Daily Electrocardiogram Research Articles

HEART RATE VARIABILITY IN THE ASSESSMENT OF ADAPTIVE CAPACITY IN NEWBORNS WITH PERINATAL INJURY OF CENTRAL NERVOUS SYSTEM

Relevance. The neurohumoral mechanisms regulating heart rhythm in newborns are a focal point of research in perinatal cardiology. This emphasis arises from the fact that heart rhythm serves as a key indicator of the functional interplay within the cardiovascular system and the overall physiological state of a newborn, acting as a primary marker of autonomic nervous system activity. Aim: To examine the characteristics of autonomic heart rhythm regulation in newborns with perinatal injuries of central nervous system through daily electrocardiogram monitoring. Subjects and methods. The study included 40 full-term newborns divided into two groups: Group I involved conditionally healthy newborns (n = 23), and Group II included newborns with hypoxic-ischemic lesions of the central nervous system (n = 17). Based on temporal and spectral analysis of heart rate variability, it was demonstrated that changes in the early neonatal period correlate with clinical signs of impaired postnatal adaptation. By the 3rd–4th day of life, all newborns exhibited a decrease in parasympathetic influence on heart rhythm and increased activity of the sympathetic division of the autonomic nervous system during the day. Hypoxic-ischemic injury of the central nervous system was associated with more pronounced autonomic dysfunction, leading to impaired regulation of the circulatory system. An imbalance between sympathetic and parasympathetic influences on the heart in newborns, who experienced asphyxia was identified as a significant arrhythmogenic factor. Heart rate variability emerges as a critical, informative marker for identifying at-risk newborns prone to developing heart rhythm disorders, facilitating timely inclusion in risk groups and ensuring appropriate follow-up care.

HV interval measure immediately before TAVI with SEV for predicting pacemaker implantation

Abstract Introduction Although improvements, new onset persistent disturbances in electrocardiogram (ECG) after transcatheter aortic valve implantation (TAVI) remains up to 34% at hospital discharge (1), needing permanent pacemaker implantation (PPM) in self-expanding valves (SEV) as high as 15-27% (2,3). In post TAVI scenario, European Society of Cardiology guidelines recommend an electrophyisiologic study centered in His-ventricular electrogram (HV) interval measure for assessing risk of progression to high auriculoventricular block (AVB), if abnormal a PPM is indicated (4,5). We aim to predict PPM through basal HV interval measurement prior TAVI with SEV. Furthermore, we aim to compare different current SEV with basal HV interval and the distinct rate of PPM before discharge. Methods and Results Single-center prospective cohort study, patients with severe aortic stenosis scheduled for TAVI, sinus rhythm at intervention day, without PPM or history of PPM indication were included. At time of TAVI, contralateral venous puncture to femoral arterial access was made, a tetrapolar catheter was advanced and placed at the septal aspect of tricuspid valve searching for His electrogram. A mobile polygraph was used to measure ECG parameters and HV interval before TAVI. Then, a tetrapolar catheter was advanced to ventricle to perform rapid stimulation as part of habitual valve implantation protocol. After procedure, we performed rhythm surveillance for at least >48-72 hours and based in electrical evolution one of three decisions was made: 1)PPM implant, 2)late post TAVI HV interval re-measure or 3)clinical daily ECG vigilance, if this last was normal, unchanged from basal or with new but stable conduction disturbances, discharge were indicated following ESC guidelines. A total of 41 patients were enrolled, median age 84±4 years, 24 females (54.5%), PR mean 198±42ms, QRS mean 112±30ms. 18 had a 1st degree AVB (40.9%) of whom 13 (72.5%) had a PR ˂240ms. EPS data showed prior HV interval mean of 55±9ms. A Mild abnormal HV interval (56-69ms) were seen in 21 patients (51.2%), of whom 12 had a narrow QRS. SEV implanted were 11 (25%) Medtronic CoreValve Evolut+, 5 (11.4%) Biosensors Allegra, 25 (56.8%) Abbott Navitor. Post TAVI procedure, 5 (12.2%) women and 8 (19.5%) men met criteria for PPM implantation before discharge. One woman was implanted 6 days after discharge due to high AVB (66ms HV interval prior TAVR). In a multivariate analysis including sex, age, PR, QRS and HV interval >55ms, valve type the RR (IC 95% 1.37-30.99) risk of PPM was 6.52 folds higher (p=0.019). Conclusions An HV interval >55ms before TAVI with SEV increases risk of PPM after TAVI and before hospital discharge. There was no difference in PPM implantation after TAVI between different SEV types in our center.

