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

The management of the asymptomatic pre-excited patient largely hinges on risk stratification and individual patient considerations and choice. A high threshold to treat patients may lead to a small overall risk of death while a low threshold clearly leads to increased invasive testing and ablation with associated cost and procedural risk. A firm recommendation to uniformly assess all by electrophysiology study or, alternatively, reassure all is inappropriate and unjustified by data as reflected in the recent guideline recommendations. The use of noninvasive and invasive parameters to identify the potentially at-risk individual with surveillance for symptoms in those comfortable with this approach or ablation for those choosing this alternative for individual reasons remains the cornerstone of best practice.

Early Repolarisation - What Should the Clinician Do?

The early repolarisation (ER) pattern is a common ECG finding. Most individuals with the ER pattern are at minimal risk for arrhythmic events. In others, ER increases the arrhythmic risk of underlying cardiac pathology. Rarely ER syndrome will manifest as a primary arrhythmogenic disorder causing ventricular fibrillation (VF). ER syndrome is defined as syncope attributed to ventricular arrhythmias or cardiac arrest attributed to ER following systematic exclusion of other etiologies. Some ECG features associated with ER portend a higher risk. However, clinically useful risk-stratifying tools to identify the asymptomatic patient at high risk are lacking. Patients with asymptomatic ER and no family history of malignant ER should be reassured. All patients with ER should continue to have modifiable cardiac risk factors addressed. Symptomatic patients should be systematically investigated, directed by symptoms.

Asymptomatic Wolff-Parkinson-White Syndrome: Who Should Be Treated?

This article discusses the merits of electrophysiology study (EPS) and/or ablation for asymptomatic preexcitation Wolff-Parkinson-White (WPW) ECG pattern. Sudden deaths in asymptomatic patients are too few to merit broad screening and aggressive intervention. It also discusses the risks of ablation and the low predictive accuracy of EPS. When WPW is an incidental finding, the decision to proceed with investigation and ablation can be made considering patients' situations and preferences. An invasive strategy is targeted at patients concerned about the low risk of life-threatening arrhythmia as a first presentation after a discussion of the risks and benefits.

The Evaluation of a Borderline Long QT Interval in an Asymptomatic Patient

QT prolongation on resting electrocardiography (ECG) is common, and the clinician is often challenged by the dilemma of excluding acquired causes and recognizing potential congenital long QT syndrome (LQTS). The hallmark of LQTS is an abnormally long QT interval. However, a normal or borderline long QT interval may be observed in up to 50% of patients with LQTS because of the intermittent nature of QT prolongation. This review presents an approach to evaluating the asymptomatic patient with a borderline long QT interval, which incorporates a comprehensive clinical assessment, rest and provocative ECG testing, and genetic testing when appropriate.

Risk of Arrhythmia and Sudden Death in Patients With Asymptomatic Preexcitation

Background—

The incidence of sudden cardiac death (SCD) and the management of this risk in patients with asymptomatic preexcitation remain controversial. The purpose of this meta-analysis was to define the incidence of SCD and supraventricular tachycardia in patients with asymptomatic Wolff-Parkinson-White ECG pattern.

Methods and Results—

We performed a systematic search of prospective, retrospective, randomized, or cohort English-language studies in EMBASE and Medline through February 2011. Studies reporting asymptomatic patients with preexcitation who did not undergo ablation were included. Twenty studies involving 1869 patients met our inclusion criteria. Participants were primarily male with a mean age ranging from 7 to 43 years. Ten SCDs were reported involving 11 722 person-years of follow-up. Seven studies originated from Italy and reported 9 SCDs. The risk of SCD is estimated at 1.25 per 1000 person-years (95% confidence interval [CI], 0.57–2.19). A total of 156 supraventricular tachycardias were reported involving 9884 person-years from 18 studies. The risk of supraventricular tachycardia was 16 (95% CI, 10–24) events per 1000 person-years of follow-up. Children had numerically higher SCD (1.93 [95% CI, 0.57–4.1] versus 0.86 [95% CI, 0.28–1.75]; P =0.07) and supraventricular tachycardia (20 [95% CI, 12–31] versus 14 [95% CI, 6–25]; P =0.38) event rates compared with adults.

