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Thomsen AF, Jacobsen PK, Køber L, Joergensen RM, Huikuri HV, Bloch Thomsen PE, Jacobsen UG, Jøns C. Risk of arrhythmias after myocardial infarction in patients with left ventricular systolic dysfunction according to mode of revascularization: a Cardiac Arrhythmias and RIsk Stratification after Myocardial infArction (CARISMA) substudy. Europace 2021; 23:616-623. [PMID: 33200171 DOI: 10.1093/europace/euaa273] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 11/11/2020] [Indexed: 11/12/2022] Open
Abstract
AIMS The Cardiac Arrhythmias and RIsk Stratification after Myocardial infArction (CARISMA) study was an observational trial including 312 patients with acute myocardial infarction (MI) and left ventricular ejection fraction (LVEF) <40%. Primary percutaneous intervention (pPCI) was introduced 2 years after start of the enrolment, dividing the population into two groups: pre- and post-pPCI. This substudy sought to describe the influence of the mode of revascularization on long-term risk of new-onset atrial fibrillation (AF), bradyarrhythmia, and ventricular tachycardia and the subsequent risk of relevant major cardiovascular events (MACE). METHODS AND RESULTS The study included the 268 patients without a history of AF. All patients received an implantable cardiac monitor (ICM) and were followed for 2 years. The choice of revascularization was made by the treating team independently of the trial and retrospectively divided into pPCI, subacute PCI, primary thrombolysis, or no revascularization. Endpoints were new-onset arrhythmia and MACE.A total of 77 patients received no revascularization, whereas 49 received thrombolysis only and 142 received any PCI. The adjusted hazard ratio (HR) for developing any arrhythmia and the subsequently risk of MACE were increased in non-revascularized or thrombolysed patients compared with PCI-patients (any arrhythmia, non-revascularization: HR = 1.7, P = 0.01 and thrombolysis: HR = 1.6, P = 0.05; MACE, non-revascularization: HR = 3.1, P = 0.05 and thrombolysis: HR = 3.1, P = 0.08). All HRs were adjusted for significant baseline and clinically considered covariates and stratified for calendar year. CONCLUSION This study is the first to demonstrate that the long-term risk of arrhythmia documented by an ICM and the subsequent risk of MACE were increased in non-revascularized or thrombolysed patients compared with PCI-patients in a post-MI population with LVEF <40%.
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Affiliation(s)
- Anna F Thomsen
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Peter Karl Jacobsen
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | - Heikki V Huikuri
- Department of Cardiology, Oulu University Hospital, Oulu, Finland
| | | | - Uffe G Jacobsen
- Department of Cardiology, Zealand University Hospital, Roskilde, Denmark
| | - Christian Jøns
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Xenogiannis I, Gatzoulis KA, Flevari P, Ikonomidis I, Iliodromitis E, Trachanas K, Vlachos K, Arsenos P, Tsiachris D, Tousoulis D, Brilakis ES, Alexopoulos D. Temporal changes of noninvasive electrocardiographic risk factors for sudden cardiac death in post-myocardial infarction patients with preserved ejection fraction: Insights from the PRESERVE-EF study. Ann Noninvasive Electrocardiol 2020; 25:e12701. [PMID: 31605453 PMCID: PMC7358883 DOI: 10.1111/anec.12701] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 07/30/2019] [Accepted: 08/12/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Several noninvasive risk factors (NIRFs) have been proposed for sudden cardiac death risk stratification in post-myocardial infarction (post-MI) patients with preserved ejection fraction (EF). However, it remains unclear if these factors change over time. METHODS We evaluated seven electrocardiographic NIRFs as they were described in the PRESERVE-EF trial in 80 post-MI patients with EF ≥ 40%, at least 40 days after revascularization and 1 year later. RESULTS Mean patient age was 56 ± 10 years, and 88% were men. Mean EF was 50 ± 5%. The prevalence of (a) positive late potentials (27.5% vs. 28.8%, p = .860), (b) >30 premature ventricular complexes/hour (8.8% vs. 11.3%, p = .598), (c) nonsustained ventricular tachycardia (8.8% vs. 5%, p = .349), (d) standard deviation of normal RR intervals <75 ms (3.8% vs. 3.8%, p = 1.000), (e) QTc derived from 24-hr electrocardiography >440 ms (men) or >450 ms (women) (17.5% vs. 17.5%, p = 1.000), (f) deceleration capacity ≤4.5 ms and heart rate turbulence onset ≥0% and slope ≤2.5 ms (2.5% vs. 3.8%. p = 1.000), and (g) ambulatory T-wave alternans ≥65 μV in two Holter channels (6.3% vs. 6.3%, p = 1.000) were similar between the two measurements. However, five patients (6.3%) without any NIRFs during the first assessment had at least one positive NIRF at the second assessment and six patients (7.5%) with at least one NIRF at baseline had no positive NIRFs at 1 year. CONCLUSIONS While the prevalence of the examined electrocardiographic NIRFs between the two examinations was similar on a population basis, some patients without NIRFs at baseline developed NIRFs at 1 year and vice versa, highlighting the need for risk factor reassessment during follow-up.