Value of basal HV Interval prior TAVR as predictor of permanent pacemaker implantation

Abstract Background/Introduction Transfemoral aortic valve replacement (TAVR) is an effective and safe treatment for severe aortic stenosis (SAoS) even in low risk patients (1,2). As population ages, the volume of TAVR procedure increases and although improvements in technology and technique, new onset persistent disturbances in the electrocardiogram (ECG) are present up to 34,8% of patients at hospital discharge(3) and the secondary need of permanent pacemaker implantation (PPM) remains high, being of 4-24% with balloon-expanding valves (BEV) and 14.7-26.7% with self-expanding valves (SEV)(3). According to ESC guidelines, an electrophyisiologic study (EPS) centered in HV interval measure with a cutoff of ≥70ms is a useful tool to assess the risk of progression to high auriculoventricular block (HAVB) in specific groups with persistent ECG abnormalities to consider PPM(4-5), but this only applies in post TAVR scenario. Measuring HV interval at the intervention day prior procedure could help optimize and assess risk for PPM post TAVR. Purpose To measure basal HV interval prior TAVR and correlate it to risk of PPM implantation before discharge and 30 days after discharge. Methods Single-center prospective cohort study, patients with SAoS scheduled for TAVR, sinus rhythm at intervention day, without PPM or history of PPM indication were included. At time of TAVR, a tetrapolar catheter was placed at the septal aspect of tricuspid valve. A mobile polygraph was used to measure ECG parameters and HV interval before TAVR. Then, tetrapolar catheter was advanced to ventricle to perform rapid stimulation as part of habitual valve implantation protocol. After procedure, a rhythm monitorization for >48-72 hrs, was made to decide, PPM, HV interval measure or clinical daily ECG vigilance with posterior discharge was performed. A 30-day post discharge follow up was expected. Results 38 patients were enrolled, median age 83.5 ± 5.5 years, 23 females (60,5%). 37 patients had SEV implanted and 1 patient had BEV implanted. Median HV interval was 54.4ms. 18 patients (47.4%) had a mild abnormal HV interval, of whom 11 had a narrow QRS. Post TAVR procedure, 15 patients (39.5%) persisted with "de novo" LBB at discharge. 5 women and 7 men, had PPM implanted before discharge. 1 woman was implanted 6 days after discharge due to HAVB (66ms HV interval prior TAVR). In a multivariate analysis including sex, age, PR, QRS and HV interval >55ms, the RR (IC 95% 1.9-70.3) risk of PPM was 13.42 folds higher (p=0.008). At a bivariate quantitative HV analysis, a higher HV period persisted significantly related to PPM outcome (p=0.001). Conclusions In our study population, a pre-existing mild to moderate prolongation of HV interval prior TAVR substantially elevates the risk of requiring PPM before discharge. 61.1% of these basal mild prolongation HV interval patients had a narrow QRS prior TAVR.HV measure prior TAVR in narrow QRSTable 1

Interpretation of electrocardiograms and results of daily ECG Holter monitoring in patients with an implanted cardiac contractility modulator

Cardiac contractility modulation (CCM) is a method of non-drug treatment of chronic heart failure (CHF) in patients with no indications for resynchronization therapy. Now, a detailed study of this method and its capabilities is ongoing, and the indications for its use are expanding. As with any other implantable device, it is important to be able to monitor the operation of the CCM, identify its dysfunction and promptly refer patients to specialized institutions. Assessment of the function of CCM- therapy can be carrying out by recording a standard 12‑channel electrocardiogram (ECG), as well as 24‑hour Holter ECG monitoring (HM-ECG). The mechanism of action of CCM-therapy is fundamentally different from that of other implantable devices. Knowledge of the features of the manifestation of CCM-therapy during instrumental studies is necessary for their correct interpretation.

Arrhythmias in patients with acute ST-elevation myocardial infarction induced by various risk factors during the first day after myocardial reperfusion by primary percutaneous coronary intervention

Introduction. Acute coronary syndrome, in particular acute ST-elevation myocardial infarction (STEMI), is often accompanied by complex hemodynamically significant arrhythmias and conduction disorders. Such patients have a worse prognosis compared to patients with sinus rhythm. Arrhythmias in patients with STEMI are facilitated by the presence of comorbidities such as arterial hypertension, diabetes mellitus, obesity, and post-COVID-19 syndrome. The aim of the study. To elucidate the nature of arrhythmias in patients with acute STEMI induced by various risk factors during the first day after myocardial reperfusion by primary percutaneous coronary intervention. Materials and methods. The study involved 50 patients aged 45 to 83 years (average age – 63,4 ± 9,6 years; men – 70,97 %, women – 29,03 %), who were treated during 2021-2023 at the cardiology and reperfusion therapy department of Cardio-vascular center of ʺSaint Panteleimon Hospital in Lvivʺ and the infarction department of ʺLviv Regional Clinical Cardiological Centerʺ. The patients under investigation were subjected to daily electrocardiogram (ECG) monitoring for 24 hours after stenting of the infarct-related coronary artery, using a 7-channel ECG recorder Solvaig 06000.7 with computer processing of the recording using the DiaCard2 software. The obtained material was further subjected to software packages Microsoft Excel 2022, Statistica 10. Results. It was established that among supraventricular rhythm disturbances the most common were premature contractions, the average number of which per patient was significantly higher in the presence of obesity. Similarly high it was in post COVID-19 patients, as well as in those with hypertension. In post-coronavirus infection and in hypertension cases, extrasystoles were often in the form of pairs, triplets, bigemia, and trigemia; paroxysms of supraventricular tachycardia were also recorded in these patients. Among the ventricular arrhythmias also the most frequent were premature cardiac contractions, significantly more oftenly recorded in patients with hypertension and those experienced COVID-19; only in these patients were documented extrasystoles in the form of pairs, triplets, bigeminy, trigeminy, runs of ʺR to Tʺ, which are currently considered as harbingers of life-threatening ventricular arrhythmias. In the presence of hypertension and post-COVID-19, episodes of unstable ventricular tachycardia were also observed. Conclusions. In patients with STEMI, both supraventricular and ventricular premature contractions and episodes of supraventricular and unstable ventricular tachycardia are quite common during the first day after primary percutaneous coronary intervention with infarct-related coronary artery stenting, which is evidence of myocardial electrical instability. The nature of rhythm disturbances in the presence of hypertension and post-COVID-19 is prognostically unfavorable and indicates a higher risk of lifethreatening arrhythmias in these patients. Myocardial revascularization should be supplemented with optimal medical treatment in order to prevent the adverse cardiovascular events in post-STEMI patients. Further research should be directed toward elucidation of predictive value of detected arrhythmias with respect to the occurrence of unfavorable cardiovascular events in the early and long-term post-infarction period.

