Clinical frailty scale as a predictor of disease severity in patients hospitalised with COVID-19 - an observational cohort study

BACKGROUND

The coronavirus disease 2019 pandemic makes proper resource allocation and prioritisation important. Frailty increases the risk of adverse outcomes and can be quantified using the Clinical frailty scale. The aim of this study was to determine the role of the Clinical frailty scale, in patients ≥65 years of age with coronavirus disease 2019, as a risk factor either for critical coronavirus disease 2019 measured as intensive care unit admission or death or as a risk factor for death.

METHODS

This was a retrospective observational study on patients ≥65 years hospitalised with coronavirus disease 2019 verified by polymerase chain reaction between 5 March 5 and 5 July 2020. The association between Clinical frailty scale and the composite primary outcome intensive care unit admission or death within 30 days post hospitalisation and the secondary outcome death within 30 days post hospitalisation was analysed using multivariable logistic regression models adjusting for gender, age, body mass index, hypertension, and diabetes. Clinical frailty scale was used as a categorical variable (fit score 1-4, frail score 5-6, and severely frail score 7-9).

RESULTS

In total, 169 patients were included (47.3% women, mean age 79.2 ± 7.8 years). In the fully adjusted model, adjusted odds ratio for intensive care unit admission or death was 1.84 (95%-confidence interval 0.67-5.03, p = .234) for frail and 6.08 (1.70-21.81, p = .006) for severely frail compared to fit patients. For death, adjusted odds ratio was 2.81 (0.89-8.88, p = .079) for frail and 9.82 (2.53-38.10, p = .001) for severely frail compared to fit patients.

CONCLUSIONS

A high Clinical frailty scale score was an independent risk factor for the composite outcome intensive care unit admission or death and for the secondary outcome death.

Swallowing function in COVID-19 patients after invasive mechanical ventilation

Objective

To explore swallowing function and risk factors associated with delayed recovery of swallowing in COVID-19 patients post invasive mechanical ventilation using the Functional Oral Intake Scale (FOIS).

Design

Longitudinal cohort study.

Setting

3 secondary-level hospitals.

Participants

Invasively ventilated patients (n=28), hospitalized with severe COVID-19 who were referred to the Speech and Language Pathology (SLP) departments post mechanical ventilation between March 5 and July 5 2020 for an evaluation of swallowing function before commencing oral diet.

Interventions

SLP assessment, advice and therapy for dysphagia.

Main outcome measures

Oral intake levels at baseline and hospital discharge according to the Functional Oral Intake Scale (FOIS). Patients were stratified according to FOIS (1-5=dysphagia, 6-7= functional oral intake). Data regarding comorbidities, frailty, intubation and tracheostomy, proning and SLP evaluation were collected.

Results

Dysphagia was found in 71% of the patients at baseline (in total 79% male, age 61 ±12 years, BMI 30 ±8 kg/m²). Median FOIS score at baseline was 2 (IQR 1) vs 5 (IQR 2.5) at hospital discharge. Patients with dysphagia were older (64 ±8.5 vs 53 ±16 years; p= 0.019), had a higher incidence of hypertension (70% vs 12%; p=0.006) were ventilated invasively longer (16 ±7 vs 10 ±2 days; p=0.017) or with tracheostomy (9 ±9 vs 1 ±2 days; p=0.03) longer. A negative association was found between swallowing dysfunction at bedside and days hospitalized (r=-0.471, p=0.01), and number of days at the Intensive Care Unit (ICU) (r=-0.48, p=0.01).

Conclusion

Dysphagia is prevalent in COVID-19 patients post invasive mechanical ventilation and is associated with number of days in hospital and number of days in the ICU. Swallowing function and tolerance of oral diet improved at discharge (p<0.001).

Health status measured by Kansas City Cardiomyopathy Questionnaire-12 in primary prevention implantable cardioverter defibrillator patients with heart failure

Background

Self-reported health status as measured by the Kansas City Cardiomyopathy Questionnaire (KCCQ) in patients with primary prevention implantable cardioverter defibrillators (ICDs) has mainly been reported from randomized trials. However, these studies are often limited to short follow-up and are subject to selection bias. The aim of this study was to assess KCCQ-12 in patients with primary prevention ICD due to either ischemic or nonischemic heart failure.

Methods

This cross-sectional observational study included all patients in Region Gävleborg, Sweden, who because of primary prevention due to heart failure, had an ICD or underwent device replacement between 2007 and 2017. After validation using medical records patients were sent and returned the KCCQ-12 by regular mail.