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Affiliation(s)
- Iosif Xenogiannis
- Second Cardiology DepartmentAttikon HospitalNational and Kapodistrian University of AthensAthensGreece
- Minneapolis Heart Institute and Minneapolis Heart Institute FoundationAbbott Northwestern HospitalMinneapolisMNUSA
| | - Konstantinos A. Gatzoulis
- First Department of CardiologyHippokrateion HospitalNational and Kapodistrian University of AthensAthensGreece
| | - Panagiota Flevari
- Second Cardiology DepartmentAttikon HospitalNational and Kapodistrian University of AthensAthensGreece
| | - Ignatios Ikonomidis
- Second Cardiology DepartmentAttikon HospitalNational and Kapodistrian University of AthensAthensGreece
| | - Efstathios Iliodromitis
- Second Cardiology DepartmentAttikon HospitalNational and Kapodistrian University of AthensAthensGreece
| | | | - Konstantinos Vlachos
- Second State Cardiology DepartmentEvangelismos HospitalAthensGreece
- Electrophysiology DepartmentHospital Haut LévêqueBordeauxFrance
| | - Petros Arsenos
- First Department of CardiologyHippokrateion HospitalNational and Kapodistrian University of AthensAthensGreece
| | - Dimitrios Tsiachris
- First Department of CardiologyHippokrateion HospitalNational and Kapodistrian University of AthensAthensGreece
| | - Dimitrios Tousoulis
- First Department of CardiologyHippokrateion HospitalNational and Kapodistrian University of AthensAthensGreece
| | - Emmanouil S. Brilakis
- Minneapolis Heart Institute and Minneapolis Heart Institute FoundationAbbott Northwestern HospitalMinneapolisMNUSA
| | - Dimitrios Alexopoulos
- Second Cardiology DepartmentAttikon HospitalNational and Kapodistrian University of AthensAthensGreece
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Worsening atrioventricular conduction after hospital discharge in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention: the HORIZONS-AMI trial. Coron Artery Dis 2018. [PMID: 28644212 DOI: 10.1097/mca.0000000000000525] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The chronic effects of ST-segment elevation myocardial infarction (STEMI) on the atrioventricular conduction (AVC) system have not been elucidated. This study aimed to evaluate the incidence, predictors, and outcomes of worsened AVC post-STEMI in patients treated with a primary percutaneous coronary intervention (PCI). PATIENTS AND METHODS The current analysis included patients from the HORIZONS-AMI trial who underwent primary PCI and had available ECGs. Patients with high-grade atrioventricular block or pacemaker implant at baseline were excluded. RESULTS Analysis of ECGs excluding the acute hospitalization period indicated worsened AVC in 131 patients (worsened AVC group) and stable AVC in 2833 patients (stable AVC group). Patients with worsened AVC were older, had a higher frequency of hypertension, diabetes, renal insufficiency, previous coronary artery bypass grafting, and predominant left anterior descending culprit lesions. Predictors of worsened AVC included age, hypertension, and previous history of coronary artery disease. Worsened AVC was associated with an increased rate of all-cause death and major adverse cardiac events (death, myocardial infarction, ischemic target vessel revascularization, and stroke) as well as death or reinfarction at 3 years. On multivariable analysis, worsened AVC remained an independent predictor of all-cause death (hazard ratio: 2.005, confidence interval: 1.051-3.827, P=0.0348) and major adverse cardiac events (hazard ratio 1.542, confidence interval: 1.059-2.244, P=0.0238). CONCLUSION Progression of AVC system disease in patients with STEMI treated with primary PCI is uncommon, occurs primarily in the setting of anterior myocardial infarction, and portends a high risk for death and major adverse cardiac events.
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Alnsasra H, Ben-Avraham B, Gottlieb S, Ben-avraham M, Kronowski R, Iakobishvili Z, Goldenberg I, Strasberg B, Haim M. High-grade atrioventricular block in patients with acute myocardial infarction. Insights from a contemporary multi-center survey. J Electrocardiol 2018; 51:386-391. [DOI: 10.1016/j.jelectrocard.2018.03.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 03/06/2018] [Accepted: 03/07/2018] [Indexed: 10/17/2022]
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Japundžić-Žigon N, Šarenac O, Lozić M, Vasić M, Tasić T, Bajić D, Kanjuh V, Murphy D. Sudden death: Neurogenic causes, prediction and prevention. Eur J Prev Cardiol 2017; 25:29-39. [PMID: 29053016 PMCID: PMC5724572 DOI: 10.1177/2047487317736827] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Sudden death is a major health problem all over the world. The most common causes of sudden death are cardiac but there are also other causes such as neurological conditions (stroke, epileptic attacks and brain trauma), drugs, catecholamine toxicity, etc. A common feature of all these diverse pathologies underlying sudden death is the imbalance of the autonomic nervous system control of the cardiovascular system. This paper reviews different pathologies underlying sudden death with emphasis on the autonomic nervous system contribution, possibilities of early diagnosis and prognosis of sudden death using various clinical markers including autonomic markers (heart rate variability and baroreflex sensitivity), present possibilities of management and promising prevention by electrical neuromodulation.
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Affiliation(s)
| | | | - Maja Lozić
- 1 Faculty of Medicine, University of Belgrade, Serbia
| | - Marko Vasić
- 1 Faculty of Medicine, University of Belgrade, Serbia
| | - Tatjana Tasić
- 1 Faculty of Medicine, University of Belgrade, Serbia
| | - Dragana Bajić
- 2 Faculty of Technical Sciences, University of Novi Sad, Serbia
| | - Vladimir Kanjuh
- 3 Department of Medical Sciences, Serbian Academy of Sciences and Arts, Serbia
| | - David Murphy
- 4 School of Clinical Sciences, University of Bristol, UK
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From psychological moments to mortality: A multidisciplinary synthesis on heart rate variability spanning the continuum of time. Neurosci Biobehav Rev 2017; 83:547-567. [PMID: 28888535 DOI: 10.1016/j.neubiorev.2017.09.006] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 09/04/2017] [Indexed: 02/05/2023]
Abstract
Heart rate variability (HRV) indexes functioning of the vagus nerve, arguably the most important nerve in the human body. The Neurovisceral Integration Model has provided a structural framework for understanding brain-body integration, highlighting the role of the vagus in adaptation to the environment. In the present paper, we emphasise a temporal framework in which HRV may be considered a missing, structural link between psychological moments and mortality, a proposal we label as Neurovisceral Integration Across a Continuum of Time (or NIACT). This new framework places neurovisceral integration on a dimension of time, highlighting implications for lifespan development and healthy aging, and helping to bridge the gap between clearly demarcated disciplines such as psychology and epidemiology. The NIACT provides a novel framework, which conceptualizes how everyday psychological moments both affect and are affected by the vagus in ways that have long-term effects on mortality risk. We further emphasize that a longitudinal approach to understanding change in vagal function over time may yield novel scientific insights and important public health outcomes.
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Passman RS, Rogers JD, Sarkar S, Reiland J, Reisfeld E, Koehler J, Mittal S. Development and validation of a dual sensing scheme to improve accuracy of bradycardia and pause detection in an insertable cardiac monitor. Heart Rhythm 2017; 14:1016-1023. [DOI: 10.1016/j.hrthm.2017.03.037] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Indexed: 11/24/2022]
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Pola-Gallego-de-Guzmán MD, Ruiz-Bailén M, Martínez-Arcos MA, Gómez-Blizniak A, Castillo Rivera AM, Molinos JC. Implant of permanent pacemaker during acute coronary syndrome: Mortality and associated factors in the ARIAM registry. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2017; 7:224-229. [PMID: 28345361 DOI: 10.1177/2048872617700867] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients with acute coronary syndrome complicated with high degree atrioventricular block still have a high mortality. A low percentage of these patients need a permanent pacemaker (PPM) but mortality and associated factors with the PPM implant in acute coronary syndrome patients are not known. We assess whether PPM implant is an independent variable in the mortality of acute coronary syndrome patients. Also, we explored the variables that remain independently associated with PPM implantation. METHODS This was an observational study on the Spanish ARIAM register. The inclusion period was from January 2001 to December 2011. This registry included all Andalusian acute coronary syndrome patients. Follow-up for global mortality was until November 2013. RESULTS We selected 27,608 cases. In 62 patients a PPM was implanted (0.024%). The mean age in PPM patients was 70.71±11.214 years versus 64.46±12.985 years in patients with no PPM. PPM implant was associated independently with age (odds ratio (OR) 1.031, 95% confidence interval (CI) 1.007-1.055), with left ventricular branch block (OR 6.622, 95% CI 2.439-18.181), with any arrhythmia at intensive care unit admission (OR 2.754, 95% CI 1.506-5.025) and with heart failure (OR 3.344, 95% CI 1.78-8.333). PPM implant was independently associated with mortality (OR 11.436, 95% CI 1.576-83.009). In propensity score analysis PPM implant was still associated with mortality (OR 5.79, 95% CI 3.27-25.63). CONCLUSION PPM implant is associated with mortality in the acute coronary syndrome population in the ARIAM registry. Advanced age, heart failure, arrhythmias and left ventricular branch block at intensive care unit admission were found associated factors with PPM implant in acute coronary syndrome patient.