Serial electrocardiogram recordings revealed a high prevalence of QT interval prolongation in patients with tuberculosis receiving fluoroquinolones

Fluoroquinolones, crucial components of treatment regimens for drug-resistant tuberculosis (TB), are associated with QT interval prolongation and risks of fatal cardiac arrhythmias. However, few studies have explored dynamic changes in the QT interval in patients receiving QT-prolonging agents. This prospective cohort study recruited hospitalized patients with TB who received fluoroquinolones. The study investigated the variability of the QT interval by using serial electrocardiograms (ECGs) recorded four times daily. This study analyzed the accuracy of intermittent and single-lead ECG monitoring in detecting QT interval prolongation. This study included 32 patients. The mean age was 68.6±13.2 years. The results revealed mild-to-moderate and severe QT interval prolongation in 13 (41%) and 5 (16%) patients, respectively. The incremental yields in sensitivity of one to four daily ECG recordings were 61.0%, 26.1%, 5.6%, and 7.3% in detecting mild-to-moderate QT interval prolongation, and 66.7%, 20.0%, 6.7%, and 6.7% in detecting severe QT interval prolongation. The sensitivity levels of lead II and V5 ECGs in detecting mild-to-moderate and severe QT interval prolongation exceeded 80%, and their specificity levels exceeded 95%. This study revealed a high prevalence of QT interval prolongation in older patients with TB who receive fluoroquinolones, particularly those with multiple cardiovascular risk factors. Sparsely intermittent ECG monitoring, the prevailing strategy in active drug safety monitoring programs, is inadequate owing to multifactorial and circadian QT interval variability. Additional studies performing serial ECG monitoring are warranted to enhance the understanding of dynamic QT interval changes in patients receiving QT-prolonging anti-TB agents.

St-Segment Elevation Myocardial Infarction with Multiple Complications: A Case Report

Introduction: ST-Segment Elevation Myocardial Infarction (STEMI) usually involves complete thrombotic occlusion of a coronary artery and require urgent reperfusion; it is one of the leading cause of global mortality and morbidity worldwide. A variety of mechanical, rhythmic, conductive, embolic or hemodynamic complications can occur following STEMI, especially when the treatment is delayed or inadequate. Clinical presentation: A 58-year-old patient with hypertension was admitted to our department for a circumferential STEMI complicated by an ischemic stroke; received 24 hours after the onset of pain. His blood pressure was 100/60 mmHg, heart rate was 55 beats/min. The examination revealed right central facial paralysis and a slight motor deficit of the right upper limb (muscle strength 4/5). The first electrocardiogram (ECG) showed a significant circumferential ST-segment elevation with Q waves in the same territory, as well as a Luchiani Wenckebach atrio-ven- tricular block. The first echocardiography performed showed apical akinesia along with the presence of an apical thrombus. Coronarography was not performed because it was not available and the patient was given curative low molecular weight heparin combined with dual antiplatelet therapy, an angiotensin converting enzyme inhibitor and high dose statins. Seventy-two hours later, the ECG showed a complete atrioventricular block with narrow QRS and the average ventricular rate was 51 beats/min. The patient was asymptomatic. Another echocardiography was performed to assess new complications and showed a rupture of the left ventricular wall and a moderate amount of circumferential pericardial effusion, without any sign of cavity compression. No particular therapeutic attitude was adopted apart from close monitoring with daily ECG and echocardiography. Ten days later, spontaneous regression of the AV Bloc was noted. Conclusion: ST-Segment Elevation Myocardial Infarction is a major cause of morbidity and mortality worldwide. A variety of complications can occur after myocardial infarction, especially when revascularisation is delayed or inadequate.

