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Tsimos KP, Korantzopoulos P, Arsenos P, Doundoulakis I, Tsiachris D, Antoniou CK, Krikonis K, Sideris S, Dilaveris P, Triantafyllou K, Soulaidopoulos S, Kanoupakis E, Fragakis N, Sideris A, Trachanas K, Iliodromitis E, Tousoulis D, Tsioufis K, Kolettis TM, Gatzoulis KA. Association of non-invasive electrocardiographic risk factors with left ventricular systolic function in post-myocardial infarction patients with mildly reduced or preserved ejection fraction: Insights from the PRESERVE-EF study. Ann Noninvasive Electrocardiol 2022; 27:e12946. [PMID: 35795926 PMCID: PMC9484020 DOI: 10.1111/anec.12946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 02/09/2022] [Accepted: 02/10/2022] [Indexed: 11/28/2022] Open
Abstract
Background Electrocardiographic non‐invasive risk factors (NIRFs) have an important role in the arrhythmic risk stratification of post‐myocardial infarction (post‐MI) patients with preserved or mildly reduced left ventricular ejection fraction (LVEF). However, their specific relation to left ventricular systolic function remains unclear. We aimed to evaluate the association between NIRFs and LVEF in the patients included in the PRESERVE‐EF trial. Methods We studied 575 post‐MI ischemia‐free patients with LVEF≥40% (mean age: 57.0 ± 10.4 years, 86.2% men). The following NIRFs were evaluated: premature ventricular complexes, non‐sustained ventricular tachycardia (NSVT), late potentials (LPs), prolonged QTc, increased T‐wave alternans, reduced heart rate variability, and abnormal deceleration capacity with abnormal turbulence. Results There was a statistically significant relationship between LPs (Chi‐squared = 4.975; p < .05), nsVT (Chi‐squared = 5.749, p < .05), PVCs (r= −.136; p < .01), and the LVEF. The multivariate linear regression analysis showed that LPs (p = .001) and NSVT (p < .001) were significant predictors of the LVEF. The results of the multivariate logistic regression analysis indicated that LPs (OR: 1.76; 95% CI: 1.02–3.05; p = .004) and NSVT (OR: 2.44; 95% CI: 1.18–5.04; p = .001) were independent predictors of the mildly reduced LVEF: 40%–49% versus the preserved LVEF: ≥50%. Conclusion Late potentials and NSVT are independently related to reduced LVEF while they are independent predictors of mildly reduced LVEF versus the preserved LVEF. These findings may have important implications for the arrhythmic risk stratification of post‐MI patients with mildly reduced or preserved LVEF.
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Affiliation(s)
- Konstantinos P Tsimos
- First Department of Cardiology, University of Ioannina Medical School, Ioannina, Greece
| | | | - Petros Arsenos
- First Department of Cardiology, Hippokrateion Hospital, National and Kapodistrian University of Athens, Athens, Greece.,Arsenos Heart & Biosignals Lab, Avlonas, Greece
| | - Ioannis Doundoulakis
- First Department of Cardiology, Hippokrateion Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Tsiachris
- First Department of Cardiology, Hippokrateion Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | | | - Skevos Sideris
- State Department of Cardiology, Hippokrateion General Hospital, Athens, Greece
| | - Polychronis Dilaveris
- First Department of Cardiology, Hippokrateion Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Stergios Soulaidopoulos
- First Department of Cardiology, Hippokrateion Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Emmanuel Kanoupakis
- Department of Cardiology, School of Medicine, Heraklion University Hospital, University of Crete, Heraklion, Greece
| | - Nikolaos Fragakis
- Third Department of Cardiology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Antonios Sideris
- Second State Department of Cardiology, Evangelismos Athens General Hospital, Athens, Greece
| | | | - Efstathios Iliodromitis
- Second Cardiology Department, Attikon Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Tousoulis
- First Department of Cardiology, Hippokrateion Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Tsioufis
- First Department of Cardiology, Hippokrateion Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Theofilos M Kolettis
- First Department of Cardiology, University of Ioannina Medical School, Ioannina, Greece
| | - Konstantinos A Gatzoulis
- First Department of Cardiology, Hippokrateion Hospital, National and Kapodistrian University of Athens, Athens, Greece
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QT interval extracted from 30-minute short resting Holter ECG recordings predicts mortality in heart failure. J Electrocardiol 2022; 72:109-114. [DOI: 10.1016/j.jelectrocard.2022.03.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 03/07/2022] [Accepted: 03/30/2022] [Indexed: 01/08/2023]
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Arsenos P, Gatzoulis KA, Tsiachris D, Dilaveris P, Sideris S, Sotiropoulos I, Archontakis S, Antoniou CK, Kordalis A, Skiadas I, Toutouzas K, Vlachopoulos C, Tousoulis D, Tsioufis K. Arrhythmic risk stratification in ischemic, non-ischemic and hypertrophic cardiomyopathy: A two-step multifactorial, electrophysiology study inclusive approach. World J Cardiol 2022; 14:139-151. [PMID: 35432775 PMCID: PMC8968455 DOI: 10.4330/wjc.v14.i3.139] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 10/28/2021] [Accepted: 02/23/2022] [Indexed: 02/06/2023] Open
Abstract
Annual arrhythmic sudden cardiac death ranges from 0.6% to 4% in ischemic cardiomyopathy (ICM), 1% to 2% in non-ischemic cardiomyopathy (NICM), and 1% in hypertrophic cardiomyopathy (HCM). Towards a more effective arrhythmic risk stratification (ARS) we hereby present a two-step ARS with the usage of seven non-invasive risk factors: Late potentials presence (≥ 2/3 positive criteria), premature ventricular contractions (≥ 30/h), non-sustained ventricular tachycardia (≥ 1episode/24 h), abnormal heart rate turbulence (onset ≥ 0% and slope ≤ 2.5 ms) and reduced deceleration capacity (≤ 4.5 ms), abnormal T wave alternans (≥ 65μV), decreased heart rate variability (SDNN < 70ms), and prolonged QTc interval (> 440 ms in males and > 450 ms in females) which reflect the arrhythmogenic mechanisms for the selection of the intermediate arrhythmic risk patients in the first step. In the second step, these intermediate-risk patients undergo a programmed ventricular stimulation (PVS) for the detection of inducible, truly high-risk ICM and NICM patients, who will benefit from an implantable cardioverter defibrillator. For HCM patients, we also suggest the incorporation of the PVS either for the low HCM Risk-score patients or for the patients with one traditional risk factor in order to improve the inadequate sensitivity of the former and the low specificity of the latter.
