Arrhythmia Burden In Patients Research Articles

Cardiac arrhythmias during and after thoracic irradiation for malignancies

BackgroundCardiac arrhythmia has been reported as a significant complication of thoracic radiotherapy. Both bradyarrhythmias and tachyarrhythmias have been reported, highlighting the arrhythmia-modulating potential of radiation in certain oncologic therapies. This study aimed to analyse the arrhythmic burden in patients with cardiac implantable electrical devices (CIEDs) undergoing thoracic irradiation, examining both immediate effects of radiotherapy and long-term sequelae post-therapy.Methods and resultsA retrospective cohort study was conducted involving patients with CIEDs who received thoracic radiotherapy between January 2012 and December 2022. Two distinct analyses were performed involving (1) daily CIED follow-ups during radiotherapy and (2) long-term arrhythmic outcomes post-therapy. For long-term outcomes, Patients were matched in a 1:2 ratio with non-irradiated controls based on age, sex, cardiovascular risk factors, cardiac disease, and beta-blocker use. Statistical analyses included negative binomial regression and propensity score matching. A total of 186 patients underwent daily CIED monitoring during radiotherapy, with 79 receiving thoracic irradiation. Thoracic irradiation was negatively associated with atrial arrhythmia (OR 0.11 [0.02;0.70, 95% CI], adjusted p = 0.0498) and there was a tendency towards less ventricular events (OR 0.14 [0.02;1.41, 95% CI], adjusted p = 0.3572) during radiotherapy in a univariate regression analysis. This association was not significant in the multivariate (OR 0.44 [0.10;1.80, 95%-CI], p = 0.16) model including a history of atrial fibrillation, diabetes and beta-blocker use. Coronary artery disease was associated with an increase in atrial and ventricular arrhythmia. For the long-term analysis, 122 patients were followed up after thoracic (N = 33) and non-thoracic radiation (N = 89) and compared to 244 matched controls drawn from approximately 10.000 CIED-patients. There was no significant increase in arrhythmic events compared to controls over a median follow-up of 6.6 months. A previous history of ventricular or atrial arrhythmic events was the strongest predictor for events during the follow-up.ConclusionThoracic radiotherapy can be safely administered in patients with CIEDs. However, patients with a history of arrhythmia are more prone to arrhythmic events during and after radiation. These findings highlight the need for personalized arrhythmia management strategies and further research to understand the mechanisms underlying the antiarrhythmic effects of thoracic radiation.Graphical

Arrhythmia burden in patients with congenital heart disease

Abstract Background The prevalence of congenital heart defects (CHD) is rising. Many patients experience arrhythmias either due to the defect itself or necessary intervention. Sudden onset of arrhythmia poses grave risks such as heart failure, stroke, or cardiac death. Research gaps exist regarding high-risk defects, age susceptibility, and prognostic implications of arrhythmia. Purpose Delineate the burden of arrhythmias in patients with CHD. Methods Patients born in the period 1970-2017 and diagnosed with CHD were identified in Swedish nationwide medical registries. Each patient was matched by birthyear and sex with ten controls from the general population. Cox proportional hazard regression model and Fine-Gray regression model with death as competing risk were used to compute risk (hazard ratio [HR]) and cumulative incidence of arrhythmias (supraventricular and ventricular arrhythmias). Estimates were compared with the matched controls. Follow-up started at time of birth. Results We included 63,559 patients and 583,205 matched controls with median follow-up of 12.8 years. Almost two-thirds of the total CHD population were born after year 2000 and 89% (n=56,564) had a simple lesion (defined as atrial or ventricular septal defect, coarctation of the aorta or malformation of the heart valves). During follow-up, 1,632 events of arrhythmia (90% of supraventricular origin) were registered in the population of patients with CHD, yielding an incidence rate of 16.4 per 10,000 person-years (versus 1.6 in the control population). The cumulative incidence of arrhythmias in the total CHD population was slightly increased during childhood compared with the control population, but rose significantly hereafter, illustrated in Figure 1, yielding an overall risk of 10.5 (CI 95%: 9.8-11.2). Stratified by lesion severity, the risk for arrhythmias was 8.7 (CI 95%: 7.6-8.7) and 30.4 (CI 95%: 26.2-35.2) in patients with simple and complex lesions, respectively. Patients with simple CHD lesions displayed a risk of 7.7 (95% CI: 7.1-8.4) for supraventricular arrhythmias and 11.5 (95% CI: 9.2-14.5) for ventricular arrhythmias. Correspondingly, patients with complex CHD lesions displayed risks of 66.7 (95% CI: 42.7-104.2) and 28.9 (95% CI: 24.8-33.6). Conclusion Arrhythmias, irrespective of origin, are common in patients with CHD and correlate with lesion severity. The overall burden of arrhythmias increased significantly after childhood. Meticulous follow-up is vital in order to prevent, detect and treat arrhythmias as it might trigger clinical deterioration and even sudden cardiac death in patients with CHD.

Magnetic Resonance-Guided StereotacticRadioablation for SeptalVentricular Tachycardias.