546 DETECTION OF INFECTIVE ENDOCARDITIS COMPLICATION: USEFULNESS OF ELECTROCARDIOGRAM

Abstract We report the case of an abscess complication of infective endocarditis detected by electrocardiogram (ECG). A 51-year-old man was admitted to the Emergency Department for fever (39 C°) and asthenia from few days. About 2 months earlier he had undergone cardiac surgery for aortic valve replacement with biological valve for severe aortic stenosis. Vital signs included low blood pressure and high respiratory rate; he was also pyretic. On cardiac auscultation he had a systolic murmur on aortic focus. He underwent blood gas analysis, which showed an increase in serum lactate, ECG, which detected a I grade atrioventricular block, and blood sampling, which showed severe increases in white blood cells, C-reactive protein and procalcitonin. Chest x-ray was normal. An echocardiogram was therefore performed: thickened and hyperechogenic cusps of the aortic biological prosthesis were detected; masses, with character of mobility at the level of the left coronary cusp (maximum size of 1.4×1cm) were also described; there was also a slight increase in transprosthetic gradients and mild valve insufficiency. The first diagnostic hypothesis was therefore that of infective endocarditis (IE), further supported by a recent odontogenic procedure for dental abscesses to which the patient would have undergone a few weeks after heart surgery (possible IE according to the Duke modified criteria). Blood cultures were performed on three samples and empirical antibiotic therapy was initiated until Streptococcus mitis was isolated (definite IE according to the Duke modified criteria) and thus Ceftriaxone was started. During hospitalization in the cardiology ward the patient presented dysarthria and left hemiplegia. A cerebral angio-computed tomography and neurological consultation were conducted and an ischemic stroke of thromboembolic origin from biological valve endocarditis was diagnosed. However, in view of the extensive ischemic hypodensity, acute reperfusion treatment was not indicated. The patient therefore underwent cardiac surgery consultancy but, due to his severe comorbidities and expired clinical conditions, there was no indication for cardiac surgery. After few days, during daily ECG recording, left main coronary artery (LMCA) stenosis-like ECG modifications were detected, with ST elevation in lead aVR in addition to marked ST depression in leads V3 through V6 and in peripherals leads (Fig.). A troponin sample was immediately taken, which would have been increased. He immediately underwent new echocardiogram which revealed a new periprosthetic abscess across left coronary cusp. Given the course of LMCA through the abscess, we believe that the acute coronary syndrome that has occurred to the patient may be due either to a compression of the LMCA by the periprosthetic abscess or to embolization of abscess material in the le LMCA. It was not possible to perform coronary angiography neither to perform cardiac surgery as the patient died a few hours later due to septic shock.

Takotsubo Syndrome after Pacemaker Implantation: A Systematic Review.

Takotsubo syndrome (TTS) is an acute cardiac condition characterized by a temporary wall motion abnormality of the left ventricle that mimics an acute coronary syndrome (ACS). TTS usually occurs following emotional or physical triggering event. More recently, sporadic cases of TTS arising after pacemaker implantation were reported. We performed a systematic review of the available literature to provide a comprehensive overview of the current knowledge about pacemaker implantation-induced TTS. The articles selected included case reports and one registry on 28 patients. Most cases occurred in women (75%), encompassing a broad age range. The mean age of the cases described was 74 years. Full recovery of cardiac function was reported in most cases (92.3%), with largely varying recovery times, on average 7 weeks. The most common comorbidity was arterial hypertension and the average ejection fraction at admission was approximately 62%. Clinical severity ranges from asymptomatic cases to severe clinical heart failure syndrome. Altogether the case fatality rate was 3.6%. For rare it might be, awareness about the potential to develop TTS after pacemaker implantation should prompt careful clinical monitoring, with daily electrocardiogram (ECG) monitoring and at least one echocardiographic examination prior to patients' discharge to allow early diagnosis and minimize the clinical risk.

A Novel Algorithm for Automated Human Single-Lead ECG Pre-Annotation and Beat-to-Beat Separation for Heartbeat Classification Using Autoencoders

An electrocardiogram (ECG) is used to check the electrical activity of the heart over a limited short-term or long-term period. Short-term observations are often used in hospitals or clinics, whereas long-term observations (often called continuous or stream-like ECG observations) are used to monitor the heart’s electrical activity on a daily basis and during different daily activities, such as sleeping, running, eating, etc. ECG can reflect the normal sinus rhythm as well as different heart problems, which might vary from Premature Atrial Contractions (PAC) and Premature Ventricular Contractions (PVC), to Sinus Arrest and many other problems. In order to perform such monitoring on a daily basis, it is very important to implement automated solutions that perform most of the work of the daily ECG analysis and could alert the doctors in case of any problem, and could even detect the type of the problem in order for the doctors to have an immediate report about the patient’s health status. This paper aims to provide a workflow for abnormal ECG signals detection from different sources of digitized ECG signals, including ambulatory devices. We propose an algorithm for ECG pre-annotation and beat-to-beat separation for heartbeat classification using Autoencoders. The algorithm includes the training of different models for different types of abnormal ECG signals, and has shown promising results for normal sinus rhythm and PVC compared to other solutions. This solution is proposed for no-noise and noisy signals as well.