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Affiliation(s)
- Petros Arsenos
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration Hospital, Athens 11527, Attika, Greece
| | - Konstantinos A Gatzoulis
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration Hospital, Athens 11527, Attika, Greece
| | | | - Polychronis Dilaveris
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration Hospital, Athens 11527, Attika, Greece
| | - Skevos Sideris
- Department of Cardiology, Hippokration Hospital, Athens 11527, Attika, Greece
| | - Ilias Sotiropoulos
- Department of Cardiology, Hippokration Hospital, Athens 11527, Attika, Greece
| | | | | | - Athanasios Kordalis
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration Hospital, Athens 11527, Attika, Greece
| | - Ioannis Skiadas
- Fifth Department of Cardiology, Hygeia Hospital, Marousi 15123, Attika, Greece
| | - Konstantinos Toutouzas
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration Hospital, Athens 11527, Attika, Greece
| | - Charalambos Vlachopoulos
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration Hospital, Athens 11527, Attika, Greece
| | - Dimitrios Tousoulis
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration Hospital, Athens 11527, Attika, Greece
| | - Konstantinos Tsioufis
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration Hospital, Athens 11527, Attika, Greece
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Doundoulakis I, Arsenos P, Tsiachris D, Kordalis A, Antoniou CK, Tsioufis K, Gatzoulis KA. Are we close to a major impact on prevention of sudden cardiac death among coronary artery disease patients? Heart Rhythm O2 2022; 3:218. [PMID: 35496452 PMCID: PMC9043356 DOI: 10.1016/j.hroo.2022.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Trachanas K, Sideris S, Arsenos P, Tsiachris D, Antoniou CK, Dilaveris P, Triantafyllou K, Xenogiannis I, Tsimos K, Efremidis M, Kanoupakis E, Flevari P, Vassilikos V, Sideris A, Korantzopoulos P, Tousoulis D, Tsioufis K, Gatzoulis K. Noninvasive risk factors for the prediction of inducibility on programmed ventricular stimulation in post-myocardial infarction patients with an ejection fraction ≥40% at risk for sudden cardiac arrest: Insights from the PRESERVE-EF study. Ann Noninvasive Electrocardiol 2021; 27:e12908. [PMID: 34873786 PMCID: PMC8916556 DOI: 10.1111/anec.12908] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/05/2021] [Accepted: 10/11/2021] [Indexed: 11/29/2022] Open
Abstract
Background In the PRESERVE‐EF study, a two‐step sudden cardiac death (SCD) risk stratification approach to detect post‐myocardial infarction (MI) patients with left ventricle ejection fraction (LVEF) ≥40% at risk for major arrhythmic events (MAEs) was used. Seven noninvasive risk factors (NIRFs) were extracted from a 24‐h ambulatory electrocardiography (AECG) and a 45‐min resting recording. Patients with at least one NIRF present were referred for invasive programmed ventricular stimulation (PVS) and inducible patients received an Implantable Cardioverter ‐ Defibrillator (ICD). Methods In the present study, we evaluated the performance of the NIRFs, as they were described in the PRESERVE‐EF study protocol, in predicting a positive PVS. In the PRESERVE‐EF study, 152 out of 575 patients underwent PVS and 41 of them were inducible. For the present analysis, data from these 152 patients were analyzed. Results Among the NIRFs examined, the presence of signal averaged ECG‐late potentials (SAECG‐LPs) ≥ 2/3 and non‐sustained ventricular tachycardia (NSVT) ≥1 eposode/24 h cutoff points were important predictors of a positive PVS study, demonstrating in the logistic regression analysis odds ratios 2.285 (p = .027) and 2.867 (p = .006), respectively. A simple risk score based on the above cutoff points in combination with LVEF < 50% presented high sensitivity but low specificity for a positive PVS. Conclusion Cutoff points of NSVT ≥ 1 episode/24 h and SAECG‐LPs ≥ 2/3 in combination with a LVEF < 50% were important predictors of inducibility. However, the final decision for an ICD implantation should be based on a positive PVS, which is irreplaceable in risk stratification.