Stereotactic arrhythmia radioablation (STAR) was introduced to treat ventricular tachycardia (VT) refractory to catheter ablation. No data are now available in the septal VT substrate setting, representing a challenge when using conventional techniques. This study sought to evaluate the arrhythmic burden in patients with septal VT treated with magnetic resonance-guided STAR (MRgSTAR). We enrolled consecutive patients with septal VT substrate. The therapy target was achieved by combining anatomic/functional and electrophysiologic information. Patients were treated with a single fraction of 25Gy adopting MRgSTAR. All patients were clinically followed up, and all implantable cardiac devices were remotely monitored. The efficacy outcome included recurrences of any sustained VT beyond the 6-week blanking period after MRgSTAR. The safety outcome was the incidence of adverse events and atrioventricular block. We included 11 patients with septal substrate VT (median age: 68 years; Q1-Q3: 64.5-78 years; 100% male). Clinical presentation was an electrical storm in 81.8% of patients. No complications occurred after MRgSTAR, and 6(54.5%) patients were discharged on the same day of treatment. During a mean follow-up of 12 ± 6months, the efficacy outcome occurred in 3 (27.3%) cases. A significative reduction of implantable cardioverter-defibrillator (ICD) therapy (23.6 before MRgSTAR vs 1.7 after MRgSTAR; P< 0.001) was observed. Left ventricular ejection fraction increased significantly after treatment (38% [Q1-Q3: 33.5%-42.0%] before MRgSTAR vs 43.8% [Q1-Q3: 35%-47%] after MRgSTAR; P=0.04). No adverse effects were observed in the implantable cardioverter-defibrillator and lead system; in the 7 patients with preserved atrioventricular conduction, no atrioventricular block was reported. MRgSTAR represents a safe and effective strategy for treating septal VT.

Ertugliflozin to Reduce Arrhythmic Burden in Patients with ICDs/CRT-Ds

BackgroundSodium–glucose cotransporter 2 inhibitors (SGLT2is) have beneficial pleiotropic effects, contributing to improved cardiovascular and renal outcomes for patients with and without diabetes. The impact of SGLT2is on arrhythmic burden remains largely unexplored through randomized trials.MethodsIn this multicenter, double-blind, randomized, placebo-controlled trial, we investigated the effects of ertugliflozin on arrhythmic burden among patients with heart failure with an ejection fraction less than 50%. All patients had an implantable cardioverter–defibrillator (ICD) with or without a cardiac resynchronization therapy device (CRT-D) and were randomized (1:1) to receive either ertugliflozin 5 mg once daily or placebo. The primary end point was the number of incident sustained (>30 seconds) ventricular tachycardia or ventricular fibrillation events from baseline to week 52. Secondary end points included the total number of non-sustained ventricular tachycardias, appropriate ICD therapies, changes in N-terminal pro-brain–type natriuretic peptide (NTproBNP) levels, and the number of heart failure hospitalizations.ResultsRandomization was prematurely terminated, after class IA guideline recommendations were published for SGLT2is in patients with heart failure regardless of the ejection fraction. The final analysis included 46 patients (11% of the originally planned sample size). The yearly rate of the primary end point was 3.5 (95% confidence interval [CI] 2.8 to 4.4) with ertugliflozin compared with 13.3 with placebo (95% CI 11.8 to 14.8; rate ratio 0.16, 95% CI 0.04 to 0.61; P<0.001). There were no apparent differences in appropriate ICD therapies, hospitalizations, NTproBNP levels, or predefined adverse and serious adverse events.ConclusionsErtugliflozin reduced sustained ventricular tachycardia or ventricular fibrillation events in adults with heart failure and an ICD compared with placebo; however, our trial ended early and thus results should be interpreted with caution. (Funded by Investigator-initiated Studies Program of Merck Sharp & Dohme Corp and Pfizer; EudraCT number, 2020-002581-14; ClinicalTrials.gov number NCT04600921.)

Ventricular arrhythmia outcomes in hypertrophic cardiomyopathy from a high level myectomy centre

Abstract Background The presence of ≥15% late gadolinium enhancement (LGE) on cardiac magnetic resonance imaging (MRI) is used as a prognostic indicator for sudden cardiac death in patients with hypertrophic cardiomyopathy (HCM). [1] According to the European Society of Cardiology clinical practice guidelines (2014), septal myectomy is only indicated for symptomatic relief from left ventricular outflow tract obstruction (LVOTO) that is refractory to medical therapy, provided LVOTO gradient ≥ 50 mmHg. [2] At present, there is scarce data correlating the burden of ventricular arrhythmia and sudden cardiac death with LGE percentage or showing benefit of myectomy in reducing the burden of the same. Purpose We aimed to compare the burden of ventricular arrhythmia burden in patients with HCM who underwent septal myectomy compared with those who did not. Methods Adult patients with HCM followed in the advanced heart failure outpatient clinic at Allegheny General Hospital were included in this study. All included patients had cardiac MRI with LGE quantification and data related to cardiac events through devices placed for various indications (such as evaluation of reported palpitations, established supraventricular tachycardia, implantable cardioverter-defibrillator for primary or secondary prevention). Patients were divided into 2 groups: those undergoing myectomy (post myectomy group) and those that did not undergo myectomy (non-myectomy group). Chi square test was used to calculate incidence of premature ventricular contractions (PVCs), non-sustained ventricular tachycardia (NSVT) and sustained ventricular tachycardia (SVT) in the non-myectomy and post myectomy group. Results 76 patients with HCM (interventricular septal thickness ≥1.5 cm and LGE positive) longitudinally followed in the Allegheny General Hospital advanced heart failure outpatient clinic from 2016 to 2022 were included. 37 patients underwent septal myectomy. Baseline characteristics of post myectomy and non-myectomy group were matched and are listed in table 1. Left ventricular mass index was expectedly higher in patients undergoing myectomy. LGE was quantified on cardiac MRI prior to myectomy (mean 16.4% in myectomy group, 14.6% in non-myectomy group). Burden of ventricular arrhythmia (PVCs, NSVT and SVT) was found to be significantly lower in the post myectomy group (n=13, 44.83%) compared to the non-myectomy group (n=36, 92.31%). None of the patients included were noted to have ventricular fibrillation or sudden cardiac death. Conclusion Septal myectomy may reduce the incidence of ventricular arrhythmia and thus impact outcomes related to sudden cardiac death. This is likely a consequence of removal of arrhythmogenic scar tissue. Larger studies are required to further evaluate the burden and correlation of ventricular arrhythmia with scar tissue volume measured on cardiac MRI.

