Ventricular Dysfunction

BACKGROUND

Frequent premature ventricular complexes (PVCs) can result in a reversible form of cardiomyopathy that usually affects the left ventricle (LV).

OBJECTIVES

The objective of this study was to assess whether frequent PVCs have an impact on right ventricular (RV) function.

METHODS

Serial cardiac magnetic resonance (CMR) studies were performed in a series of 47 patients before and after ablation of frequent PVCs.

RESULTS

Patients with RV cardiomyopathy (ejection fraction [EF] <0.45) had more frequent PVCs than did patients without decreased RV function (23% ± 11% vs 15% ± 11%, P = 0.03). Likewise, patients with LV cardiomyopathy (EF <0.50) had more frequent PVCs than did patients without decreased LV function (23% ± 10% vs 14% ± 12%, P = 0.003). LV dysfunction was present in 21 patients (45%). In patients with LV dysfunction, 15 patients (32%) had biventricular dysfunction, and 6 patients (13%) had isolated LV dysfunction. A total of 19 patients (40%) had RV dysfunction, and 4 of the patients with RV dysfunction (9%) had isolated RV dysfunction. Cardiac magnetic resonance was repeated 1.9 ± 1.3 years after ablation. In patients with successful ablation, RV function improved, and in patients without successful ablation, RV function did not significantly change (before and after ablation RVEF 0.45 ± 0.09 and 0.52 ± 0.09; P < 0.001 vs. 0.46 ± 0.07 and 0.48 ± 0.04; P = 0.14, respectively).

CONCLUSIONS

Frequent PVCs can cause RV cardiomyopathy that parallels LV cardiomyopathy and is reversible with successful ablation.

Obstetric and fetal/neonatal outcomes in pregnant women with frequent premature ventricular complexes and structurally normal heart

BACKGROUND

High premature ventricular complex (PVC) burden may increase the risk of left ventricular dysfunction and all-cause mortality. We aimed to evaluate maternal and neonatal outcomes of pregnant women with structurally normal heart having PVC burden ≥1%.

METHODS

This retrospective cohort study used data from Chang Gung Research Database. Pregnancies from January 1, 2005, through June 30, 2020, with documented maternal PVC burden ≥1% by 24-h Holter monitor were identified. Pregnant women with a diagnosis of structural heart disease or arrhythmias other than PVC were excluded. We used propensity score matching (PSM) to balance the covariates between the PVC group and normal control group. The PVC group was classified into low-PVC (<10%) and high-PVC burden subgroups. The maternal and neonatal outcomes were assessed through 6 months after delivery or termination.

RESULTS

After PSM, there were 214, 61, and 46 pregnant women enrolled in the normal control group, low-PVC burden, and high-PVC burden subgroups, respectively. The high-PVC and low-PVC burden subgroups had composite adverse maternal and neonatal events similar to the control group without use of antiarrhythmic drugs (AADs), but a higher proportion of placental abruption was observed in the high-PVC burden subgroup. Maternal age, diabetes, and overweight were significant predictors of composite adverse maternal events, whereas only maternal age was a significant predictor of composite adverse neonatal events.

CONCLUSIONS

High PVC burden was not associated with poor composite adverse maternal and neonatal outcomes with no need of AADs therapy in pregnant women with structurally normal heart.

Age-related reference intervals for ambulatory electrocardiographic parameters in healthy individuals

Background

The advent of novel monitoring technologies has dramatically increased the use of ambulatory electrocardiography (AECG) devices. However, few studies have conducted detailed large-scale investigations on the incidence of arrhythmias over 24 h, especially ectopy, in healthy individuals over a wide age range.

Objectives

This study aimed to investigate the incidence of arrhythmias detected using AECG and associated factors, in healthy individuals, over a wide age range.

Methods

In this cross-sectional study, we performed AECG on 365 healthy volunteers (median [interquartile range]: 48 [36, 67], 20-89 years, 165 men) under free-running conditions for 24 h. Ultrasonic echocardiography and heart rate variability analysis were performed to explore the factors associated with the incidence of arrhythmias.

Results

The 97.5th percentile of single ventricular ectopy (VE) was 149/day, 254/day, and 1,682/day in the 20-39-, 40-59- and 60-89-year age groups, respectively; that of single supraventricular ectopy (SVE) was 131/day, 232/day, and 1,063/day, respectively. Multivariate analysis revealed that aging was the only independent significant factor influencing the frequency of VE (β = 0.207, P = 0.001). Age (β = 0.642, P < 0.001), body mass index (BMI) (β = -0.112, P = 0.009), and the root mean square of successive differences in RR intervals (β = 0.097, P = 0.035) were factors significantly associated with SVE frequency.

Conclusions

Age-specific reference intervals of VE and SVE in a large population of healthy participants over a wide age range were generated. VE and SVE increased with age; SVE was influenced by BMI and the aging-induced decrease in parasympathetic tone activity.