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Affiliation(s)
| | - Skevos Sideris
- State Department of Cardiology, Hippokrateion General Hospital, Athens, Greece
| | - Petros Arsenos
- First Department of Cardiology, Hippokrateion General Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - Dimitrios Tsiachris
- First Department of Cardiology, Hippokrateion General Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - Christos-Konstantinos Antoniou
- First Department of Cardiology, Hippokrateion General Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - Polychronis Dilaveris
- First Department of Cardiology, Hippokrateion General Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | | | - Iosif Xenogiannis
- Second Department of Cardiology, Attikon General Hospital, National and Kapodistrian University of Athens School of Medicine, Chaidari, Greece
| | - Konstantinos Tsimos
- Department of Cardiology, Faculty of Medicine, University of Ioannina, Ioannina, Greece
| | - Michalis Efremidis
- Second State Department of Cardiology, Evangelismos Athens General Hospital, Athens, Greece
| | - Emmanuel Kanoupakis
- Department of Cardiology, Heraklion University Hospital, University of Crete, School of Medicine, Heraklion, Greece
| | - Panagiota Flevari
- Second Department of Cardiology, Attikon General Hospital, National and Kapodistrian University of Athens School of Medicine, Chaidari, Greece
| | - Vassilios Vassilikos
- Third Department of Cardiology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Antonios Sideris
- Second State Department of Cardiology, Evangelismos Athens General Hospital, Athens, Greece
| | | | - Dimitrios Tousoulis
- First Department of Cardiology, Hippokrateion General Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - Konstantinos Tsioufis
- First Department of Cardiology, Hippokrateion General Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - Konstantinos Gatzoulis
- First Department of Cardiology, Hippokrateion General Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
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Zekios KC, Mouchtouri ET, Lekkas P, Nikas DN, Kolettis TM. Sympathetic Activation and Arrhythmogenesis after Myocardial Infarction: Where Do We Stand? J Cardiovasc Dev Dis 2021; 8:jcdd8050057. [PMID: 34063477 PMCID: PMC8156099 DOI: 10.3390/jcdd8050057] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 04/30/2021] [Accepted: 05/12/2021] [Indexed: 12/11/2022] Open
Abstract
Myocardial infarction often leads to progressive structural and electrophysiologic remodeling of the left ventricle. Despite the widespread use of β-adrenergic blockade and implantable defibrillators, morbidity and mortality from chronic-phase ventricular tachyarrhythmias remains high, calling for further investigation on the underlying pathophysiology. Histological and functional studies have demonstrated extensive alterations of sympathetic nerve endings at the peri-infarct area and flow-innervation mismatches that create a highly arrhythmogenic milieu. Such accumulated evidence, along with the previously well-documented autonomic dysfunction as an important contributing factor, has stirred intense research interest for pharmacologic and non-pharmacologic neuromodulation in post-infarction heart failure. In this regard, aldosterone inhibitors, sacubitril/valsartan and sodium-glucose cotransporter type 2 inhibitors have shown antiarrhythmic effects. Non-pharmacologic modalities, currently tested in pre-clinical and clinical trials, include transcutaneous vagal stimulation, stellate ganglion modulation and renal sympathetic denervation. In this review, we provide insights on the pathophysiology of ventricular arrhythmogenesis post-myocardial infarction, focusing on sympathetic activation.
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Affiliation(s)
- Konstantinos C. Zekios
- 1st Department of Cardiology, University Hospital of Ioannina, 1 St. Niarxou Avenue, 45500 Ioannina, Greece; (K.C.Z.); (D.N.N.)
- Department of Cardiology, University of Ioannina, 1 St. Niarxou Avenue, 45500 Ioannina, Greece;
| | - Eleni-Taxiarchia Mouchtouri
- Department of Cardiology, University of Ioannina, 1 St. Niarxou Avenue, 45500 Ioannina, Greece;
- Cardiovascular Research Institute, 1 St. Niarxou Avenue, 45500 Ioannina, Greece;
| | - Panagiotis Lekkas
- Cardiovascular Research Institute, 1 St. Niarxou Avenue, 45500 Ioannina, Greece;
| | - Dimitrios N. Nikas
- 1st Department of Cardiology, University Hospital of Ioannina, 1 St. Niarxou Avenue, 45500 Ioannina, Greece; (K.C.Z.); (D.N.N.)
| | - Theofilos M. Kolettis
- 1st Department of Cardiology, University Hospital of Ioannina, 1 St. Niarxou Avenue, 45500 Ioannina, Greece; (K.C.Z.); (D.N.N.)