Results

A total of 118 questionnaires were analyzed (response rate 71.1%). The mean age was 70.9 ± 9.8 years, and a minority was female (n = 20, 16.9%). The mean overall summary score was 71.5 ± 22.4, there was no significant difference between ischemic and nonischemic heart failure (69.5 ± 23.1 vs. 74.4 ± 21.3; p = 0.195). Atrial fibrillation at baseline was associated with lower score for the domains Symptom frequency (70.2 ± 23.2 vs. 82.2 ± 19.2; p = 0.006) and Social limitation (62.1 ± 26.0 vs. 75.6 ± 26.6; p = 0.006) as well as the overall summary score (63.9 ± 21.3 vs. 74.8 ± 22.2; p = 0.004).

Conclusion

In a real-world setting, primary prevention ICD patients with heart failure report an acceptable disease-specific health status at long-term follow-up. Ischemic and nonischemic etiology showed similar health status whereas atrial fibrillation was associated with worse outcome.

Health-related quality of life in patients with implantable cardioverter defibrillators in Sweden: a cross-sectional observational trial

OBJECTIVES

Decisions regarding implantable cardioverter defibrillators (ICDs) must consider information about presumed health-related quality of life (HRQL). The purpose of the study was to assess HRQL in patients with ICD and compare it to a Swedish age-matched and sex-matched population.

DESIGN

Cross-sectional observational trial.

SETTING

Swedish ICD cohort.

INTERVENTIONS

Short form 36 (SF-36) questionnaires from ICD recipients implanted 2007-2017 (response rate 77.2%) were analysed using Mann-Whitney U test and effect size (ES).

RESULTS

In total, 223 patients (mean age 71.1±9.7 years, 82.1% men) were included. In most SF-36 domains (physical functioning (PF), role physical, general health (GH), vitality, social functioning and mental health), the score for patients with ICD was significantly lower (ES range 0.23-0.41, ie, small difference) than norms, except for bodily pain and role emotional. Both the physical component summary (PCS) and the mental component summary (MCS) scores had ES=0.31. Men and women had similar scores. Primary and secondary prevention patients scored similarly, except for worse GH in primary prevention (p=0.016, ES=0.35). Atrial fibrillation was associated with worse PF (ES=0.41) and PCS (ES=0.38). Appropriate therapy, inappropriate shock or complications requiring surgery were not associated with lower scores in any domain. In primary prevention due to ischaemic versus non-ischaemic cardiomyopathy, no domain was significantly different. PCS decreased with higher age strata (p=0.002) in contrast to MCS (p=0.986).

CONCLUSIONS

Patients with ICDs have lower physical and mental HRQL than age-matched and sex-matched norms; however, the ESs are small. HRQL is similar regardless of sex, primary/secondary prevention indication, appropriate therapy, inappropriate shock or complications, but decreases with advancing age.

A case report of acute Leriche syndrome: aortoiliac occlusive disease due to embolization from left ventricular thrombus caused by myocarditis

Background

Leriche syndrome is the triad of symptoms consisting of claudication, erectile dysfunction, and absence of femoral pulses. Inflammatory disease of the heart muscle, myocarditis, may occur because of immune system activation, drug exposure or infections.

Case presentation

A 31-year-old man with no previous medical history presented to the emergency department with acute back pain that had started suddenly during weightlifting, which was initially misdiagnosed as spinal disc herniation. The patient returned four hours later and a thoracoabdominal computed tomography showed a large thrombus in the aortoiliac region creating a total occlusion. Vascular surgery with embolectomy was immediately performed. Further investigation with echocardiography revealed deteriorated systolic dysfunction with marked hypokinesia and two large thrombi in the left ventricle. Cardiac magnetic resonance imaging showed late contrast enhancement of the inferolateral and septal regions, which indicated a recent myocarditis.

Conclusion

Myocarditis can result in multiple embolization with diverse organ manifestation including total occlusion of the aortoiliac arteries, which required urgent embolectomy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02031-4.

'Life with a device': the octogenarians' experiences with an implantable cardioverter-defibrillator-a qualitative study

AIMS

Implantable cardioverter-defibrillator (ICD) treatment has expanded due to its effectiveness. However, there are concerns about complications, and use in the most elderly has been questioned. There is scarce data on qualitative aspects regarding experiences of living with an ICD among patients above the age of 80 years. The aim of this study was to explore octogenarians' experience, knowledge, and attitude of living with an ICD.

METHOD AND RESULTS

We used semi-structured interviews to collect data from 20 patients, aged 80-89 years (90% men). The data were then structured and analysed through deductive thematic analysis network approach using the ATLAS.ti v.8.4 software. The framework of the analysis was based on the Successful Aging Theory. Three main themes emerged regarding the patients' experiences: Life goes on; Their Health, The Janus-Faced Device; Their attitudes, and Mind the gap; Their knowledge. None of the octogenarians regretted receiving their ICD, instead, they presented with feelings such as gratitude towards the device. However, a lack of knowledge about the devices was expressed, which can be a risk for potential complications, in turn causing suffering and unnecessary concerns.

