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Pinsky AM, Kulkarni VK, Bos JM, Neves R, Allison TG, Ackerman MJ. Proceed with caution: Standard protocol exercise stress tests fail to replicate the diagnostic utility of supine-stand tests for long QT syndrome. Pacing Clin Electrophysiol 2024; 47:455-461. [PMID: 38348899 DOI: 10.1111/pace.14945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 01/14/2024] [Accepted: 01/25/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND Long QT syndrome (LQTS) is a sudden death predisposing condition characterized by ECG-derived prolongation of the QT interval. Previous studies have demonstrated that the supine-stand test may aid in the diagnosis of LQTS as patients fail to shorten their QT interval in response to standing up. The aim of this study was to evaluate the diagnostic accuracy of ECG data derived from standard protocol, clinically performed treadmill exercise stress tests (TESTs) in their ability to mimic the formal supine-stand test. METHODS We performed a retrospective review of 478 TESTs from patients evaluated for LQTS. Patients referred for evaluation of LQTS but who were dismissed as normal served as controls. Heart rate & QT values were obtained from standard protocol TESTs. RESULTS Overall, 243 patients with LQTS (125 LQT1, 63 LQT2, 55 LQT3; 146 [60%] female, mean age at TEST 30 ± 17 years) and 235 controls (142 [60%] female, mean age 24 ± 15 years) were included. The paired ΔQTc (QTcStand -QTcSupine ) was similar between LQTS (-5 ± 26) and controls (-2 ± 25; p = .2). During position change, the QT interval shortened by ≥20 ms in 33% of LQTS patients, remained unchanged in 62%, and increased in 5% of LQTS patients which was similar to controls (shortened in 40%, unchanged in 54%, and increased in 6% of controls; p = .2). Receiver-operator curve analysis to test the diagnostic ability of supine-stand ΔQT performed poorly in differentiating LQTS from controls with an of AUC 0.52 (p = .4). CONCLUSION TESTs should be used with caution when trying to interpret supine-stand changes for diagnosis of LQTS.
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Affiliation(s)
- Alexa M Pinsky
- Department of Cardiovascular Medicine (Division of Heart Rhythm Services), Windland Smith Rice Genetic Heart Rhythm Clinic, Mayo Clinic, Rochester, Minnesota, USA
| | - Veda K Kulkarni
- Department of Cardiovascular Medicine (Division of Heart Rhythm Services), Windland Smith Rice Genetic Heart Rhythm Clinic, Mayo Clinic, Rochester, Minnesota, USA
| | - J Martijn Bos
- Department of Cardiovascular Medicine (Division of Heart Rhythm Services), Windland Smith Rice Genetic Heart Rhythm Clinic, Mayo Clinic, Rochester, Minnesota, USA
| | - Raquel Neves
- Department of Cardiovascular Medicine (Division of Heart Rhythm Services), Windland Smith Rice Genetic Heart Rhythm Clinic, Mayo Clinic, Rochester, Minnesota, USA
| | - Thomas G Allison
- Department of Cardiovascular Medicine (Division of Heart Rhythm Services), Windland Smith Rice Genetic Heart Rhythm Clinic, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael J Ackerman
- Department of Cardiovascular Medicine (Division of Heart Rhythm Services), Windland Smith Rice Genetic Heart Rhythm Clinic, Mayo Clinic, Rochester, Minnesota, USA
- Department of Pediatric and Adolescent Medicine (Division of Pediatric Cardiology), Mayo Clinic, Rochester, Minnesota, USA
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Abrahams T, Davies B, Laksman Z, Sy RW, Postema PG, Wilde AAM, Krahn AD, Han HC. Provocation testing in congenital long QT syndrome: A practical guide. Heart Rhythm 2023; 20:1570-1582. [PMID: 37481219 DOI: 10.1016/j.hrthm.2023.07.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 07/01/2023] [Accepted: 07/14/2023] [Indexed: 07/24/2023]
Abstract
Congenital long QT syndrome (LQTS) is a hereditary cardiac channelopathy with an estimated prevalence of 1 in 2500. A prolonged resting QT interval corrected for heart rate (QTc interval) remains a key diagnostic component; however, the QTc value may be normal in up to 40% of patients with genotype-positive LQTS and borderline in a further 30%. Provocation of QTc prolongation and T-wave changes may be pivotal to unmasking the diagnosis and useful in predicting genotype. LQTS provocation testing involves assessment of repolarization during and after exercise, in response to changes in heart rate or autonomic tone, with patients with LQTS exhibiting a maladaptive repolarization response. We review the utility and strengths and limitations of 4 forms of provocation testing-stand-up test, exercise stress test, epinephrine challenge, and mental stress test-in diagnosing LQTS and provide some practical guidance for performing provocation testing. Ultimately, exercise testing, when feasible, is the most useful form of provocation testing when considering diagnostic sensitivity and specificity.