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Affiliation(s)
| | - Manuel Ruiz-Bailén
- 1 Intensive Care Unit, Complejo Hospitalario de Jaén, Spain.,2 University of Jaén, Spain
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Barra S, Providência R, Lourenço Gomes P, Silva J, Seca L, Nascimento J, Leitão-Marques AM. [Prediction of cerebrovascular event risk following myocardial infarction]. Rev Port Cardiol 2014; 30:655-63. [PMID: 22005309 DOI: 10.1016/s0870-2551(11)70004-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2010] [Accepted: 01/18/2011] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Patients with coronary artery disease (CAD) are at increased risk of stroke. The aim of this study was to analyze the prognostic accuracy of selected clinical and laboratory variables in stroke risk prediction following discharge after myocardial infarction (MI). METHODS We analyzed 404 consecutive patients (aged 68.1±13.7 years; 63.4% male; 37.4% with diabetes) without previous stroke who were discharged in sinus rhythm after being admitted for MI. The following data were collected: cardiovascular risk factors, admission blood glucose (BG), HbA1c, creatinine, peak troponin levels; glomerular filtration rate (GFR) by the MDRD formula; maximum Killip class; GRACE score for in-hospital and 6-month mortality; and extent of CAD. Patients were followed for two years and each variable was tested as a possible predictor of cerebrovascular events (stroke or transient ischemic attack [TIA]). RESULTS During follow-up, 27 patients were admitted for stroke or TIA. The presence of diabetes, hypertension, dyslipidemia and previously known CAD, type of MI (STEMI vs NSTEMI) and extent of CAD did not predict cerebrovascular risk. The following variables were associated with higher stroke risk: GFR <60ml/min/m(2) (p=0.029, OR 2.65, 95% CI 1.07-6.55); maximum Killip class >1 (p=0.025, OR 2.71, 95% CI 1.10-6.69); GRACE in-hospital mortality >180 (p=0.001, OR 4.09, 95% CI 1.64-10.22); admission BG >140 mg/dl (p=0.001, OR 5.74, 95% CI 1.87-17.58); GRACE 6-month mortality >150 (p=0.001, OR 4.50, 95% CI 1.80-6.27); and peak troponin >42ng/ml (p=0.032, OR 2.64, 95% CI 1.06-6.59). Logistic regression analysis produced a model with the predictors GRACE 6-month mortality >150 (OR 3.26; p=0.014) and admission BG >7.7mmol/l (OR 4.09; p=0.017) that fitted the data well (Hosmer-Lemeshow: p=0.916). DISCUSSION/CONCLUSIONS In patients with MI, variables known to be predictors of in-hospital mortality, including admission BG, renal function, acute heart failure and GRACE score, were found to be useful predictors of stroke during 2-year follow-up. While both GRACE score for 6-month mortality >150 and admission BG >7.7 mmol/l were independent predictors of stroke, CV risk factors, previously known CAD, and extent of CAD assessed by coronary angiography did not improve stroke risk prediction. This study highlights the need for even more aggressive secondary prevention in patients most at risk.
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Affiliation(s)
- Sérgio Barra
- Serviço de Cardiologia, Centro Hospitalar de Coimbra, Coimbra, Portugal.
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Ruwald ACH, Bloch Thomsen PE, Gang U, Jørgensen RM, Huikuri HV, Jons C. New-onset atrial fibrillation predicts malignant arrhythmias in post-myocardial infarction patients--a Cardiac Arrhythmias and RIsk Stratification after acute Myocardial infarction (CARISMA) substudy. Am Heart J 2013; 166:855-63.e3. [PMID: 24176441 DOI: 10.1016/j.ahj.2013.08.017] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Accepted: 08/17/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND After myocardial infarction (MI) the risk of sudden cardiac death due to arrhythmias is substantial. OBJECTIVE The purpose of this study was to investigate if new-onset atrial fibrillation (AF) is associated with development of potential malignant brady- and tachyarrhythmias after an acute MI. METHODS The study included 277 post-MI patients from the CARISMA study with left ventricular ejection fraction ≤ 40%, New York Heart Association class I, II, or III and no history of AF. All patients were implanted with an implantable cardiac monitor within 4 to 27 days after an acute MI and followed every 3 months for 2 years. Time-dependent association between new-onset AF > 30 s and the development of bradyarrhythmias and/or ventricular tachyarrhythmias were investigated using Cox proportional hazard regressions. RESULTS New-onset AF was associated with an increased risk of bradyarrhythmias when adjusting for male gender and baseline age, left ventricular ejection fraction and QRS width (HR = 2.8 [1.3-5.8], P = .006). Similarly, new-onset AF predicted ventricular tachyarrhythmias when adjusting for New York Heart Association class ≥ II and baseline QRS width (HR = 2.3 [1.2-4.4], P = .019). After dividing ventricular tachyarrhythmias into subgroups of non-sustained ventricular tachycardia (VT), sustained VT and ventricular fibrillation (VF), new-onset AF was significantly associated with an increased risk of non-sustained- and sustained VT but not VF (non-sustained VT: HR = 3.5 [1.7-7.2], P < .001, sustained VT: HR = 4.2 [1.1-15.7], P = .035, VF: HR = 1.1 [0.2-5.8], P = .877). CONCLUSION In patients surviving a MI with reduced left ventricular systolic function, new-onset AF is associated with a significantly increased risk of developing ventricular brady- and tachyarrhythmias.
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Affiliation(s)
- Anne-Christine Huth Ruwald
- Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark; University of Rochester Medical Center, Heart Research Follow-Up Program, Rochester, NY.