CONCLUSION

Overall, the ICD did not pose a threat towards successful ageing. It was mainly considered a life-saving device. However, the lack of knowledge might hinder informed choices close to death and contribute to ethical dilemmas when deactivation of the ICD is a reasonable option.

[Factor Xa inhibitors - equivalent to low molecular weight heparin for the treatment of cancer-associated venous thromboembolism]

Venous thromboembolism (VTE) is a common cause of morbidity and mortality in cancer patients. Cancer-associated VTE has an increased risk of recurrence and often cancer confers an increased risk of bleeding, which complicates treatment with anticoagulation. Traditionally, patients with cancer-associated VTE was treated with low molecular weight heparin (LMH). In total, 4 randomized controlled trials have compared non-vitamin K antagonist oral anticoagulantia (NOAC) with LMH. The NOACs studied are the factor Xa inhibitors apixaban, edoxaban, and rivaroxaban. A metaanalysis of these 4 trials have shown at least similar efficacy for prevention of new VTE and a similar risk of bleeding.

Seventh time lucky-A case report of multiple radiofrequency ablations for right ventricular outflow tract tachycardia

Right ventricular outflow tachycardia initially refractory to radiofrequency ablation may be successfully treated after radiofrequency ablation at multiple sites. Repeated radiofrequency ablations as well as cooperation across borders with referral to an international center of excellence may be required in complicated cases.

Patient-reported feasibility of chest and thumb ECG after cryptogenic stroke in Sweden: an observational study

OBJECTIVES

The aim of this study was to assess the feasibility, based on a questionnaire, of the chest and thumb ECG system Coala Heart Monitor in patients who recently had a stroke.

DESIGN

Observational study.

SETTING

Two stroke units, Region Gävleborg, Sweden.

PARTICIPANTS AND INTERVENTIONS

This study, Transient ECG Assessment in Stroke Evaluation (TEASE), included patients who had a stroke between 2017 and 2019. Patients eligible for anticoagulation in the presence of atrial fibrillation were scheduled for 28 days monitoring.

PRIMARY AND SECONDARY OUTCOME MEASURES

The questionnaire regarding feasibility of monitoring included seven questions, using a 100 mm Visual Analogue Scale which covered overall satisfaction, technical feasibility, remember to monitor, physical application, feeling of security, help from others and recommendation to others. A lower score indicated better outcome.

RESULTS

The prespecified number of 100 patients underwent the monitoring and 83 out of the 97 alive patients returned the questionnaire (response rate 85.6%). The median age was 69.5 years, mean CHA₂DS₂-VASc score was 4.4±1.3 points and 59.0% were men (n=49). The median time from index stroke to start of monitoring was 7.0 days. Patients performed on average 90.1%±15.0% of scheduled ECG-transmissions. In all seven questions, the median score ranged from 4 to 8. The vast majority reported acceptable outcomes, that is, the 95th percentile ranged from 30 to 54. There was no significant difference between men and women with regard to any of the seven questions (p values ranging from 0.117 to 0.849). Two of the seven outcome scores correlated significantly to patient age (Spearman's r=-0.238 and r=-0.308, and p values 0.031 and 0.005 for 'overall satisfaction' and 'remember to monitor', respectively).

CONCLUSION

In stroke survivors, chest and thumb ECG two times per day over a period of 4 weeks is feasible from a patient's perspective. The Coala Heart Monitor provides a valuable and convenient tool for monitoring after stroke.

TRIAL REGISTRATION NUMBER

NCT03301662.

Naxos disease - a narrative review

INTRODUCTION

Naxos disease is a rare entity that manifests with woolly hair, keratosis of extremities, and cardiac manifestations that resemble arrhythmogenic right ventricular cardiomyopathy. It is inherited in an autosomal recessive pattern and mutations affecting plakoglobin and desmoplakin have been identified. There is an increased risk of arrhythmias, including sudden cardiac death at a young age. Right ventricular systolic dysfunction often progresses and left ventricular involvement may also occur.

AREAS COVERED

This article reviews historic background, epidemiology, clinical characteristics, genetics, and pathogenesis as well as therapeutic management and future perspectives.

EXPERT OPINION

The principles of evaluation and treatment are based on arrhythmogenic right ventricular cardiomyopathy (ARVC) and general heart failure guidelines, because specific data on Naxos disease are limited. Therefore, larger registries on Naxos disease are welcome in order to gain more knowledge about clinical course and risk stratification. Translational research on pathophysiological mechanisms has evolved, including promising approaches using stem cells for novel targets.

Diagnostic yield of chest and thumb ECG after cryptogenic stroke, Transient ECG Assessment in Stroke Evaluation (TEASE): an observational trial

OBJECTIVE

In stroke survivors, atrial fibrillation (AF) is typically evaluated solely by short-term ECG monitoring in the stroke unit. Prolonged continuous ECG monitoring or insertable cardiac monitors require substantial resources. Chest and thumb ECG could provide an alternative means of AF detection, which in turn could allow prompt anticoagulation to prevent recurrent stroke. The objective of this study was to assess the yield of newly diagnosed AF during 28 days of chest and thumb ECG monitoring two times per day in cryptogenic stroke.