- Department of Cardiology, University of Ioannina, 1 St. Niarxou Avenue, 45500 Ioannina, Greece;
- Cardiovascular Research Institute, 1 St. Niarxou Avenue, 45500 Ioannina, Greece;
- Correspondence:
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7
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Gatzoulis KA, Dilaveris P, Arsenos P, Tsiachris D, Antoniou CK, Sideris S, Kolettis T, Kanoupakis E, Sideris A, Flevari P, Vassilikos V, Kappos K, Maounis T, Katsivas A, Kotsakis A, Karvounis H, Kossyvakis C, Leventopoulos G, Kalpakos D, Tousoulis D, Anastasakis A, Efthimiadis G, Fragakis N, Simantirakis E, Korantzopoulos P, Hahalis G, Kordalis A, Efremidis M, Kostopoulou A, Skiadas I, Margos P, Paraskevaidis S, Paravolidakis K, Klettas D, Mavrogeni S, Kranidis A, Iliodromitis E, Lazaridis K, Pyrgakis V, Androulakis A, Vlachopoulos C. Arrhythmic risk stratification in nonischemic dilated cardiomyopathy: The ReCONSIDER study design – A two-step, multifactorial, electrophysiology-inclusive approach. Hellenic J Cardiol 2021; 62:169-172. [DOI: 10.1016/j.hjc.2020.03.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 03/13/2020] [Accepted: 03/19/2020] [Indexed: 12/13/2022] Open
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8
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Gatzoulis KA, Tsiachris D, Arsenos P, Antoniou CK, Dilaveris P, Sideris S, Kanoupakis E, Simantirakis E, Korantzopoulos P, Goudevenos I, Flevari P, Iliodromitis E, Sideris A, Vassilikos V, Fragakis N, Trachanas K, Vernardos M, Konstantinou I, Tsimos K, Xenogiannis I, Vlachos K, Saplaouras A, Triantafyllou K, Kallikazaros I, Tousoulis D. Arrhythmic risk stratification in post-myocardial infarction patients with preserved ejection fraction: the PRESERVE EF study. Eur Heart J 2020; 40:2940-2949. [PMID: 31049557 PMCID: PMC6748724 DOI: 10.1093/eurheartj/ehz260] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Revised: 12/26/2018] [Accepted: 04/10/2019] [Indexed: 12/13/2022] Open
Abstract
Aims Sudden cardiac death (SCD) annual incidence is 0.6–1% in post-myocardial infarction (MI) patients with left ventricular ejection fraction (LVEF)≥40%. No recommendations for implantable cardioverter-defibrillator (ICD) use exist in this population. Methods and results We introduced a combined non-invasive/invasive risk stratification approach in post-MI ischaemia-free patients, with LVEF ≥ 40%, in a multicentre, prospective, observational cohort study. Patients with at least one positive electrocardiographic non-invasive risk factor (NIRF): premature ventricular complexes, non-sustained ventricular tachycardia, late potentials, prolonged QTc, increased T-wave alternans, reduced heart rate variability, abnormal deceleration capacity with abnormal turbulence, were referred for programmed ventricular stimulation (PVS), with ICDs offered to those inducible. The primary endpoint was the occurrence of a major arrhythmic event (MAE), namely sustained ventricular tachycardia/fibrillation, appropriate ICD activation or SCD. We screened and included 575 consecutive patients (mean age 57 years, LVEF 50.8%). Of them, 204 (35.5%) had at least one positive NIRF. Forty-one of 152 patients undergoing PVS (27–7.1% of total sample) were inducible. Thirty-seven (90.2%) of them received an ICD. Mean follow-up was 32 months and no SCDs were observed, while 9 ICDs (1.57% of total screened population) were appropriately activated. None patient without NIRFs or with NIRFs but negative PVS met the primary endpoint. The algorithm yielded the following: sensitivity 100%, specificity 93.8%, positive predictive value 22%, and negative predictive value 100%. Conclusion The two-step approach of the PRESERVE EF study detects a subpopulation of post-MI patients with preserved LVEF at risk for MAEs that can be effectively addressed with an ICD. Clinicaltrials.gov identifier NCT02124018 ![]()
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Affiliation(s)
- Konstantinos A Gatzoulis
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokrateion Hospital, 114 Vasilissis Sofias avenue, Athens, Attica, Greece
| | - Dimitrios Tsiachris
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokrateion Hospital, 114 Vasilissis Sofias avenue, Athens, Attica, Greece
| | - Petros Arsenos
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokrateion Hospital, 114 Vasilissis Sofias avenue, Athens, Attica, Greece
| | - Christos-Konstantinos Antoniou
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokrateion Hospital, 114 Vasilissis Sofias avenue, Athens, Attica, Greece
| | - Polychronis Dilaveris
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokrateion Hospital, 114 Vasilissis Sofias avenue, Athens, Attica, Greece
| | - Skevos Sideris
- State Department of Cardiology, Hippokrateion Hospital, 114 Vasilissis Sofias avenue, Athens, Attica, Greece
| | - Emmanuel Kanoupakis
- Department of Cardiology, University Hospital of Heraklion, University of Crete, Panepistimiou street, Heraklion, Crete, Greece
| | - Emmanouil Simantirakis
- Department of Cardiology, University Hospital of Heraklion, University of Crete, Panepistimiou street, Heraklion, Crete, Greece
