Ivabradine as a treatment option for junctional ectopic tachycardia in an adult female

A Junctional ectopic tachycardia diagnosis was performed using two electrophysiological maneuvers in an adult female with a narrow-complex supraventricular tachycardia with a bystander AV-node slow pathway conduction, who previously underwent catheter ablation attempts for an atrio-ventricular nodal re-entrant tachycardia misdiagnosis. The first maneuver was atrial entrainment with an atrial-His-His-atrial response. The second was based on the response to a premature atrial complex delivered at different phases of the tachycardia cycle confirming that anterograde slow pathway conduction and retrograde fast pathway were not involved. Considering that verapamil, diltiazem, bisoprolol + flecainide, and nadolol were ineffective, we tried ivabradine with no sustained arrhythmias during 18-months.

Validation of Utstein-Based score to predict return of spontaneous circulation (UB-ROSC) in patients with out-of-hospital cardiac arrest

BACKGROUND AND AIMS

The Utstein Based-ROSC (UB-ROSC) score has been developed to predict ROSC in OHCA victims. Aim of the study was to validate the UB-ROSC score using two Utstein-based OHCA registries: the SWiss REgistry of Cardiac Arrest (SWISSRECA) and the Lombardia Cardiac Arrest Registry (Lombardia CARe), northern Italy.

METHODS

Consecutive patients with OHCA of any etiology occurring between January 1st, 2019 and December 31st 2021 were included in this retrospective validation study. UB-ROSC score was computed for each patient and categorized in one of three subgroups: low, medium or high likelihood of ROSC according to the UB-ROSC cut-offs (≤-19; -18 to 12; ≥13). To assess the performance of the UB-ROSC score in this new cohort, we assessed both discrimination and calibration. The score was plotted against the survival to hospital admission.

RESULTS

A total of 12.577 patients were included in the study. A sustained ROSC was obtained in 2.719 patients (22%). The UB-ROSC model resulted well calibrated and showed a good discrimination (AUC 0.71, 95% CI 0.70-0.72). In the low likelihood subgroup of UB-ROSC, only 10% of patients achieved ROSC, whereas the proportion raised to 36% for a score between -18 and 12 (OR 5.0, 95% CI 2.9-8.6, p < 0.001) and to 85% for a score ≥13 (OR 49.4, 95% CI 14.3-170.6, p < 0.001).

CONCLUSIONS

UB-ROSC score represents a reliable tool to predict ROSC probability in OHCA patients. Its application may help the medical decision-making process, providing a realistic stratification of the probability for ROSC.

Continuous stellate ganglion block for ventricular arrhythmias: case series, systematic review, and differences from thoracic epidural anaesthesia

AIMS

Percutaneous stellate ganglion block (PSGB) through single-bolus injection and thoracic epidural anaesthesia (TEA) have been proposed for the acute management of refractory ventricular arrhythmias (VAs). However, data on continuous PSGB (C-PSGB) are scant. The aim of this study is to report our dual-centre experience with C-PSGB and to perform a systematic review on C-PSGB and TEA.

METHODS AND RESULTS

Consecutive patients receiving C-PSGB at two centres were enrolled. The systematic literature review follows the latest Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. Our case series (26 patients, 88% male, 60 ± 16 years, all with advanced structural heart disease, left ventricular ejection fraction 23 ± 11%, 32 C-PSGBs performed, with a median duration of 3 days) shows that C-PSGB is feasible and safe and leads to complete VAs suppression in 59% and to overall clinical benefit in 94% of cases. Overall, 61 patients received 68 C-PSGBs and 22 TEA, with complete VA suppression in 63% of C-PSGBs (61% of patients). Most TEA procedures (55%) were performed on intubated patients, as opposed to 28% of C-PSGBs (P = 0.02); 63% of cases were on full anticoagulation at C-PSGB, none at TEA (P < 0.001). Ropivacaine and lidocaine were the most used drugs for C-PSGB, and the available data support a starting dose of 12 and 100 mg/h, respectively. No major complications occurred, yet TEA discontinuation rate due to side effects was higher than C-PSGB (18 vs. 1%, P = 0.01).

CONCLUSION

Continuous PSGB seems feasible, safe, and effective for the acute management of refractory VAs. The antiarrhythmic effect may be accomplished with less concerns for concomitant anticoagulation compared with TEA and with a lower side-effect related discontinuation rate.

Electrical storm treatment by percutaneous stellate ganglion block: the STAR study

BACKGROUND AND AIMS

An electrical storm (ES) is a clinical emergency with a paucity of established treatment options. Despite initial encouraging reports about the safety and effectiveness of percutaneous stellate ganglion block (PSGB), many questions remained unsettled and evidence from a prospective multicentre study was still lacking. For these purposes, the STAR study was designed.

METHODS

This is a multicentre observational study enrolling patients suffering from an ES refractory to standard treatment from 1 July 2017 to 30 June 2023. The primary outcome was the reduction of treated arrhythmic events by at least 50% comparing the 12 h following PSGB with the 12 h before the procedure. STAR operators were specifically trained to both the anterior anatomical and the lateral ultrasound-guided approach.

RESULTS

A total of 131 patients from 19 centres were enrolled and underwent 184 PSGBs. Patients were mainly male (83.2%) with a median age of 68 (63.8-69.2) years and a depressed left ventricular ejection fraction (25.0 ± 12.3%). The primary outcome was reached in 92% of patients, and the median reduction of arrhythmic episodes between 12 h before and after PSGB was 100% (interquartile range -100% to -92.3%). Arrhythmic episodes requiring treatment were significantly reduced comparing 12 h before the first PSGB with 12 h after the last procedure [six (3-15.8) vs. 0 (0-1), P < .0001] and comparing 1 h before with 1 h after each procedure [2 (0-6) vs. 0 (0-0), P < .001]. One major complication occurred (0.5%).

CONCLUSIONS

The findings of this large, prospective, multicentre study provide evidence in favour of the effectiveness and safety of PSGB for the treatment of refractory ES.

Amplitude spectral area of ventricular fibrillation can discriminate survival of patients with out-of-hospital cardiac arrest

Background

Evidence of the association between AMplitude Spectral Area (AMSA) of ventricular fibrillation and outcome after out-of-hospital cardiac arrest (OHCA) is limited to short-term follow-up. In this study, we assess whether AMSA can stratify the risk of death or poor neurological outcome at 30 days and 1 year after OHCA in patients with an initial shockable rhythm or with an initial non-shockable rhythm converted to a shockable one.

Methods

This is a multicentre retrospective study of prospectively collected data in two European Utstein-based OHCA registries. We included all cases of OHCAs with at least one manual defibrillation. AMSA values were calculated after data extraction from the monitors/defibrillators used in the field by using a 2-s pre-shock electrocardiogram interval. The first detected AMSA value, the maximum value, the average value, and the minimum value were computed, and their outcome prediction accuracy was compared. Multivariable Cox regression models were run for both 30-day and 1-year deaths or poor neurological outcomes. Neurological cerebral performance category 1-2 was considered a good neurological outcome.

Results

Out of the 578 patients included, 494 (85%) died and 10 (2%) had a poor neurological outcome at 30 days. All the AMSA values considered (first value, maximum, average, and minimum) were significantly higher in survivors with good neurological outcome at 30 days. The average AMSA showed the highest area under the receiver operating characteristic curve (0.778, 95% CI: 0.7-0.8, p < 0.001). After correction for confounders, the highest tertiles of average AMSA (T3 and T2) were significantly associated with a lower risk of death or poor neurological outcome compared with T1 both at 30 days (T2: HR 0.6, 95% CI: 0.4-0.9, p = 0.01; T3: HR 0.6, 95% CI: 0.4-0.9, p = 0.02) and at 1 year (T2: HR 0.6, 95% CI: 0.4-0.9, p = 0.01; T3: HR 0.6, 95% CI: 0.4-0.9, p = 0.01). Among survivors at 30 days, a higher AMSA was associated with a lower risk of mortality or poor neurological outcome at 1 year (T3: HR 0.03, 95% CI: 0-0.3, p = 0.02).

Discussion

Lower AMSA values were significantly and independently associated with the risk of death or poor neurological outcome at 30 days and at 1 year in OHCA patients with either an initial shockable rhythm or a conversion rhythm from non-shockable to shockable. The average AMSA value had the strongest association with prognosis.

Obesity: a gender-view

PURPOSE

There is a growing awareness of the importance of understanding gender differences in obesity. The aim of this short review was to revise the current evidence on anthropometric characteristics and nutritional and pharmacological aspects of obesity from a gender perspective.

METHODS

A literature search within PubMed was performed. Selected publications related to obesity and gender differences were reviewed.

RESULTS

The prevalence of obesity among men is higher than in women, but women have a higher percentage of body fat content compared to men, and gender appears to be an important factor in the manifestation of central (android) or peripheral (gynoid) obesity. In addition, while in most clinical trials, women are still underrepresented, in clinical registration trials of anti-obesity drugs, women are commonly up-represented and gender-specific analysis is uncommon. Considering that adipose tissue is one of the factors affecting the volume of distribution of many drugs, mainly lipophilic drugs, gender differences might be expected in the pharmacokinetics and pharmacodynamics of anti-obesity drugs. Indeed, although Liraglutide 3 mg, a long-acting glucagon-like peptide-1 receptor agonist, and naltrexone/bupropion display lipophilic properties, currently, a gender-dose adjustment for both these drugs administration is not recommended. In addition, despite that predicted responders to treatment offer substantial opportunities for efficient use, especially of expensive new therapies, such as anti-obesity drugs, data on gender differences to identify early responders to both these have not yet been investigated. Finally, bariatric surgery gender disparity reflects healthcare practices. Weight loss similar, but differing effects: women need more correction and face psychology challenges; men have worse physiology and fewer comorbidity improvements.

CONCLUSION

Gender differences exist in obesity prevalence and phenotype, body fat distribution, drug efficacy, clinical trial representation, and different secondary effects of bariatric surgery. Gender is an important variable in obesity analysis.

The impact of COVID-19 pandemic on out-of-hospital cardiac arrest: An individual patient data meta-analysis

AIM

Prior studies have reported increased out-of-hospital cardiac arrests (OHCA) incidence and lower survival during the COVID-19 pandemic. We evaluated how the COVID-19 pandemic affected OHCA incidence, bystander CPR rate and patients' outcomes, accounting for regional COVID-19 incidence and OHCA characteristics.