Sacubitril/valsartan and arrhythmic burden in patients with heart failure and reduced ejection fraction: a systematic review and meta-analysis.

The aim of this study was to assess whether angiotensin receptor/neprilysin inhibitor (ARNI) decreases ventricular arrhythmic burden compared to angiotensin-converting enzyme inhibitors or angiotensin receptor antagonist (ACE-I/ARB) treatment in chronic heart failure with reduced ejection fraction (HFrEF) patients. Further, we assessed if ARNI influenced the percentage of biventricular pacing. A systematic review of studies (both RCTs and observational studies) including HFrEF patients and those receiving ARNI after ACE-I/ARB treatment was conducted using Medline and Embase up to February 2023. Initial search found 617 articles. After duplicate removal and text check, 1 RCT and 3 non-RCTs with a total of 8837 patients were included in the final analysis. ARNI was associated with a significative reduction of ventricular arrhythmias both in RCT (RR 0.78 (95% CI 0.63-0.96); p = 0.02) and observational studies (RR 0.62; 95% CI 0.53-0.72; p < 0.001). Furthermore, in non-RCTs, ARNI also reduced sustained (RR 0.36 (95% CI 0.2-0.63); p < 0.001), non-sustained VT (RR 0.67 (95% CI 0.57-0.80; p = 0.007), ICD shock (RR 0.24 (95% CI 0.12-0.48; p < 0.001), and increased biventricular pacing (2.96% (95% CI 2.25-3.67), p < 0.001). In patients with chronic HFrEF, switching from ACE-I/ARB to ARNI treatment was associated with a consistent reduction of ventricular arrhythmic burden. This association could be related to a direct pharmacological effect of ARNI on cardiac remodeling.Trial registration: CRD42021257977.

Comparative arrhythmia patterns among patients on tyrosine kinase inhibitors.

Tyrosine kinase inhibitors (TKIs) are widely used in the treatment of hematologic malignancies. Limited studies have shown an association between treatment-limiting arrhythmias and TKI, particularly ibrutinib, a Bruton's tyrosine kinase (BTK) inhibitor. We sought to comprehensively assess the arrhythmia burden in patients receiving ibrutinib vs non-BTK TKI vs non-TKI therapies. We performed a retrospective analysis of consecutive patients who received long-term cardiac event monitors while on ibrutinib, non-BTK TKIs, or non-TKI therapy for a hematologic malignancy between 2014 and 2022. One hundred ninety-three patients with hematologic malignancies were included (ibrutinib = 72, non-BTK TKI = 46, non-TKI therapy = 75). The average duration of TKI therapy was 32months in the ibrutinib group vs 64months in the non-BTK TKI group (p = 0.003). The ibrutinib group had a higher prevalence of atrial fibrillation (n = 32 [44%]) compared to the non-BTK TKI (n = 7 [15%], p = 0.001) and non-TKI (n = 15 [20%], p = 0.002) groups. Similarly, the prevalence of non-sustained ventricular tachycardia was higher in the ibrutinib group (n = 31, 43%) than the non-BTK TKI (n = 8 [17%], p = 0.004) and non-TKI groups (n = 20 [27%], p = 0.04). TKI therapy was held in 25% (n = 18) of patients on ibrutinib vs 4% (n = 2) on non-BTK TKIs (p = 0.005) secondary to arrhythmias. In this large retrospective analysis of patients with hematologic malignancies, patients receiving ibrutinib had a higher prevalence of atrial and ventricular arrhythmias compared to those receiving other TKI, with a higher rate of treatment interruption due to arrhythmias.

Early atrial fibrillation detection is associated with higher arrhythmic burden in patients with loop recorder after an embolic stroke of undetermined source

BackgroundAfter an embolic stroke of undetermined source (ESUS), long-term monitoring is recommended to start an anticoagulation therapy in patients with documented atrial fibrillation (AF). Literature is sparse about the AF burden following an ESUS, although this might have significant implications in terms of clinical management and therapeutic strategy. Our primary aim was to evaluate a possible association between early detection of AF (within 90 days from the ILR implantation) and higher AF burden. MethodsThis is a retrospective single-center study of 129 consecutive patients who received implantable loop recorders (ILRs) after an ESUS for detection of subclinical AF and their AF burden. ResultsMean age was 70.3 ± 10.4 years old (males: 51.9%). Atrial fibrillation was found in 40.3% of patients. Patients with AF were older, presented a higher CHAD2S2-Vasc Score and greater left atrial volume compared with patients without AF. The median AF burden was 1.2%; 59% of patients had the first AF episode within 90 days from the ILR implant while 41% experienced the first episode later than 90 days. The AF burden was significantly higher in the former group. Of note, the univariate analysis showed that only early AF detection was significantly associated with AF burden >1% (OR 20.0; 95% CI 1.68–238.6, p = 0.01). ConclusionsThe early AF detection was found to be significantly associated with a higher burden of AF.