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Affiliation(s)
- Timothy Abrahams
- Victorian Heart Institute & Monash Health Heart, Victorian Heart Hospital, Monash University, Melbourne, Victoria, Australia
| | - Brianna Davies
- Center for Cardiovascular Innovation, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Zachary Laksman
- Center for Cardiovascular Innovation, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Raymond W Sy
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Pieter G Postema
- Department of Cardiology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands; Heart Failure & Arrhythmias, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands; European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart (ERN GUARD-Heart), Academic Medical Center, Amsterdam, The Netherlands
| | - Arthur A M Wilde
- Department of Cardiology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands; Heart Failure & Arrhythmias, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands; European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart (ERN GUARD-Heart), Academic Medical Center, Amsterdam, The Netherlands
| | - Andrew D Krahn
- Center for Cardiovascular Innovation, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Hui-Chen Han
- Victorian Heart Institute & Monash Health Heart, Victorian Heart Hospital, Monash University, Melbourne, Victoria, Australia.
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Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M. 2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Eur Heart J 2022; 43:3997-4126. [PMID: 36017572 DOI: 10.1093/eurheartj/ehac262] [Citation(s) in RCA: 822] [Impact Index Per Article: 411.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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Henein MY, Vancheri S, Longo G, Vancheri F. The Impact of Mental Stress on Cardiovascular Health—Part II. J Clin Med 2022; 11:jcm11154405. [PMID: 35956022 PMCID: PMC9369438 DOI: 10.3390/jcm11154405] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/23/2022] [Accepted: 07/26/2022] [Indexed: 12/03/2022] Open
Abstract
Endothelial dysfunction is one of the earliest manifestations of atherosclerosis, contributing to its development and progression. Mental stress induces endothelial dysfunction through increased activity of the sympathetic nervous system, release of corticotropin-releasing hormone from the hypothalamus, inhibition of nitric oxide (NO) synthesis by cortisol, and increased levels of pro-inflammatory cytokines. Mental-stress-induced increased output of the sympathetic nervous system and concomitant withdrawal of the parasympathetic inflammatory reflex results in systemic inflammation and activation of a neural–hematopoietic–arterial axis. This includes the brainstem and subcortical regions network, bone marrow activation, release of leukocytes into the circulation and their migration to the arterial wall and atherosclerotic plaques. Low-grade, sterile inflammation is involved in all steps of atherogenesis, from coronary plaque formation to destabilisation and rupture. Increased sympathetic tone may cause arterial smooth-muscle-cell proliferation, resulting in vascular hypertrophy, thus contributing to the development of hypertension. Emotional events also cause instability of cardiac repolarisation due to brain lateralised imbalance of cardiac autonomic nervous stimulation, which may lead to asymmetric repolarisation and arrhythmia. Acute emotional stress can also provoke severe catecholamine release, leading to direct myocyte injury due to calcium overload, known as myocytolysis, coronary microvascular vasoconstriction, and an increase in left ventricular afterload. These changes can trigger a heart failure syndrome mimicking acute myocardial infarction, characterised by transient left ventricular dysfunction and apical ballooning, known as stress (Takotsubo) cardiomyopathy. Women are more prone than men to develop mental-stress-induced myocardial ischemia (MSIMI), probably reflecting gender differences in brain activation patterns during mental stress. Although guidelines on CV prevention recognise psychosocial factors as risk modifiers to improve risk prediction and decision making, the evidence that their assessment and treatment will prevent CAD needs further evaluation.