METHODS

Individual patient data meta-analysis of studies which provided a comparison of OHCA incidence during the first pandemic wave (COVID-period) with a reference period of the previous year(s) (pre-COVID period). We computed COVID-19 incidence per 100,000 inhabitants in each of 97 regions per each week and divided it into its quartiles.

RESULTS

We considered a total of 49,882 patients in 10 studies. OHCA incidence increased significantly compared to previous years in regions where weekly COVID-19 incidence was in the fourth quartile (>136/100,000/week), and patients in these regions had a lower odds of bystander CPR (OR 0.49, 95%CI 0.29-0.81, p = 0.005). Overall, the COVID-period was associated with an increase in medical etiology (89.2% vs 87.5%, p < 0.001) and OHCAs at home (74.7% vs 67.4%, p < 0.001), and a decrease in shockable initial rhythm (16.5% vs 20.3%, p < 0.001). The COVID-period was independently associated with pre-hospital death (OR 1.73, 95%CI 1.55-1.93, p < 0.001) and negatively associated with survival to hospital admission (OR 0.68, 95%CI 0.64-0.72, p < 0.001) and survival to discharge (OR 0.50, 95%CI 0.46-0.54, p < 0.001).

CONCLUSIONS

During the first COVID-19 pandemic wave, there was higher OHCA incidence and lower bystander CPR rate in regions with a high-burden of COVID-19. COVID-19 was also associated with a change in patient characteristics and lower survival independently of COVID-19 incidence in the region where OHCA occurred.

Amplitude spectral area of ventricular fibrillation and defibrillation success at low energy in out-of-hospital cardiac arrest

The optimal energy for defibrillation has not yet been identified and very often the maximum energy is delivered. We sought to assess whether amplitude spectral area (AMSA) of ventricular fibrillation (VF) could predict low energy level defibrillation success in out-of-hospital cardiac arrest (OHCA) patients. This is a multicentre international study based on retrospective analysis of prospectively collected data. We included all OHCAs with at least one manual defibrillation. AMSA values were calculated by analyzing the data collected by the monitors/defibrillators used in the field (Corpuls 3 and Lifepak 12/15) and using a 2-s-pre-shock electrocardiogram interval. We run two different analyses dividing the shocks into three tertiles (T1, T2, T3) based on AMSA values. 629 OHCAs were included and 2095 shocks delivered (energy ranging from 100 to 360 J; median 200 J). Both in the "extremes analysis" and in the "by site analysis", the AMSA values of the effective shocks at low energy were significantly higher than those at high energy (p = 0.01). The likelihood of shock success increased significantly from the lowest to the highest tertile. After correction for age, call to shock time, use of mechanical CPR, presence of bystander CPR, sex and energy level, high AMSA value was directly associated with the probability of shock success [T2 vs T1 OR 3.8 (95% CI 2.5-6) p < 0.001; T3 vs T1 OR 12.7 (95% CI 8.2-19.2), p < 0.001]. AMSA values are associated with the probability of low-energy shock success so that they could guide energy optimization in shockable cardiac arrest patients.

Sacubitril/valsartan effects on arrhythmias and left ventricular remodelling in heart failure: An observational study

AIMS

Conflicting results have been reported in the literature on the potential antiarrhythmic effect of sacubitril/valsartan in heart failure patients with reduced ejection fraction (HFrEF). The objectives of this study were: 1- to evaluate the long term effects of sacubitril/valsartan on arrhythmic burden in HFrEF patients; 2- to evaluate the correlation between the reduction of premature ventricular complexes during f-up and reverse remodelling.

METHODS

We identified 255 consecutive HFrEF patients treated with sacubitril/valsartan between March 2017 and May 2020 and followed by the Heart Failure and Cardiac Transplant Unit of IRCCS San Matteo Hospital in Pavia (Italy). Within this subgroup, 153 patients underwent 24 h-Holter-ECG or implantable cardioverter defibrillators (ICD) interrogation at baseline, at 12 months (t1) and at 24 months (t2) and transthoracic echocardiography at baseline and after 12 months after the beginning of sacubitril/valsartan. Cardiac-related hospitalizations were analyzed in the 12 months preceding and during 24 months following the drug starting date.

RESULTS

Global burden of 24-h premature ventricular complexes (PVC) was significantly reduced at 12 months (t1) and at 24 months (t2) as compared to the same period before treatment (1043 [304-3360] vs 768 [82-2784] at t1 vs 114 [9-333] at t2, P = 0.000). In the subgroup of patients implanted with biventricular ICD (n = 30), the percentage of biventricular pacing increased significantly (96% [94-99] vs 98% [96-99] at t1 vs 98%[97-100] at t2; P = 0.027). The burden of non-sustained ventricular tachycardia and sustained ventricular tachycardia did not change from baseline to t1 and t2, but a reduction of patients with at least one ICD appropriate shock was reported. The correlations between reduction in 24 h PVC and reduction in LV-ESVi or improvement in LVEF were not statistically significant (respectively R = 0.144, P = 0.197 and R = -0.190, P = 0.074). Heart failure related hospitalizations decreased during follow up (11.1% in the year before treatment vs 4.6% at t1 and 4.6% at t2; P = 0.040).

CONCLUSION

Sacubitril/valsartan reduced the number of premature ventricular complexes and increased the percentage of biventricular pacing in a cohort of HFrEF patients already on optimal medical therapy. PVC reduction did not correlate with reverse left ventricular remodelling. Whether sacubitril/valsartan has any direct antiarrhythmic effects is an issue to be better explored in future studies.

Use of Mechanical Chest Compression for Resuscitation in Out-Of-Hospital Cardiac Arrest-Device Matters: A Propensity-Score-Based Match Analysis

BACKGROUND

Devices for mechanical cardiopulmonary resuscitation (CPR) are recommended when high quality CPR cannot be provided. Different devices are available, but the literature is poor in direct comparison studies. Our aim was to assess whether the type of mechanical chest compressor could affect the probability of return of spontaneous circulation (ROSC) and 30-day survival in Out-of-Hospital Cardiac Arrest (OHCA) patients as compared to manual standard CPR.

METHODS

We considered all OHCAs that occurred from 1 January 2015 to 31 December 2022 in seven provinces of the Lombardy region equipped with three different types of mechanical compressor: Autopulse^®(ZOLL Medical, MA), LUCAS^® (Stryker, MI), and Easy Pulse^® (Schiller, Switzerland).

RESULTS

Two groups, 2146 patients each (manual and mechanical CPR), were identified by propensity-score-based random matching. The rates of ROSC (15% vs. 23%, p < 0.001) and 30-day survival (6% vs. 14%, p < 0.001) were lower in the mechanical CPR group. After correction for confounders, Autopulse^® [OR 2.1, 95%CI (1.6-2.8), p < 0.001] and LUCAS^® [OR 2.5, 95%CI (1.7-3.6), p < 0.001] significantly increased the probability of ROSC, and Autopulse^® significantly increased the probability of 30-day survival compared to manual CPR [HR 0.9, 95%CI (0.8-0.9), p = 0.005].

CONCLUSION

Mechanical chest compressors could increase the rate of ROSC, especially in case of prolonged resuscitation. The devices were dissimilar, and their different performances could significantly influence patient outcomes. The load-distributing-band device was the only mechanical chest able to favorably affect 30-day survival.

aMplitude spectral area of ventricular fibrillation and amiOdarone Study in patients with out-of-hospital cArdIaC arrest. The MOSAIC study

Objective

Antiarrhythmic drugs are recommended for out of hospital cardiac arrest (OHCA) with shock-refractory ventricular fibrillation (VF). Amplitude Spectral Area (AMSA) of VF is a quantitative waveform measure that describes the amplitude-weighted mean frequency of VF, it correlates with intramyocardial adenosine triphosphate (ATP) concentration, it is a predictor of shock efficacy and an emerging indicator to guide defibrillation and resuscitation efforts. How AMSA might be influenced by amiodarone administration is unknown.

Methods

In this international multicentre observational study, all OHCAs receiving at least one shock were included. AMSA values were calculated by retrospectively analysing the pre-shock ECG interval of 2 s. Multivariable models were run and a propensity score based on the probability of receiving amiodarone was created to compare two randomly matched samples.

Results

2,077 shocks were included: 1,407 in the amiodarone group and 670 in the non-amiodarone group. AMSA values were lower in the amiodarone group [8.8 (6-12.7) mV·Hz vs. 9.8 (6-14) mV·Hz, p = 0.035]. In two randomly matched propensity score-based groups of 261 shocks, AMSA was lower in the amiodarone group [8.2 (5.8-13.5) mV·Hz vs. 9.6 (5.6-11.6), p = 0.042]. AMSA was a predictor of shock success in both groups but the predictive power was lower in the amiodarone group [Area Under the Curve (AUC) non-amiodarone group 0.812, 95%CI: 0.78-0.841 vs. AUC amiodarone group 0.706, 95%CI: 0.68-0.73; p < 0.001].

Conclusions

Amiodarone administration was independently associated with the probability of recording lower values of AMSA. In patients who have received amiodarone during cardiac arrest the predictive value of AMSA for shock success is significantly lower, but still statistically significant.

