Application of the 2015 ACC/AHA/HRS guidelines for risk stratification for sudden death in adult patients with asymptomatic pre-excitation

["Asymptomatic WPW" : Is treatment necessary?]

The term "asymptomatic WPW" (Wolff-Parkinson-White) is often used as a synonym for ventricular pre-excitation of the WPW type due to an accessory pathway characterized by a short PR interval and a delta wave on the electrocardiogram (ECG) without the clinical occurrence of paroxysmal tachycardia. Asymptomatic WPW is often diagnosed in young and otherwise healthy people. There is a small associated risk of sudden cardiac death due to rapid antegrade conduction over the accessory pathway during atrial fibrillation. This paper highlights aspects of noninvasive and invasive risk stratification, therapy by catheter ablation, and the ongoing risk-benefit discussion in asymptomatic WPW.

N-terminal pro-B-type natriuretic peptide and D-dimer combined with left atrial diameter to predict the risk of ischemic stroke in nonvalvular atrial fibrillation

OBJECTIVES

We aimed to explore the potential role of N-terminal pro-B-type natriuretic peptide (NT-proBNP), d-dimer, and the echocardiographic parameter left atrial diameter (LAD) in identifying and predicting the occurrence of ischemic stroke (IS) in patients with nonvalvular atrial fibrillation (NVAF).

METHODS

We conducted a retrospective study of 445 patients with NVAF in the First Affiliated Hospital of Nanchang University. They were divided into the NVAF (309 cases) and NVAF with stroke (136 cases) groups according to whether acute ischemic stroke (AIS) occurred at admission. Multivariate logistic regression was used to analyze the odds ratio (OR) of NT-proBNP, d-dimer, and LAD for IS. The predictive value of NT-proBNP, d-dimer, and LAD in identifying the occurrence of IS in NVAF was determined by plotting the receiver operating characteristic (ROC) curves.

RESULTS

NT-proBNP, d-dimer, and LAD levels were significantly higher in the NVAF with stroke group than in the NVAF group (p < .05). NT-ProBNP, d-dimer, and LAD were independently associated with IS in NVAF patients (odds ratio [OR] = 1.12, 95% confidence interval [CI]: 1.08-1.16; OR = 1.87, 95% CI: 1.37-2.55; OR = 1.21, 95% CI: 1.13-1.28, p < .01). The optimal cutoff points for NT-ProBNP, d-dimer, and LAD levels to distinguish the NVAF group from the NVAF with stroke group were 715.0 pg/ml, 0.515 ng/ml, and 38.5 mm, respectively, with the area under the curve (AUC) being [0.801 (95% CI: 0.76-0.84); 0.770 (95% CI: 0.72-0.85); 0.752 (95% CI: 0.71-0.80), p < .01]. The combined score of NT-proBNP, d-dimer, and LAD improved the predictive efficacy of the single index, with an AUC of 0.846 (95% CI: 0.81-0.88, p < .01), sensitivity of 77.2%, and specificity of 76.4%.

CONCLUSION

NT-proBNP, d-dimer, and the echocardiographic parameter LAD have outstanding value in predicting the risk of IS in patients with NVAF.

Comparison of Outcomes of Catheter Ablation in Asymptomatic Versus Symptomatic Preexcitation to Guidelines and Beyond

Management of asymptomatic subjects with preexcitation remains controversial. Our objective was to analyze the reasons an electrophysiological study (EPS) was performed in an asymptomatic population referred for the procedure, and compare the results of catheter ablation between asymptomatic and symptomatic patients. Patients ≥18 years of age with preexcitation referred for an EPS and ablation were grouped as either symptomatic or asymptomatic. We analyzed in both subsets for (1) reasons for the procedure, (2) EPS results (anterograde effective refractory period of the accessory pathway, tachycardia/atrial fibrillation inducibility, anatomical localization), (3) success of the procedure, and (4) incidence of complications. We included 175 patients, 121 of which were symptomatic (39 ± 16 years) and 54 were asymptomatic (35 ± 14 years, p = NS not significant). The most frequent symptoms were palpitations (87%) and syncope (7%). EPS was performed in 44 of 54 asymptomatic patients mainly because of involvement in sports (60%) or high-risk employment (14%). Anterograde effective refractory period was significantly longer in asymptomatic patients (314 ± 55 milliseconds) than in symptomatic patients (278 ± 46 milliseconds; p <0.001). Orthodromic tachycardia inducibility was significantly higher in symptomatic than in asymptomatic patients (69% and 27%, respectively; p <0.001). A total of 170 accessory pathways (49% left free wall, 12% right free wall, 39% septal) were observed without significant differences in the anatomical location between groups. Catheter ablation was attempted in all patients, succeeding in 98% of symptomatic and 95% of asymptomatic patients, without major complications in either group. In conclusion, the reasons for invasive evaluation of asymptomatic patients with preexcitation may be outside the scope of current guidelines. Catheter ablation produces excellent results without major complications.