| | - Panagiotis Korantzopoulos
- First Cardiology Division, University Hospital of Ioannina, University of Ioannina, Stavros Niarchos avenue, Ioannina, Epirus, Greece
| | - Ioannis Goudevenos
- First Cardiology Division, University Hospital of Ioannina, University of Ioannina, Stavros Niarchos avenue, Ioannina, Epirus, Greece
| | - Panagiota Flevari
- Second Cardiology Department, National and Kapodistrian University of Athens, Attikon Hospital, 1 Rimini street, Chaidari, Attica, Greece
| | - Efstathios Iliodromitis
- Second Cardiology Department, National and Kapodistrian University of Athens, Attikon Hospital, 1 Rimini street, Chaidari, Attica, Greece
| | - Antonios Sideris
- Second State Cardiology Department, Evangelismos Hospital, 45-47 Ipsilantou street, Athens, Attica, Greece
| | - Vassilios Vassilikos
- Third Cardiology Department, Aristotle University Medical School, Hippokrateion Hospital, 49 Konstantinoupoleos street, Thessaloniki, Macedonia, Greece
| | - Nikolaos Fragakis
- Third Cardiology Department, Aristotle University Medical School, Hippokrateion Hospital, 49 Konstantinoupoleos street, Thessaloniki, Macedonia, Greece
| | - Konstantinos Trachanas
- State Department of Cardiology, Hippokrateion Hospital, 114 Vasilissis Sofias avenue, Athens, Attica, Greece
| | - Michail Vernardos
- Department of Cardiology, University Hospital of Heraklion, University of Crete, Panepistimiou street, Heraklion, Crete, Greece
| | - Ioannis Konstantinou
- Department of Cardiology, University Hospital of Heraklion, University of Crete, Panepistimiou street, Heraklion, Crete, Greece
| | - Konstantinos Tsimos
- First Cardiology Division, University Hospital of Ioannina, University of Ioannina, Stavros Niarchos avenue, Ioannina, Epirus, Greece
| | - Iosif Xenogiannis
- Second Cardiology Department, National and Kapodistrian University of Athens, Attikon Hospital, 1 Rimini street, Chaidari, Attica, Greece
| | - Konstantinos Vlachos
- Second State Cardiology Department, Evangelismos Hospital, 45-47 Ipsilantou street, Athens, Attica, Greece
| | - Athanasios Saplaouras
- Second State Cardiology Department, Evangelismos Hospital, 45-47 Ipsilantou street, Athens, Attica, Greece
| | - Konstantinos Triantafyllou
- Third Cardiology Department, Aristotle University Medical School, Hippokrateion Hospital, 49 Konstantinoupoleos street, Thessaloniki, Macedonia, Greece
| | - Ioannis Kallikazaros
- State Department of Cardiology, Hippokrateion Hospital, 114 Vasilissis Sofias avenue, Athens, Attica, Greece
| | - Dimitrios Tousoulis
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokrateion Hospital, 114 Vasilissis Sofias avenue, Athens, Attica, Greece
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Arsenos P, Gatzoulis KA, Doundoulakis I, Dilaveris P, Antoniou C, Stergios S, Sideris S, Ilias S, Tousoulis D. Arrhythmic risk stratification in heart failure mid-range ejection fraction patients with a non-invasive guiding to programmed ventricular stimulation two-step approach. J Arrhythm 2020; 36:890-898. [PMID: 33024466 PMCID: PMC7532265 DOI: 10.1002/joa3.12416] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 06/15/2020] [Accepted: 07/10/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Although some post myocardial infarction (post-MI) and dilated cardiomyopathy (DCM) patients with mid-range ejection fraction heart failure (HFmrEF/40%-49%) face an increased risk for arrhythmic sudden cardiac death (SCD), current guidelines do not recommend an implantable cardiac defibrilator (ICD). We risk stratified hospitalized HFmrEF patients for SCD with a combined non-invasive risk factors (NIRFs) guiding to programmed ventricular stimulation (PVS) two-step approach. METHODS Forty-eight patients (male = 83%, age = 64 ± 14 years, LVEF = 45 ± 5%, CAD = 69%, DCM = 31%) underwent a NIRFs screening first-step with electrocardiogram (ECG), SAECG, Echocardiography and 24-hour ambulatory ECG (AECG). Thirty-two patients with presence of one of three NIRFs (SAECG ≥ 2 positive criteria for late potentials, ventricular premature beats ≥ 240/24 hours, and non-sustained ventricular tachycardia [VT] episode ≥ 1/24 hours) were further investigated with PVS. Patients were classified as either low risk (Group 1, n = 16, NIRFs-), moderate risk (Group 2, n = 18, NIRFs+/PVS-), and high risk (Group 3, n = 14, NIRFs+/PVS+). All in Group 3 received an ICD. RESULTS After 41 ± 18 months, 9 of 48 patients, experienced the major arrhythmic event (MAE) endpoint (clinical VT/fibrillation = 3, appropriate ICD activation = 6). The endpoint occurred more frequently in Group 3 (7/14, 50%) than in Groups 1 and 2 (2/34, 5.8%). Logistic regression model adjusted for PVS, age, and LVEF revealed that PVS was an independent MAE predictor (OR: 21.152, 95% CI: 2.618-170.887, P = .004). Kaplan-Meier curves diverged significantly (log rank, P < .001) while PVS negative predictive value was 94%. CONCLUSIONS In hospitalized HFmrEF post-MI and DCM patients, a NIRFs guiding to PVS two-step approach efficiently detected the subgroup at increased risk for MAE.
