European Heart Rhythm Association Consensus Research Articles

Diagnostic approach at specialized syncope units in the netherlands: a cross-sectional, nationwide survey

Abstract Introduction The European Society of Cardiology Guidelines recommend a structural approach for the initial evaluation of syncope patients, yet implementation of such approach appears cumbersome. There are several specialized Syncope Units in the Netherlands. Here we investigated the diagnostic strategy of specialized Syncope Units and adherence areas for syncope patients. Purpose We aimed to identify the current network of Syncope Units in the Netherlands and to assess to which extent the units fulfil requirements as indicated by the European Heart Rhythm Association consensus and the current guidelines. Methods All units Neurology, Internal Medicine, and Cardiology in hospitals in the Netherlands were contacted. Units with specialized Syncope care were included and requested to fill out a questionnaire of 25 questions regarding which medical specialties are involved during evaluation, which diagnostic tests are available and being performed and which adherence regions were associated. We specifically investigated whether the Syncope Units adhered to the consensus statements 1 and 3 as described by the European Heart Rhythm Association position paper as gold standard for best practices. Results Specialized care for syncope was reported in 20/72 hospitals. Most (17/20) reported that multiple specialties are involved during the initial evaluation. 19/20 had either Neurology, Cardiology, or both responsible for the Syncope Unit. 18/20 perform guideline-based orthostatic blood pressure measurement. A non-invasive-beat-to-beat blood pressure monitor was present in 11/20 units. 16/20 perform tilt table testing and do > 48 per year, 3/16 this was during the initial evaluation and 15/20 perform carotid sinus massage. The adherence areas cover 64.2% of the Netherlands. Both European Heart Rhythm Association consensus statements 1 and 3 for best practice were met in 4/20 of the Syncope Units, 4/20 only met consensus statement 1 and 14/20 only met consensus statement 3. Conclusion We identified 20 Syncope Units in the Netherlands. The diagnostic approach varies in the medical specialties involved, protocols for cardiovascular testing, and timing of diagnostic tests. Most units did not completely perform the Guideline suggested initial evaluation. Four out of 20 Syncope Units met the European Heart Rhythm Association consensus statements for best clinical practice.Overview Syncope Units NetherlandsAdherence of the Syncope Unit

Infections of cardiac implantable electronic devices: epidemiology, mechanisms and preventive measures.

Cardiac implantable electronic devices (CIED) infections represent a complication associated with high morbidity and mortality. Despite enormous efforts to prevent them, the rates of infections continue to rise out of proportion to the reported increase in CIED implantation rates. Following extensive research of various prevention strategies and new technologies, several organizations have issued recommendations and consensus papers covering the topic. The aim of this narrative review is to provide a summary of the existing preventive strategies put forward by the European Heart Rhythm Association consensus document, and European Society of Cardiology guidelines and introduce the most recent developments in the field, including optimized surgical site management and appropriate periprocedural antithrombotic drugs use. It also provides an overview of epidemiology, mechanisms, risk factors, and risk stratification approaches. It focuses on the pre-, intra-, and postprocedural actions to be taken in order to mitigate CIED infection risks. Future directions in the prevention of CIED infections have also been addressed.

Transvenous Lead Extraction: Outcomes From a Single Centre Providing a National Service for New Zealand.