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Nalliah CJ, Zaman S, Narayan A, Sullivan J, Kovoor P. Coronary artery reperfusion for ST elevation myocardial infarction is associated with shorter cycle length ventricular tachycardia and fewer spontaneous arrhythmias. Europace 2013; 16:1053-60. [DOI: 10.1093/europace/eut307] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Volosin K, Stadler RW, Wyszynski R, Kirchhof P. Tachycardia detection performance of implantable loop recorders: results from a large 'real-life' patient cohort and patients with induced ventricular arrhythmias. Europace 2013; 15:1215-22. [DOI: 10.1093/europace/eut036] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Shrivastav M, Shrivastav R, Makkar J, Biffi M. Patient selection for ambulatory cardiac monitoring in the Indian healthcare environment. HEART ASIA 2013; 5:112-9. [PMID: 27326100 DOI: 10.1136/heartasia-2012-010228] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2012] [Revised: 05/23/2013] [Accepted: 05/26/2013] [Indexed: 11/03/2022]
Abstract
Cardiovascular disease (CVD) in India comprises the bulk of non-communicable diseases, resulting in 2 million deaths per year. The incidence of CVD in India is estimated to be up to four times higher than in other countries. Though the quantification of the prevalence of rhythm disorders in India is not available, it can be inferred to be proportionately high. Identification and treatment of arrhythmia is limited by several socioeconomic factors including low health insurance penetration, limited reimbursement and high out-of-pocket expenditures. Thus, there exists a need in India to (1) select an appropriate tool that is both high yielding and cost effective and (2) employ a suitable patient selection method. This paper focuses on these two aspects for cardiac arrhythmia diagnosis using ambulatory monitoring technology, while keeping in mind the dynamics of the Indian healthcare setting.
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Affiliation(s)
| | | | - Jitendra Makkar
- Department of Cardiology , Fortis Escorts Hospital , Jaipur , India
| | - Mauro Biffi
- Institute of Cardiology, University of Bologna , Bologna , Italy
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Clinical significance of late high-degree atrioventricular block in patients with left ventricular dysfunction after an acute myocardial infarction--a Cardiac Arrhythmias and Risk Stratification After Acute Myocardial Infarction (CARISMA) substudy. Am Heart J 2011; 162:542-7. [PMID: 21884874 DOI: 10.1016/j.ahj.2011.06.021] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2011] [Accepted: 06/05/2011] [Indexed: 11/21/2022]
Abstract
BACKGROUND High-degree atrioventricular block (HAVB) is a frequent complication in the acute stages of a myocardial infarction associated with an increased rate of mortality. However, the incidence and clinical significance of HAVB in late convalescent phases of an AMI is largely unknown. The aim of this study was to assess the incidence and prognostic value of late HAVB documented by continuous electrocardiogram (ECG) monitoring in post-AMI patients with reduced left ventricular function. METHODS The study included 286 patients from the CARISMA study with AMI and left ventricular ejection fraction of 40% or less. An insertable loop recorder was implanted 5 to 21 days after AMI for incessant arrhythmia surveillance. Furthermore, ECG documentation was supplemented by a 24-hour Holter monitoring conducted at week 6 post-AMI. The clinical significance of HAVB occurring more than 21 days after AMI was examined with respect to development of major heart failure events and major ventricular tachyarrhythmic events. RESULTS During a median follow-up of 1.9 years (interquartile range 0.9-2.0), late HAVB was documented in 30 patients. The risk of major heart failure events (hazard ratio [HR] 4.08 [1.38-12.09], P = .01) and major ventricular tachyarrhythmic events (HR = 5.41 [1.88-15.58], P = .002) were significantly increased in patients who developed late HAVB. CONCLUSION High-degree atrioventricular block documented by continuous ECG monitoring occurring more than 3 weeks after AMI is a frequent complication in post-AMI patients with left ventricular dysfunction. Furthermore, HAVB is associated with ominous prognostic implications of both potentially lethal arrhythmias and heart failure.
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Barra S, Providência R, Gomes PL, Silva J, Seca L, Nascimento J, Leitao-Marques A. Prediction of cerebrovascular event risk following myocardial infarction. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2011. [DOI: 10.1016/s2174-2049(11)70004-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Gang UJO, Jons C, Jorgensen RM, Abildstrom SZ, Messier MD, Haarbo J, Huikuri HV, Thomsen PEB, Raatikainen MJP, Hartikainen J, Virtanen V, Boland J, Anttonen O, Hoest N, Boersma LVA, Platou ES, Becker D, Schrijver G, Robbe H, Mahaux V, Christiansen LK, Huikuri P, Karjalainen P. Risk markers of late high-degree atrioventricular block in patients with left ventricular dysfunction after an acute myocardial infarction: a CARISMA substudy. Europace 2011; 13:1471-7. [DOI: 10.1093/europace/eur165] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
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Jons C, Jacobsen UG, Joergensen RM, Olsen NT, Dixen U, Johannessen A, Huikuri H, Messier M, McNitt S, Thomsen PEB. The incidence and prognostic significance of new-onset atrial fibrillation in patients with acute myocardial infarction and left ventricular systolic dysfunction: A CARISMA substudy. Heart Rhythm 2011; 8:342-8. [DOI: 10.1016/j.hrthm.2010.09.090] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2010] [Revised: 09/09/2010] [Accepted: 09/09/2010] [Indexed: 11/29/2022]
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Jons C, Raatikainen P, Gang UJ, Huikuri HV, Joergensen RM, Johannesen A, Dixen U, Messier M, McNitt S, Thomsen PEB. Autonomic dysfunction and new-onset atrial fibrillation in patients with left ventricular systolic dysfunction after acute myocardial infarction: a CARISMA substudy. J Cardiovasc Electrophysiol 2011; 21:983-90. [PMID: 20487120 DOI: 10.1111/j.1540-8167.2010.01795.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) increases morbidity and mortality in patients with previous myocardial infarction and left ventricular systolic dysfunction. The purpose of this study was to identify patients with a high risk for new-onset AF in this population using invasive and noninvasive electrophysiological tests. METHODS The study included 271 patients from the Cardiac Arrhythmias and RIsk Stratification after Myocardial InfArction (CARISMA) study with an acute myocardial infarction (AMI) and left ventricular ejection fraction ≤40% without previous AF at enrollment. Within 21 days after the AMI, an implantable loop recorder was inserted and used to diagnose AF over the 2-year study duration. The following tests were performed: heart rate variability (HRV) and turbulence (HRT) analyses from repeated 24-hour Holter recordings, 2-dimensional (2D)-echocardiograms, exercise test, and programmed electrophysiologic stimulation. RESULTS A total of 101 patients (37%) developed AF during the study. Predictive measures included several indexes of HRV including reduced low-frequency (LF) power from spectral HRV analysis (adjusted HR = 1.6, P = 0.034), HRT slope ≤2.5 (HR = 1.6, P = 0.032) and Detrended Fluctuation Analysis (DFA1) from HRV analysis (HR = 1.8, P = 0.011); all are measures of cardiac autonomic nervous system dysfunction. Combined with age >60 years, low values for LF, HRT slope, and DFA1 provided a powerful risk score for prediction of new-onset AF (1-2 points: HR = 4.3, P = 0.001, 3-4 points: HR = 7.0, P < 0.001). CONCLUSION Abnormal HRV and HRT parameters, which are associated with disturbances in the cardiac autonomic regulation, are associated with increased risk of new-onset AF independently of conventional clinical risk variables.