METHODS

This study, Transient ECG Assessment in Stroke Evaluation, included patients who had a stroke from Region Gävleborg, Sweden, between 2017 and 2019. Patients with a recent ischaemic stroke without documented AF (or other reasons for anticoagulation) before or during ECG evaluation in the stroke unit were evaluated using the Coala Heart Monitor connected to a smartphone application for remote monitoring.

RESULTS

The prespecified number of 100 patients (mean age 67.6±10.8 years; 60% men) was analysed. In nine patients (9%, number needed to screen 11) AF but no other significant atrial arrhythmias (>30 s) was diagnosed. The mean CHA₂DS₂-VASc score was similar among patients with AF and no AF (4.9±1.1 vs 4.3±1.3; p=0.224) and patients with AF were older (74.3±9.0 vs 66.9±10.8; p=0.049). Patients performed on average 90.1%±15.0% of scheduled transmissions.

CONCLUSION

In evaluation of cryptogenic stroke, 9% of patients had AF detected using chest and thumb ECG two times per day during 1 month. In many stroke survivors, this is a feasible approach and they will be potentially protected from recurrent stroke by anticoagulation treatment.

TRIAL REGISTRATION NUMBER

NCT03301662.

[Dengue caused life-threatening arrhythmia]

Dengue is a mosquito-borne viral disease found in tropical and sub-tropical climates worldwide. Due to globalization and climate change dengue is an increasing global concern. Symptoms typically appear 3-14 days after inoculation by the Aedes mosquito and most commonly manifests as a self-limiting febrile illness. However, in severe dengue, plasma leakage may be profound and result in hemorrhage, disseminated intravascular coagulation and circulatory collapse. The dengue virus may also cause organ dysfunction. Cases of myocarditis, myocardial dysfunction and arrhythmias including atrioventricular block have been reported. The atrioventricular block often resolves spontaneously but pharmacological and pacing support may be required. We report a case of dengue in a patient who was admitted to a Swedish hospital after visiting India. In this case total atrioventricular block without ventricular escape rhythm resolved spontaneously and no pacemaker was necessary.

[The failing right ventricle]

Right-sided heart failure is a common disease that leads to increased morbidity and mortality. Despite this it is ill understood. Echocardiography is currently the primary mode for diagnosis and tricuspid annular plane systolic excursion and fractional area change are good measurements to use for assessment. Volume management is central in treatment of both acute and chronic right-sided heart failure. In acute failure achieving effective diuresis is often more important than the addition of fluids. In the treatment of chronic heart failure, no strong evidence supports the use of RAAS-blockers, beta-blockers, aldosterone antagonists or digoxin. In the case of right-sided heart failure caused by pulmonary arterial hypertension vasodilator therapy may be of use, but not in cases of other forms of pulmonary hypertension.

P1152Health-related quality of life among implantable cardioverter defibrillator patients compared to age- and sex-matched norms

Background The decision to implant an ICD integrates presumed health-related quality of life (HRQL).

Purpose To assess HRQL in ICD patients using the questionnaire SF-36, and compare it to a Swedish age- and sex-matched population.

Methods SF-36 of ICD patients 2007-2017 (response rate 77.2%) were analysed using the Mann-Whitney U-test and effect size (ES).

Results In total, 223 patients (mean age 71.1 ±9.7 years) were included of whom 33.6% had a CRTD. A majority were men 82.1% (n = 183) and 60.1% (n = 134) had an ICD due to primary prevention. SF-36 score are summarized as Table 1. Mean age was similar between men and women (71.1 vs 70.9 years) and there were no significant difference score at any domain, including both component scores. Primary and secondary prevention patients (mean age 70.3 vs 72.3 years) scored similar except for worse GH in PP (p = 0.016, ES 0.35). A history of atrial fibrillation at baseline was associated with worse PF (ES 0.41) and PCS (ES 0.38). Neither appropriate therapy, inappropriate shock, nor complications requiring surgery, were associated with lower scores in any domain. In primary prevention due to ischemic vs non-ischemic cardiomyopathy no domain were significantly different. PCS decreased with higher age strata (p = 0.002) in contrast to MCS (p = 0.986).

Conclusion Patients with ICDs have lower physical and mental HRQL than age- and sex matched norms; however the effect sizes are small. HRQL is similar regardless of sex, primary vs secondary prevention indication, appropriate therapy, inappropriate shock or complications but decreases with age.