Conclusion—

The low incidence of SCD and low risk of supraventricular tachycardia argue against routine invasive management in most asymptomatic patients with the Wolff-Parkinson-White ECG pattern.

Treatment of asymptomatic catecholaminergic polymorphic ventricular tachycardia

Catecholaminergic polymorphic ventricular tachycardia is a rare genetic disorder caused by mutations in genes involved in the intracellular calcium homeostasis of cardiac cells. Affected patients typically present with life-threatening ventricular arrhythmias precipitated by emotional/physical stress. The diagnosis is based on the demonstration of polymorphic or bidirectional ventricular tachycardia associated with adrenergic stress. Genetic testing can be confirmatory in some patients. Treatment for catecholaminergic polymorphic ventricular tachycardia includes medical and surgical efforts to suppress the effects of epinephrine at the myocardial level and/or modulation of calcium homeostasis. Mortality is high when untreated and sudden cardiac death may be the first manifestation of the disease. First-degree relatives of a proband should be offered genetic testing if the causal mutation is known. If the family mutation is not known, relatives should be clinically evaluated with provocative testing. In the absence of rigorous trials, prophylactic treatment of the asymptomatic catecholaminergic polymorphic ventricular tachycardia patient appears to reduce morbidity and mortality.

Role for the left atrial appendage occlusion device in managing thromboembolic risk in atrial fibrillation

Only 50% of patients who would benefit from warfarin therapy for atrial fibrillation (AF) receive treatment because of clinical concerns regarding chronic anti-coagulation. Percutaneous strategies to treat AF, including pulmonary vein isolation with a curative intent or atrioventricular nodal ablation and implantation of a permanent pacemaker for palliative rate control, have not eliminated the need to manage thromboembolic risk. With the development of a percutaneous left atrial appendage (LAA) occlusion device (the WATCHMAN percutaneous left atrial appendage occluder - Atritech Inc., Plymouth, MN, USA) for thromboembolic protection in non-valvular AF a significant therapeutic option for select patients may be available. We present the first case performed in Australia (24 November 2009) and explore this new methodology.

KCNJ2 variant of unknown significance reclassified as long QT syndrome causing ventricular fibrillation

KCNJ2 is the only gene implicated in Andersen-Tawil syndrome. Sudden cardiac arrest is rare in Andersen-Tawil syndrome. However, sudden cardiac arrest is often the index presentation in other forms of long QT syndrome. We present an unreported variant in the KCNJ2 gene, associated with long QT syndrome, that presented with ventricular fibrillation. Exercise testing and adrenaline infusion were useful in assigning pathogenicity to this variant of unknown significance.

Left ventricular ejection fraction and absence of ACE inhibitor/angiotensin II receptor blocker predicts appropriate defibrillator therapy in the primary prevention population

INTRODUCTION

Implantable cardioverter defibrillators (ICD) significantly reduce mortality in patients with left ventricular (LV) dysfunction. However, little is known of the predictors of appropriate device activation in the primary prevention population. The aim of the present study was to determine predictors of appropriate device therapy in patients receiving ICDs for primary prevention.

METHODS & RESULTS

One hundred twenty-six patients with a left ventricular ejection fraction (LVEF) of < 35% and no prior documented ventricular arrhythmias underwent ICD implantation. The ICD implanted was single chamber in 60 (48%), dual chamber in 10 (8%), and biventricular in 56 (44%) patients and programmed with a single ventricular fibrillation (VF) zone at >180 beats per minute. Mean age was 58 +/- 13 years and mean LVEF was 23 +/- 7%. Fifty-two percent had ischemic cardiomyopathy and 66% were New York Heart Association heart failure class II/III. During a mean follow-up period of 589 +/- 353 days, 17 (13%) patients received appropriate device therapy and three (4%) received inappropriate shocks. Appropriate ICD therapy was associated with reduced LVEF (mean 19.9% vs 23.7%, P = 0.02) and the patients were less likely to have received angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blockers (AIIRB) (65% vs 90%, P = 0.04). Multivariate analysis revealed lack of ACEI/AIIRB (odds ratio [OR]= 0.06, 95% confidence interval [CI]= 0.01-0.37, P = <0.01) and lower LVEF (OR = 0.88, 95% CI 0.79-0.98, P = 0.02) predicted appropriate device activation. There was no difference in transplant-free survival between the appropriate therapy and no/inappropriate therapy groups, LVEF <20% and LVEF >20% group, and lack of ACEI/AIIRB and ACEI/AIIRB group.