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Affiliation(s)
- Michael Y. Henein
- Institute of Public Health and Clinical Medicine, Umea University, 90187 Umea, Sweden;
- Brunel University, Middlesex, London UB8 3PH, UK
- St. George’s University, London SW17 0RE, UK
| | - Sergio Vancheri
- Radiology Department, I.R.C.C.S. Policlinico San Matteo, 27100 Pavia, Italy;
| | - Giovanni Longo
- Cardiovascular and Interventional Department, S. Elia Hospital, 93100 Caltanissetta, Italy;
| | - Federico Vancheri
- Department of Internal Medicine, S. Elia Hospital, 93100 Caltanissetta, Italy
- Correspondence:
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Yang Y, Lv T, Li S, Liu P, Gao Q, Zhang P. Utility of Provocative Testing in the Diagnosis and Genotyping of Congenital Long QT Syndrome: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2022; 11:e025246. [PMID: 35861842 PMCID: PMC9707831 DOI: 10.1161/jaha.122.025246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 04/27/2022] [Indexed: 11/16/2022]
Abstract
Background Diagnosis is particularly challenging in concealed or asymptomatic long QT syndrome (LQTS). Provocative testing, unmasking the characterization of LQTS, is a promising alternative method for the diagnosis of LQTS, but without uniform standards. Methods and Results A comprehensive search was conducted in PubMed, Embase, and the Cochrane Library through October 14, 2021. The fixed effects model was used to assess the effect of the provocative testing on QTc interval. A total of 22 studies with 1137 patients with LQTS were included. At baseline, QTc interval was 40 ms longer in patients with LQTS than in controls (mean difference [MD], 40.54 [95% CI, 37.43-43.65]; P<0.001). Compared with the control group, patients with LQTS had 28 ms longer ΔQTc upon standing (MD, 28.82 [95% CI, 23.05-34.58]; P<0.001), nearly 30 ms longer both at peak exercise (MD, 27.31 [95% CI, 21.51-33.11]; P<0.001) and recovery 4 to 5 minutes (MD, 29.85 [95% CI, 24.36-35.35]; P<0.001). With epinephrine infusion, QTc interval was prolonged both in controls and patients with QTS, most obviously in LQT1 (MD, 68.26 [95% CI, 58.91-77.60]; P<0.001) and LQT2 (MD, 60.17 [95% CI, 50.18-70.16]; P<0.001). Subgroup analysis showed QTc interval response to abrupt stand testing and exercise testing varied between LQT1, LQT2, and LQT3, named Type Ⅰ, Type Ⅱ, and Type Ⅲ. Conclusions QTc trend Type Ⅰ and Type Ⅲ during abrupt stand testing and exercise testing can be used to propose a prospective evaluation of LQT1 and LQT3, respectively. Type Ⅱ QTc trend combined epinephrine infusion testing could distinguish LQT2 from control. A preliminary diagnostic workflow was proposed but deserves further evaluation.
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Affiliation(s)
- Ying Yang
- School of Clinical MedicineTsinghua UniversityBeijingChina
| | - Ting‐ting Lv
- Department of CardiologySchool of Clinical MedicineBeijing Tsinghua Changgung HospitalTsinghua UniversityBeijingChina
| | - Si‐yuan Li
- Department of CardiologySchool of Clinical MedicineBeijing Tsinghua Changgung HospitalTsinghua UniversityBeijingChina
| | - Peng Liu
- School of Clinical MedicineTsinghua UniversityBeijingChina
| | - Qing‐gele Gao
- School of Clinical MedicineTsinghua UniversityBeijingChina
| | - Ping Zhang
- School of Clinical MedicineTsinghua UniversityBeijingChina
- Department of CardiologySchool of Clinical MedicineBeijing Tsinghua Changgung HospitalTsinghua UniversityBeijingChina
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6
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Krahn AD, Laksman Z, Sy RW, Postema PG, Ackerman MJ, Wilde AAM, Han HC. Congenital Long QT Syndrome. JACC Clin Electrophysiol 2022; 8:687-706. [PMID: 35589186 DOI: 10.1016/j.jacep.2022.02.017] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 02/16/2022] [Accepted: 02/16/2022] [Indexed: 12/14/2022]
Abstract
Congenital long QT syndrome (LQTS) encompasses a group of heritable conditions that are associated with cardiac repolarization dysfunction. Since its initial description in 1957, our understanding of LQTS has increased dramatically. The prevalence of LQTS is estimated to be ∼1:2,000, with a slight female predominance. The diagnosis of LQTS is based on clinical, electrocardiogram, and genetic factors. Risk stratification of patients with LQTS aims to identify those who are at increased risk of cardiac arrest or sudden cardiac death. Factors including age, sex, QTc interval, and genetic background all contribute to current risk stratification paradigms. The management of LQTS involves conservative measures such as the avoidance of QT-prolonging drugs, pharmacologic measures with nonselective β-blockers, and interventional approaches such as device therapy or left cardiac sympathetic denervation. In general, most forms of exercise are considered safe in adequately treated patients, and implantable cardioverter-defibrillator therapy is reserved for those at the highest risk. This review summarizes our current understanding of LQTS and provides clinicians with a practical approach to diagnosis and management.