BNP combined with echocardiographic parameters to predict the risk of cardioembolic stroke

BACKGROUND

Previous studies have found that BNP and some indicators of cardiac structure and function are closely associated with atrial fibrillation, so we aim to investigate the potential role of BNP and echocardiographic parameters to identify the acute ischemic stroke with atrial fibrillation patients who have high risks of cardioembolic stroke based on it.

METHODS

436 AIS patients were divided into an AF group and non-AF group on the basis of the electrocardiogram and Holter results. Then we compared vascular risk factors, laboratory test indicators, and echocardiographic parameters among different groups.

RESULTS

AIS with AF group had significantly higher age, CHD, previous medication, creatinine, d-dimer, fibrinogen, CRP, BNP, LAD, LVDd, LVDs and lower cholesterol, triglyceride, LDL and ejection fraction than the non-AF group (P < 0.05). Increased BNP, LAD, LVDd, LVDs and ejection fraction reduction were independent risk factors to predict cardioembolic stroke. BNP and LAD could be the two most effective indicators of the high risk of cardioembolic stroke. The area under the curve (AUC) of BNP and LAD were 0.791 [95%CI (0.743-0.838), p < 0.001), 0.786 [95%CI (0.739-0.833), p < 0.001]. The combined score we designed improved the prediction effect of single-indicator. The AUC of it was 0.822 with a sensitivity of 69.5% and specificity of 83.9%.There was an apparent positive correlation between BNP and LAD in AIS patients (r = 0.327, P < 0.001).

CONCLUSION

BNP combined with echocardiographic parameters has outstanding value to predict the risk of cardioembolic stroke, especially for BNP and LAD.

Anti-arrhythmic therapy in athletes

The spectrum of arrhythmias that may be encountered in athletes ranges from isolated ectopic beats to ventricular tachycardia, usually in the context of a structurally normal heart. Anti-arrhythmic therapy in these individuals may be particularly challenging because of the young age, the hypervagotonic state, the desire to maintain a high physical performance, the reluctance to take medications and the need to avoid molecules included in the list of prohibited drugs of the World Anti-Doping Agency. Furthermore, the possible serious adverse effects of anti-arrhythmic drugs should be balanced against the benign nature of arrhythmias in patients with no underlying heart disease. The review summarizes the most common arrhythmias of athletes and the possible therapeutic options, including anti-arrhythmic drugs and non-pharmacological interventions. Eligibility criteria according to current guidelines are also addressed.

Coexistence of atrioventricular accessory pathways and drug-induced type 1 Brugada pattern

BACKGROUND

Atrial arrhythmias, particularly atrioventricular nodal reentrant tachycardia, can coexist with drug-induced type 1 Brugada electrocardiogram (ECG) pattern (DI-Type1-BrP). The present study was designed to determine the prevalence of DI-Type1-BrP in patients with atrioventricular accessory pathways (AV-APs) and to investigate the clinical, electrocardiographic, electrophysiologic, and genetic characteristics of these patients.

METHODS

One-hundred twenty-four consecutive cases of AV-APs and 84 controls underwent an ajmaline challenge test to unmask DI-Type1-BrP. Genetic screening and analysis was performed in 55 of the cases (19 with and 36 without DI-Type1-BrP).

RESULTS

Patients with AV-APs were significantly more likely than controls to have a Type1-BrP unmasked (16.1 vs 4.8%, P = 0.012). At baseline, patients with DI-Type1-BrP had higher prevalence of chest pain, QR/rSr' pattern in V₁ and QRS notching/slurring in V₂ and aVL during preexcitation, rSr' pattern in V₁ -V₂ , and QRS notching/slurring in aVL during orthodromic atrioventricular reentrant tachycardia (AVRT) compared to patients without DI-Type1-BrP. Abnormal QRS configuration (QRS notching/slurring and/or fragmentation) in V₂ during preexcitation was present in all patients with DI-Type1 BrP. The prevalence of spontaneous preexcited atrial fibrillation (AF) and history of AF were similar (15% vs 18.3%, P = 0.726) in patients with and without DI-Type1-BrP, respectively. The prevalence of mutations in Brugada-susceptibility genes was higher (36.8% vs 8.3%, P = 0.02) in patients with DI-Type1-BrP compared to patients without DI-Type1-BrP.

CONCLUSIONS

DI-Type1-BrP is relatively common in patients with AV-APs. We identify 12-lead ECG characteristics during preexcitation and orthodromic AVRT that point to an underlying type1-BrP, portending an increased probability for development of malignant arrhythmias.