The effect of rs776746 polymorphism in the <i>CYP3A5</i> gene on heart rate when using bisoprolol in patients with acute coronary syndrome

Aim. The aim of this work was to study the occurrence of the rs776746 allelic variant of the CYP3A5 gene and its effect on heart rate (HR) when using bisoprolol in patients hospitalized with acute coronary syndrome (ACS).Materials and methods. The study included patients with ACS who were prescribed bisoprolol for clinical indications. All patients underwent molecular genetic testing. In order to evaluate the effectiveness of the therapy with bisoprolol, all patients underwent Holter electrocardiogram (ECG) monitoting on days 10, the following parameters were assessed: minimum, average, maximum heart rate and heart rate during an exercise test. The stress test was performed as a ladder test.Results. The study involved 97 patients (63,5±10,5 years), including 60 men and 37 women. The frequency of occurrence of the desired alleles of the CYP3A5 gene was: CYP3A5*3 - 93%, and CYP3A5*1 - 7%, which corresponds to its prevalence in the European population. 84 carriers of the CYP3A5*3*3 genotype (87%), 12 heterozygous carriers of the *1 allele (12%) and one patient with the *1*1 genotype (1%) were identified. In order to search for differences in the effects of bisoprolol depending on the genetically predetermined activity of CYP3A5, we divided the general group of patients into two subgroups: subgroup 1 (CYP3A5*3*3), represented by carriers of the genotype associated with the synthesis of the inactive form of CYP3A5, and subgroup 2 (CYP3A5*1*3 and CYP3A5*1*1), represented by carriers of at least one allele encoding the synthesis of a fully functional protein CYP3A5, coupled with an increased metabolic rate. Patients did not differ in clinical and demographic characteristics. By the time of daily ECG monitoring, both groups reached comparable heart rate values. In carriers of at least one CYP3A5*1 allele (n = 13), associated with an increased metabolic rate, the daily dose of bisoprolol on the 10th day of hospitalization was significantly higher (p <0.05). The only carrier of the homozygous CYP3A5 *1*1 variant receives bisoprolol at a daily dose of 10 mg. Taking into account the close to significant differences in glomerular filtration rate (GFR) in patients in the groups with the studied genetic variants, and the known eliminating role of the kidneys for bisoprolol, a linear regression model was built with the inclusion of factors that could affect the dose of bisoprolol: GFR, functional class of chronic heart failure, gender, age, number of simultaneously assigned CYP3A5 substrates. Of the parameters listed, only the CYP3A5 genotype significantly predicted the dose of bisoprolol (F=8.5; p<0.005; R2=0.096).Conclusion. In this study, it was demonstrated for the first time that patients with different genetic variants of CYP3A5, in particular with respect to the rs776746 polymorphism, may differ in individual requirements for the dose of bisoprolol.

Analysis of cardiac conduction disorders in adult patients in the early postoperative period after Ozaki surgery

Purpose. To assess the disorders of the cardiac conduction system (CCS) that occurred in the early postoperative period after aortic valve (AV) replacement by the Ozaki method.Methods. The study included 256 patients after a successfully performed Ozaki procedure. Patients with a history of open cardiac surgery, with an implanted pacemaker, with permanent atrial fibrillation, with simultaneous Ozaki surgery with correction of another pathology, in case of repeated surgery on AV in the next six months, with lethal outcome, under the age of 18 years, when it is impossible to analyze the CCS dynamics were excluded. The mean age was 57.9±11.1 years, the male sex was 119 people (46.5%), the body mass index was 29.7±5.5 kg/m2 , diabetes was observed in 40 patients (15.6%), anamnesis of CCS disorders in 10 (3.9%), CCS disorders on the baseline electrocardiogram (ECG) in 32 (12.5%). Conduction abnormalities were assessed according to the anamnesis and the results of daily ECG recording.Results. In the early postoperative period, CCS disorders were registered in 35 patients (13.7%), of whom 27 (10.6%) had their first occurrence, and 8 (3.1%) had previously existed. By the time of discharge, persistent CCS disorders (which occurred for the first time and in the case of progression of pre-existing blocks) remained in 11 (4.3%): 8 (3.1%) had bundle branch blocks, 3 (1.2%) had atrioventricular blocks that required implantation of a permanent pacemaker. Patients with pacemaker had initial conduction abnormalities. The most frequent dysfunction of the CСS was the left bundle branch block (LBBB) (45.5%). We analyzed 14 variables as predictors of the onset or progression of persistent CCS disorders. Two independent predictors were identified - the presence of conduction abnormalities on the baseline ECG and the time of cardiopulmonary bypass. In patients with persistent conduction disturbances in the postoperative period, CCS disorders on the baseline ECG were more common - 36.4% compared with patients without CCS disorders after surgery - 11.4% (p=0.035) and there was a longer duration of cardiopulmonary bypass 140.6±41.1 min. and 122.4±26.1 min. respectively (p=0.03).Conclusion. The most frequent disorder of the conduction was the LBBB. None of the first dysfunctions of CCS led to the implantation of the pacemaker. The presence of initial ECG conduction disturbances and the time of cardiopulmonary

Negative prognostic implications of non-sustained ventricular tachycardias in patients after prophylactic defibrillator implantation