With increasing demand for cardiac implantable electronic devices there is a parallel increase in the need for transvenous lead extraction (TLE). Due to its small population, all TLE procedures in New Zealand are currently performed in a single centre, Auckland City Hospital. We analysed the clinical characteristics and outcomes of those undergoing TLE since this service was established. We performed a retrospective, single-centre cohort study of all TLE procedures between October 2015 and December 2021. Definitions from the European Lead Extraction Controlled study, Heart Rhythm Society, European Heart Rhythm Association consensus documents were used. A total of 247 patients had 480 leads extracted, averaging 40 TLE procedures annually. Patients had a median lead dwell time of 6 (interquartile range [IQR] 3-11) years, 60 (13%) of leads had been in-situ >15 years, median age 61 (IQR 48-70) years, 73 (30%) female, 28 (11%) Māori, 23 (9%) Pasifika. Lead dysfunction (115 patients, 47%) and infection (90 patients, 37%) were the most common indications for TLE. Complete clinical and radiological success was achieved for 96% and 95%, respectively. Procedure-related complications occurred in 16 (7%) patients. Major intra-procedure complications occurred in 5 patients (2%), including 2 (1%) deaths. Death within one year of TLE occurred in 13 (26%) with systemic infection, 5 (3%) with local infection, and 5 (3%) with non-infection indications for TLE, p <0.01. TLE is associated with high radiographic and clinical success, low complication, and low mortality rate. At our single centre providing a national service, TLE outcomes are comparable with those achieved internationally.

Bacteremia due to non–Staphylococcus aureus gram-positive cocci and risk of cardiovascular implantable electronic device infection

Cardiovascular implantable electronic device (CIED) infection carries significant morbidity and mortality with bacteremia being a possible marker of device infection. A clinical profile of non-Staphylococcus aureus gram-positive cocci (non-SA GPC) bacteremia in patients with CIED has been limited. To examine characteristics of patients with CIED who developed non-SA GPC bacteremia and risk of CIED infection. We reviewed all patients with CIED who developed non-SA GPC bacteremia at the Mayo Clinic between 2012 and 2019. The 2019 European Heart Rhythm Association Consensus Document was used to define CIED infection. A total of 160 patients with CIED developed non-SA GPC bacteremia. CIED infection was present in 90 (56.3%) patients, in whom 60 (37.5%) were classified as definite and 30 (18.8%) as possible. This included 41 (45.6%) cases of coagulase-negative Staphylococcus (CoNS), 30 (33.3%) cases of Enterococcus, 13 (14.4%) cases of viridans group streptococci (VGS), and 6 (6.7%) cases of other organisms. The adjusted odds of CIED infection in cases due to CoNS, Enterococcus, and VGS bacteremia were 19-, 14-, and 15-fold higher, respectively, as compared with other non-SA GPC. In patients with CIED infection, the reduction in risk of 1-year mortality associated with device removal was not statistically significant (hazard ratio 0.59; 95% confidence interval 0.26-1.33; P = .198). The prevalence of CIED infection in non-SA GPC bacteremia was higher than previously reported, particularly in cases due to CoNS, Enterococcus species, and VGS. However, a larger cohort is needed to demonstrate the benefit of CIED extraction in patients with infected CIED due to non-SA GPC.

Management of infections in patients with cardiac implantable electronic devices

Implantation of pacemakers and cardiac defibrillators is a life-saving treatment but can put our patients at risk of infections, increasing morbidity and mortality and prolonging hospitalization with a significant financial healthcare burden. A preventive strategy is crucial but, while several strategies such as administration of intravenous antibiotic therapy before implantation are well recognized, other uncertainties remain. The main gaps regard the use of periprocedural measures, including antibacterial envelope to prevent device infection, the appropriate management of antithrombotic therapy before and after device implantation and timing of device reimplantation. To address these issues, some important randomized clinical trials and a European Heart Rhythm Association consensus document have recently been published. The aim of this article is to review current knowledge on the management of infections in patients with cardiac implantable electronic devices to help not only electrophysiologists, but also physicians in their daily practice.

Evaluation of European Heart Rhythm Association consensus in patients with cardiovascular implantable electronic devices and Staphylococcus aureus bacteremia.