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Affiliation(s)
- Petros Arsenos
- First Department of Cardiology and Electrophysiology LaboratoryHippokration General HospitalNational and Kapodistrian University of Athens School of MedicineAthensGreece
- Arsenos Heart and Biosignals LabAvlonasGreece
| | - Konstantinos A. Gatzoulis
- First Department of Cardiology and Electrophysiology LaboratoryHippokration General HospitalNational and Kapodistrian University of Athens School of MedicineAthensGreece
| | - Ioannis Doundoulakis
- First Department of Cardiology and Electrophysiology LaboratoryHippokration General HospitalNational and Kapodistrian University of Athens School of MedicineAthensGreece
| | - Polychronis Dilaveris
- First Department of Cardiology and Electrophysiology LaboratoryHippokration General HospitalNational and Kapodistrian University of Athens School of MedicineAthensGreece
| | - Christos‐Konstantinos Antoniou
- First Department of Cardiology and Electrophysiology LaboratoryHippokration General HospitalNational and Kapodistrian University of Athens School of MedicineAthensGreece
| | - Soulaidopoulos Stergios
- First Department of Cardiology and Electrophysiology LaboratoryHippokration General HospitalNational and Kapodistrian University of Athens School of MedicineAthensGreece
| | - Skevos Sideris
- State Department of CardiologyHippokration General HospitalAthensGreece
| | | | - Dimitrios Tousoulis
- First Department of Cardiology and Electrophysiology LaboratoryHippokration General HospitalNational and Kapodistrian University of Athens School of MedicineAthensGreece
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10
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Updating the Risk Stratification for Sudden Cardiac Death in Cardiomyopathies: The Evolving Role of Cardiac Magnetic Resonance Imaging. An Approach for the Electrophysiologist. Diagnostics (Basel) 2020; 10:diagnostics10080541. [PMID: 32751773 PMCID: PMC7460122 DOI: 10.3390/diagnostics10080541] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 07/27/2020] [Accepted: 07/28/2020] [Indexed: 12/11/2022] Open
Abstract
The prevention of sudden cardiac death (SCD) in cardiomyopathies (CM) remains a challenge. The current guidelines still favor the implantation of devices for the primary prevention of SCD only in patients with severely reduced left ventricular ejection fraction (LVEF) and heart failure (HF) symptoms. The implantation of an implantable cardioverter-defibrillator (ICD) is a protective barrier against arrhythmic events in CMs, but the benefit does not outweigh the cost in low risk patients. The identification of high risk patients is the key to an individualized prevention strategy. Cardiac magnetic resonance (CMR) provides reliable and reproducible information about biventricular function and tissue characterization. Furthermore, late gadolinium enhancement (LGE) quantification and pattern of distribution, as well as abnormal T1 mapping and extracellular volume (ECV), representing indices of diffuse fibrosis, can enhance our ability to detect high risk patients. CMR can also complement electro-anatomical mapping (EAM), a technique already applied in the risk evaluation and in the ventricular arrhythmias ablation therapy of CM patients, providing a more accurate assessment of fibrosis and arrhythmic corridors. As a result, CMR provides a new insight into the pathological substrate of CM. CMR may help identify high risk CM patients and, combined with EAM, can provide an integrated evaluation of scar and arrhythmic corridors in the ablative therapy of ventricular arrhythmias.
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11
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Gatzoulis K, Tsiachris D, Balta G, Antoniou CK, Arsenos P, Dilaveris P, Tousoulis D. Cardiac rhythm management devices and ablation procedures in psychiatric patients: A case series and review of the literature. HEART AND MIND 2020. [DOI: 10.4103/hm.hm_74_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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12
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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 2019; 25:e12701. [PMID: 31605453 DOI: 10.1111/anec.12701] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 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 Department, Attikon Hospital, National and Kapodistrian University of Athens, Athens, Greece.,Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Konstantinos A Gatzoulis
- First Department of Cardiology, Hippokrateion Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Panagiota Flevari
- Second Cardiology Department, Attikon Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Ignatios Ikonomidis
- Second Cardiology Department, Attikon Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Efstathios Iliodromitis
- Second Cardiology Department, Attikon Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Konstantinos Vlachos
- Second State Cardiology Department, Evangelismos Hospital, Athens, Greece.,Electrophysiology Department, Hospital Haut Lévêque, Bordeaux, France
| | - Petros Arsenos
- First Department of Cardiology, Hippokrateion Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Tsiachris
- First Department of Cardiology, Hippokrateion Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Tousoulis
- First Department of Cardiology, Hippokrateion Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Emmanouil S Brilakis
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Dimitrios Alexopoulos
- Second Cardiology Department, Attikon Hospital, National and Kapodistrian University of Athens, Athens, Greece
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13
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Kinoshita T, Hashimoto K, Yoshioka K, Miwa Y, Yodogawa K, Watanabe E, Nakamura K, Nakagawa M, Nakamura K, Watanabe T, Yusu S, Tachibana M, Nakahara S, Mizumaki K, Ikeda T. Risk stratification for cardiac mortality using electrocardiographic markers based on 24-hour Holter recordings: the JANIES-SHD study. J Cardiol 2019; 75:155-163. [PMID: 31474497 DOI: 10.1016/j.jjcc.2019.07.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 07/02/2019] [Accepted: 07/06/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Recent guidelines have stated that left ventricular ejection fraction (LVEF) is the gold standard marker for identifying patients at risk for cardiac mortality. However, little information is present regarding electrocardiographic (ECG) markers. This study aimed to assess ECG markers for predicting mortality or serious arrhythmia in patients with structural heart disease (SHD). METHODS In total, 1829 patients were enrolled into the Japanese Multicenter Observational Prospective Study (JANIES study). In this study, we analyzed data of 719 patients (569 men, age 64 ± 13 years) with SHD including mainly ischemic heart disease (65.8%). As ECG markers based on 24-hour Holter recordings, nonsustained ventricular tachycardia (NSVT), ventricular late potentials, and heart rate turbulence (HRT) were assessed. The primary endpoint was all-cause mortality, and the secondary endpoint was fatal arrhythmic events. RESULTS During a mean follow-up of 21 ± 11 months, all-cause mortality was eventually observed in 39 patients (5.4%). Among those patients, 32 patients (82%) suffered from cardiac causes such as heart failure and arrhythmia. Multivariate Cox regression analysis showed that after adjustment for age and LVEF, documented NSVT [hazard ratio = 2.46, 95% confidence interval (CI): 1.16-5.18, p = 0.02] and abnormal HRT (hazard ratio = 2.40, 95% CI: 1.16-4.93, p = 0.02) were significantly associated with the primary endpoint. These two ECG markers also had significant predictive values with the secondary endpoint. The combined assessment of two ECG markers improved predictive accuracy. CONCLUSION This study demonstrated that combined assessment of documented NSVT and abnormal HRT based on 24-hour Holter ECG recordings are recommended for predicting future serious events in this population.