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Affiliation(s)
- Christian Jons
- Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark.
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Bloch Thomsen PE, Jons C, Raatikainen MP, Moerch Joergensen R, Hartikainen J, Virtanen V, Boland J, Anttonen O, Gang UJ, Hoest N, Boersma LV, Platou ES, Becker D, Messier MD, Huikuri HV. Long-Term Recording of Cardiac Arrhythmias With an Implantable Cardiac Monitor in Patients With Reduced Ejection Fraction After Acute Myocardial Infarction. Circulation 2010; 122:1258-64. [DOI: 10.1161/circulationaha.109.902148] [Citation(s) in RCA: 193] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Poul Erik Bloch Thomsen
- From the Gentofte University Hospital, Copenhagen, Denmark (P.E.B.T., C.J., R.M.J., U.J.G.); Department of Internal Medicine, University of Oulu, Oulu, Finland (H.V.H., M.J.P.R.); Department of Internal Medicine, University of Kuopio, Kuopio, Finland (J.H.); Department of Cardiology, University of Tampere, Tampere, Finland (V.V.); Department of Internal Medicine, Hopital Citadelle, Liege, Belgium (J.B.); Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland (O.A.); Glostrup
| | - Christian Jons
- From the Gentofte University Hospital, Copenhagen, Denmark (P.E.B.T., C.J., R.M.J., U.J.G.); Department of Internal Medicine, University of Oulu, Oulu, Finland (H.V.H., M.J.P.R.); Department of Internal Medicine, University of Kuopio, Kuopio, Finland (J.H.); Department of Cardiology, University of Tampere, Tampere, Finland (V.V.); Department of Internal Medicine, Hopital Citadelle, Liege, Belgium (J.B.); Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland (O.A.); Glostrup
| | - M.J. Pekka Raatikainen
- From the Gentofte University Hospital, Copenhagen, Denmark (P.E.B.T., C.J., R.M.J., U.J.G.); Department of Internal Medicine, University of Oulu, Oulu, Finland (H.V.H., M.J.P.R.); Department of Internal Medicine, University of Kuopio, Kuopio, Finland (J.H.); Department of Cardiology, University of Tampere, Tampere, Finland (V.V.); Department of Internal Medicine, Hopital Citadelle, Liege, Belgium (J.B.); Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland (O.A.); Glostrup
| | - Rikke Moerch Joergensen
- From the Gentofte University Hospital, Copenhagen, Denmark (P.E.B.T., C.J., R.M.J., U.J.G.); Department of Internal Medicine, University of Oulu, Oulu, Finland (H.V.H., M.J.P.R.); Department of Internal Medicine, University of Kuopio, Kuopio, Finland (J.H.); Department of Cardiology, University of Tampere, Tampere, Finland (V.V.); Department of Internal Medicine, Hopital Citadelle, Liege, Belgium (J.B.); Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland (O.A.); Glostrup
| | - Juha Hartikainen
- From the Gentofte University Hospital, Copenhagen, Denmark (P.E.B.T., C.J., R.M.J., U.J.G.); Department of Internal Medicine, University of Oulu, Oulu, Finland (H.V.H., M.J.P.R.); Department of Internal Medicine, University of Kuopio, Kuopio, Finland (J.H.); Department of Cardiology, University of Tampere, Tampere, Finland (V.V.); Department of Internal Medicine, Hopital Citadelle, Liege, Belgium (J.B.); Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland (O.A.); Glostrup
| | - Vesa Virtanen
- From the Gentofte University Hospital, Copenhagen, Denmark (P.E.B.T., C.J., R.M.J., U.J.G.); Department of Internal Medicine, University of Oulu, Oulu, Finland (H.V.H., M.J.P.R.); Department of Internal Medicine, University of Kuopio, Kuopio, Finland (J.H.); Department of Cardiology, University of Tampere, Tampere, Finland (V.V.); Department of Internal Medicine, Hopital Citadelle, Liege, Belgium (J.B.); Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland (O.A.); Glostrup
| | - J. Boland
- From the Gentofte University Hospital, Copenhagen, Denmark (P.E.B.T., C.J., R.M.J., U.J.G.); Department of Internal Medicine, University of Oulu, Oulu, Finland (H.V.H., M.J.P.R.); Department of Internal Medicine, University of Kuopio, Kuopio, Finland (J.H.); Department of Cardiology, University of Tampere, Tampere, Finland (V.V.); Department of Internal Medicine, Hopital Citadelle, Liege, Belgium (J.B.); Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland (O.A.); Glostrup
| | - Olli Anttonen
- From the Gentofte University Hospital, Copenhagen, Denmark (P.E.B.T., C.J., R.M.J., U.J.G.); Department of Internal Medicine, University of Oulu, Oulu, Finland (H.V.H., M.J.P.R.); Department of Internal Medicine, University of Kuopio, Kuopio, Finland (J.H.); Department of Cardiology, University of Tampere, Tampere, Finland (V.V.); Department of Internal Medicine, Hopital Citadelle, Liege, Belgium (J.B.); Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland (O.A.); Glostrup
| | - Uffe Jakob Gang
- From the Gentofte University Hospital, Copenhagen, Denmark (P.E.B.T., C.J., R.M.J., U.J.G.); Department of Internal Medicine, University of Oulu, Oulu, Finland (H.V.H., M.J.P.R.); Department of Internal Medicine, University of Kuopio, Kuopio, Finland (J.H.); Department of Cardiology, University of Tampere, Tampere, Finland (V.V.); Department of Internal Medicine, Hopital Citadelle, Liege, Belgium (J.B.); Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland (O.A.); Glostrup
| | - Nis Hoest
- From the Gentofte University Hospital, Copenhagen, Denmark (P.E.B.T., C.J., R.M.J., U.J.G.); Department of Internal Medicine, University of Oulu, Oulu, Finland (H.V.H., M.J.P.R.); Department of Internal Medicine, University of Kuopio, Kuopio, Finland (J.H.); Department of Cardiology, University of Tampere, Tampere, Finland (V.V.); Department of Internal Medicine, Hopital Citadelle, Liege, Belgium (J.B.); Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland (O.A.); Glostrup
| | - Lucas V.A. Boersma
- From the Gentofte University Hospital, Copenhagen, Denmark (P.E.B.T., C.J., R.M.J., U.J.G.); Department of Internal Medicine, University of Oulu, Oulu, Finland (H.V.H., M.J.P.R.); Department of Internal Medicine, University of Kuopio, Kuopio, Finland (J.H.); Department of Cardiology, University of Tampere, Tampere, Finland (V.V.); Department of Internal Medicine, Hopital Citadelle, Liege, Belgium (J.B.); Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland (O.A.); Glostrup
| | - Eivin S. Platou
- From the Gentofte University Hospital, Copenhagen, Denmark (P.E.B.T., C.J., R.M.J., U.J.G.); Department of Internal Medicine, University of Oulu, Oulu, Finland (H.V.H., M.J.P.R.); Department of Internal Medicine, University of Kuopio, Kuopio, Finland (J.H.); Department of Cardiology, University of Tampere, Tampere, Finland (V.V.); Department of Internal Medicine, Hopital Citadelle, Liege, Belgium (J.B.); Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland (O.A.); Glostrup