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Affiliation(s)
- Andrew D Krahn
- Center for Cardiovascular Innovation, Heart Rhythm Services, Division of Cardiology, University of British Columbia, Vancouver, BC, Canada.
| | - Zachary Laksman
- Center for Cardiovascular Innovation, Heart Rhythm Services, Division of Cardiology, University of British Columbia, Vancouver, BC, Canada
| | - Raymond W Sy
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Pieter G Postema
- Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Michael J Ackerman
- Department of Cardiovascular Medicine, Division of Heart Rhythm Services, Windland Smith Rice Genetic Heart Rhythm Clinic, Mayo Clinic, Rochester, Minnesota, USA; Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota, USA; Departments of Molecular Pharmacology and Experimental Therapeutics, Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Arthur A M Wilde
- Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam University Medical Centers, Amsterdam, the Netherlands; European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARD-Heart), Academic University Medical Center, Amsterdam, the Netherlands
| | - Hui-Chen Han
- Center for Cardiovascular Innovation, Heart Rhythm Services, Division of Cardiology, University of British Columbia, Vancouver, BC, Canada; Victorian Heart Institute, Monash University, Clayton, VIC, Australia
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7
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Cimarosti B, Canac R, Girardeau A, Arnaud M, Francheteau Q, Probst V, Lemarchand P, Redon R, Gourraud JB, Gaborit N, Lamirault G. Generation of human induced pluripotent stem cell lines from two patients affected by catecholamine-induced QT prolongation (CIQTP). Stem Cell Res 2022; 59:102649. [PMID: 34995842 DOI: 10.1016/j.scr.2021.102649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 12/29/2021] [Indexed: 11/26/2022] Open
Abstract
Catecholamine-induced QT prolongation (CIQTP) is an inherited cardiac disease characterized by a normal baseline ECG and a risk of sudden cardiac death by ventricular arrhythmia due to a QT prolongation that only appears during catecholergic stimulation, especially mental stress. Induced pluripotent stem cells (hiPSCs) were generated from peripheral blood mononuclear cells collected from two CIQTP-affected patients from two different families. These two hiPSC lines are a valuable model to study biological alterations due to CIQTP.
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Affiliation(s)
- Bastien Cimarosti
- Université de Nantes, CHU Nantes, CNRS, INSERM, l'institut du thorax, F-44000 Nantes, France
| | - Robin Canac
- Université de Nantes, CHU Nantes, CNRS, INSERM, l'institut du thorax, F-44000 Nantes, France
| | - Aurore Girardeau
- Université de Nantes, CHU Nantes, CNRS, INSERM, l'institut du thorax, F-44000 Nantes, France
| | - Marine Arnaud
- Université de Nantes, CHU Nantes, CNRS, INSERM, l'institut du thorax, F-44000 Nantes, France
| | - Quentin Francheteau
- Université de Nantes, CHU Nantes, INSERM, CNRS, SFR Santé, FED 4203, INSERM UMS 016, CNRS UMS 3556, F-44000 Nantes, France
| | - Vincent Probst
- Université de Nantes, CHU Nantes, CNRS, INSERM, l'institut du thorax, F-44000 Nantes, France
| | - Patricia Lemarchand
- Université de Nantes, CHU Nantes, CNRS, INSERM, l'institut du thorax, F-44000 Nantes, France
| | - Richard Redon
- Université de Nantes, CHU Nantes, CNRS, INSERM, l'institut du thorax, F-44000 Nantes, France
| | - Jean-Baptiste Gourraud
- Université de Nantes, CHU Nantes, CNRS, INSERM, l'institut du thorax, F-44000 Nantes, France
| | - Nathalie Gaborit
- Université de Nantes, CHU Nantes, CNRS, INSERM, l'institut du thorax, F-44000 Nantes, France
| | - Guillaume Lamirault
- Université de Nantes, CHU Nantes, CNRS, INSERM, l'institut du thorax, F-44000 Nantes, France.