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14
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Gatzoulis KA, Kanoupakis E, Antoniou CK, Sideris A, Kolettis TM. Reconsidering arrhythmic risk stratification in dilated cardiomyopathy – Beyond ventricular contractility and gene mutability. Hellenic J Cardiol 2019; 60:196-197. [DOI: 10.1016/j.hjc.2018.07.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Revised: 07/02/2018] [Accepted: 07/13/2018] [Indexed: 01/22/2023] Open
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15
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Sawicka KM, Wawryniuk A, Daniluk J, Karwan S, Florek-Łuszczki M, Chmielewski J, Łuszczki JJ. Influence of dronedarone (a class III antiarrhythmic drug) on the anticonvulsant potency of four classical antiepileptic drugs in the tonic-clonic seizure model in mice. J Neural Transm (Vienna) 2018; 126:115-122. [PMID: 30535773 PMCID: PMC6373245 DOI: 10.1007/s00702-018-1940-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 10/05/2018] [Indexed: 12/16/2022]
Abstract
Increasing evidence indicates that some antiarrhythmic drugs play a pivotal role in seizures, not only in vivo studies on animals, but also in clinical trials. Some of these antiarrhythmic drugs potentiate or alleviate the anticonvulsant action of the classical antiepileptic drugs. The aim of this study was to determine the influence of dronedarone (DRO-a multichannel blocker belonging to the class III of antiarrhythmic drugs) on the anticonvulsant effects of four standard antiepileptic drugs (carbamazepine, phenobarbital, phenytoin and valproate) in the tonic-clonic seizure model in mice. Potential acute adverse effects exerted by the antiepileptic drugs combined with DRO were evaluated in three behavioral tests (chimney, grip-strength and passive avoidance). To confirm the nature of interaction, total brain concentrations of antiepileptic drugs were measured. DRO (50 mg/kg, i.p.) significantly reduces the anticonvulsant potency of phenytoin (P < 0.05), having no impact on that of carbamazepine, phenobarbital and valproate in the tonic-clonic seizure model in mice. DRO (50 mg/kg) neither changed total brain concentrations of phenytoin in mice, nor affected normal behavior in experimental animals subjected to the chimney, grip-strength and passive avoidance tests. In conclusion, DRO should not be combined with phenytoin because it reduced the anticonvulsant effects of the latter drug in experimental animals. The combined administration of DRO with carbamazepine, phenobarbital and valproate resulted in neutral interaction between these drugs in the tonic-clonic seizure model in mice.
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Affiliation(s)
- Katarzyna M Sawicka
- Department of Internal Medicine in Nursing, Medical University of Lublin, Lublin, Poland.,Department of Pathophysiology, Medical University of Lublin, Lublin, Poland
| | - Agnieszka Wawryniuk
- Department of Internal Medicine in Nursing, Medical University of Lublin, Lublin, Poland
| | - Jadwiga Daniluk
- Department of Internal Medicine in Nursing, Medical University of Lublin, Lublin, Poland.,Pope John Paul II State School of Higher Education in Biala Podlaska, Biala Podlaska, Poland
| | | | | | - Jarosław Chmielewski
- Institute of Environmental Protection-National Research Institute in Warsaw, Warsaw, Poland
| | - Jarogniew J Łuszczki
- Department of Pathophysiology, Medical University of Lublin, Lublin, Poland. .,Isobolographic Analysis Laboratory, Institute of Rural Health, Lublin, Poland.