| | - Daniel Becker
- From the Gentofte University Hospital, Copenhagen, Denmark (P.E.B.T., C.J., R.M.J., U.J.G.); Department of Internal Medicine, University of Oulu, Oulu, Finland (H.V.H., M.J.P.R.); Department of Internal Medicine, University of Kuopio, Kuopio, Finland (J.H.); Department of Cardiology, University of Tampere, Tampere, Finland (V.V.); Department of Internal Medicine, Hopital Citadelle, Liege, Belgium (J.B.); Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland (O.A.); Glostrup
| | - Marc D. Messier
- From the Gentofte University Hospital, Copenhagen, Denmark (P.E.B.T., C.J., R.M.J., U.J.G.); Department of Internal Medicine, University of Oulu, Oulu, Finland (H.V.H., M.J.P.R.); Department of Internal Medicine, University of Kuopio, Kuopio, Finland (J.H.); Department of Cardiology, University of Tampere, Tampere, Finland (V.V.); Department of Internal Medicine, Hopital Citadelle, Liege, Belgium (J.B.); Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland (O.A.); Glostrup
| | - Heikki V. Huikuri
- From the Gentofte University Hospital, Copenhagen, Denmark (P.E.B.T., C.J., R.M.J., U.J.G.); Department of Internal Medicine, University of Oulu, Oulu, Finland (H.V.H., M.J.P.R.); Department of Internal Medicine, University of Kuopio, Kuopio, Finland (J.H.); Department of Cardiology, University of Tampere, Tampere, Finland (V.V.); Department of Internal Medicine, Hopital Citadelle, Liege, Belgium (J.B.); Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland (O.A.); Glostrup
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Jons C, Moerch Joergensen R, Hassager C, Gang UJ, Dixen U, Johannesen A, Olsen NT, Hansen TF, Messier M, Huikuri HV, Bloch Thomsen PE. Diastolic dysfunction predicts new-onset atrial fibrillation and cardiovascular events in patients with acute myocardial infarction and depressed left ventricular systolic function: a CARISMA substudy. EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2010; 11:602-7. [DOI: 10.1093/ejechocard/jeq024] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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22
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Gang UJO, Jons C, Jorgensen RM, Abildstrom SZ, Haarbo J, Messier MD, Huikuri HV, Thomsen PEB. Heart rhythm at the time of death documented by an implantable loop recorder. Europace 2009; 12:254-60. [DOI: 10.1093/europace/eup383] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Goldberger JJ, Cain ME, Hohnloser SH, Kadish AH, Knight BP, Lauer MS, Maron BJ, Page RL, Passman RS, Siscovick D, Stevenson WG, Zipes DP. American Heart Association/american College of Cardiology Foundation/heart Rhythm Society scientific statement on noninvasive risk stratification techniques for identifying patients at risk for sudden cardiac death: a scientific statement from the American Heart Association Council on Clinical Cardiology Committee on Electrocardiography and Arrhythmias and Council on Epidemiology and Prevention. Heart Rhythm 2009; 5:e1-21. [PMID: 18929319 DOI: 10.1016/j.hrthm.2008.05.031] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2008] [Indexed: 11/18/2022]
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Sabir IN, Usher-Smith JA, Huang CLH, Grace AA. Risk stratification for sudden cardiac death. PROGRESS IN BIOPHYSICS AND MOLECULAR BIOLOGY 2009; 98:340-6. [PMID: 19351522 DOI: 10.1016/j.pbiomolbio.2009.01.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Recent advances in pharmacological and device-based therapies have provided a range of management options for patients at risk of sudden cardiac death (SCD). Since all such interventions come with their attendant risks, however, stratification procedures aimed at identifying those who stand to benefit overall have gained a new degree of importance. This review assesses the value of risk stratification measures currently available in clinical practice, as well as of others that may soon enter the market. Parameters that may be obtained only by performing invasive cardiac catheterisation procedures are considered separately from those that may be derived using more readily available non-invasive techniques. It is concluded that effective stratification is likely to require the use of composite parameters and that invasive procedures might only be justified in specific sub-groups of patients.
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Affiliation(s)
- Ian N Sabir
- Physiological Laboratory, University of Cambridge, Downing Street, Cambridge, UK.
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25
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Huikuri HV, Raatikainen MJP, Moerch-Joergensen R, Hartikainen J, Virtanen V, Boland J, Anttonen O, Hoest N, Boersma LVA, Platou ES, Messier MD, Bloch-Thomsen PE. Prediction of fatal or near-fatal cardiac arrhythmia events in patients with depressed left ventricular function after an acute myocardial infarction. Eur Heart J 2009; 30:689-98. [PMID: 19155249 PMCID: PMC2655314 DOI: 10.1093/eurheartj/ehn537] [Citation(s) in RCA: 180] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Aims To determine whether risk stratification tests can predict serious arrhythmic events after acute myocardial infarction (AMI) in patients with reduced left ventricular ejection fraction (LVEF ≤ 0.40). Methods and results A total of 5869 consecutive patients were screened in 10 European centres, and 312 patients (age 65 ± 11 years) with a mean LVEF of 31 ± 6% were included in the study. Heart rate variability/turbulence, ambient arrhythmias, signal-averaged electrocardiogram (SAECG), T-wave alternans, and programmed electrical stimulation (PES) were performed 6 weeks after AMI. The primary endpoint was ECG-documented ventricular fibrillation or symptomatic sustained ventricular tachycardia (VT). To document these arrhythmic events, the patients received an implantable ECG loop-recorder. There were 25 primary endpoints (8.0%) during the follow-up of 2 years. The strongest predictors of primary endpoint were measures of heart rate variability, e.g. hazard ratio (HR) for reduced very-low frequency component (<5.7 ln ms2) adjusted for clinical variables was 7.0 (95% CI: 2.4–20.3, P < 0.001). Induction of sustained monomorphic VT during PES (adjusted HR = 4.8, 95% CI, 1.7–13.4, P = 0.003) also predicted the primary endpoint. Conclusion Fatal or near-fatal arrhythmias can be predicted by many risk stratification methods, especially by heart rate variability, in patients with reduced LVEF after AMI.