PO-05-159 IMPACT OF ARRHYTHMIAS IN PATIENTS ADMITTED WITH SARCOIDOSIS: A NATIONWIDE PERSPECTIVE

Sarcoidosis is a chronic granulomatous disorder with multiorgan involvement. Cardiac sarcoidosis is characterized by the growth of granulomas in any part of the heart which portends a poor prognosis. These granulomas can cause conduction abnormalities. However, less is known about the in-hospital outcomes in patients with sarcoidosis who have concurrent arrhythmias. We aimed to identify whether arrhythmia impacted these outcomes. Objective was to study the impact of arrhtymias on in-hospital outcomes in patients with sarcoidosis. We queried the National Inpatient Sample (NIS) database of 2018- 2020. Adults admitted with a primary or secondary diagnosis of sarcoidosis were included. This population was stratified into those with and without arrhythmia {atrial fibrillation [AF], atrial flutters, SVTs, heart blocks [first, second degree, complete heart blocks (CHB)], ventricular tachycardia [VT] and fibrillation [VF]}. Demographics and association with other comorbidities was studied. Multivariate regression analysis was performed to identify the impact of arrhythmias taking mortality as primary outcome and total hospital cost as secondary. A total of 383385 hospitalised patients had sarcoidosis. Of those, 85205 (22.22%) had arrhythmias. Mean age was 59 years and 54.03% were females. Traditional cardiac risk factors like diabetes mellitus (39.79% vs 37.61%, p<0.05),and hyperlipidemia (48.39% vs 38.79%, p<0.01) were more prevalent in the cohort of sarcoid patients with arrhythmias. The prevalence of valvular abnormalities(25.12% vs 16.85%,p<0.01), CAD (33.32% vs 17.72%, p<0.01) and old myocardial infarction (8.9% vs 5.32%, p<0.01) was also significantly higher in these patients. After adjusting for covariates, the odds of mortality was higher with VF, VT, CHB and AF in adult patients with sarcoidosis (table 1). The total hospital charge was also considerably more in sarcoid patients with concomitant VF, VT, CHB and AF (table 1). This study concludes that patients with sarcoidosis have a higher prevalence of risk factors like diabetes and hyperlipidemia and also how the presence of underlying arrhythmias leads to significantly worse outcomes in terms of mortality and in-hospital cost. These findings necessitate the need for further research to understand the pathophysiology of arrhythmias in Sarcoidosis cohort. This will further help in guiding therapeutic interventions to prevent the burden of arrhythmias in patients with sarcoidosis to improve patient outcomes.

The Effect of Sacubitril-Valsartan on Ventricular Arrhythmia Burden in Patients With Heart Failure With Reduced Ejection Fraction.

Introduction Heart failure with reduced ejection fraction (HFrEF) patients are prone to developing ventricular arrhythmias. In the PARADIGM-HF trial, sacubitril-valsartan (SV) showed a reduction in the composite endpoint of death and HF hospitalization in HFrEF patients; subgroup analysis of this trial revealed a reduction in both sudden death and deaths from worsening HF. The mechanism by which SV may affect the incidence of ventricular arrhythmias is currently under debate, and the literature provides conflicting results. The aim of our study was to evaluate the potential antiarrhythmic effect of this drug in patients with HFrEF carrying an implantable cardiac defibrillator (ICD) or a cardiac resynchronization therapy with a defibrillator (CRT-D). Methods This was a single-center, observational and retrospective study. Inclusion criteria were implantation of an ICD or CRT-D device between 2009 and 2019, age ≥18 years, left ventricle ejection fraction (LVEF) ≤40%, New York Heart Association (NYHA) functional class ≥II, and treatment with an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker for at least 12 months, followed by replacement with SV. Exclusion criteria were NYHA class IV, frequent alterations in chronic medication for HFrEF, and implantation of an ICD or CRT-D after the introduction of SV. The primary outcome was the occurrence of ventricular arrhythmias in the form of appropriate device shocks, ventricular fibrillation, or ventricular tachycardia. The comparisons were performed between two periods of time (12 months before and 12 months after SV) in the same group of patients. Results Fifty-four patients met the inclusion criteria. The mean age was 69.5 ± 1.65 years, and 74.1% of patients were male. The number of patients experiencing appropriate shocks was significantly lower after SV initiation (2% vs. 18%; p=0.016). The percentage of VT (13 vs. 20%; p=0.549) and VF episodes (4% vs. 13% for VF; p=0.289) were also lower, but these differences were not statistically significant. There were no significant differences in the value of NT-proBNP (1128 vs. 775 pg/mL; p=0.858), LVEF (28.4 vs. 29.6%; p=0.315), and left ventricular end-diastolic diameter (65.0 vs. 66.0 mm; p=0.5492). Conclusion SV seems to reduce the risk of arrhythmic events requiring appropriate shock therapy.