Abstract Funding Acknowledgements Type of funding sources: None. Background Non-sustained ventricular tachycardia (NSVT) is frequent phenomenon in severe heart failure with reduced ejection fraction (HFrEF) patients, and causes any negative impacts on such patients. In the Japanese Circulation Society (JCS) and Japanese Heart Rhythm Society (JHRS) guidelines, NSVT is regarded as a major component of indication for implantable cardioverter defibrillator (ICD) implantation. However, the long-term prognostic significance of NSVT in severe HFrEF is incompletely resolved. Purpose The aim of this study is to investigate the relation between prior NSVT episodes and major adverse cardiac events (MACEs) in HFrEF patients with an ICD as primary prophylaxis. Methods We retrospectively analyzed our ICD database. Patients underwent primary prophylactic ICD implantation from 2007 to 2018 following ICD recommendation of JCS and JHRS guidelines. Patients met the criteria of receiving optimal medication therapy, symptomatic heart failure (New York Heart Association classification II or greater), and severe cardiac dysfunction (left ventricular ejection fraction (LVEF) is 35% or less). In the case of ischemic cardiomyopathy (ICM), implantation of ICD was done at least 40 days after myocardial infarction and at least 90 days after revascularization. Incidence of NSVT episodes were identified through daily electrocardiogram (ECG), Holter ECG or monitor ECG in the hospital. MACEs were defined as composite outcome of cardiovascular death, heart failure hospitalization, and appropriate ICD therapies. Results A total of 148 consecutive patients were enrolled (male, 120 (81%); age, 62.1±11.8 years; LVEF, 23.0±5.86%; left ventricular end-diastolic diameter (LVDd), 67.6±9.26mm; paroxysmal or persistent atrial fibrillation (AF), 38 (26%); NSVT, 113 (76%); use of class III antiarrhythmic drugs, 48 (32%); ICM, 49 (33%); cardiac resynchronization therapy (CRT), 63 (43%)). The median follow-up duration was 58.5 months. As a result of comparison of the Kaplan-Meier curve between NSVT group (n=113) and non-NSVT group (n=35), cardiovascular death, heart failure hospitalization, and appropriate ICD therapy were not statistically different (Figures). Of those, MACEs were occurred to 60 patients (41%). The results of cox-regression analysis showed LVDd (HR: 1.07, 95% CI: 1.03-1.12, p<0.001), AF (HR: 2.88, 95% CI: 1.56-5.31, p<0.001) and ICM (HR: 1.78, 95% CI: 1.00-3.16, p=0.049) were the independent predictors of MACEs, however NSVT was not (Table). Conclusions In this Japanese population, the long-term prognosis of severe HFrEF patients is considered to be comparable regardless of prior NSVT episodes. However, the incidence of MACEs in patients with severe HFrEF after ICD implantation was substantially high. ICM, left ventricle size, and atrial fibrillation were the potential risk factors for MACEs as the previous reports showed.

Early detection of atrial fibrillation in patients with heart failure reduces the risk of subsequent hospitalization: a subanalysis of the randomized TIM-HF2 trial.

To evaluate the rate of new-onset atrial fibrillation (AF) and the potential improved outcome in heart failure (HF) patients using non-invasive remote patient management (RPM) compared with usual care (UC). This analysis assessed a subgroup of 1538 patients of the TIM-HF2 trial with chronic HF, New York Heart Association Class II or III, admission to hospital for HF within 12 months before randomization, and a left ventricular ejection fraction (LVEF) of 45% or lower. Patients with AF in the baseline electrocardiogram (ECG), with an implanted cardiac device, a history of ablation therapy, and recent anticoagulation were excluded, leaving 347 patients for final analysis (RPM = 175; UC = 172). The percentage of days lost due to unplanned cardiovascular hospitalization or death of any cause (primary endpoint of TIM-HF2), the rate of newly detected AF, and the hospitalization rate due to AF were analysed. For patients with new AF, there was a significant reduction for the primary endpoint in the RPM group [5.5%, 95% confidence interval (CI) 0-11.6 vs. UC: 14.6%, 95% CI 8.0-21.2; P < 0.001]. Within the first 3 months, the detection rate of new AF was significantly higher in the RPM group (5.1%) compared with UC (1.2%), P = 0.035. After 1 year, 23 patients (13.1%) assigned to RPM and 12 patients (7.0%) assigned to UC had newly detected AF, P = 0.056. Unplanned hospitalizations related to AF were significantly lower in the RPM group (2 out of 23 patients vs. UC: 10 out of 12 patients; P < 0.001). In this subgroup of HF patients in the TIM-HF2 trial, non-invasive daily ECG transmission leads to a four times higher detection rate of new AF compared with UC. This was associated with a significant reduction of days lost due to unplanned cardiovascular hospitalizations, especially hospitalizations related to AF.