Association Between Postresuscitation 12-Lead ECG Features and Early Mortality After Out-of-Hospital Cardiac Arrest: A Post Hoc Subanalysis of the PEACE Study

Background Once the return of spontaneous circulation after out-of-hospital cardiac arrest is achieved, a 12-lead ECG is strongly recommended to identify candidates for urgent coronary angiography. ECG has no apparent role in mortality risk stratification. We aimed to assess whether ECG features could be associated with 30-day survival in patients with out-of-hospital cardiac arrest. Methods and Results All the post-return of spontaneous circulation ECGs from January 2015 to December 2018 in 3 European centers (Pavia, Lugano, and Vienna) were collected. Prehospital data were collected according to the Utstein style. A total of 370 ECGs were collected: 287 men (77.6%) with a median age of 62 years (interquartile range, 53-70 years). After correction for the return of spontaneous circulation-to-ECG time, age >62 years (hazard ratio [HR], 1.78 [95% CI, 1.21-2.61]; P=0.003), female sex (HR, 1.5 [95% CI, 1.05-2.13]; P=0.025), QRS wider than 120 ms (HR, 1.64 [95% CI, 1.43-1.87]; P<0.001), the presence of a Brugada pattern (HR, 1.49 [95% CI, 1.39-1.59]; P<0.001), and the presence of ST-segment elevation in >1 segment (HR, 1.75 [95% CI, 1.59-1.93]; P<0.001) were independently associated with 30-day mortality. A score ranging from 0 to 26 was created, and by dividing the population into 3 tertiles, 3 classes of risk were found with significantly different survival rate at 30 days (score 0-4, 73%; score 5-7, 66%; score 8-26, 45%). Conclusions The post-return of spontaneous circulation ECG can identify patients who are at high risk of mortality after out-of-hospital cardiac arrest earlier than other forms of prognostication. This provides important risk stratification possibilities in postcardiac arrest care that could help to direct treatments and improve outcomes in patients with out-of-hospital cardiac arrest.

Vitamin D and chronotype: is there any relationship in individuals with obesity?

PURPOSE

Chronotype is the attitude to perform most of the daily activities in the morning ("morning chronotype", MC) or in the evening ("evening chronotype", EC). The latter, as well as vitamin D deficiency, has been associated with an increased risk of obesity-related complications, likely through the promotion of insulin resistance. Therefore, we aimed to investigate whether there is any relationship between vitamin D (25-OH-D) and chronotype in individuals with obesity.

METHODS

In this cross-sectional study, we enrolled 59 individuals (43.1 ± 13 years; 17M/42F) with obesity. Anthropometric parameters, lifestyle habits, personal medical history, chronotype, insulin resistance, and 25-OH-D were assessed.

RESULTS

Individuals with EC presented significantly higher BMI than MC (p < 0.001), greater waist (p = 0.012), and hip circumferences (p = 0.001). Individuals with EC showed significantly lower insulin sensitivity (p = 0.017) and 25-OH-D than MC. In addition, the prevalence of vitamin D deficiency and impaired fasting glucose was significantly higher in EC than in MC. 25-OH-D directly correlated with chronotype score (r = 0.351; p = 0.019) whereas inversely with BMI (r = - 0.363; p = 0.016). The regression analysis showed that BMI was most tightly associated with 25-OH-D concentrations (β = - 0.323, p = 0.032), followed by chronotype score (β = 0.340, p = 0.042). Using chronotype score as the dependent variable, BMI significantly predicted a lower chronotype score (β = - 0.586, p < 0.001).

CONCLUSION

The present study showed that 25-OH-D, as well as chronotype, correlate independently with obesity.

Liraglutide and polycystic ovary syndrome: is it only a matter of body weight?

Despite Polycystic Ovary Syndrome (PCOS) is a very prevalent disorder among women of reproductive age, there is widespread agreement that until now, no pharmacological options are available to tackle the entire spectrum of clinical manifestations encountered in the clinical practice. Obesity and insulin resistance, which commonly characterized this syndrome, prompted the design of studies investigating the effects of glucagon-like peptide 1 (GLP-1) receptor agonists (GLP-1RA) in PCOS. Indeed, a very impressive number of randomized controlled clinical trials (RCTs) and systematic reviews provided robust evidence on the effectiveness of GLP-1RA in PCOS as a new, appealing approach, producing both satisfactory and permanent weight loss, and improvement of insulin resistance at the same time. However, most of the subjects included in the RCTs are PCOS patients with obesity/overweight, whereas a portion of PCOS women, which can even reach 50%, might present a lean phenotype. Moreover, some benefits on clinical and metabolic features of PCOS may not have fully emerged due to the low or medium doses employed in the vast majority of the current studies. Thus, pitfalls in the methodology of these studies have led sometimes to misleading results. In addition, some aspects of GLP-1 beyond weight loss, such as preclinical evidence on GLP-1 effects in directly modulating the hypothalamus-pituitary-gonadal axis, or the effects of GLP-1RA on clinical and biochemical expression of hyperandrogenism, still deserve a greater insight, especially in light of a possible therapeutic use in PCOS women independently of obesity. Aim of this review is to further unravel the possible role of GLP-1 in PCOS pathogenesis, tempting to provide additional supports to the rationale of treatment with GLP-1RA in the management of PCOS also independent of weight loss. For this purpose, the outcomes of RCTs investigating in PCOS the anthropometric and metabolic changes have been treated separately to better underpin the effects of GLP-1 RA, in particular liraglutide, beyond weight loss.

Effects of very low-calorie ketogenic diet on hypothalamic-pituitary-adrenal axis and renin-angiotensin-aldosterone system

BACKGROUND

The hypothalamic-pituitary-adrenal (HPA) axis is a neuroendocrine system involved in controlling stress responses in humans under physiological and pathological conditions; cortisol is the main hormone produced by the HPA axis. It is known that calorie restriction acts as a stressor and can lead to an increase in cortisol production. Renin-angiotensin-aldosterone system (RAAS) is a complex endocrine network regulating blood pressure and hydrosaline metabolism, whose final hormonal effector is aldosterone. RAAS activation is linked to cardiometabolic diseases, such as heart failure and obesity. Obesity has become a leading worldwide pandemic, associated with serious health outcomes. Calorie restriction represents a pivotal strategy to tackle obesity. On the other hand, it is well known that an increased activity of the HPA may favour visceral adipose tissue expansion, which may jeopardize a successful diet-induced weight loss. Very low-calorie ketogenic diet (VLCKD) is a normoprotein diet with a drastic reduction of the carbohydrate content and total calorie intake. Thanks to its sustained protein content, VLCKD is extremely effective to reduce adipose tissue while preserving lean body mass and resting metabolic rate.

PURPOSE

The purpose of this narrative review is to gain more insights on the effects of VLCKD on the HPA axis and RAAS, in different phases of weight loss and in different clinical settings.

Short-time effects of ketogenic diet or modestly hypocaloric Mediterranean diet on overweight and obese women with polycystic ovary syndrome

INTRODUCTION

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women during reproductive age. It is characterized clinically by oligo-ovulation or anovulation, hyper-androgenism, and the presence of polycystic ovaries. Often comorbid with insulin resistance, dyslipidemia, and obesity, it also carries significant risk for the development of cardio-vascular and metabolic sequelae, including diabetes and metabolic syndrome. In light of these evidences, the most therapeutic option prescribed to PCOS women with obesity, regardless of the phenotype from the severity of clinical expression, is lifestyle correction by diet and physical activity.

PURPOSE

The aim of this study was to evaluate the association between PCOS with KD in overweight and/or obese women with PCOS, and evaluate the possible beneficial effects on metabolic and endocrine parameters, compared to a standard, balanced hypocaloric diet such as Mediterranean diet (MD).

METHODS

Participants were assigned to receive, in a 1:1 ratio, one of the two following dietary sequences: KD or MD. In all subjects anthropometric parameters, body composition and metabolic and endocrine parameters were obtained at baseline and after dietetic treatment.

RESULTS

Our results showed a significant change in the anthropometric and biochemical parameters in both groups after both diet therapies, with statistically significant differences (p < 0.001). Though, the reductions of all parameters were significantly greater in KD group than in MD group.

CONCLUSION

Our results suggest that a reduction of dietary intake of carbohydrates by KD may be considered as a valuable non-pharmacological treatment for PCOS.

Weight stigma speaks Italian, too

PURPOSE

Weight stigma is the negative weight related attitudes and beliefs towards individuals because of their overweight or obesity. Subjects with obesity are often victim of weight-related stigma resulting in a significant negative social consequence. As obesity epidemic is growing so fast, there is urgency to act on weight-stigma related social consequences being potentially serious and pervasive. This study investigated experiences, interpersonal sources, and context of weight stigma in Italy in a sample of adult subjects with obesity.

METHODS

An online questionnaire was distributed to respondents via a snowball sampling method among subjects with obesity belonging to Italian Associations for people living with obesity aged 18 years and above.

RESULTS

Four hundred and three respondents (47.18 ± 9.44 years; body mass index (BMI) 33.2 ± 8.48 kg/m²) participated to the study. Most respondents were females (94.8%). The age first dieted was 15.82 ± 7.12 years. The mean period of obesity was 27.49 ± 11.41 years. Frequency analyses reported that stigmatizing situations were experienced by 98% of participants: 94.82% during adulthood, 89.88% during adolescence and 75.39% during childhood. Verbal mistreatments (92.43%) was the most reported stigmatizing situation, strangers (92.43%) were the most common interpersonal sources of stigma and public settings (88.08%) were the most common location of stigma.

CONCLUSIONS

Identifying strategies acting on the identified weight stigma targets could contribute to reduce weight stigma and thus to result in important implications for obesity treatment in Italy.

Three-year trends in out-of-hospital cardiac arrest across the world: second report from the International Liaison Committee on Resuscitation (ILCOR)

BACKGROUND

The International Liaison Committee on Resuscitation (ILCOR) Research and Registries Working Group previously reported data on systems of care and outcomes of out-of-hospital cardiac arrest (OHCA) in 2015 from 16 national and regional registries. To describe the temporal trends with updated data on OHCA, we report the characteristics of OHCA from 2015 through 2017.

METHODS

We invited national and regional population-based OHCA registries for voluntary participation and included emergency medical services (EMS)-treated OHCA. We collected descriptive summary data of core elements of the latest Utstein style recommendation during 2016 and 2017 at each registry. For registries that participated in the previous 2015 report, we also extracted the 2015 data.

RESULTS

Eleven national registries in North America, Europe, Asia, and Oceania, and 4 regional registries in Europe were included in this report. Across registries, the estimated annual incidence of EMS-treated OHCA was 30.0-97.1 individuals per 100,000 population in 2015, 36.4-97.3 in 2016, and 40.8-100.2 in 2017. The provision of bystander cardiopulmonary resuscitation (CPR) varied from 37.2% to 79.0% in 2015, from 2.9% to 78.4% in 2016, and from 4.1% to 80.3% in 2017. Survival to hospital discharge or 30-day survival for EMS-treated OHCA ranged from 5.2% to 15.7% in 2015, from 6.2% to 15.8% in 2016, and from 4.6% to 16.4% in 2017.