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Affiliation(s)
- Heikki V Huikuri
- Department of Internal Medicine, University of Oulu, PO Box 5000, Kajaanintie 50, 90014 Oulu, Finland.
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26
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Brignole M, Bellardine Black CL, Thomsen PEB, Sutton R, Moya A, Stadler RW, Cao J, Messier M, Huikuri HV. Improved Arrhythmia Detection in Implantable Loop Recorders. J Cardiovasc Electrophysiol 2008; 19:928-34. [PMID: 18410328 DOI: 10.1111/j.1540-8167.2008.01156.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Michele Brignole
- Department of Cardiology, Arrhythmologic Centre, Ospedali del Tigullio, Lavagna, Italy
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27
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Goldberger JJ, Cain ME, Hohnloser SH, Kadish AH, Knight BP, Lauer MS, Maron BJ, Page RL, Passman RS, Siscovick D, Stevenson WG, Zipes DP. American Heart Association/American College of Cardiology Foundation/Heart Rhythm Society Scientific Statement on Noninvasive Risk Stratification Techniques for Identifying Patients at Risk for Sudden Cardiac Death. J Am Coll Cardiol 2008; 52:1179-99. [DOI: 10.1016/j.jacc.2008.05.003] [Citation(s) in RCA: 140] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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28
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Somers VK, White DP, Amin R, Abraham WT, Costa F, Culebras A, Daniels S, Floras JS, Hunt CE, Olson LJ, Pickering TG, Russell R, Woo M, Young T. Sleep apnea and cardiovascular disease: an American Heart Association/american College Of Cardiology Foundation Scientific Statement from the American Heart Association Council for High Blood Pressure Research Professional Education Committee, Council on Clinical Cardiology, Stroke Council, and Council On Cardiovascular Nursing. In collaboration with the National Heart, Lung, and Blood Institute National Center on Sleep Disorders Research (National Institutes of Health). Circulation 2008; 118:1080-111. [PMID: 18725495 DOI: 10.1161/circulationaha.107.189375] [Citation(s) in RCA: 639] [Impact Index Per Article: 39.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Chauhan VS, Selvaraj RJ. Utility of microvolt T-wave alternans to predict sudden cardiac death in patients with cardiomyopathy. Curr Opin Cardiol 2007; 22:25-32. [PMID: 17143041 DOI: 10.1097/hco.0b013e328011aa49] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Sudden cardiac death remains a major cause of mortality among patients with cardiomyopathy and implantable cardioverter-defibrillator therapy has been shown to improve survival in these patients. Effective use of prophylactic implantable cardioverter-defibrillator therapy requires accurate risk stratification beyond assessment of ejection fraction, however. Repolarization alternans is a harbinger of ventricular arrhythmias and its measurement from body-surface recordings, also known as microvolt T-wave alternans, is emerging as an effective prognostic tool in these patients based on recent clinical trials. RECENT FINDINGS We review the pathogenesis and determinants of repolarization alternans. The current techniques for measuring T-wave alternans from the body surface are compared, including the spectral and modified moving average methods. Recent clinical trials evaluating the prognostic utility of T-wave alternans in patients with ischemic and nonischemic cardiomyopathy and no prior arrhythmic events are summarized. The findings of these studies are discussed in the context of implantable cardioverter-defibrillator prophylaxis. Body-surface T-wave alternans is an evolving technique and its limitations are presented along with approaches to improve its predictive accuracy. SUMMARY Risk stratification with T-wave alternans has the potential to guide prophylactic implantable cardioverter-defibrillator therapy in a growing population of patients with cardiomyopathy.
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Affiliation(s)
- Vijay S Chauhan
- Division of Cardiology, University Health Network, Toronto, Canada.
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Abstract
Ambulatory electrocardiographic (AECG) monitoring is an essential tool in the diagnostic evaluation of patients with cardiac arrhythmias. Recent advances in solid-state technology have improved the quality of the ECG signals and new dedicated algorithms have expanded the clinical application of software-based AECG analysis systems. These advances, in addition to the availability of inexpensive large storage capacities, and very long-term continuous high-quality AECG monitoring, have opened new potential uses for AECG. New digital recorders have the capability of multichannel simultaneous recordings (from 3 to 12 leads) and for telemetred signal transduction. These possibilities will expand the traditional uses of AECG for arrhythmia detection, as arrhythmia monitoring to assess drug and device efficacies has been further defined by new studies. The analysis of transient ST-segment deviation still remains controversial, but considerably more data are now available, especially about the prognostic value of detecting asymptomatic ischaemia. Heart rate variability analysis has shown promise for predicting mortality rates in cardiac patients at high risk. We review recent advances in this field of non-invasive cardiac testing.
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Affiliation(s)
- Frank Enseleit
- Clinic of Cardiology, Cardiovascular Center, University Hospital Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland
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RAATIKAINEN MPEKKA, HUIKURI HEIKKIV. Response to the Letter of Drs. Sanjiv M. Narayan, Joseph M. Smith, and Michael E. Cain:. Pacing Clin Electrophysiol 2005. [DOI: 10.1111/j.1540-8159.2005.00232_2.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Raatikainen MJP, Jokinen V, Virtanen V, Hartikainen J, Hedman A, Huikuri HV. Microvolt T-wave alternans during exercise and pacing in patients with acute myocardial infarction. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2005; 28 Suppl 1:S193-7. [PMID: 15683495 DOI: 10.1111/j.1540-8159.2005.00110.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Cardiac Arrhythmias and Risk Stratification after Myocardial infarction (CARISMA) is a prospective multicenter trial designed to document the incidence of cardiac arrhythmias after acute myocardial infarction (AMI), and to assess the predictive accuracy of various arrhythmic risk markers. In this substudy of the CARISMA trial, microvolt T-wave alternans (TWA) was assessed with specific equipment 6 weeks after AMI during bicycle exercise, atrial (A) pacing, and simultaneous ventricular and atrial (V + A) pacing in 80 patients with left ventricular ejection fraction (LVEF) <40%. The agreement between the acute test results was determined by overall proportion of concordance and the kappa statistic. Sustained TWA was observed in 24, 45, and 50% of the patients during the exercise test, A pacing, and V + A pacing, respectively. The number of indeterminate TWA was significantly lower during V + A pacing (n = 7) than exercise test (n = 34). The TWA concordance rate was 71% between exercise and V + A pacing (kappa= 0.53, P = 0.001), 79% between exercise and A pacing (kappa= 0.54, P < 0.001), and 95% between the two pacing modes (kappa= 0.89, P < 0.001). Patients with positive TWA in all tests had lower LVEF (28 +/- 7% vs 35 +/- 9%, P < 0.01) and wider QT dispersion (99 +/- 44 ms vs 67 +/- 38 ms, P < 0.01) than those with inconsistent test result. The low number of indeterminate tests and high concordance between the test results indicate that V + A pacing may provide a valuable means to assess TWA in patients who cannot complete the exercise test.