Effects of lockdown on physical activity and arrhythmia burden in patients with an implantable cardioverter-defibrillator: the COVID-19 Lockdown ICD-Carelink (CLIC) study

Abstract Background Both COVID-19 and the measures taken to control the pandemic may significantly affect cardiovascular health. The effects of a lockdown on physical activity and its potential consequences for arrhythmia burden remain largely unknown. Purpose In this study, we investigated the effect of the lockdown during the first COVID-19 wave on patients' physical activity and arrhythmia burden. Methods All patients with an ICD connected to a Carelink home-monitoring system from two Dutch hospitals were included. Anonymized data on physical activity, heart rate, and occurrence of ventricular tachycardia/fibrillation (VT/VF), and atrial fibrillation/tachycardia (AF/AT) were obtained and were compared between March-April 2020 (lockdown) and March-April 2019 (reference) within each patient. The study was approved by the local ethics committee. Results The ICDs of 531 patients registered significantly less activity during de lockdown period compared to the reference period (210±104 min vs 182±103 min, p&amp;lt;0.0001, Figure 1, panels A and B), while weather conditions improved (1A). Daytime and nighttime heart rates were significantly lower during lockdown compared to the reference period (71.3±9 bpm vs 72.6±9 bpm, p&amp;lt;0.0001 and 63.4±9 vs 63.8±9, p=0.02, respectively). AF/AT burden increased (Figure 2A) while number of VT/VF episodes decreased (2B). There was no significant difference in number of NSVT episodes. Conclusion During the lockdown in the first COVID-19 wave, the Carelink system revealed significantly less activity, increase in AF/AT burden and decrease in VT/VF episodes. Further investigation is needed to understand the relationship between physical activity and the occurrence of arrhythmias in ICD patients. Funding Acknowledgement Type of funding sources: None.

432 SACUBITRIL/VALSARTAN AND RISK OF SUPRAVENTRICULAR ARRHYTHMIAS AS DETECTED BY REMOTE MONITORING IN HEART FAILURE PATIENTS

Abstract Introduction Sacubitril/valsartan (ARNI) has demonstrated a significant benefit compared to angiotensin inhibitor (enalapril) in decreasing both morbidity and mortality in patients with heart failure with reduced ejection fraction (HFrEF). While. recent studies demonstrated that in HFrEF patients, ARNI decreased ventricular arrhythmias no data is available with regards to the supraventricular arrhythmic burden in HFrEF patients with an implantable cardioverter defibrillator (ICD) or cardiac resynchronisation therapy-defibrillator (CRT-D) and remote monitoring. The aim of out study was to assess if ARNI therapy was able to significantly reduce supraventricular arrhythmias. More specifically the primary endpoint was the incidence of AT/AF episodes, as detected by the device. Secondary endpoints included the total burden of AT/AF, the mean number of premature ventricular contractions (PVC) per hour and the percentage of biventricular pacing per day (in patients with CRT-D). Methods We conducted a multicentre, observational, prospective registry : the SAVE THE RHYTHM (SAacubitril Valsartan rEal-world registry evaluating THE arRHYTHMia burden in HFrEF patients with implantable cardioverter defibrillator). We enrolled all patients with HFrEF, ICD or CRT-D actively followed through remote monitoring and starting treatment with sacubitril/valsartan. All patients were followed-up for at least one year. Results At the end of enrollment, 265 patients from 5 centres had at least one sacubitril/valsartan prescription (88% males, age 68±10 years). The annual incidence of AT/AF episodes decreased from 16.6% before sacubitril/valsartan to 12.8%, 6.7% and 0.7% according to the maximum tolerated dose (24/26 mg, 49/51 mg and 97/103 mg, respectively; p=0.026). After treatment with sacubitril/valsartan, patients with at least one episode of AT/AF decreased from 32.6% to 26.5% (24/26 mg), 24.3% (49/51 mg) and 6.9% (97/103 mg); p=.041. A significant decrease in the number of PVC (-28 per hour) and in the rate of appropriate shock (-0.8% per year) were seen in patients with a previous diagnosis of paroxysmal or persistent AF. Patients with permanent AF (n=7) experienced no benefits from sacubitril/valsartan therapy in terms of arrhythmic burden reduction. Patients with a CRT device (41%) experienced a significant increase in biventricular pacing time (+3% per day). Discussion Therapy with sacubitril/valsartan could decrease arrhythmic burden in patients with non-permanent AF and HFrEF and reduce subclinical supraventricular arrhythmias in patients with no history of AF.