CONCLUSION

We observed an upward temporal trend in provision of bystander CPR in most registries. Although some registries showed favourable temporal trends in survival, less than half of registries in our study demonstrated such a trend.

Impact of sex and role of coronary artery disease in out-of-hospital cardiac arrest presenting with refractory ventricular arrhythmias

Introduction

There are limited data on sex-related differences in out-of hospital cardiac arrests (OHCAs) with refractory ventricular arrhythmias (VA) and, in particular, about their relationship with cardiovascular risk profile and severity of coronary artery disease (CAD).

Purpose

Aim of this study was to characterize sex-related differences in clinical presentation, cardiovascular risk profile, CAD prevalence, and outcome in OHCA victims presenting with refractory VA.

Methods

All OHCAs with shockable rhythm that occurred between 2015 and 2019 in the province of Pavia (Italy) and in the Canton Ticino (Switzerland) were included.

Results

Out of 680 OHCAs with first shockable rhythm, 216 (33%) had a refractory VA. OHCA patients with refractory VA were younger and more often male. Males with refractory VA had more often a history of CAD (37% vs. 21%, p 0.03). In females, refractory VA were less frequent (M : F ratio 5 : 1) and no significant differences in cardiovascular risk factor prevalence or clinical presentation were observed. Male patients with refractory VA had a significantly lower survival at hospital admission and at 30 days as compared to males without refractory VA (45% vs. 64%, p < 0.001 and 24% vs. 49%, p < 0.001, respectively). Whereas in females, no significant survival difference was observed.

Conclusions

In OHCA patients presenting with refractory VA the prognosis was significantly poorer for male patients. The refractoriness of arrhythmic events in the male population was probably due to a more complex cardiovascular profile and in particular due to a pre-existing CAD. In females, OHCA with refractory VA were less frequent and no correlation with a specific cardiovascular risk profile was observed.

A comprehensive and easy-to-use ECG algorithm to predict the coronary occlusion site in ST-segment elevation myocardial infarction

BACKGROUND

Several electrocardiogram (ECG) criteria have been proposed to predict the location of the culprit occlusion in specific subsets of patients presenting with ST-segment elevation myocardial infarction (STEMI). The aim of this study was to develop, through an independent validation of currently available criteria, a comprehensive and easy-to-use ECG algorithm, and to test its diagnostic performance in real-world clinical practice.

METHODS

We analyzed ECG and angiographic data from 419 consecutive STEMI patients submitted to primary percutaneous coronary intervention over a one-year period, dividing the overall population into derivation (314 patients) and validation (105 patients) cohorts. In the derivation cohort, we tested >60 previously published ECG criteria, using the decision-tree analysis to develop the algorithm that would best predict the infarct-related artery (IRA) and its occlusion level. We further assessed the new algorithm diagnostic performance in the validation cohort.

RESULTS

In the derivation cohort, the algorithm correctly predicted the IRA in 88% of cases and both the IRA and its occlusion level (proximal vs mid-distal) in 71% of cases. When applied to the validation cohort, the algorithm resulted in 88% and 67% diagnostic accuracies, respectively. In a real-world comparative test, the algorithm performed significantly better than expert physicians in identifying the site of the culprit occlusion (P = .026 vs best cardiologist and P < .001 vs best emergency medicine doctor).

CONCLUSIONS

Derived from an extensive literature review, this comprehensive and easy-to-use ECG algorithm can accurately predict the IRA and its occlusion level in all-comers STEMI patients.

1105 VENTRICULAR FIBRILLATION SPECTRAL AREA (AMSA) AND LOW-ENERGY SHOCK SUCCESS PREDICTION IN PATIENTS WITH OUT-OF-HOSPITAL CARDIAC ARREST

Introduction

In case of cardiac arrest due to ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT), the optimal energy level for defibrillation is that which achieves defibrillation and minimize the current-induced myocardial damage. Therefore, it would be reasonable to reduce the energy level as well as the number of shocks. ECG-based VF waveform analysis features such as amplitude spectral area (AMSA) have been recently introduced as predictors of shock success but their predictivity for shock success with low energy level is not known.

We aimed to assess whether AMSA of VF is able to predict the efficacy of low energy level for defibrillation in out-of-hospital cardiac arrest (OHCA) patients.

Methods

All the OHCAs with at least one shockable rhythm occurred from January 2015 to December 2020 in the province of Pavia, Italy, were considered. AMSA values were calculated by retrospectively analyzing the data collected by the Corpuls 3 monitors/defibrillators and by using a 2-second-pre-shock ECG interval.

Results

Among 4619 OHCA, AMSA values and energy for defibrillation were documented in 791 shocks, of which 45% received a shock at low energy (&lt;= 150J) and 55% at high energy (&gt;150J).

The rate of efficacy between the two groups did not differ significantly (44% vs 38%, p=0.102), however in patients efficaciously treated with low energy, AMSA was higher compared to those efficaciously treated with high energy [13.2 mV·Hz (12.5-14.2) vs 10.8 (10.1-11.5), p&lt;0.001]. Moreover, AMSA was found to be different even when comparing ineffective shock at low energy with effective shock at high energy [(6.6 (4.6-10) vs 10.8 (8.1-13.8), p&lt;0.001] and similar when comparing ineffective shock at low and at high energy [6.6 (4.6-10) vs 6.3 (4.5-8.7), p=0.21].

By dividing AMSA values into three tertiles the rate of shock success at low energy was found to be different: [T1 (0.7-6.2) 4.2%; T2 (6.2-10.8) 13%; T3 (10.8-63.2) 42%, Chi squared p&lt;0.001 and p for trend &lt;0.001]. After correction for age, sex, amiodarone use, call to shock time, AMSA values corresponding to the third and second tertile were associated with higher probability of shock success compared with the values in the lowest tertile [T3 OR 15 (95%CI 7-30), p&lt; 0.001; T2 OR 3 (95%CI 1-7), p= 0.002].

Conclusion

Amplitude spectral area (AMSA) of VF is a predictor of shock success at low energy. This could be useful to optimize the choice of energy limiting the current related myocardial injury.

958 IMPACT OF CARDIAC SYMPATHETIC DENERVATION ON ELECTRICAL STORMS IN PATIENTS WITH CARDIOMIOPATHIES

Background

Cardiac Sympathetic Denervation (CSD) has been recently proposed for the treatment of refractory ventricular arrhythmias (VAs) in patients with cardiomyopathy (CMP). A multicentric American and Indian case series suggested a greater efficacy of bilateral denervation (BCSD), compared to the left-side only procedure (LCSD), albeit with the potential prize of an increased need for atrial pacing due to the right-side innervation of the sinus node. The impact of CSD on the risk of electrical storms (ES) in CMP has never been evaluated.

Aim

To describe our multicenter Italian experience with CSD in CMP patients with drug and/or catheter ablation refractory VAs, with a specific focus on ES incidence.

Methods

Thirty patients with CMP and refractory VAs underwent either LCSD or BCSD between April 2016 and June 2022. Among them, one patient received first LCSD and then right-side denervation due to ES recurrence after LCSD: to properly assess the risk of ES after LCSD and BCSD he was included in both groups with the corresponding follow-up, leading to 5 cases of LCSD and 26 cases of BCSD. All patients had a Video–Assisted Thoracoscopic Surgery (VATS), in 8 cases associated with the robotic technique. The main reason (3/5 cases, 60%) to perform LCSD instead of BCSD since the beginning was sinus bradycardia in single ICD lead recipients.

Results

87% of pts were male, the mean age was 56 ± 16 yrs and the mean LVEF 31± 12%; most (n=26, 85%) suffered non-ischemic cardiomyopathy and 37% were in NYHA functional class ≥3. Main indications for CSD were represented by refractory polymorphic/fast VAs (cycle length &lt;250 msec) in 60% of pts and by refractory monomorphic VAs episodes in the rest. Except for 5 patients (17%) with previous thyrotoxicosis, the majority were either on amiodarone (n=19, 63%) or on sotalol (n=3, 10%) before CSD and 53% had previously undergone ≥1 catheter ablation for VAs. The median follow-up (FU) after denervation was 15 months (IQR 5-42 months).

No major complication directly related to the procedure occurred. Overall, 11 patients (37%) either died during FU (n=8, 27%), mostly due to end-stage heart failure, or underwent heart transplant (n=3, 10%). After denervation, the percentage of patients with ES decreased from 77% to 40% (p&lt;0.01), while patients with appropriate shocks decreased from 100% to 60%. The antiarrhythmic benefit was even more pronounced among the 26 patients who received BCSD: ES incidence decreased from 85% to 39% (p&lt;0.01), appropriate shock incidence from 100% to 54% (p&lt;0.01), while no significant changes in ES and ICD shock incidence were observed after the few LCSD procedures (n=5). A NYHA class &lt;3 was associated with a trend toward a better response after BCSD (37% vs 54% incidence of ICD shock, p=0.05).

Conclusions

Our case series of CSD in cardiomyopathies represents the largest reported in Europe and the first ever to specifically evaluate the impact of denervation on electrical storms. The occurrence of electrical storm was more than halved by bilateral CSD confirming the powerful protective effect of BCSD also on this ominous phenomenon. The greater antiarrhythmic benefit observed among patients with better functional class suggests the opportunity to perform this procedure earlier on in the trajectory of patients with progressive heart failure.

Blocking nerves and saving lives: Left stellate ganglion block for electrical storms

Patients who present with electrical storms (ES) due to rapid recurrence of ventricular tachycardia/ventricular fibrillation represent major medical emergencies without easy solutions. Antiarrhythmic drugs have limited value, and ES need to be stopped quickly to prevent irreversible patient deterioration and death. Since the mid-1970s, we have provided the rationale for interrupting cardiac sympathetic nerves and evidence of its antifibrillatory action in different clinical settings. Slowly but progressively, from isolated clinical reports to small case series, increasing evidence has indicated that pharmacologic stellate ganglion block (SGB) is highly effective in interrupting ES. However, medical guidelines have largely ignored SGB, and few centers are prepared to perform SGB in actual emergencies. Our own experience shows that a direct anatomic approach that does not require echocardiographic assistance can be performed rapidly, thus saving time in highly critical patients. In this review, we retrace the evolution in our understanding of the mechanism of action of SGB, discuss the current approaches and their limitations, and review the correct indications that overcome still existing biases. Furthermore, we propose a practical solution to increase the availability of SGB to more patients by extending the number of centers where this approach can be rapidly implemented.