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16
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Gatzoulis KA, Arsenos P, Dilaveris P, Antoniou CK, Sideris S, Tousoulis D. Life-saving ICD activation in a high-risk early heart failure dilated cardiomyopathy patient. Is it time to reconsider our primary prevention approach? Hellenic J Cardiol 2018; 59:238-240. [DOI: 10.1016/j.hjc.2017.09.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 09/04/2017] [Accepted: 09/19/2017] [Indexed: 01/19/2023] Open
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17
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Gatzoulis KA, Arsenos P, Trachanas K, Dilaveris P, Antoniou C, Tsiachris D, Sideris S, Kolettis TM, Tousoulis D. Signal-averaged electrocardiography: Past, present, and future. J Arrhythm 2018; 34:222-229. [PMID: 29951136 PMCID: PMC6010001 DOI: 10.1002/joa3.12062] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Accepted: 03/28/2018] [Indexed: 01/12/2023] Open
Abstract
Signal-averaged electrocardiography records delayed depolarization of myocardial areas with slow conduction that can form the substrate for monomorphic ventricular tachycardia. This technique has been examined mostly in patients with coronary artery disease, but its use has been declined over the years. However, several lines of evidence, derived from hitherto clinical data in patients with healed myocardial infarction, indicate that signal-averaged electrocardiography remains a valuable tool in risk stratification, especially when incorporated into algorithms encompassing invasive and noninvasive indices. Such an approach can aid the more precise identification of candidates for device therapy, in the context of primary prevention of sudden cardiac death. This article reappraises the value of signal-averaged electrocardiography as a predictor of arrhythmic outcome in patients with ischemic heart disease and discusses potential future indications.
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Affiliation(s)
- Konstantinos A. Gatzoulis
- Electrophysiology Laboratory and First University Department of CardiologyHippokration General HospitalNational and Kapodestrian University of AthensAthensGreece
| | - Petros Arsenos
- Electrophysiology Laboratory and First University Department of CardiologyHippokration General HospitalNational and Kapodestrian University of AthensAthensGreece
| | | | - Polychronis Dilaveris
- Electrophysiology Laboratory and First University Department of CardiologyHippokration General HospitalNational and Kapodestrian University of AthensAthensGreece
| | - Christos Antoniou
- Electrophysiology Laboratory and First University Department of CardiologyHippokration General HospitalNational and Kapodestrian University of AthensAthensGreece
| | | | - Skevos Sideris
- Department of CardiologyHippokration General HospitalAthensGreece
| | - Theofilos M. Kolettis
- Department of CardiologyUniversity of IoanninaIoanninaGreece
- Cardiovascular Research InstituteIoanninaGreece
| | - Dimitrios Tousoulis
- Electrophysiology Laboratory and First University Department of CardiologyHippokration General HospitalNational and Kapodestrian University of AthensAthensGreece
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18
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Arrhythmic risk stratification in non-ischemic dilated cardiomyopathy: Where do we stand after DANISH? Trends Cardiovasc Med 2017; 27:542-555. [DOI: 10.1016/j.tcm.2017.06.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 05/21/2017] [Accepted: 06/02/2017] [Indexed: 12/13/2022]
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19
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Gatzoulis KA, Sideris A, Kanoupakis E, Sideris S, Nikolaou N, Antoniou CK, Kolettis TM. Arrhythmic risk stratification in heart failure: Time for the next step? Ann Noninvasive Electrocardiol 2017; 22. [PMID: 28252256 DOI: 10.1111/anec.12430] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 01/10/2017] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Primary prevention of sudden cardiac death by means of implantable cardioverter-defibrillators constitutes the holy grail of arrhythmology. However, current risk stratification algorithms lead to suboptimal outcomes, by both allocating ICDs to patients not deriving any meaningful survival benefit and withholding them from those erroneously considered as low-risk for arrhythmic mortality. METHODS In the present review article we will attempt to present shortcomings of contemporary guidelines regarding sudden death prevention in ischemic and dilated cardiomyopathy patients and present available data suggesting encouraging results following implementation of multifactorial approaches, by using multiple modalities, both noninvasive and invasive. Invasive electrophysiological testing, namely programmed ventricular stimulation, will be discussed in greater length to highlight both its potential usefulness and currently ongoing multicenter studies aiming to provide evidence necessary to make the next step in sudden death risk stratification. RESULTS Promising findings have been reported by multiple study groups regarding novel strategies for both negative selection of low and positive selection of relatively preserved ejection fraction patients as candidates for ICD implantation. CONCLUSIONS The era of ejection fraction as the sole risk stratifier for arrhythmic risk in heart failure appears to be drawing to an end, especially if current underway large studies validate previous findings.
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Affiliation(s)
- Konstantinos A Gatzoulis
- Electrophysiology Laboratory, First Department of Cardiology, "Hippokration" General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Antonios Sideris
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology, "Evangelismos" General Hospital of Athens, Athens, Greece
| | - Emmanuel Kanoupakis
- Department of Cardiology, University General Hospital of Heraklion, Heraklion, Greece
| | - Skevos Sideris
- State Department of Cardiology, "Hippokration" General Hospital, Athens, Greece
| | - Nikolaos Nikolaou
- Department of Cardiology, "Konstantopouleio" General Hospital, Athens, Greece
| | - Christos-Konstantinos Antoniou
- Electrophysiology Laboratory, First Department of Cardiology, "Hippokration" General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Theofilos M Kolettis
- Department of Cardiology, University General Hospital of Ioannina, Ioannina, Greece
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