Ventricular arrhythmia burden in patients with implantable cardioverter defibrillator and remote patient monitoring during different time intervals of the COVID-19 pandemic

PurposeThe current study investigated whether the changes in patient care in times of the COVID-19 pandemic, especially the reduction of in-person visits, would result in a deterioration of the arrhythmic and clinical condition of patients with an implantable cardioverter defibrillator (ICD) and remote patient monitoring.MethodsData were obtained from a local ICD registry. 140 patients who received ICD implantation at our department and had remote patient monitoring were included. The number of patients with ventricular arrhythmias, appropriate ICD therapy, the number of visits to our outpatient clinic and hospitalization due to acute coronary syndrome, stroke or heart failure were compared during three time intervals of the COVID-19 pandemic (first (LD1) and second (LD2) national lockdown in Germany and the time after the first lockdown (postLD1)) and a time interval 1 year before the pandemic began (preCOV). Each time interval was 49 days long.ResultsPatients had significantly fewer visits to our outpatient clinic during LD1 (n = 13), postLD1 (n = 22) and LD2 (n = 23) compared to the time interval before the pandemic (n = 43, each p ≤ 0.05). The number of patients with sustained ventricular arrhythmias, appropriate ICD therapy and clinical events showed no significant difference during the time intervals of the COVID-19 pandemic and the time interval 1 year prior.ConclusionsThe lockdown measures necessary to reduce the risk of infection during the COVID-19 pandemic, led to a reduction of in-person patient visits, but did not result in a deterioration of the arrhythmic and clinical condition of ICD patients with remote patient monitoring.

Incidence of atrial and ventricular arrhythmias in patients with CIEDs and COVID-19

Abstract Background It remains unclear whether COVID-19 infection is associated with increased arrhythmia burden in patients with cardiac implantable electronic devices (CIEDs). Methods We identified 46 patients tested positive for COVID-19 between 01/03/2020 and 31/05/2021 in our cohort of 1209 patients with CIED (3.8%). Data on arrhythmia burden during a 9 week period (a 4 week “pre-infection” period: P1, the week before the positive Covid-19 test: P2, and the 4 weeks afterwards: P3) was accessible in 35 patients. Results 83% of patients were not hospitalised. Five patients (14.3%) (all non-hospitalised) had high rate atrial (HRA) events, 4 of which exclusively during P1 and/or P2. Thirty-two non-sustained VT (NSVT) episodes were recorded in 8 patients, one degenerating in VF requiring ICD shock (occurring in P2). One patient had frequent NSVT each week. After exclusion of this outlier, a numerical 4-fold increase in weekly NSVT episodes was observed between P1 and P3 (Patients with NSVT: 0.07±0.12 vs. 0.29±0.17 episodes/week, p=0.057; entire cohort: 0.015±0.060 vs. 0.059±0.138 episodes/week, p=0.16) (Figure 1). In P3, hospitalised patients had a trend towards higher NSVT burden vs. non-hospitalised patients (2/6 (33.3%) vs. 4/29 (13.8%), p=0.27) which was not apparent before the positive Covid-19 test. Conclusion Our single-centre experience suggests that COVID-19 infection may result in an increase in VA but not atrial arrhythmia burden in patients with CIED. Funding Acknowledgement Type of funding sources: None.

Effects of lockdown on physical activity and arrhythmia burden in patients with an implantable cardioverter-defibrillator: the COVID-19 Lockdown ICD-Carelink (CLIC) study

Abstract Background Both COVID-19 and the measures taken to control the pandemic may significantly affect cardiovascular health. The effects of a lockdown on physical activity and its potential consequences for arrhythmia burden remain largely unknown. Purpose In this study, we investigated the effect of the lockdown during the first COVID-19 wave on patients' physical activity and arrhythmia burden. Methods All patients with an ICD connected to a Carelink home-monitoring system from two Dutch hospitals were included. Anonymized data on physical activity, heart rate, and occurrence of ventricular tachycardia/fibrillation (VT/VF), and atrial fibrillation/tachycardia (AF/AT) were obtained and were compared between March-April 2020 (lockdown) and March-April 2019 (reference) within each patient. The study was approved by the local ethics committee. Results The ICDs of 531 patients registered significantly less activity during de lockdown period compared to the reference period (210±104 min vs 182±103 min, p&amp;lt;0.0001, Figure 1, panels A and B), while weather conditions improved (1A). Daytime and nighttime heart rates were significantly lower during lockdown compared to the reference period (71.3±9 bpm vs 72.6±9 bpm, p&amp;lt;0.0001 and 63.4±9 vs 63.8±9, p=0.02, respectively). AF/AT burden increased (Figure 2A) while number of VT/VF episodes decreased (2B). There was no significant difference in number of NSVT episodes. Conclusion During the lockdown in the first COVID-19 wave, the Carelink system revealed significantly less activity, increase in AF/AT burden and decrease in VT/VF episodes. Further investigation is needed to understand the relationship between physical activity and the occurrence of arrhythmias in ICD patients. Funding Acknowledgement Type of funding sources: None.

Effects of lockdown on physical activity and arrhythmia burden in patients with an implantable cardioverter-defibrillator: the Covid-19 Lockdown ICD-Carelink (CLIC) study