Ventricular fibrillation amplitude spectral area as a guide to deliver the optimal energy level for defibrillation

Introduction

In case of cardiac arrest due to ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT), the optimal energy should be the lowest energy effective to achieve defibrillation minimizing the current-induced myocardial damage. Therefore, it would be ideal to minimize the energy level as well as the number of shocks during resuscitation. ECG-based VF waveform analysis features such as amplitude spectral area have been recently introduced as predictors of shock success, but their predictivity for shock success with low energy level is not known.

Purpose

To assess whether amplitude spectral area (AMSA) of VF is able to predict the efficacy of low energy level defibrillation in out-of-hospital cardiac arrest (OHCA) patients.

Methods

All the OHCAs with at least one shockable rhythm that occurred from January 2015 to December 2020 were considered. AMSA values were calculated by retrospectively analyzing the data collected by the Corpuls 3 monitors/defibrillators and by using a 2-second-pre-shock ECG interval.

Results

Among 4619 OHCAs, resuscitation was attempted in 2982 (64%) and at least one shock was delivered in 697 (15%). AMSA values and defibrillation energy were available for 791 shocks, of which 45% received shock at low energy (&gt;150J) and 55% at high energy (&gt;150J). The rate of efficacy between the two groups was similar (44% vs 38%, p=0.102). However, in patients efficaciously treated with shock at low energy, AMSA was higher compared to those treated with shock at high energy [13.2 mV Hz (IQR 10.2–17) vs 10.8 mV Hz (IQR 8–13.8), p&lt;0.001]. Moreover, AMSA values were significantly different when comparing ineffective shock at low energy with effective shock at high energy [6.6 mV Hz (IQR 4.6–10) vs 10.8 mV Hz (IQR 8.1–13.8), p&lt;0.001] and similar when comparing ineffective shock at low and high energy [6.6 mV Hz (IQR 4.6–10) vs 6.3 mV Hz (IQR 4.5–8.7), p=0.21]. By dividing AMSA values into three tertiles, the rate of shock success at low energy was statistically different: [T1 (0.7–6.2 mV Hz) 4.2%; T2 (6.2–10.8 mV Hz) 13%; T3 (10.8–63.2 mV Hz) 42%; Chi-squared p&lt;0.001 and p for trend &lt;0.001]. After correction for age, sex, amiodarone use and call to shock time, AMSA values corresponding to the third and second tertile were associated with higher probability of shock success at low energy compared to the lowest tertile [T3 OR 15 (95% CI 7–30), p&lt;0.001; T2 OR 3 (95% CI 1–7), p=0.002].

Conclusion

Ventricular fibrillation amplitude spectral area is a predictor of shock success at a low energy level. This could be useful to optimize both time and dose-energy to patients, yielding the highest chance for successful defibrillation while reducing the number of futile shocks and thus limiting the total current myocardial energy as well as CPR interruptions.

Funding Acknowledgement

Type of funding sources: None.

Gender differences in amplitude spectral area (AMSA) of ventricular fibrillation in patients with out-of-hospital cardiac arrest

Introduction

Ventricular fibrillation (VF) Amplitude Spectral Area (AMSA) is a well-established predictor of successful defibrillation and return of spontaneous circulation (ROSC). Attending to the limited evidence on the topic, gender seems to affect AMSA, and higher values have been reported in females. The aim of this work was to investigate the effect of gender in AMSA values for patients suffering out-of-hospital cardiac arrest (OHCA).

Methods

We enrolled 4619 consecutive OHCA patients from January 2015 to December 2020 in the LombardiaCare Registry. We considered only those subjects with attempted cardio-pulmonary resuscitation (697 patients) and at least one shock delivered. A total of 250 patients were considered (40 F/ 210 M) with 830 shocks (100 F/ 730 M). AMSA values were computed for the ventricular fibrillation in the 2-s pre-shock interval of the ECG recorded by the Corpuls3 defibrillator (Corpuls, Kaufering, Germany).

Results

Female patients were older than male [median (IQR): 70.5 (62–72) vs 67 (55–75) years, p=0.01], with cardiac arrest more frequently at home (84% vs 76%, p=0.003), fewer shocks [2 (1–4) vs 4 (2–7), p=0.004] and higher percentage of success (53% vs 40%, p=0.009). On the contrary, cardiac arrest duration [ 58.7 (31–69) vs 57.6 (41.4–77.3) min, p=0.366] and the rate of ROSC (32% vs 33%, p=0.88) were similar in both groups.

Higher AMSA values were found in female patients [10.3 Hz-mV (6.6–13.5) vs 7.9 Hz-mV (5.2–12.1), p=0.0007]. At a multivariable analysis, after correction for witnessed status, bystanders CPR, amiodarone administration, age and call-to shock time, male sex was found to be independently associated with the probability of having low values of AMSA, below the median value of 8.3 Hz-mV [OR 2.15 (95% CI1.35–3.43), p=0.001].

Despite gender stratification ROC curve analysis confirmed AMSA as a predictor of shock success [AUC-F: 0.75 (95% CI 0.65–0.83), p&lt;0.001; AUC-M: 0.78 (95% CI 0.74–0.81)] and ROSC [AUC-F: 0.69 (95% CI 0.59–0.68), p=0.008; AUCM: 0.84 (95% CI 0.81–0.87)].

Conclusion

Female sex is related to higher AMSA values. As AMSA reflects the energetical status and the ATP levels in the myocardial cells during cardiac arrest, this difference may be due to lower incidence and lower severity of cardiac ischemic disease in women. AMSA remains a valid predictor of both shock success and ROSC for female and male patients. Further investigations are needed to support and comprehend these conclusions.

Funding Acknowledgement

Type of funding sources: None.

How arrhythmic risk changes over time in patients with low risk Brugada syndrome

Background

Brugada Syndrome (BrS) is an inherited disorder associated with an increased risk of sudden cardiac death (SCD) and is diagnosed by the presence of a Brugada type I ECG pattern, either spontaneous or drug-induced. A spontaneous ECG pattern is one of the two main risk factors for SCD, along with syncope. However, there is still no clear evidence on how and how often to screen patients with drug-induced BrS to detect a spontaneous ECG pattern, therefore allowing to reassess their arrhythmic risk.

Purpose

To determine how many subjects develop a spontaneous ECG pattern among a pool of patients with low risk BrS (drug-induced pattern without history of syncope at the time of diagnosis) observed through systematic ECG Holter monitoring.

Methods

We retrospectively collected data for all patients with low risk BrS treated at our center for at least 12 months between 2016 and 2021. Each patient was tested yearly with at least one 12-lead 24-hour ECG Holter monitoring with high precordial leads (V1-V2, V3-V4, V5-V6 respectively in 2nd, 3rd and 4th intercostal space parasternal left and right). In case of spontaneous pattern detection at two recordings, patients underwent electrophysiological study (EPS) and in case of inducible ventricular arrhythmias, implantable cardiac defibrillator (ICD) placement.

Results

We included 63 patients with low risk BrS. During a median follow-up of 48 months: 1 patient died for SCD (1.6%), 1 experienced syncope (1.6%) and 19 exhibited a spontaneous ECG pattern (30.2%). Of these 19 patients: 18 were males and 5 had a mutation of SCN5A; the average age at the time of spontaneous pattern detection was 48.1±11.5 years. The average number of ECG holters/per patient/per year was 1.1±0.6, the average number of ECG Holters until the detection of a spontaneous pattern was 3.3±1.8, whilst the average number of months in between the diagnosis and the detection of a spontaneous pattern was 43.2±41.1.

After the observation of a spontaneous pattern: 6 patients were excluded from further investigation (as they had already undergone EPS or refused), 1 was directly treated with ICD and 12 underwent EPS, 4 of whom consequently underwent ICD placement. Among these 5 patients who underwent ICD placement – 7.9% of the original 63 patients – we observed 1 appropriate ICD intervention (antitachycardia pacing), 1 inappropriate ICD shock and 1 ICD related complication.

Conclusions

In our population of patients with low risk BrS the detection of a spontaneous ECG pattern is the most common determinant of risk reclassification. Systematic ECG Holter monitoring disclosed the presence of a spontaneous ECG pattern in a relevant number of subjects, allowing to reassess their arrhythmic risk and indication for ICD placement. Our study stresses the importance of periodic evaluation of low risk BrS patients with ECG Holter monitoring and the need for further investigation to define the optimal monitoring strategy.

Funding Acknowledgement

Type of funding sources: None.

Amiodarone and ventricular fibrillation amplitude of spectral area in patients with out-of-hospital cardiac arrest. Is there an effect?

Background

The use of antiarrhythmic drug therapy is usually recommended in addition to defibrillation in shockable cardiac arrest. The role of the amplitude spectral area (AMSA) of ventricular fibrillation as a predictor of defibrillation efficacy has been established, but little is known about how amiodarone could affect AMSA values.

Purpose

The aim of our study was to evaluate whether the administration of amiodarone during resuscitation could affect AMSA and to verify if AMSA preserves its predictive role of shock success in OHCA patients treated with amiodarone.

Material

All the OHCAs with an attempted resuscitation and at least one shockable rhythm which occurred from January 2015 to December 2020 in the province of Pavia were considered. AMSA values were calculated by retrospectively analyzing the data collected by the Corpuls 3 monitors/defibrillators (Corpuls, Kaufering, Germany) used in the field and by considering a pre-shock interval of 2 seconds.