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8
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Lankaputhra M, Voskoboinik A. Congenital Long QT Syndrome: A Clinician's Guide. Intern Med J 2021; 51:1999-2011. [PMID: 34151491 DOI: 10.1111/imj.15437] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 05/31/2021] [Accepted: 06/15/2021] [Indexed: 11/29/2022]
Abstract
Congenital long QT syndrome (LQTS) is a familial cardiac ion channelopathy first described over sixty years ago. It is characterised by prolonged ventricular repolarization (long QT on ECG), ventricular arrhythmias and associated syncope or sudden cardiac death. As the most closely studied cardiac channelopathy, over the decades we have gained a deep appreciation of the complex genetic model of LQTS. Variability in genetic expression and incomplete penetrance leads to a heterogenous phenotype that can be challenging to clinically classify. In recent times, progress has been made in diagnostic method, risk stratification and treatment options. This review has been written as a guide for the general cardiologist to understand the basic pathophysiology, diagnosis, and management priorities for the most encountered LQTS subtypes: LQT1, LQT2 and LQT3. This article is protected by copyright. All rights reserved.
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Affiliation(s)
| | - Aleksandr Voskoboinik
- Division of Cardiology, Alfred Health, Melbourne, Australia.,Division of Cardiology Western Health, Monash University & Baker Heart & Diabetes Institute, Melbourne, Australia
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Stiles MK, Wilde AAM, Abrams DJ, Ackerman MJ, Albert CM, Behr ER, Chugh SS, Cornel MC, Gardner K, Ingles J, James CA, Juang JMJ, Kääb S, Kaufman ES, Krahn AD, Lubitz SA, MacLeod H, Morillo CA, Nademanee K, Probst V, Saarel EV, Sacilotto L, Semsarian C, Sheppard MN, Shimizu W, Skinner JR, Tfelt-Hansen J, Wang DW. 2020 APHRS/HRS expert consensus statement on the investigation of decedents with sudden unexplained death and patients with sudden cardiac arrest, and of their families. J Arrhythm 2021; 37:481-534. [PMID: 34141003 PMCID: PMC8207384 DOI: 10.1002/joa3.12449] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 10/14/2020] [Indexed: 12/26/2022] Open
Abstract
This international multidisciplinary document intends to provide clinicians with evidence-based practical patient-centered recommendations for evaluating patients and decedents with (aborted) sudden cardiac arrest and their families. The document includes a framework for the investigation of the family allowing steps to be taken, should an inherited condition be found, to minimize further events in affected relatives. Integral to the process is counseling of the patients and families, not only because of the emotionally charged subject, but because finding (or not finding) the cause of the arrest may influence management of family members. The formation of multidisciplinary teams is essential to provide a complete service to the patients and their families, and the varied expertise of the writing committee was formulated to reflect this need. The document sections were divided up and drafted by the writing committee members according to their expertise. The recommendations represent the consensus opinion of the entire writing committee, graded by Class of Recommendation and Level of Evidence. The recommendations were opened for public comment and reviewed by the relevant scientific and clinical document committees of the Asia Pacific Heart Rhythm Society (APHRS) and the Heart Rhythm Society (HRS); the document underwent external review and endorsement by the partner and collaborating societies. While the recommendations are for optimal care, it is recognized that not all resources will be available to all clinicians. Nevertheless, this document articulates the evaluation that the clinician should aspire to provide for patients with sudden cardiac arrest, decedents with sudden unexplained death, and their families.