Table 1. SF-36 ICD patients(n = 223) Swedish Norms (n = 171) Mean (SD) Mean (SD) p-value Effect size Physical Functioning (PF) 65.1 (28.1) 75.5 (26.0) 0.0002 0.38 Role Physical (RP) 56.9 (44.1) 66.7 (40.4) 0.0466 0.23 Bodily Pain (BP) 71.9 (29.9) 71.0 (27.2) 0.6395 NS General Health (GH) 56.2 (21.7) 65.9 (25.3) ≤0.0001 0.41 Vitality (VT) 58.0 (24.8) 68.1 (27.2) ≤0.0001 0.39 Social Functioning (SF) 80.1 (24.4) 85.9 (22.9) 0.0025 0.25 Role Emotional (RE) 72.2 (39.9) 76.7 (35.7) 0.3730 NS Mental Health (MH) 76.2 (19.4) 83.8 (20.9) ≤0.0001 0.38 Physical Component Summary (PCS) 40.7 (12.3) 44.4 (11.6) 0.0052 0.31 Mental Component Summary (MCS) 48.6 (10.8) 51.9 (10.5) 0.0010 0.31 Health-related quality of life among ICD patients compared to age- and sex-matched Swedish norms.

[Peripartum cardimyopathy - risk of delayed diagnosis]

Peripartum cardiomyopathy is defined as heart failure, with ejection fraction less than 45% that presents late during pregnancy or the first five months postpartum. Despite being described first in 1849 by Ritchie the mechanisms behind the disease are still not fully understood. However, oxidative stress during pregnancy and the cleavage of prolactine into its 16 kDa fragment appears to play a role in the pathophysiology of peripartum cardiomyopathy. In addition to optimal therapy for heart failure bromocriptine, an inhibitor of prolactine release, should be considered. Prevalence and prognosis varies geographically. Most often left ventricular ejection fraction is normalized after six months but sometimes the disease is associated with deteriorating heart failure and death. Therefore it is important for health care professionals caring for women in the peripartum period to be aware of the signs and symptoms of the diagnosis.

Long-term follow-up of implantable cardioverter defibrillator patients with regard to appropriate therapy, complications, and mortality

BACKGROUND

An implantable cardioverter defibrillator (ICD) is recommended for patients with symptomatic heart failure with ejection fraction ≤35% despite optimal medical therapy. More recently, the benefits of ICDs have been questioned in nonischemic cardiomyopathy (CM).

AIM

To examine the incidence of appropriate therapy, complications, mortality, and cause of death among ICD patients in an unselected validated cohort. In primary prevention, appropriate therapy in ischemic versus nonischemic CM will be evaluated.

METHODS

A retrospective observational study of patients in Region Gävleborg, Sweden, who underwent ICD implantation or replacement between 2007 and 2017.

RESULTS

In total, 438 patients (mean age at implant: 65.9 ± 11.2 years, 82.0% males, mean follow-up: 5.2 ± 4.0 years) were included. There were 108 (24.7%) deaths (49.1% due to heart failure) and 94.9% survived the first year. Cumulative incidence of appropriate therapy at 5-year was 31.6%. Cumulative incidence of inappropriate shock at 5-year was 9.1%. A total of 98 complications requiring surgical intervention occurred (annual rate: 4.3%). In total, 236 patients with primary prevention due to ischemic (61.9%) or nonischemic (38.1%) CM were included. During a mean follow-up of 3.9 ± 2.5 years, for appropriate therapy, there was no significant difference (P = .985) between ischemic (cumulative incidence at 1, 3, and 5 years: 6.4%, 17.1%, and 19.6%) and nonischemic CM (cumulative incidence at 1, 3, and 5 years: 5.6%, 13.6%, and 24.4%).

CONCLUSION

Ischemic and nonischemic CM confer similar risk of ventricular arrhythmia. This supports current guidelines regarding primary-prevention ICD. Short-term survival is excellent but complications remain a problem.

[Myotonic dystrophy type 1 - a rare cause of bradycardia in the young]

Myotonic dystrophy type 1 (Steinert's disease) is a rare but important cause of bradycardia in the young. Syncope is primarily considered to be caused by high-degree atrioventricular block II-III but may also be caused by sinus node dysfunction. Life-threatening ventricular arrhythmias do occur, and in cases with impaired systolic left ventricular function, indication for a primary preventive implantable cardiac defibrillator should be evaluated. All patients with myotonic dystrophy type 1 should undergo clinical assessment, 12-lead ECG, 24-hour Holter, and echocardiography annually. We here describe the case of a 24-year-old woman who received a pacemaker due to sinus arrests with syncope caused by myotonic dystrophy type 1.

[Spontaneous coronary artery dissection - a cause of acute coronary syndrome in the peripartum period]

Spontaneous coronary artery dissection can be caused by a tear in the intima or a bleeding in the wall of a coronary artery. It is a possible cause of acute coronary syndrome and should be suspected in patients with few risk factors for coronary artery disease. The condition is overrepresented in women particularly during the peripartum period. We present a case where a 36-year-old woman, three days after delivering her third child, presented with myocardial infarction with nonobstructive coronary arteries. She later presented again with ST-elevation myocardial infarction and coronary angiography with optical coherence tomography revealed coronary dissection that was treated with percutaneous coronary intervention.