CONCLUSION

Appropriate device activation occurred in 13% of patients in a primary prevention population. LVEF and absence of ACEI/AIIRB predicted appropriate ICD therapy.

A model of cell cycle behavior dominated by kinetics of a pathway stimulated by growth factors

A modified version of a previously developed mathematical model [Obeyesekere et al., Cell Prolif. (1997)] of the G1-phase of the cell cycle is presented. This model describes the regulation of the G1-phase that includes the interactions of the nuclear proteins, RB, cyclin E, cyclin D, cdk2, cdk4 and E2F. The effects of the growth factors on cyclin D synthesis under saturated or unsaturated growth factor conditions are investigated based on this model. The solutions to this model (a system of nonlinear ordinary differential equations) are discussed with respect to existing experiments. Predictions based on mathematical analysis of this model are presented. In particular, results are presented on the existence of two stable solutions, i.e., bistability within the G1-phase. It is shown that this bistability exists under unsaturated growth factor concentration levels. This phenomenon is very noticeable if the efficiency of the signal transduction, initiated by the growth factors leading to cyclin D synthesis, is low. The biological significance of this result as well as possible experimental designs to test these predictions are presented.

Pharmacologic management of tachycardia

BACKGROUND

Cardiac arrhythmias may present with palpitations, chest pain, shortness of breath, dizziness and syncope. Diagnosis may be complicated by an inability to document the arrhythmia particularly when symptoms are infrequent and short lived.

OBJECTIVE

This article aims to provide an overview of the pharmacological management of supraventricular tachycardia including atrial flutter and haemodynamically stable ventricular tachycardia. Management of atrial fibrillation is discussed in a companion article in this issue.

DISCUSSION

Antiarrhythmic medications are effective in reducing symptoms, however, side effects are frequent. Fortunately nonpharmacological strategies such as catheter ablation have evolved which offer long term cure in the majority of patients. However, despite technological advances, pharmacotherapy retains an important place in the therapeutic approach to cardiac arrhythmias in many patients. It is important to remember that pharmacological management should also address any underlying cardiac disease process.

A mathematical model of haemopoiesis as exemplified by CD34 cell mobilization into the peripheral blood

A mathematical model for the kinetics of haemopoietic cells, including CD34+cells, is proposed. This minimal model reflects the known kinetics of haemopoietic progenitor cells, including peripheral blood CD34+ cells, white blood cells and platelets, in the presence of granulocyte colony-stimulating factor. Reproducing known perturbations within this system, subjected to granulocyte colony-stimulating factor treatment and apheresis of peripheral blood progenitor cells (CD34+ cells) in healthy individuals allows validation of the model. Predictions are made with this model for reducing the length of time with neutropenia after high-dose chemotherapy. Results based on this model indicate that myelosuppressive treatment together with infusion of CD34+ peripheral blood progenitor cells favours a faster recovery of the haemopoietic system than with granulocyte colony-stimulating factor alone. Additionally, it predicts that infusion of white blood cells and platelets can relieve the symptoms of neutropenia and thrombocytopenia, respectively, without drastically hindering the haemopoietic recovery period after high dose chemotherapy.

A mathematical model for cell density and proliferation in squamous epithelium after single-dose irradiation

PURPOSE

To establish a mathematical model describing changes in cell density in squamous epithelia induced by single-dose irradiation. Detailed data from previous studies in mouse tongue epithelium have been used for this study.

MATERIALS AND METHODS

The major mechanisms of the epithelial regeneration response, i.e. loss of division asymmetry and accelerated proliferation of stem cells, in combination with residual, abortive proliferation of sterilized cells, have been included in a tissue compartment model. These phenomena have been incorporated via three parameters; T(delay), the duration of the cell cycle block; T(min), the minimum stem cell cycle time due to acceleration; and T(stop), the duration of abortive proliferation. The compartments introduced in the model are normal stem cells, S1; sterilized stem cells, S2; and post-mitotic, functional cells, F. The flux rats between the tissue compartments were defined by autoregulation of the stem cell population, and by overall cell numbers. The model was applied to fit experimental data on changes in oral mucosal cell density after single-dose exposure with 13 and 20 Gy. The best-fit sets of parameters were identified by L2 norm error analysis based on the total cell count.