Abstract Funding Acknowledgements Type of funding sources: None. Background: Both COVID-19 and the measures taken to control the pandemic may significantly affect cardiovascular health. The effects of a lockdown on physical activity and its potential consequences for arrhythmia burden remain largely unknown. Purpose: In this study, we investigated the effect of the lockdown during the first COVID-19 wave on patients’ physical activity and arrhythmia burden. Methods: All patients with an ICD connected to a Carelink home-monitoring system from two Dutch hospitals were included. Anonymized data on physical activity, heart rate, and occurrence of ventricular tachycardia/fibrillation (VT/VF), and atrial fibrillation/tachycardia (AF/AT) were obtained and were compared between March-April 2020 (lockdown) and March-April 2019 (reference) within each patient. The study was approved by the local ethics committee. Results: The ICDs of 531 patients registered significantly less activity during de lockdown period compared to the reference period (21,895±12,394min vs 25,173±12,532min, p&amp;lt;0.0001, panel a). Daytime and nighttime heart rates were significantly lower during lockdown compared to the reference period (71.3±9bpm vs 72.6±9bpm, p&amp;lt;0.0001 and 63.4±9 vs 63.8±9, p=0.02, respectively). 94 patients with VT/VF during the reference period did not show any VT/VF during lockdown, while only 4 patients without VT/VF during the reference period showed VT/VF during lockdown (p&amp;lt;0.0001, panel B). There was no significant difference in the occurrence of NSVT or AF/AT. Conclusion: During the lockdown in the first COVID-19 wave, the Carelink system revealed significantly less activity and lower heart rates. Moreover, there was a significant reduction in the occurrence of VT/VF.

CE-541-04 CARDIAC ARRHYTHMIAS IN POST-ACUTE SEQUELAE OF SARS-COV-2 INFECTION ASSESSED BY AMBULATORY RHYTHM MONITORING

Many COVID-19 survivors report ongoing cardiopulmonary symptoms and organ dysfunction in a poorly understood syndrome known as post-acute sequelae of COVID-19 (PASC). Risk of arrhythmias is elevated in acute COVID-19 infection, especially in hospitalized patients with severe infection. In the post-acute period, palpitations are commonly reported, but little is known about the risk of arrhythmias in patients with PASC. To characterize the burden of arrhythmias in individuals with PASC at least 1 year after SARS-CoV-2 infection and the correlation between symptoms and clinically significant arrhythmias. As part of the LIINC COVID-19 recovery cohort (NCT04362150), we conducted ambulatory rhythm monitoring using the Bardy Diagnostics Carnation Ambulatory Monitor (CAM) for up to 14 days on participants at least 1 year after PCR-confirmed COVID-19 infection without prior CVD. Cardiopulmonary symptoms were assessed through interviews at the time of enrollment, at the time of initiation of rhythm monitoring, and through a journal used during the rhythm monitoring period. Among 27 participants, 13 reported cardiopulmonary symptoms. Median age was 56 and 48% were female (Table 1); monitoring was performed at a median of 16.5 months after infection. Those with PASC pushed the symptom button 4.2 more times on average (95% CI -1.4 to 10.3; p=0.13). After adjustment for age and sex, cardiopulmonary symptoms were not associated with an increased burden of PACs (β = -0.04, 95%CI -0.15 to 0.07, p = 0.47), PVCs (β = 0.21, 95%CI -0.22 to 0.65, p = 0.31), or supraventricular tachycardia episodes (β = 3.0 per week, 95%CI -3.1 to 9.2, p = 0.31). Average HR (β = -1.66, 95%CI -12.8 to 9.5, p = 0.076) and HR variability (β = 2.5, 95%CI -10.3 to 15.3, p = 0.69) were not significantly different between those with and without symptoms. Similar results were found after adjusting for LVEF, LV strain, and LA volume index. Button pushes correlated with SVT in only one participant who had PASC and none without PASC. In the first study to assess cardiac arrhythmia burden in patients with PASC through ambulatory rhythm monitoring, we did not find significant associations between the presence of cardiopulmonary symptoms after COVID-19 and PAC burden, PVC burden, SVT episodes, average HR, or HR variability.

Acute coronary syndrome after insect bites: a systematic review of available literature

Kounis syndrome is a hypersensitivity coronary disorder induced by exposure to several triggers; the most common are antibiotics, followed by insect bites. We reviewed the literature and identified 66 patients who experienced acute coronary syndrome after insect bites. The median age was 51 years, and 19.0% were women and only 12% had a history of allergy. The most involved insects were bee and wasp (86%) and the most frequent clinical manifestations were chest pain and anaphylaxis (36% and 29%, respectively). ST-segment elevation was the most common electrocardiographic finding (>70%). There was a not negligible rate of complications (15%), with a possible increased arrhythmic burden in patients without significant coronary atherosclerosis. Acute coronary syndrome after insect bites is not so rare and it could have serious complications, with a possible increased arrhythmic burden in patients without significant coronary atherosclerosis.

Burden of arrhythmias in patients with obstructive sleep apnea and its impact on mortality: a descriptive study from the National Inpatient Sample