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Affiliation(s)
- Martin K Stiles
- Waikato Clinical School Faculty of Medicine and Health Science The University of Auckland Hamilton New Zealand
| | - Arthur A M Wilde
- Heart Center Department of Clinical and Experimental Cardiology Amsterdam University Medical Center University of Amsterdam Amsterdam the Netherlands
| | | | | | | | - Elijah R Behr
- Cardiovascular Clinical Academic Group, Molecular and Clinical Sciences Institute St George's University of London, and St George's University Hospitals NHS Foundation Trust London UK
| | | | - Martina C Cornel
- Amsterdam University Medical Center Vrije Universiteit Amsterdam Clinical Genetics Amsterdam Public Health Research Institute Amsterdam the Netherlands
| | | | - Jodie Ingles
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute The University of Sydney Sydney Australia
| | | | - Jyh-Ming Jimmy Juang
- Cardiovascular Center and Division of Cardiology Department of Internal Medicine National Taiwan University Hospital and National Taiwan University College of Medicine Taipei Taiwan
| | - Stefan Kääb
- Department of Medicine I University Hospital LMU Munich Munich Germany
| | | | | | | | - Heather MacLeod
- Data Coordinating Center for the Sudden Death in the Young Case Registry Okemos MI USA
| | | | - Koonlawee Nademanee
- Chulalongkorn University Faculty of Medicine, and Pacific Rim Electrophysiology Research Institute at Bumrungrad Hospital Bangkok Thailand
| | | | - Elizabeth V Saarel
- Cleveland Clinic Lerner College of Cardiology at Case Western Reserve University Cleveland OH USA
- St Luke's Medical Center Boise ID USA
| | - Luciana Sacilotto
- Heart Institute University of São Paulo Medical School São Paulo Brazil
| | - Christopher Semsarian
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute The University of Sydney Sydney Australia
| | - Mary N Sheppard
- Cardiovascular Clinical Academic Group, Molecular and Clinical Sciences Institute St George's University of London, and St George's University Hospitals NHS Foundation Trust London UK
| | - Wataru Shimizu
- Department of Cardiovascular Medicine Nippon Medical School Tokyo Japan
| | | | - Jacob Tfelt-Hansen
- Department of Forensic Medicine Faculty of Medical Sciences Rigshospitalet Copenhagen Denmark
| | - Dao Wu Wang
- The First Affiliated Hospital of Nanjing Medical University Nanjing China
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10
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Dose response to nadolol in congenital long QT syndrome. Heart Rhythm 2021; 18:1377-1383. [PMID: 33905813 DOI: 10.1016/j.hrthm.2021.04.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 04/20/2021] [Accepted: 04/21/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Beta-blocker therapy is the cornerstone of treatment for patients with long QT syndrome (LQTS). Few details on the dose to be used are available. As the response is variable between patients, we systematically evaluated the effect of treatment by performing an exercise test. OBJECTIVE The purpose of this study was to explore dose response to nadolol on exercise test in LQTS patients in order to propose a more personalized therapeutic approach. METHODS LQTS patients followed at the Reference Centre for Hereditary Arrhythmic Diseases of Nantes with at least 1 exercise test under nadolol were included retrospectively between 1993 and 2017. All patients underwent gradual cycle exercise tests. Doses adjusted to weight and response to treatment were recorded and evaluated by the percentage of age-predicted maximum heart rate reached on exercise test. RESULTS Ninety-five patients were included in the study, and 337 stress tests under nadolol were analyzed. No correlation existed between dose and percentage of age-predicted maximum heart rate on exercise tests. Twenty-one patients were overresponders, mostly LQTS1, and 20 were underresponders, mainly LQTS2 (P = .0229). Forty-two patients had at least 3 stress tests under nadolol. We found a negative correlation between dose change and percentage of age-predicted maximum heart rate change (P <.0001). We then proposed a table to adapt dose according to exercise test response. CONCLUSION Our study demonstrated a major variability of dose response to nadolol in patients with LQTS, thus underlining the need for a tailored dosage for each patient. Intraindividual analysis showed a relatively constant dose-response relationship, allowing guided dose adaptation after the first exercise test.