Comparative analysis of daily electrocardiogram monitoring recording using the “standard” and “optimized” techniques of electrode placement on the chest

Objective. To analyze a HM ECG recording in the placement of the electrodes in accordance with the procedure established by the manufacturer for the domestic recorder “Cardian-SDM” and in changed placement of the electrodes.Materials and methods. The study included 30 patients, the average age of the subjects was 34.7 ± 16.9 years, the median was 23 years, of which males accounted for 40 % (n = 12), females – 60 % (n = 18). When analyzing the HM ECG, the amplitude of the main ECG teeth, the displacement of the ST segment, and the change in the morphology of extrasystolic complexes were evaluated using the “standard” and “optimized” recording techniques. Such parameters as sensitivity and specificity of the proposed method were determined. The statistical analysis was carried out using the SPSS Statistics program.23 and Microsoft Excel.Results. During the automatic analysis of significant deviations in the amplitude of the ECG waves, rhythm disturbances, no ST segment changes were not registered when using the “optimized” technique compared to the “standard” one. The analysis of 30 HM ECG episodes taking into account the amplitude of the main teeth according to the “optimized” technique has a specificity of 93.4 % and sensitivity of 96.7 %, the deviation of the amplitude parameters has no significant differences, p &gt; 0.05.Conclusion. The changes in the amplitude of the teeth did not exceed 10 %, the duration of the complexes, segments, and intervals did not change, p &gt; 0.05. The specificity of the proposed “optimized” technique was 93.4 %, sensitivity – 96.7 %. The “optimized” technique can be used instead of the existing one to improve the quality of the ECG recorded in patients during physical exercise.

A Systems-Based Morbidity and Mortality Conference Was Associated With a Transient Reduction in ECG Completion Times.

During its monthly morbidity and mortality conference (MMC), the University of Colorado Division of Cardiology reviewed a "near-miss" patient safety event involving the delayed completion of a Stat-priority (ie, statim, meaning high priority) electrocardiogram (ECG). Because critical and interprofessional stakeholders participated in the conference, we hypothesized that the MMC would be associated with reduced ECG completion times. Data were collected for in-hospital ECGs performed at the University of Colorado Hospital between January 1, 2017, and June 30, 2018. An interrupted time series analysis was used to estimate the immediate and ongoing impact of the MMC (held on February 28, 2018) on ECG completion times, stratified by order priority (Stat, Now, or Routine). The percentage of delayed Stat-priority ECGs was analyzed as a secondary outcome. Before the MMC, ECG completion times were stable for all order priorities ( P > .2), but the proportion of delayed Stat-priority ECGs increased from 5% in January 2017 to 20% in February 2018 ( P < .01). The MMC was associated with an immediate reduction in average daily ECG completion times for Routine (-18.4 minutes, P = .03) and Now (-8 minutes, P = .024) priority ECGs. No reduction was seen for Stat ECGs ( P = .97), though the percentage of delayed Stat ECGs stopped increasing ( P = .63). In the post-MMC period, completion times for Routine-priority ECGs increased and approached pre-MMC levels. The MMC was associated with an immediate, but temporary, improvement in ECG completion times. Although the observed clinical benefit of the MMC is novel, these data support the need for more durable reforms to sustain initial improvements.

Dynamics of Holter electrocardiogram monitoring in patients with chronic heart failure and atrial fibrillation on the background of cardiac contractility modulation

To evaluate the dynamics of cardiac arrhythmias on the background of cardiac contractility modulation (MCC) in patients with chronic heart failure (CHF) and various forms of atrial fibrillation (AF) on the basis of daily electrocardiogram (ECG) monitoring. In 100 patients with CHF and AF, the following studies were performed before implantation of the MCC device and after 12 months of follow-up: 12-channel ECG with an estimate of the width of the QRS complex, transthoracic echocardiography (EchoCG), and Holter ECG monitoring. All patients received long-term optimal drug therapy for CHF before surgery. The results obtained indicate that there is no effect of MCC on the development and progression of ventricular arrhythmias in patients with CHF and AF during the year of follow-up, both extrasystole and tachyarrhythmias, regardless of the etiology and LVEF (less than 35% or more than 35%), and a decrease in the frequency of AF paroxysms in patients with CHF during treatment. These results are due to the reverse remodeling of the LV myocardium under the influence of the MCC device. The use of MСС in patients with CHF and AF is a safe method of therapy that does not induce cardiac arrhythmias, including ventricular extrasystole. Large-scale comparative studies are required to evaluate these results.

Objective and subjective assessment of the recurrence of atrial fibrillation after cryoballoon ablation of the pulmonary veins

Background: Adequate diagnosis of recurrent atrial fibrillation after the surgical treatment in patients with paroxysmal forms of the disease appears to be a difficult task. Aims: The manuscript is devoted to a comparative analysis of the results of subjective and objective assessment of atrial fibrillation recurrence after cryoballoon ablation of the pulmonary veins. Material and methods: 301 patients were included in the study. All of them consequentially underwent cryoballoon ablation of the pulmonary veins in the period of October, 2016 November, 2019. The inclusion criteria were as follows: symptomatic atrial fibrillation; confirmation of atrial fibrillation by instrumental diagnostic methods. The exclusion criteria were the following: a combination of atrial fibrillation and atrial flutter at the time of surgery; history of open-heart procedures and catheter procedures to cease atrial fibrillation; the presence of concomitant cardiac and "arrhythmogenic" pathology. Results: In the period of May 01-30, 2020, 100% (n=301) of the patients included in the study were assessed by the method of targeted survey. The median duration of the postoperative period to the time of a patient's survey was 21 (3; 43) months. The interviews have shown that 136 (45%) patients noted a return of complaints associated with atrial fibrillation recurrence in the postoperative period. There was a clear tendency towards a decrease in the total number of patients with complaints of the clinical recurrence of the disease, depending on the time elapsed since the surgical procedure. The longer the period from the moment of surgery, the lower the number of patients with recurrence. Of 136 patients with recurrent complaints associated with atrial fibrillation, 97 (71%) were able to conduct the daily electrocardiogram monitoring. Of these, the instrumental recurrence of atrial fibrillation was confirmed in 59 patients, which amounted to 20% of all the patients included in the study (n=301). Conclusion: To establish the true number of atrial fibrillation recurrence after cryoballoon ablation of the pulmonary veins, a targeted survey of patients is desirable for up to 12 months after the surgery. The patients with complaints which suggest atrial fibrillation recurrence, even if these complaints do not correspond to the preoperative ones, should be invited for the instrumental diagnostics of arrhythmia.