Results

Of 4619 OHCAs, 697 underwent attempted CPR with at least one shock delivered. Of these, AMSA was available on 250 patients (male 84%, median age 67 years), for a total of 830 shocks, of which 534 (64%) shocks were in patients receiving amiodarone. The success rate of each single shock was similar in the two groups (amiodarone 42% vs no amiodarone 41%, p=0.68). The AMSA median values were significantly lower in the amiodarone group as compared to the non-amiodarone group when shocks were delivered to patients older than 67 years old [median difference: 1.55 mV Hz (95% CI 0.6–2.5), p=0.0013] or receiving bystander CPR [median difference 0.9 mV Hz (95% CI 0.1–1.8), p=0.03] or after more than 33 minutes from the emergency call to each single shock [median difference: 0.91 mV Hz (95% CI 1.9–0.01), p=0.047]. AMSA value lower than the median (8.3 Hz mV) was associated with a lower probability of shock success (19% vs 64%, p&lt;0.001). According to a multivariate analysis corrected for age, sex, witnessed status, call to shock time and bystander CPR, the probability of having AMSA lower than the median was independently associated with the administration of amiodarone [OR 1.5 (95% CI 1.1–2.1) p=0.009]. At ROC curves analysis, amongst patients receiving amiodarone, AMSA was confirmed to be a predictor of both shock success and ROSC [AUC 0.755 (95% CI 0.72–0.79), p&lt;0.001 and AUC 0.826 (95% CI 0.79–0.86), p&lt;0.001 respectively], similarly to the general population [AUC 0.778 (95% CI0.75–0.81), p&lt;0.001; AUC 0.817 (95% CI 0.79–0.84), p&lt;0.001].

Conclusions

Amiodarone administration is independently associated with lower values of AMSA. This could justify the lack of benefit from amiodarone administration in term of defibrillation success which would be expected by the administration of an antiarrhythmic drug during the resuscitation. Moreover, AMSA maintains its predictive value for shock success and ROSC rate in patients receiving amiodarone as well as in the general population.

Funding Acknowledgement

Type of funding sources: None.

Anatomical-based percutaneous left stellate ganglion block in patients with refractory electrical storm: efficacy and safety

Background

The autonomic system plays a pivotal role in ventricular arrhythmogenesis. Percutaneous stellate ganglion block (PSGB) is a technique known since many years for analgesic purposes, which has recently proven its antiarrhythmic effect suitable for an emergency setting. However, evidences are limited and heterogeneous.

Purpose

To assess the efficacy and safety of PSGB performed with an anterior paratracheal approach using anatomical landmarks in consecutive patients with electrical storm refractory to conventional treatment.

Methods

Patients with electrical storm were consecutively enrolled from November 2017 to January 2022. Left PSGB (PLSGB) was performed after failure of at least one intravenous antiarrhythmic drug. Its repetition or a continuous infusion of the local anaesthetic were considered in selected cases. Clinical data, the characteristics of the block and the occurrence of complications were collected. The efficacy was evaluated by comparing the number of arrhythmias treated with ATP or DC-shocks by external or internal defibrillator in the hour before the block with that in the hour after the procedure. Per-patient efficacy was assessed by comparing the number of ATP/shocks in the 24 hours before the procedure with that in the 24 hours after the last procedure.

Results

28 patients were enrolled: 78% male, mean age 65.4±14.2 years; 9 with dilated cardiomyopathy, 8 with chronic ischemic heart disease, 7 with ST-elevation myocardial infarction, 2 with non-ST-elevation myocardial infarction, 1 with arrhythmogenic right ventricular dysplasia and 1 with drug intoxication; the average ejection fraction was 24.2±15%. A total of 44 PLSGBs were performed: 18 for ventricular tachycardia (VT), 11 for ventricular fibrillation (VF) and 15 for both VT and VF episodes; 7 on intubated patients, 3 in extracorporeal circulation, 7 in cardiogenic/septic shock, 22 on patients on single antiplatelet therapy, 7 on dual antiplatelet therapy, 25 on anticoagulant therapy. PLSGBs were performed during intravenous infusion of antiarrhythmics (amiodarone in 24, lidocaine in 27 procedures). The local anaesthetic used was lidocaine 200 mg in 16/44 PLSGB, bupivacaine 50 mg in 4/44 and both in 24/44. The per-procedure analysis showed a significant reduction of the number of ATP/shocks in the hour after PLSGB compared with the hour before [0 (0–0) vs 5 (1–8) p&lt;0.001]. Similarly, in the per-patient analysis, the number of ATP/shocks significantly decreased in the 24 hours after the PLSGB compared with that in the 24 hours before [0 (0–1.5) vs 6.5 (4.5–15.5) p&lt;0.001]. No complications occurred.

Conclusions

This is the largest case series so far in which PLSGB has proven to be highly effective and safe in the treatment of challenging patients with refractory electrical storm. Its safety and the exiguity of the equipment required for the anatomical approach make PLSGB a technique that can be easily performed by cardiologists at the bedside.

Funding Acknowledgement

Type of funding sources: None.

A comprehensive and easy-to-use ECG algorithm to predict the coronary occlusion site in ST-segment elevation myocardial infarction

Background

Several electrocardiogram (ECG) criteria have been proposed to predict the location of the culprit occlusion in specific subsets of patients presenting with ST-segment elevation myocardial infarction (STEMI).

Purpose

The aim of this study was to develop, through an independent validation of currently available criteria, a comprehensive and easy-to-use ECG algorithm, and to test its diagnostic performance and reliability in real-world clinical practice.

Methods

We analyzed ECG and angiographic data from 408 consecutive STEMI patients submitted to primary percutaneous coronary intervention, dividing the overall population into derivation (306 patients) and validation (102 patients) cohorts. In the derivation cohort, we tested &gt;60 previously published ECG criteria, using the decision-tree analysis to develop the algorithm that would best predict the infarct-related artery (IRA) and its occlusion level. We further assessed the new algorithm diagnostic performance and reliability in the validation cohort.

Results

In the derivation cohort, the algorithm correctly predicted the IRA in 91% of cases and both the IRA and its occlusion level (proximal vs. mid-distal) in 73% of cases. When applied to the validation cohort, the algorithm resulted in 90% and 69% diagnostic accuracies, respectively. In a real-world comparative test, the algorithm performed significantly better than expert physicians in identifying the site of the culprit occlusion (p=0.026 vs. best cardiologist and p&lt;0.001 vs.best emergency medicine doctor). The algorithm showed almost perfect reliability (Cohen's kappa 0.86) between a cardiologist and an ambulance paramedic.

Conclusions

Derived from an extensive literature review, this comprehensive and easy-to-use ECG algorithm can accurately predict the IRA and its occlusion level in all-comers STEMI patients.

Funding Acknowledgement

Type of funding sources: None.

Body composition and obstructive sleep apnoea assessment in adult patients with Prader-Willi syndrome: a case control study

INTRODUCTION

In Prader-Willi syndrome (PWS) adult patients, sleep-breathing disorders, especially obstructive sleep apnoea syndrome (OSAS), are very common, whose missed or delayed diagnosis can contribute to further increase cardiovascular morbidity and mortality.

PURPOSE

The aim of this cross-sectional study was to evaluate differences in sleep-breathing parameters obtained by overnight cardiorespiratory polygraphy in 13 adult PWS patients and 13 individuals with non-syndromic obesity as controls matched by age, sex, and BMI.

METHODS

In all subjects' anthropometric parameters, body composition using bioimpedance analysis and overnight cardiorespiratory monitoring parameters were obtained.

RESULTS

Ten (76.9%) PWS patients were diagnosed with OSAS, most notably nine (69.2%) and one PWS (7.7%) with mild and severe OSAS, respectively. Compared with the control group, PWS patients had evidence of higher apnoea-hypopnea index (AHI) (p = 0.04) and oxyhaemoglobin desaturation index (ODI) (p = 0.009). However, no differences were found between the two groups regarding OSAS categories or diagnosis of nocturnal respiratory failure. In the PWS group, there were no significant correlations among AHI, ODI and hypoxemia index (T90) and anthropometric measurements, fat mass (FM), and FM percentage (%). Conversely, in the control group, the sleep-related respiratory indices evaluated correlated positively with BMI, waist circumference, FM and FM%.

CONCLUSIONS

This study confirmed that AHI and ODI indices were worse in PWS than in age, sex and BMI-matched controls. The lack of their significant association with the anthropometric parameters and FM supported the existence of PWS-related mechanisms in OSAS pathophysiology that are independent of visceral obesity and FM.

Complete Revascularization and One-Year Survival with Good Neurological Outcome in Patients Resuscitated from an Out-of-Hospital Cardiac Arrest

Background. The survival benefit of complete versus infarct-related artery (IRA)-only revascularization during the index hospitalization in patients resuscitated from an out-of-hospital cardiac arrest (OHCA) with multivessel disease is unknown. Methods. We considered all the OHCA patients prospectively enrolled in the Lombardia Cardiac Arrest Registry (Lombardia CARe) from 1 January 2015 to 1 May 2021 who underwent coronary angiography (CAG) at the Fondazione IRCCS Policlinico San Matteo (Pavia). Patients’ prehospital, angiographical and survival data were reviewed. Results. Out of 239 patients, 119 had a multivessel coronary disease: 69% received IRA-only revascularization, and 31% received a complete revascularization: 8 during the first procedure and 29 in a staged-procedure after a median time of 5 days [IQR 2.5−10.3]. The complete revascularization group showed significantly higher one-year survival with good neurological outcome than the IRA-only group (83.3% vs. 30.4%, p < 0.001). After correcting for cardiac arrest duration, shockable presenting rhythm, peak of Troponin-I, creatinine on admission and the need for circulatory support, complete revascularization was independently associated with the probability of death and poor neurological outcome [HR 0.3 (95%CI 0.1−0.8), p = 0.02]. Conclusions. This observation study shows that complete myocardial revascularization during the index hospitalization improves one-year survival with good neurological outcome in patients resuscitated from an OHCA with multivessel coronary disease.

Cardiac arrest and coronavirus disease 2019

PURPOSE OF REVIEW

The impact of the coronavirus disease 2019 (COVID-19) on the cardiovascular system has been highlighted since the very first weeks after the severe acute respiratory syndrome coronavirus 2 identification. We reviewed the influence of COVID-19 pandemic on cardiac arrest, both considering those occurred out of the hospital (OHCA) and in the hospital (IHCA).

RECENT FINDINGS

An increase in OHCA incidence occurred in different countries, especially in those regions most burdened by the COVID-19, as this seems to be bounded to the pandemic trend. A change of OHCA patients' characteristics, with an increase of the OHCA occurred at home, a decrease in bystander cardiopulmonary resuscitation and automated external defibrillator use before Emergency Medical Service (EMS) arrival and an increase in non-shockable rhythms, have been highlighted. A dramatic drop in the OHCA patients' survival was pointed out in almost all the countries, regardless of the high or low-incidence of COVID-19 cases. Concerning IHCA, a reduction in survival was highlighted in patients with COVID-19 who sustained a cardiac arrest.