[Device-detected atrial arrhythmia - when is anticoagulation indicated?]

Atrial high rate episodes (AHRE) are frequently detected in patients with pacemakers or implantable cardioverter defibrillators. AHRE episodes ≥5 minutes are associated with increased risk of ischemic stroke. There is no clear temporal relationship between AHRE and ischemic stroke, therefore atrial arrhythmia could be suspected to at least in part be a risk marker and not solely a direct cause of stroke. No results have been published on the effect of anticoagulation in patients with AHRE, but several studies are in progress. The European Heart Rhythm Association (EHRA) recommends anticoagulation for patients with AHRE ≥5.5 hours per day and a CHA2DS2-VASc score of ≥2 (≥3 in females). Anticoagulation may be considered for CHA2DS2-VASc scores of 1 (2 in females). In patients with several risk factors anticoagulation should be considered also in cases with shorter duration of AHRE.

[The wearable cardioverter defibrillator - temporary protection against sudden cardiac death]

Ventricular tachycardia or ventricular fibrillation can be terminated by defibrillation and implantable cardioverter defibrillators (ICDs) prevent sudden cardiac death. Since 2001 the wearable cardioverter defibrillator (WCD) has been available to provide temporary protection; it safely and effectively detects and terminates ventricular tachyarrhythmias. VEST (published in 2018) compared the effect of WCD in patients with ejection fraction ≤35 percent following myocardial infarction. Total mortality was reduced but sudden cardiac death did not reach statistical significance. According to European guidelines a WCD could be used to protect patients during the time they are evaluated for ICD; for example, during the three-month period with optimal medical therapy awaiting recovery of a low ejection fraction. It could also be considered during the period following extraction due to endocarditis before reimplantation of ICD or during the waiting period for heart transplant.

Apical hypertrophic cardiomyopathy with preexcitation presenting as a myocardial infarction and ischemic stroke with a history of recurrent syncope: A case report

Contrast-enhanced echocardiography or cardiac magnetic resonance imaging is of value in the diagnosis of apical hypertrophic cardiomyopathy. Apical hypertrophic cardiomyopathy is rare in Caucasians, and gene negativity does not rule out the diagnosis. Risk stratification for sudden cardiac death and decisions about anticoagulation in cases with atrial fibrillation should be based on guidelines.

[Syncope - contemporary management]

Syncope is the chief complaint in 1-2 percent of emergency department visits. Syncope belongs to the broader category transient loss of consciousness (TLOC), defined as a short loss of consciousness with loss of awareness and responsiveness, and with subsequent amnesia for the event. Syncope is defined as TLOC due to cerebral hypoperfusion, with rapid onset and spontaneous complete recovery. The main categories of syncope are reflex syncope, orthostatic hypotension, and cardiac syncope. The 2018 guidelines by the European Society of Cardiology emphasizes the process of risk stratification in the initial management of suspected syncope. Risk stratification serves to separate the patients with likely orthostatic and reflex syncope with good prognosis from the patients with likely cardiac syncope and high short-term risk of an adverse outcome. It determines the appropriate next level of care. Further evaluation should be based on clinical suspicion and frequency of symptoms.

A case of fulminant perimyocarditis leading to extensive ECMO treatment and spinal injury resulting in paraplegia

Perimyocarditis has varying disease manifestations and prognosis. It may rapidly deteriorate into a life-threatening state requiring advanced intensive care including veno-arterial extra-corporeal membrane oxygenation, which may be lifesaving. Close follow-up is warranted to detect both short-term and long-term complications.

[Postural orthostatic tachycardia syndrome]

Postural orthostatic tachycardia syndrome (POTS) is a condition where the patient experiences tachycardia (a rise in heart rate of at least 30 beats per minute, 40 in people between the ages of 12 and 19) upon assuming the upright position, in the absence of orthostatic hypotension (a fall in systolic blood pressure of more than 20 mmHg). The majority of patients are young women. Symptoms are experienced frequently during standing, and include dizziness, fatigue, palpitations, tremulousness, blurred vision and sometimes syncope - although presyncope is more common. The diagnosis requires that symptoms have been present for at least six months and lack another medical explanation. The pathophysiology is believed to be multifactorial; peripheral sympathetic denervation, excessive sympathetic drive, hypovolemia and deconditioning have been reported in POTS. Patient education is fundamental in the management of POTS, including information regarding symptoms and exacerbating factors as well as methods for increasing arterial pressure. Exercise is believed to be effective. Several drugs can be used to relieve symptoms, although none of them are licensed for the treatment of POTS. We describe a case that illustrates that POTS can be debilitating, which requires awareness of the condition among clinicians.