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Affiliation(s)
- M J Pekka Raatikainen
- University of Oulu, Department of Internal Medicine, Division of Cardiology, Oulu, Finland.
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Paisey JR, Yue AM, Treacher K, Roberts PR, Morgan JM. Implantable loop recorders detect tachyarrhythmias in symptomatic patients with negative electrophysiological studies. Int J Cardiol 2005; 98:35-8. [PMID: 15676163 DOI: 10.1016/j.ijcard.2003.06.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2003] [Revised: 06/20/2003] [Accepted: 06/21/2003] [Indexed: 10/26/2022]
Abstract
BACKGROUND Implantable loop recorders (ILR) are a valuable tool in the investigation of syncope and compare favourably with non-invasive and intracardiac electrophysiological assessment of bradycardia. They are known to detect tachyarrhythmias but have not been shown to add to the diagnostic yield of electrophysiological testing in symptomatic patients. METHODS We prospectively studied the first 41 patients (aged 48+/-19 years) in whom ILR were used at our institution after negative electrophysiological studies (EPS). All patients were symptomatic with palpitations (11), syncope (22) or both (8). Nine patients had known structural heart disease (two ischaemic, four cardiomyopathy, two valvular and one congenital). Patients were assessed according to demographic factors, symptoms and investigations. Loop recordings were analysed and assessed according to conventional criteria. RESULTS Among 41 patients in whom electrophysiological studies had failed to demonstrate arrhythmias, six were found to have clinically significant tachyarrhythmias (four ventricular and two supraventricular). CONCLUSION ILR diagnose prognostically significant tachyarrhythmias in symptomatic patients with negative electrophysiological studies.
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Affiliation(s)
- John R Paisey
- Wessex Cardiothoracic Centre, Southampton University Hospitals, Southampton SO16 6YD, UK.
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Krahn AD, Klein GJ, Skanes AC, Yee R. Insertable loop recorder use for detection of intermittent arrhythmias. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2004; 27:657-64. [PMID: 15125724 DOI: 10.1111/j.1540-8159.2004.00502.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The advent of prolonged monitoring with the implanted loop recorders has revolutionized the quest for detection of elusive infrequent arrhythmias in patients with unexplained syncope. The capability of prolonged monitoring has permitted us to obtain symptom rhythm correlation in the majority of patients suspected to have underlying infrequent arrhythmia. The implanted loop recorder is easily implanted in the left pectoral region with a minimally invasive procedure, providing at least 14 months of continuous monitoring that is both patient and automatically activated. Several recent studies suggest that it plays a major role in patients with infrequent symptoms and suspected arrhythmia, including patients with syncope and conduction disturbances, mild to moderate underlying heart disease, and atypical epilepsy. In a randomized trial, the device was found to be cost-effective and improved diagnostic yield compared to conventional tilt and electrophysiological testing. Wider application of prolonged monitoring is ongoing, including assessment of ventricular arrhythmias, atrial fibrillation, and conduction disturbances. The implantable loop recorder is most useful in patients with infrequent unexplained syncope when noninvasive testing is negative.
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Affiliation(s)
- Andrew D Krahn
- Division of Cardiology, University of Western Ontario, London, Ontario, Canada.
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Otasević P, Nesković AN, Popović Z, Vlahović A, Vuković M, Borzanović B, Popović AD. [Effect of thrombolytic therapy on occurrence of complex ventricular arrhythmias in the late hospitalization period in acute myocardial infarct: relation with long-term remodeling of the left ventricle]. VOJNOSANIT PREGL 2003; 60:547-53. [PMID: 14608832 DOI: 10.2298/vsp0305547o] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The impact of thrombolytic therapy on the incidence of complex ventricular arrhythmias is not yet clarified. The aim of this study was to investigate the impact of thrombolytic therapy on the incidence of complex ventricular arrhythmias, as well as long term association between complex ventricular arrhythmias and left ventricular remodelling, and their impact on five-year lethality. METHODS Ninety seven consecutive patients with first acute myocardial infarction (streptokinase was administered in 58 patients), underwent 24-hours Holter monitoring at discharge. Ventricular arrhythmias were classified according to Lown classification, and patients were grouped into the group with simple ventricular arrhythmias (Lown class 0 to 2), and the group with complex ventricular arrhythmias (Lown class 3 to 5). Echocardiography was performed at discharge, and six and twelve months after the infarction. Left ventricular volume indexes and ejection fraction was determined using Simpson's biplane formula. RESULTS In patients with complex ventricular arrhythmias left ventricular volume indexes were higher and ejection fraction was lower throughout the study, whereas wall motion score index was higher one year after the infarction. On the other hand, these variables were similar throughout the follow-up within the groups of patients with and without complex ventricular arrhythmias who received thrombolytic therapy. The incidence of complex ventricular arrhythmias was similar in thrombolyzed and non-thrombolyzed patients (11/58 vs. 5/39). There was no difference in five year lethality between patients with and without complex ventricular arrhythmias (4/16 vs. 13/81 patients). CONCLUSION Our data indicated that left ventricular remodelling in patients with complex ventricular arrhythmias was not progressive after hospital discharge. The presence of complex ventricular arrhythmias was not associated with the increased five-year lethality, despite of more pronounced left ventricular remodelling. It occurred that thrombolysis per se had no influence on the incidence of complex ventricular arrhythmias in the late hospital phase after the first acute myocardial infarction.
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Affiliation(s)
- Petar Otasević
- Institut za kardiovaskularne bolesti, Dedinje, Centar za kardiovaskularna istrazivanja Dr Aleksandar D. Popović, Beograd
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Krahn AD, Klein GJ, Skanes AC, Yee R. Use of the implantable loop recorder in evaluation of patients with unexplained syncope. J Cardiovasc Electrophysiol 2003; 14:S70-3. [PMID: 12950523 DOI: 10.1046/j.1540-8167.14.s9.19.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Syncope is a complex symptom with multiple potential etiologies that can be difficult to establish. The major obstacles to diagnosis are the periodic and unpredictable nature of events and the high spontaneous remission rate. Short-term ECG monitoring often is unproductive when initial noninvasive testing is negative due to the low probability of recurrence during the brief monitoring period. Implantable loop recorders extend the ability to monitor cardiac patients, enhancing the diagnostic yield to as high as 85% in difficult to diagnose syncope. Several recent studies suggest that prolonged monitoring with an implantable loop recorder has a role in patients with syncope and conduction disturbances, negative tilt testing, and unexplained seizures, and may be superior to conventional testing with tilt and electrophysiologic studies.
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Affiliation(s)
- Andrew D Krahn
- Division of Cardiology, University of Western Ontario, London, Ontario, Canada.
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