SUMMARY

Cardiac arrest occurrence and survival were deeply affected by the pandemic. Informative campaigns to the population to call EMS in case of need and the re-allocation of the prehospital resources basing on the pandemic trend are needed to improve survival.

Barriers associated with emergency medical service activation in patients with ST-segment elevation acute coronary syndromes

Many ST-segment elevation acute coronary syndrome (STEACS) patients fail to activate the Emergency Medical System (EMS), with possible dramatic consequences. Prior studies focusing on barriers to EMS activation included patients with any acute coronary syndrome (ACS) without representation of southern European populations. We aimed to investigate the barriers to EMS call for patients diagnosed for STEACS in Italy. A prospective, single-center, survey administered to all patients treated with primary percutaneous coronary intervention for STEACS in a tertiary hospital in northern Italy from 01/06/2018 to 31/05/2020. The questionnaire was filled out by 293 patients. Of these, 191 (65.2%) activated the EMS after symptoms onset. The main reasons for failing to contact EMS were the perception that the symptoms were unrelated to an important health problem (45.5%) and that a private vehicle is faster than EMS to reach the hospital (34.7%). Patients who called a private doctor after symptoms onset did not call EMS more frequently than those who did not and 30% of the patients who did not call the EMS would still act in the same way if a new episode occurred. Previous history of cardiovascular disease was the only predictor of EMS call. Information campaigns are urgently needed to increase EMS activation in case of suspected STEACS and should be primary focused on patients without cardiovascular history, on the misperception that a private vehicle is faster than EMS activation, and on the fact that cardiac arrest occurs early and may be prevented by EMS activation.

Impact of gender on survival of out-of-hospital cardiac arrest presenting with refractory ventricular arrhythmias and role of coronary artery disease

Funding Acknowledgements

Type of funding sources: None.

Introduction

Clinical presentation and outcome of out-of-hospital cardiac arrest (OHCA) presenting with shockable rhythm may vary between males and females. Very limited data exist on gender-related differences in OHCAs with refractory ventricular arrhythmias (VA) and, in particular, on distribution and prevalence of coronary artery disease (CAD).

Purpose

The aim of this study was to characterize gender-related outcome, prevalence and severity of CAD in OHCA victims presenting with shockable rhythm and refractory VA.

Methods

All OHCAs presenting with shockable rhythm occurred between 2015 and 2019 in the province of Pavia (Italy) and in the Canton Ticino (Switzerland) were included.

Results

Out of 3592 OHCAs, 685 presented with shockable rhythm and, of them, 212 had a refractory VA. Overall, male gender was independently associated with a lower probability of survival both at hospital admission and at 30-days (OR 0.63, 95% CI 0.58-0.67, p &lt;0.001 and OR 0.82 95% CI 0.74-0.91, p &lt;0.001, respectively) and presented with a more severe CAD. Male gender was 5-times more frequently associated with OHCA presenting with refractory VA. Despite of a more favourable OHCA presentation (i.e. more often OHCA witnessed, public place occurrence and CPR initiated by bystander) male patients with refractory VA had a lower likelihood of survival (OR 0.25, 95% CI 0.21-0.30). A higher prevalence (81%) of CAD was observed in OHCAs presenting with refractory VA but not a higher number of diseased vessels.

Conclusions

Male gender is more frequently associated with refractory VA, lower probability of survival and higher prevalence and severity of CAD. CAD severity, however, does not significantly affect refractory VA presentation.

Temporal trend of QRS voltage amplitude on surface sensing in patients with arrhythmogenic cardiomyopathy implanted with a subcutaneous ICD

Funding Acknowledgements

Type of funding sources: None.

Introduction

Previous studies have reported a significant decrease in ventricular sensing amplitude during follow-up in patients with arrhythmogenic cardiomyopathy (ACM) implanted with trans-venous implantable cardioverter defibrillator (ICD). No data are yet available on sensing amplitudes values over time for subcutaneous ICD (S-ICD). Low QRS voltage on surface ECG is one of the diagnostic clues in ACM. This, together with the progressive nature of the disease and the not-negligible incidence of inappropriate shocks due to oversensing, raise safety concerns on the use of S-ICD in this population.

Aim

The aim of this study was to evaluate the trend of QRS amplitude on subcutaneous ECG (S-ECG) over time in patients with ACM implanted with S-ICD.

Methods

We conducted a retrospective analysis on a cohort of consecutive patients with ACM implanted with S-ICD in two tertiary centers, prospectively enrolled in the home-monitoring program. The S-ECGs recorded by the S-ICD at the time of first and last data transmission were analyzed. The voltage amplitude was estimated for each QRS complex available, and the values obtained were compared between the two time points (i.e. baseline and last follow-up available). The primary endpoint of our study was the proportion of patients in which the decrease of QRS amplitude during follow-up was statistically significant.

Results

Eleven patients (1 female, 9%) were enrolled in this study. The mean age was 43±10 years. An exclusive right ventricular involvement was reported in 5 patients (46%), 2 patients (18%) had an exclusive left ventricular, and 4 (36%) a biventricular involvement. Three patients (27%) were implanted in secondary prevention. During a median follow-up of 9 months (IQR 6-17), 6 patients (55%, 95%CI 24-84%) experienced a statistically significant reduction in the S-ECG QRS amplitude (Figure A). Considering these 6 patients, the mean absolute reduction was -0.46±0.32 mV corresponding to a relative reduction of -19%±11%. Moreover, we found a statistically significant correlation between follow-up duration and QRS amplitude relative reduction (r=-0.89, p=0.018, Figure B). No patients experienced inappropriate shocks.

Conclusions

In a cohort of ACM patients implanted with S-ICD the majority of patients experienced a significant reduction in the amplitude of QRS voltage during follow-up, confirming a potential safety concern on the use of S-ICD in this population. Further studies are needed to investigate this issue.

C8 THE CEREBRAL PERFORMANCE CATEGORY IN THE DECISION–MAKING PROCESS OF IMPLANTING AN ICD IN OUT–OF–HOSPITAL CARDIAC ARREST SURVIVORS WITH BAD NEUROLOGICAL OUTCOME

Introduction

According to the European Society of Cardiology guidelines secondary prevention ICD implantation is a class I indication only for those patients with an estimated survival &gt; 1 year with a good functional status. However, it is not specified how to assess the functional status and its evaluation could be quite difficult in the case of out–of–hospital cardiac arrest (OHCA) survivors with major neurological outcomes. Cerebral Performance Category (CPC) is the most widespread scale to define the neurological and functional outcome of OHCA survivors, but it is not known if it can be used to guide ICD implantation.

Objective

To evaluate whether the presence of a bad neurological outcome (CPC &gt; 2) at discharged could be used as a prognostic index in order to evaluate the implantation of an ICD in OHCA survivors. Materials and Methods. We considered all the patients who had a cardiac arrest from 01/10/2014 to 30/09/2019 presenting a CPC&gt; 2 at discharge. The territory included was that of the Province of Pavia (550000 inhabitants) from 2014 to 2018 and of the Provinces of Pavia, Lodi, Cremona and Mantua (1550000 inhabitants) from 2019. We assessed the survival and the neurological status variation at 1–year.

Results

In the study period, CPR was attempted in 2998 confirmed OHCAs. 227 patients (7.6%) were discharged alive and in 218 of these, CPC was available. 51 patients (23.4%) had a CPC&gt;2 at discharge (22 CPC = 3, 24 CPC = 4 and 5 CPC = A). 1–year follow–up was available in 200 patients: among 158 alive, 12 (7.6%) had CPC&gt;2 (7 CPC = 3 and 5 CPC = 4). 1–year survival of patients with CPC&gt;2 at discharge was significantly lower those discharged with CPC≤2 (39.6% vs 91.6% p &lt; 0.001). Only 19/48 patients discharged with CPC&gt;2 survived at 1 year: a good cerebral performance was recovered in 6 patients (31.6%), while CPC&gt;2 persisted in 11 (58%) and the CPC value was unknown in 2 of them.

Conclusions

Our results highlight that 1–year survival is quite low in patients with CPC&gt;2 at discharge and that an improvement in cerebral performance occurs only in a minority of them. This evidence suggests the need for clinical re–evaluation after the event in order to carefully evaluate whether to implant an ICD in this kind of patients.

C26 COMPLETE REVASCULARISATION IMPROVES SURVIVAL OF PATIENTS RESUSCITATED AFTER AN OUT–OF–HOSPITAL CARDIAC ARREST

Background

Sudden cardiac death is a major issue in industrialised countries and survival of patients after out–of–hospital cardiac arrest (OHCA) remains low. Acute myocardial infarction (AMI) is the principal cause of OHCA and myocardial revascularisation plays a positive role on survival. In this setting little is known about the role of complete (CR) versus culprit–only revascularisation (IR) on survival.

Purpose

The aim of this study was to assess whether CR could lead to a better one–year survival as compared to IR. Methods. Among patients prospectively enrolled in the Lombardia CARe OHCA registry from January 1 2015 to May 1 2021, who underwent a coronary angiography (CAG) at the Fondazione IRCCS Policlinico San Matteo were enrolled in this study. CAGs were retrospectively reviewed by two interventional cardiologists. Prehospital and survival data were retrieved from the registry.