[The leadless pacemaker system: present applications and future perspectives]

Cardiac devices are ever evolving, since 1958 we have come a long way from Senning's and Elmqvist's ingenious but crude first implantable pacemaker. The leadless intracardiac pacemaker (weight 2 grams) can be implanted in its entirety in the right ventricle through a femoral transcatheter approach. Currently, the leadless pacemaker system only offers VVI-mode. Studies show promising results, with lower complication rates than transvenous pacemaker systems. To date, there are no randomized controlled studies comparing leadless and transvenous pacemakers and no long-term follow-up. Due to this, high cost, and lack of experience, for now, leadless pacemakers can only be recommended for patients with indication for VVI pacemaker and in whom transvenous pacemaker leads are unfeasible. To illustrate this, we describe a case where a leadless pacemaker provided the solution to difficult venous access.

[Aortic stenosis is a common disease which requires individualized treatment]

Aortic stenosis is the most common valvular heart disease and the prevalence increases with age. Common symptoms include dyspnea, angina, and syncope. Echocardiography is a cornerstone in diagnosis of aortic stenosis. Severe aortic stenosis is defined as peak aortic jet velocity ≥4 m/s, a mean transvalvular gradient ≥40 mmHg, and/or an aortic valve area <1.0 cm2. The two-year mortality in patients with symptomatic aortic stenosis is 50 percent without intervention. The only efficient treatment is intervention, either open heart valve replacement or percutaneous transcatheter implantation of an aortic valve prosthesis (TAVI), which both provide symptomatic relief and improved survival. Many patients with aortic stenosis are elderly with comorbidities, thus making treatment decision challenging and requiring individual judgement.

A protocol for a prospective observational study using chest and thumb ECG: transient ECG assessment in stroke evaluation (TEASE) in Sweden

INTRODUCTION

Atrial fibrillation (AF) causes ischaemic stroke and based on risk factor evaluation warrants anticoagulation therapy. In stroke survivors, AF is typically detected with short-term ECG monitoring in the stroke unit. Prolonged continuous ECG monitoring requires substantial resources while insertable cardiac monitors are invasive and costly. Chest and thumb ECG could provide an alternative for AF detection poststroke.The primary objective of our study is to assess the incidence of newly diagnosed AF during 28 days of chest and thumb ECG monitoring in cryptogenic stroke. Secondary objectives are to assess health-related quality of life (HRQoL) using short-form health survey (SF-36) and the feasibility of the Coala Heart Monitor in patients who had a stroke.

METHODS

Stroke survivors in Region Gävleborg, Sweden, will be eligible for the study from October 2017. Patients with a history of ischaemic stroke without documented AF before or during ECG evaluation in the stroke unit will be evaluated by the chest and thumb ECG system Coala Heart Monitor. The monitoring system is connected to a smartphone application which allows for remote monitoring and prompt advice on clinical management. Over a period of 28 days, patients will be monitored two times a day and may activate the ECG recording at symptoms. On completion, the system is returned by mail. This system offers a possibility to evaluate the presence of AF poststroke, but the feasibility of this system in patients who recently suffered from a stroke is unknown. In addition, HRQoL using SF-36 in comparison to Swedish population norms will be assessed. The feasibility of the Coala Heart Monitor will be assessed by a self-developed questionnaire.

ETHICS AND DISSEMINATION

The study was approved by The Regional Ethical Committee in Uppsala (2017/321). The database will be closed after the last follow-up, followed by statistical analyses, interpretation of results and dissemination to a scientific journal.

TRIAL REGISTRATION NUMBER

NCT03301662; Pre-results.

Eosinophilic granulomatosis with polyangiitis: myocardial thickening reversed by corticosteroids

Background

In 1951 Churg and Strauss first described the clinical condition now known as eosinophilic granulomatosis with polyangiitis (EGPA), characterized by asthma, nasal polyposis, rhinosinusitis, hypereosinophilia with organ infiltration, and necrotizing vasculitis. It is classified as an antineutrophil cytoplasmic antibody (ANCA) associated vasculitis, but ANCA negativity is common and more frequently encountered in EGPA with myocardial involvement. Long-term survival has substantially improved with corticosteroid treatment but myocardial involvement is still the leading cause of death in EGPA.

Case presentation

A 53-year old man with a history of asthma and nasal polyposis presented with acute chest pain and elevated troponin; a percutaneous coronary intervention was performed. The left ventricle was described as hypertrophic. After 20 days the myocardium had markedly increased in thickness of both the right and left ventricle. Evaluation revealed hypereosinophilia in the blood and nasal mucosal tissue, which confirmed the diagnosis of EGPA. He presented with signs of active vasculitis including weight loss, tiredness, intracerebral hemorrhage, and increasing serum creatinine. After 6 days of corticosteroid treatment, the myocardium returned to its initial thickness.