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11
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Abstract
Long QT syndrome (LQTS) is a cardiovascular disorder characterized by an abnormality in cardiac repolarization leading to a prolonged QT interval and T-wave irregularities on the surface electrocardiogram. It is commonly associated with syncope, seizures, susceptibility to torsades de pointes, and risk for sudden death. LQTS is a rare genetic disorder and a major preventable cause of sudden cardiac death in the young. The availability of therapy for this lethal disease emphasizes the importance of early and accurate diagnosis. Additionally, understanding of the molecular mechanisms underlying LQTS could help to optimize genotype-specific treatments to prevent deaths in LQTS patients. In this review, we briefly summarize current knowledge regarding molecular underpinning of LQTS, in particular focusing on LQT1, LQT2, and LQT3, and discuss novel strategies to study ion channel dysfunction and drug-specific therapies in LQT1, LQT2, and LQT3 syndromes.
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Affiliation(s)
| | - Isabelle Deschênes
- Department of Physiology and Cell Biology, The Ohio State University, Columbus, Ohio
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12
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Stiles MK, Wilde AAM, Abrams DJ, Ackerman MJ, Albert CM, Behr ER, Chugh SS, Cornel MC, Gardner K, Ingles J, James CA, Jimmy Juang JM, Kääb S, Kaufman ES, Krahn AD, Lubitz SA, MacLeod H, Morillo CA, Nademanee K, Probst V, Saarel EV, Sacilotto L, Semsarian C, Sheppard MN, Shimizu W, Skinner JR, Tfelt-Hansen J, Wang DW. 2020 APHRS/HRS expert consensus statement on the investigation of decedents with sudden unexplained death and patients with sudden cardiac arrest, and of their families. Heart Rhythm 2021; 18:e1-e50. [PMID: 33091602 PMCID: PMC8194370 DOI: 10.1016/j.hrthm.2020.10.010] [Citation(s) in RCA: 147] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 10/09/2020] [Indexed: 12/13/2022]
Abstract
This international multidisciplinary document intends to provide clinicians with evidence-based practical patient-centered recommendations for evaluating patients and decedents with (aborted) sudden cardiac arrest and their families. The document includes a framework for the investigation of the family allowing steps to be taken, should an inherited condition be found, to minimize further events in affected relatives. Integral to the process is counseling of the patients and families, not only because of the emotionally charged subject, but because finding (or not finding) the cause of the arrest may influence management of family members. The formation of multidisciplinary teams is essential to provide a complete service to the patients and their families, and the varied expertise of the writing committee was formulated to reflect this need. The document sections were divided up and drafted by the writing committee members according to their expertise. The recommendations represent the consensus opinion of the entire writing committee, graded by Class of Recommendation and Level of Evidence. The recommendations were opened for public comment and reviewed by the relevant scientific and clinical document committees of the Asia Pacific Heart Rhythm Society (APHRS) and the Heart Rhythm Society (HRS); the document underwent external review and endorsement by the partner and collaborating societies. While the recommendations are for optimal care, it is recognized that not all resources will be available to all clinicians. Nevertheless, this document articulates the evaluation that the clinician should aspire to provide for patients with sudden cardiac arrest, decedents with sudden unexplained death, and their families.