Detection of new-onset atrial fibrillation in heart failure patients using daily non-invasive ECG monitoring in the TIM-HF2 telemedicine trial

Abstract Background Heart failure (HF) and atrial fibrillation (AF) impair the prognosis when they occur concomitantly. Recent telemedical studies suggest that HF patients with AF may derive a greater benefit from telemedicine care but the results are inconsistent. The rate of newly detected AF in HF patients by daily non-invasive electrocardiogram (ECG) monitoring is unknown and a possible influence on the outcome of remote patient management (RPM) remains unclear. Purpose We aimed to investigate the detection of new atrial fibrillation in patients assigned to RPM in comparison to patients assigned to usual care (UC) in the TIM-HF2 trial. Methods The prospective, multicentre and controlled TIM-HF2 trial randomised 1538 patients (765 RPM, 773 UC). All patients had a 12-channel ECG at baseline and after one year at the final study visit. Patients who were assigned to RPM additionally transmitted a daily ECG to the telemedical centre (TMC). We excluded all patients with pacemaker including implantable cardioverter defibrillator (ICD) or cardiac resynchronisation therapy (CRT) in the baseline ECG, leaving 879 patients for analysis (RPM: 442 and UC: 437). The patients were stratified into patients with SR and patients with AF according to the rhythm documented at baseline. The primary endpoint of this analysis was newly documented AF within one year after randomisation. We analysed the daily to the telemedical centre transmitted ECGs of patients assigned to RPM with the documented rhythm status of the ECGs performed at the final study visit of patients assigned to UC. Results 569 patients had SR and 310 patients had AF at baseline. The proportion of patients with AF was nearly the same in the RPM (159, 36.0%) and the UC (151, 34.6%) group. 68 patients (24.0%) were detected with new atrial fibrillation in the RPM group compared to 22 patients (7.8%) in the UC trial arm during the one-year follow-up (p&amp;lt;0.001, number needed to screen 6). Conclusion In patients with heart failure and daily ECG transmission, atrial fibrillation was detected three times more frequently in comparison to usual care within one year. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): The TIM-HF2 study was supported by a research grant of the German Federal Ministry of Education and Research (grant numbers 13KQ0904A, 13KQ0904B, 13KQ1104A). The TIM-HF2 study was a part of the research and development project “Gesundheitsregion der Zukunft Nordbrandenburg – Fontane” (Fontane). The Fontane system was developed in private–public partnership (PPP) supported by research and development grants from the German Federal Ministry of Education and Research, the European Regional Development, and the Federal State Brandenburg.

Amiodarone-Induced Hypothyroidism

Aim: to present a clinical case of amiodarone-induced hypothyroidism in a patient with paroxysmal atrial fi brillation.Results. Before taking amiodarone, the patient suffered from subclinical hypothyroidism. The level of thyroid stimulating hormone (TSH) was 6.2 mIU/L, thyroxine (T4) — 9.2 pmol/L. Against the background of taking amiodarone in a maintenance dose of 200 mg per day 5 days a week with a break of 2 days, clinically severe hypothyroidism developed with a TSH level of more than 16 mIU/L. An electrocardiogram (ECG) recorded sinus bradycardia with a heart rate (HR) of 37 beats per minute. Paroxysms of atrial fi brillation have stopped. According to the daily ECG monitoring recorded throughout the sinus rhythm with maximum heart rate of 92 beats/min., minimum of 35 beats/min. The circadian rhythm profi le was correct. No pauses were detected for more than two seconds. Transient atrioventricular block was of 1 degree (during sleep). Ectopic activity was represented by supraventricular extrasystoles 112 per day: 107 single, 1 pair, 1 group. Ventricular extrasystoles: 55 per day: polymorphic, solitary. No diagnostically signifi cant elevation or depression of the ST segment was detected. After the abolition of amiodarone, thyroid function was recovered. Levothyroxine was not prescribed. However, paroxysms of atrial fi brillation began to occur again. For the prevention of paroxysms, sotalol 160 mg per day was prescribed.Conclusion. Thus, the development of clinically pronounced amiodarone-induced hypothyroidism has contributed to the existing thyroid dysfunction in the patient. The assessment of the thyroid gland function and its further monitoring in the process of taking the drug is prescribed. Amiodarone therapy is performed in case of ineffectiveness of other antiarrhythmic drugs and, as a rule, is not used for primary prescription.