Abstract Background Obstructive sleep apnea (OSA) accounts for significant mortality and morbidity worldwide. A limited but emerging literature has revealed increased risk of sudden cardiac death in patients with OSA. There is paucity of data on arrhythmia burden in patients with OSA, particularly in hospitalized patients. Purpose Therefore, we sought to study the prevalence of atrial and ventricular arrhythmias among hospitalized patients with OSA and examine its impact on sudden cardiac death and in-hospital mortality. Methods All patients over 18 years of age with OSA were extracted from the National Inpatient Sample (NIS) from 2009–10 using 9th revision of International Classification of Diseases (ICD-9) code 327.23. Demographic data, hospital characteristics, comorbid conditions, and arrhythmia burden including different types of arrhythmia were identified. Clinical outcomes were in-hospital mortality, length of stay and sudden cardiac death. Logistic regression analysis was performed to determine the impact of arrhythmia on in-hospital mortality in patients with OSA. Hospital level discharge weights provided by NIS were used to obtain national estimates of OSA hospitalizations. Results OSA was prevalent in 2.8% (n=1,114,297) of all hospitalizations among which 20.1% had any arrhythmia (n=223,974). Patients with arrhythmia were older, more likely to be males, and had higher prevalence of risk factors and comorbid conditions except for chronic liver disease, and smoking (p&amp;lt;0.0001 for all). Arrhythmia burden analysis revealed increase prevalence of both atrial and ventricular arrhythmia in patients with OSA compared to general population. In-hospital mortality (3.48% vs 1.27%; p&amp;lt;0.0001), length of hospital stay (6.4±0.1 vs 5±0.1; p&amp;lt;0.001) and sudden cardiac death (1.34% vs 0.4%; p&amp;lt;0.0001) were higher in OSA patients with arrhythmia compared to OSA patients without arrhythmia. Presence of arrhythmia in OSA patients was associated with increased in-hospital mortality in both unadjusted [OR 2.79 (2.62–2.98); p&amp;lt;0.001] and multivariable model adjusted for all risk factors and comorbid conditions [OR 1.83 (1.69–1.98); p&amp;lt;0.001]. Conclusion Arrhythmia burden was higher in patients with OSA compared to the general population. Presence of arrhythmia among OSA patients was independently associated with increased in-hospital mortality and longer hospital stays. Routine evaluation to assess arrhythmia burden in patients in OSA could be a potential target to decrease sudden cardiac death in this high risk population. Funding Acknowledgement Type of funding sources: None.

VENTRICULAR TACHYCARDIA ELECTRICAL STORM AS A MANIFESTATION OF REVERSE VARIANT TAKOTSUBO CARDIOMYOPATHY

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Takotsubo cardiomyopathy (TTC) is a syndrome with transient systolic dysfunction in the absence of obstructive coronary arteries with the reverse variant being a rare entity (1,2). Here, we report a case of reverse TTC presenting with monomorphic ventricular tachycardia (VT) electrical storm. CASE PRESENTATION: A 76 year-old female with a history of recently diagnosed Stage IIIB lung adenocarcinoma presented to the emergency room with shortness of breath. On presentation, her vitals were: BP 134/82, pulse 120 beats/min, SPO2 93% in room air. Initial EKG showed no significant ST-T wave changes and normal QTc. Labs were significant for uptrending troponin from 0.8 to 4 ng/mL. Aspirin and heparin infusion were started for possible NSTEMI with a plan for catheterization. That night, she developed unstable, monomorphic VT (Figure 1). Consecutive synchronized cardioversions and amiodarone boluses were unsuccessful. Patient's VT terminated with repeated boluses of lidocaine followed by lidocaine infusion. Stat echocardiogram showed an ejection fraction of 25-30% with anterior and anteroseptal hypokinesis. Emergency cardiac catheterization revealed non-obstructive coronary arteries with akinesis of the basal wall and sparing of the apex suggesting reverse TTC (Figure 2). She was transferred to the critical care unit where she was transitioned to amiodarone infusion with no further VT episodes and was initiated on guideline-directed medical therapy. DISCUSSION: TTC usually occurs due to a surge of catecholamines leading to myocardial damage. The typical variant demonstrates apical ballooning with basal hypokinesis. Rarely, there may be basal hypokinesis with apical sparing, the reverse variant (2). Arrhythmias are uncommon in typical TTC and prior studies have indicated a low incidence of VT (3.2%) (3). There is sparse literature describing the incidence of VT or VT storm in the reverse variant. One of the postulated mechanisms for VT in TTC is transient QTc prolongation, however this remains controversial. (3). The incidence of arrhythmias is thought to be more prevalent during the acute phase leading to increased in-hospital mortality (3). Additionally, it remains uncertain whether prophylactic antiarrhythmics are beneficial in this population subset. Further studies are warranted to understand which variants of TTC develop critical arrhythmias. CONCLUSIONS: Reverse variant is a rare subset of TTC which can present with critical arrhythmias including VT storm. Awareness of this manifestation can help clinicians with early recognition and management of these critical arrhythmias. REFERENCE #1: Bybee KA., Prasad A. Stress-related cardiomyopathy syndromes. Circulation 2008;118(4):397–409. Doi: 10.1161/CIRCULATIONAHA.106.677625. REFERENCE #2: Templin C., Ghadri JR., Diekmann J., et al. Clinical Features and Outcomes of Takotsubo (Stress) Cardiomyopathy. New England Journal of Medicine 2015;373(10):929–38. Doi: 10.1056/NEJMoa1406761. REFERENCE #3: Pant S, Deshmukh A, Mehta K, et al. Burden of arrhythmias in patients with Takotsubo Cardiomyopathy (Apical Ballooning Syndrome). International Journal of Cardiology [Internet] 2013;170(1):64–68. Available from: https://doi.org/10.1016/j.ijcard.2013.10.041 DISCLOSURES: No relevant relationships by Anneka Hutton, source=Web Response No relevant relationships by Gagan Neupane, source=Web Response No relevant relationships by Enoemem Okpokpo, source=Web Response No relevant relationships by Bharadwaj Satyavolu, source=Web Response No relevant relationships by Raksha Sharma, source=Web Response No relevant relationships by Tracey Topacio, source=Web Response