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Affiliation(s)
- Martin K Stiles
- Waikato Clinical School, Faculty of Medicine and Health Science, The University of Auckland, Hamilton, New Zealand
| | - Arthur A M Wilde
- Amsterdam University Medical Center, University of Amsterdam, Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam, the Netherlands
| | | | | | | | - Elijah R Behr
- Cardiovascular Clinical Academic Group, Molecular and Clinical Sciences Institute, St George's, University of London, and St George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Sumeet S Chugh
- Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Martina C Cornel
- Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Clinical Genetics, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | | | - Jodie Ingles
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, Australia
| | | | - Jyh-Ming Jimmy Juang
- Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Stefan Kääb
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | | | - Andrew D Krahn
- The University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Heather MacLeod
- Data Coordinating Center for the Sudden Death in the Young Case Registry, Okemos, Michigan, USA
| | | | - Koonlawee Nademanee
- Chulalongkorn University, Faculty of Medicine, and Pacific Rim Electrophysiology Research Institute at Bumrungrad Hospital, Bangkok, Thailand
| | | | - Elizabeth V Saarel
- Cleveland Clinic Lerner College of Cardiology at Case Western Reserve University, Cleveland, Ohio, and St Luke's Medical Center, Boise, Idaho, USA
| | - Luciana Sacilotto
- Heart Institute, University of São Paulo Medical School, São Paulo, Brazil
| | - Christopher Semsarian
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, Australia
| | - Mary N Sheppard
- Cardiovascular Clinical Academic Group, Molecular and Clinical Sciences Institute, St George's, University of London, and St George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Jonathan R Skinner
- Cardiac Inherited Disease Group, Starship Hospital, Auckland, New Zealand
| | - Jacob Tfelt-Hansen
- Department of Forensic Medicine, Faculty of Medical Sciences, Rigshospitalet, Copenhagen, Denmark
| | - Dao Wu Wang
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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Ahmad MI, Majeed CN, Chaudhary D, Dutta A, Jogu HR, Soliman EZ. Relation of Marital Status and QT Interval Prolongation (from the Third National Health and Nutrition Examination Survey). Am J Cardiol 2019; 124:211-215. [PMID: 31084996 DOI: 10.1016/j.amjcard.2019.04.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 03/31/2019] [Accepted: 04/04/2019] [Indexed: 10/27/2022]
Abstract
Although the link between marital status and mortality is well established, the pathophysiological basis is unclear. An investigation of the association of marital status with prolonged QT interval may highlight the underlying mechanism for poor outcomes associated with being unmarried. This analysis included 6,562 participants (mean age 58.6 years, 52% women, 50.1% non-Hispanic whites) without a history of cardiovascular disease from the Third National Health and Nutrition Examination Survey. QT was automatically measured from digital 12-lead electrocardiogram in a central reading center. Marital status was defined by self-report as married and unmarried (never married, divorced/separated or widowed). A multivariable logistic regression model was used to examine cross-sectional association between marital status and prolonged QT interval (≥450 ms in men, ≥460 ms in women). Compared with married, unmarried was associated with 46% higher odds of the prolonged QT interval (odds ratio [OR] 95% confidence interval [95% CI]: 1.46[1.16-1.83]). This association was stronger among men versus women (OR[95% CI]: 1.75[1.27-2.41] vs 1.26[0.92-1.73] respectively; interaction p value = 0.03) and in younger versus older participants (OR [95% CI]: 1.72[1.21-2.42] vs 1.40[1.05-1.88], respectively; interaction p value = 0.002). When the types of unmarried were compared to married, a dose-response relation with prolonged QT was observed with the highest odds in never married followed by divorced/separated, and then widowed. In conclusion, marital status is associated with a prolonged QT interval, especially among men and younger participants. Prolonged QT interval may indicate a biologic substrate through which social isolation defined by unmarried state increases the risk of poor outcomes in the future.
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Churet M, Luttoo K, Hocini M, Haïssaguerre M, Sacher F, Duchateau J. Diagnostic reproducibility of epinephrine drug challenge interpretation in suspected long QT syndrome. J Cardiovasc Electrophysiol 2019; 30:896-901. [DOI: 10.1111/jce.13926] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 03/06/2019] [Accepted: 03/09/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Maxime Churet
- Department of Cardiology‐Cardiac Electrophysiology and PacingBordeaux University HospitalBordeaux France
| | - Khaled Luttoo
- Department of Cardiology‐Cardiac Electrophysiology and PacingBordeaux University HospitalBordeaux France
| | - Mélèze Hocini
- Department of Cardiology‐Cardiac Electrophysiology and PacingBordeaux University HospitalBordeaux France
| | - Michel Haïssaguerre
- Department of Cardiology‐Cardiac Electrophysiology and PacingBordeaux University HospitalBordeaux France
| | - Frédéric Sacher
- Department of Cardiology‐Cardiac Electrophysiology and PacingBordeaux University HospitalBordeaux France
| | - Josselin Duchateau
- Department of Cardiology‐Cardiac Electrophysiology and PacingBordeaux University HospitalBordeaux France
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