Results

We enrolled 239 patients [mean age 63.7±12.4 years; male 79.9%; shockable presenting rhythm 84.1%; AMI at post ROSC ECG 67.9%; ejection fraction 37% (30–45), circulatory support with ECMO 10.9%]. Among the 119 (50%) patients with multi–vessel disease, 82 (69%) received IR whereas 37 (31%) received CR [8 during the first procedure, 29 in a second procedure with a median time after OHCA of 5 (2.5–10) days]. This latter group showed significantly higher one–year survival (54.9% vs 16.2%, p &lt; 0.001). At univariable logistic regression only a shockable presenting rhythm and the presence of chronic total occlusion (CTO) were significantly associated with the probability of receiving a CR [OR 5.1 (95%CI 1.1–22), p = 0.03; OR 0.37 (95%CI 0.16–0.85), p = 0.02 respectively]. However, at multivariable regression analysis only CTO was significantly associated with the probability of receiving a CR [OR 0.36 (95%CI 0.15–0.9), p = 0.007]. At Cox multivariable regression model cardiac arrest duration (longer that the median value of 24 min) and CR were independently associated with the probability of death [HR 3.6 (95%CI 1.9–6.9), p &lt; 0.001; HR 0.2 (95%CI 0.1–0.9), p = 0.02]. Similarly, cardiac arrest duration, CR and a shockable presenting rhythm were associated with the probability of death or poor neurologic outcome [HR 3.3 (95%CI 1.8–6), p &lt; 0.001; HR 0.5 (95%CI 0.3–0.9), p = 0.03 and HR 0.2 (95%CI 0.1–0.5), p &lt; 0.001].

Conclusions

Complete revascularisation is independently associated with a better one–year survival in patients resuscitated from an out–of–hospital cardiac arrest.

C60 12–LEAD POST–ROSC ELECTROCARDIOGRAM DISCRIMINATES SURVIVAL TO HOSPITAL DISCHARGE. A SUB–ANALYSIS OF THE PEACE STUDY

Background

Once the return of spontaneous circulation (ROSC) after an out–of–hospital cardiac arrest (OHCA) is achieved in patients with an ST–elevation myocardial infarction, the acquisition of a 12–lead electrocardiogram (ECG) is strongly recommended in order to determine candidates for urgent coronary angiography. However, little is known so far about the association of ECG features and survival to hospital discharge in OHCA patients.

Methods

We analysed all the post–ROSC ECGs collected from January 2015 to December 2018 in three European centres (Pavia, Lugano and Vienna). For every ECG, the main features were analysed and filed in the database together with the pre–hospital data collected for every patient according to the Utstein style.

Results

We collected 370 ECGs: 287 males (77.6%); median age 62 years old (IQR 53–70 years); 121 from Pavia (32.7%), 38 from Lugano (10.3%) and 211 from Vienna (57.0%). In Cox univariable regression, age older than 62 years [HR 1.7 (95% IC 1.1–2.4), p = 0.007], QRS wider than 120 msec [HR 1.87 (95% IC 1.3–2.7), p &lt; 0.001], ST elevation in more than one segment [HR 1.7(95% IC 1.2–2.5),p=0.003], the presence of left bundle branch block (LBBB) [HR 1.7 (95% IC 1.1–2.9), p = 0.03] and a right bundle branch block [HR 1.8 (95% IC 1.1–2.8), p = 0.01] were all associated with death before hospital discharge. In multivariable Cox regression, adjusted for the ROSC–to–ECG time, age older than 62 years [HR 1.6 (95% IC 1.1–2.3), p = 0.01], QRS wider than 120 msec [HR 1.7 (95%IC 1.2–2.5), p = 0.004] and the presence of ST elevation in more than one segment [HR 1.7 (95%IC 1.2–2.5), p = 0.004] were independently associated with death before hospital discharge. By considering these latter three risk factors, the rate of survival to hospital discharge was significantly influenced by their number [no risk factor: 80.8%; 1 factor: 71.2%; 2 factors: 61.9%; 3 factors: 34.4%; p &lt; 0.001, p for trend &lt;0.001]. With a Cox regression model, considering the absence of risk factor as a reference, we confirmed that having 2 or 3 risk factors was significantly associated with death before hospital discharge [HR 1.9 (95%IC 1–3.5), p = 0.037 e HR 5.1(95%IC 2.6–10.1), p &lt; 0.001 respectively].

Conclusions

Our study confirms the central role of ECG in STEMI patients resuscitated after an OHCA and proves that post–ROSC ECG features can be used for both the selection of patients who may benefit from urgent coronary angiography as well as for prognostic stratifications.

P9 TEMPORAL TREND OF QRS VOLTAGE AMPLITUDE ON SURFACE SENSING IN PATIENTS WITH ARRHYTHMOGENIC CARDIOMYOPATHY IMPLANTED WITH A SUBCUTANEOUS ICD

Introduction

Previous studies have reported a significant decrease in ventricular sensing amplitude during follow–up in patients with arrhythmogenic cardiomyopathy (ACM) implanted with trans–venous implantable cardioverter defibrillator (ICD). No data are yet available on sensing amplitude values over time for subcutaneous ICD (S–ICD). Low QRS voltage on surface ECG is one of the diagnostic clues in ACM. This, together with the progressive nature of the disease and the not–negligible incidence of inappropriate shocks due to oversensing, raise safety concerns on the use of S–ICD in this population. The aim of this study was to evaluate the trend of QRS amplitude on subcutaneous ECG (S–ECG) over time in patients with ACM implanted with S–ICD.

Methods

We conducted a retrospective analysis on a cohort of consecutive patients with ACM implanted with S–ICD in two Italian tertiary centers, prospectively enrolled in the home–monitoring program. The S–ECGs recorded at the time of first and last data transmission were analyzed. The voltage amplitude was estimated for each QRS complex available, and the values obtained were compared between the two time points (i.e. baseline and last follow–up available). The primary endpoint of our study was the proportion of patients in which the decrease of QRS amplitude during follow–up was statistically significant.

Results

Eleven patients (1 female, 9%) were enrolled in this study. The mean age was 43±10 years. An exclusive right ventricular involvement was reported in 5 patients (46%), 2 patients (18%) had an exclusive left ventricular, and 4 (36%) a biventricular involvement. Three patients (27%) were implanted in secondary prevention. During a median follow–up of 9 months (IQR 6–17), 6 patients (55%, 95%CI 24–84%) experienced a statistically significant reduction in the S–ECG QRS amplitude (Fig. A). Considering these 6 patients, the mean absolute reduction was –0.46±0.32 mV corresponding to a relative reduction of –19%±11%. Moreover, we found a statistically significant correlation between follow–up duration and QRS amplitude relative reduction (r=–0.89, p = 0.018, Fig. B). No patients experienced inappropriate shocks.

Conclusions

In a cohort of ACM patients implanted with S–ICD the majority of patients experienced a significant reduction in the amplitude of QRS voltage during follow–up, confirming a potential safety concern on the use of S–ICD in this population. Further studies are needed to investigate this issue.

P30 CARDIAC ARRESTS IN SPORTS: WHAT IS DIFFERENT COMPARED TO OTHER PUBLIC PLACES?

Introduction

Cardiac arrests in sports can involve professional athletes, amateurs, but also spectators of sports competitions. Sports facilities are the only ones for which the current law provides for the presence of an automatic external defibrillator (AED) and trained personnel, unlike other public places (schools, work, street, station, general public buildings) where it is only recommended.

Objective

To compare patient characteristics, presentation rhythm, bystander cardiopulmonary resuscitation (CPR), AED use before emergency medical services (EMS) arrival, and return of spontaneous circulation (ROSC) longer than 30 seconds in the Utstein category of out–of–hospital cardiac arrests (OHCAs) in sports compared to events in other public places.

Materials and Methods

We considered all the OHCAs occurred from 01/01/2015 to 31/12/2020 in the provinces of Pavia, Lodi, Cremona, Mantua and Varese (2400000 inhabitants), excluding the OHCAs occurred at home, in long–term care facilities and witnessed by the EMS.

Results

During the study period, 22 OHCAs occurred in sports and 552 in other public places (school, work, street, station, public buildings). The age is similar in the two groups [sport 59 years (IQR 53.5–66.7) vs other 63 years (IQR 51–75), p = 0.2]. In sports, there is a trend in favor of shockable rhythms (13/22=59% vs 185/552=33%, p = 0.1). The percentage of CPR performed by bystanders in sports is significantly higher than in other public places (20/22=91% vs 299/552=54%, p = 0.003), as the bystander AED use (11/22=50% vs 64/552=12%, p &lt; 0.001) and bystander AED shock (7/22=31% vs 27/552=5%, p &lt; 0.001) before EMS arrival. A ROSC greater than 30 seconds was obtained in 59% of OHCAs in sports, with a statistically significant difference compared to events in other public places (13/22=59% vs 166/552=30%, p = 0.015).

Conclusions

During sports competitions there is a greater ability to intervene in case of cardiac arrest, which determines a higher probability of obtaining ROSC, although in terms of age or presentation rhythm the patients are comparable to OHCA victims in other places public. These results suggest the need for an AED and trained personnel in other public places as well.

Long-Term Outcome After Out-of-Hospital Cardiac Arrest: An Utstein-Based Analysis

Background: No data are available regarding long-term survival of out-of-hospital cardiac arrest (OHCA) patients based on different Utstein subgroups, which are expected to significantly differ in terms of survival. We aimed to provide the first long-term survival analysis of OHCA patients divided according to Utstein categories.

Methods: We analyzed all the 4,924 OHCA cases prospectively enrolled in the Lombardia Cardiac Arrest Registry (Lombardia CARe) from 2015 to 2019. Pre-hospital data, survival, and cerebral performance category score (CPC) at 1, 6, and 12 months and then every year up to 5 years after the event were analyzed for each patient.

Results: A decrease in survival was observed during the follow-up in all the Utstein categories. The risk of death of the “all-EMS treated” group exceeded the general population for all the years of follow-up with standardized mortality ratios (SMRs) of 23 (95%CI, 16.8–30.2), 6.8 (95%CI, 3.8–10.7), 3.8 (95%CI, 1.7–6.7), 4.05 (95%CI, 1.9–6.9), and 2.6 (95%CI, 1.03–4.8) from the first to the fifth year of follow-up. The risk of death was higher also for the Utstein categories “shockable bystander witnessed” and “shockable bystander CPR”: SMRs of 19.4 (95%CI, 11.3–29.8) and 19.4 (95%CI, 10.8–30.6) for the first year and of 6.8 (95%CI, 6.6–13) and 8.1 (95%CI, 3.1–15.3) for the second one, respectively. Similar results were observed considering the patients discharged with a CPC of 1–2.

Conclusions: The mortality of OHCA patients discharged alive from the hospital is higher than the Italian standard population, also considering those with the most favorable OHCA characteristics and those discharged with good neurological outcome. Long-term follow-up should be included in the next Utstein-style revision.