Conclusion

Rapid and marked thickening of the myocardium is not frequently reported but may occur in EGPA. Myocardial thickening in EGPA can be quickly reversed by corticosteroids, and is most likely caused by edema.

Left ventricular non-compaction cardiomyopathy with coronary artery anomaly complicated by ventricular tachycardia

Background

Non-compaction cardiomyopathy (NCCM) is characterized by prominent trabeculations, deep intertrabecular recesses, and a thick non-compacted endocardial myocardium. Prevalence in the general population remains unclear, but echocardiography series report 0.05%. During fetal development muscle fibers and trabeculae should compact into a solid myocardium and when this fails, NCCM occurs. The condition is genetic, even though acquired forms have been described. Worsening myocardial dysfunction may lead to heart failure and/or arrhythmias.

Case presentation

A 52-year-old man presented with heart failure. The diagnosis of NCCM was confirmed after echocardiography and cardiac magnetic resonance tomography. Interestingly, the angiogram revealed a coronary anomaly, in which the circumflex artery rose aberrantly from the right coronary artery. Due to left ventricular ejection fraction being less than 35% despite optimal pharmacological therapy, an implantable cardioverter defibrillator (ICD) was implanted and four years later a ventricular tachycardia was terminated by antitachycardia pacing.

Conclusion

We describe a case of NCCM with a concomitant coronary anomaly, in which systolic myocardial dysfunction developed. The ICD subsequently terminated a life-threatening ventricular arrhythmia, which supports risk stratification based on low ejection fraction and possibly coronary anomaly.

Electrical storm in the inflamed heart: ventricular tachycardia due to myocarditis

Electrical storm during the acute inflammatory phase caused by myocarditis may be resistant to antiarrhythmic therapy. Cardiac imaging including magnetic resonance tomography, positron emission tomography, and endomyocardial biopsy are crucial to guide potential therapeutic options. Optimal management involves a multidisciplinary approach, including expertise beyond cardiology.

Determination of selenium in freshwaters by cathodic stripping voltammetry after UV irradiation

An analytical method was developed for the determination of total dissolved selenium in fresh waters, using linear sweep cathodic stripping voltammetry (CSV) in combination with UV photolytic digestion. Both the CSV method, based on the electrodeposition and stripping of Cu(2)Se, and the UV irradiation procedure were investigated in detail. In the presence of dissolved organic substances, as in freshwaters, Se(VI) is reduced to Se(IV) by UV irradiation in 0.1M hydrochloric acid. Glucose can be used as the carbon source in samples low in natural dissolved organic carbon (DOC). The photolytic yields of Se(IV) were about 90% in both cases. Five freshwater samples were analysed for total selenium by CSV after UV photolysis, and by hydride generation atomic absorption spectrometry (HG-AAS) after oxidative digestion followed by reduction with hydrochloric acid. The results agreed well and the concentrations were in the range 70-190 ng/l., well above the detection limit of the CSV method at 2 ng/l.

Nerve cells in transplanted pancreatic islets: no effects of cyclosporin or tacrolimus on immediate neuronal survival

Previous experiments have demonstrated that neuronal cells within pancreatic islets survive the isolation procedure and constitute an integral part of transplanted pancreatic islets. The aim of the present study was to investigate to what extent immunosuppressive drugs affects the acute survival of intra-islet neurons after pancreatic islet transplantation. For this purpose, C57BL/6 mice were syngeneically transplanted with 250 islets under the renal capsule. The animals were treated for 7 consecutive days with subcutaneous injections of cyclosporin, tacrolimus or vehicle. After this, the animals were killed and the grafts were removed, fixed and stained for the presence of the neuron-specific protein PGP 9.5. The number of nerves were then morphologically quantitated. No differences between the experimental groups were seen, and the number of nervous elements were approximately 5 per mm2 in all animals. It is concluded that immunosuppressive treatment does not affect the acute survival of graft neurons after experimental islet transplantation.

Engraftment and growth of transplanted pancreatic islets

Transplantation of pancreatic islets may provide a cure for type 1 diabetes. However, this treatment can currently be offered only to very few patients. To improve transplantation success we need to understand better the mechanisms of how the implanted islets survive, grow and/or maintain adequate function. We herein report on our studies to evaluate the factors responsible for the engraftment, i.e. revascularization, reinnervation etc., of transplanted islets and relate these factors to the metabolism and growth of the islets. Graft metabolism can be monitored by microdialysis probes that allow for the measurement of minute amounts of islet metabolites and hormonal products. Growth of the endocrine cells can be stimulated both in vitro before implantation and in vivo post-transplantation. Another problem is rejection of transplanted islets, which may be overcome by the microencapsulation of islets. The knowledge gained by the present studies will enable us to elucidate the optimal treatment of islets to ensure a maximal survival of the transplanted islets, and may be applied also to clinical islet transplantation.