RESULTS

For 13 Gy, the best fit was achieved with T(min) = 1.0 days, T(delay) = 1.2 days and T(stop) = 7.5 days. For 20 Gy, the parameters were, T(min) =0.7 days, T(delay)= 1.0 days and T(stop) =9.5 days. In both data sets, T(min) was the most influential parameter. The resulting fluctuations in stem cell numbers were in good accordance with changes in radiation tolerance after 13 Gy.

CONCLUSIONS

The model can be used to define dose-dependent parameters describing the morphological response of squamous epithelia to single-dose irradiation. Based on these parameters, post-irradiation fluctuations in radiosensitivity can be predicted. For developing more complex and reliable mathematical models, which could incorporate transit divisions or fractionated radiotherapy, further experimental data at various dose levels are required.

A mathematical model of the regulation of the G1 phase of Rb+/+ and Rb-/- mouse embryonic fibroblasts and an osteosarcoma cell line

A mathematical model integrating the roles of cyclin D, cdk4, cyclin E, cdk2, E2F and RB in control of the G1 phase of the cell cycle is described. Experimental results described with murine embryo fibroblasts (MEFs), either Rb+/+ or Rb-/-, and with the RB-deficient osteosarcoma cell line, Saos-2, served as the basis for the formulation of this mathematical model. A model employing the known interactions of these six proteins does not reproduce the experimental observations described in the MEFs. The appropriate modelling of G1 requires the inclusion of a sensing mechanism which adjusts the activity of cyclin E/cdk2 in response to both RB concentration and growth factors. Incorporation of this sensing mechanism into the model allows it to reproduce most of the experimental results observed in Saos-2 cells, Rb-/- MEFS, and Rb+/+ MEFs. The model also makes specific predictions which have not been tested experimentally.

A model of the G1 phase of the cell cycle incorporating cyclin E/cdk2 complex and retinoblastoma protein

A mathematical model of cyclin E, cdk2 and retinoblastoma protein control of the G1 phase of the human cell cycle is proposed. The model includes retinoblastoma (Rb) protein phosphorylation by a cyclin E/cdk2 complex and its subsequent dephosphorylation at the end of the cell cycle. The numerical solutions to this model demonstrates the cyclic behavior of the cyclin E/cdk2 complex, with and without Rb function, cell cycle. This model suggests an inhibition of cyclin E/cdk2 complex formation (or its activation) by hypophosphorylated retinoblastoma protein. The experimental results of cell cycle arrest upon injection of transforming growth factor-beta, alpha-interferon or D-erythro-sphingosine during G1 phase are reproduced. Cell cycle behavior predicted by this model for increasing the concentration of hypophosphorylated retinoblastoma protein during the G1 phase is discussed. Additional results are obtained by numerical simulation.

A model for regulation of the cell cycle incorporating cyclin A, cyclin B and their complexes

A mathematical model for the cell cycle is proposed that incorporates the known biochemical reactions involving both cyclin A and cyclin B, the interactions of these cyclins with cdc2 and cdk2, and the controlling effects of cdc25 and weel. The model also postulates the existence of an as yet unknown phosphatase involved in the formation of maturation promoting factor. The model produces solutions that agree qualitatively with a wide variety of experimentally observed cell-cycle behaviour. Conditions under which the model could explain the initial rapid divisions of embryonic cells and the transition to the slower somatic cell cycle are also discussed.

Mathematical models for the cellular concentrations of cyclin and MPF

Several mathematical models have been proposed for regulation of the cell cycle in early embryos by cyclin and maturation-promoting factor (MPF). In this paper the previously proposed models for cyclin and MPF activity are analyzed, and the validity of those models based on the mathematical behavior of their solutions and on physical considerations are discussed. In addition, three further models are proposed that exhibit the periodic behavior necessary for modeling the mitotic clock but that do not have certain of the limitations of the other models.