Cardiovascular implantable electronic device (CIED) implantation has markedly increased over the past 2 decades. Staphylococcus aureus bacteremia (SAB) occurs in patients with CIED, and determination of device infection often is difficult. The purpose of this study was to examine the rate and clinical characteristics of SAB in patients living with CIED using the 2019 European Heart Rhythm Association (EHRA) international consensus document. We conducted a retrospective study of patients with CIED who were hospitalized at Mayo Clinic, Rochester, with SAB from 2012 to 2019. Patients who met CIED infection criteria after SAB based on EHRA criteria were identified. A descriptive statistic and time-dependent Cox model were used. Overall, 110 patients with CIED developed SAB, of whom 92 (83.6%) underwent transesophageal echocardiogram (TEE). Fifty-seven (51.8%) and 31 (28.2%) patients met criteria for definite and possible CIED infections, respectively. At 30-day follow-up, the cumulative rate of patients undergoing complete device extraction was 80.0% in the definite CIED infection group, compared with 38.8% and 32.9% in the possible and rejected CIED infection groups, respectively. We found that CIED extraction was associated with an 83% reduction in risk of 1-year mortality in the definite CIED infection group. The rate of CIED infections after SAB was higher than that reported previously. Increased use of TEE and a novel case definition with broader diagnostic criteria likely were operative, in part, in accounting for the higher rate of CIED infections complicating SAB. Complete device removal is critical in patients with definite CIED infection to improve 1-year mortality.

Infection prevention of cardiac devices – European Heart Rhythm Association consensus 2020

In recent decades, there has been a steady increase in the number of cardiac implantable electronic devices (CIED) procedures and complexity of implanted systems. Simultaneously a significant increase of complication’s rate has been observed including infections with rates ranging from 0,5 to 3,4% annually. Infectious complications can be divided into two groups: related to microbial colonization of parts of the system during implantation and related to bloodstream infection. Factors that increase the risk of infection could be: patient-related, procedure-related, or device-related. Some of them are modifiable, whereas others are non-modifiable. Among the most relevant are: pocket haematoma, infection/fever within 24 hours before procedure, temporary pacing, concomitant diseases, procedure duration and operator experience. There are numerous simple measures that can be undertaken pre-procedurally, during procedure and post procedure, which can significantly reduce the risk of CIED infection. The paper discusses the key messages of the 2020 EHRA document.

Lessons from the current European Heart Rhythm Association consensus document on screening for atrial fibrillation.

In this paper, we reviewed the atrial fibrillation screening strategies in a stepwise manner and discussed the uncertainties in the assessment of the need for anticoagulation in light of the recently published European Heart Rhythm Association consensus document. We reviewed not only the methods and tools but also the role of health care professionals and patient organizations in addition to cost-effectiveness issues.

What we have learned from the European Heart Rhythm Association consensus document on device-detected subclinical atrial tachyarrhythmias.

Although various cardiac monitoring methods were developed to detect subclinical arrhythmias, guidelines do not address in detail the management of subclinical atrial fibrillation and tachyarrhythmias. The European Heart Rhythm Association recently published a consensus document that addresses the clinical importance, implications, and management of device-detected subclinical atrial tachyarrhythmias. This paper comprehensively reviews the diagnostic tools to detect subclinical atrial arrhythmias and discusses the pathophysiologic link between device-detected subclinical atrial fibrillation and stroke. In this invited review, in the light of this paper and current scientific data, we aimed to summarize how to manage subclinical atrial arrhythmias.

Bleeding risk assessment and management in atrial fibrillation patients. Key messages for clinical practice from the European Heart Rhythm Association position statement

The prevention of thromboembolism is the main therapeutic goal in patients with atrial fibrillation (AF). Vitamin K antagonists have been proved highly effective in preventing thromboembolic events in patients with AF and despite recent advances in oral anticoagulation they remain the most widely used agents. Anticoagulation increases the incidence of bleeding; however, in the field of stroke prevention in AF the clinical benefit of vitamin K antagonists clearly outweighs potential risks. The annual incidence of major bleeding among individuals with AF on oral anticoagulation varies widely, ranging from 1.3% to 7.2%. Several factors affect bleeding risk including the intensity of anticoagulation, the efficacy of monitoring modalities, and patient characteristics. This multifactorial etiology makes prediction of bleeding risk complex, necessitating the derivation and validation of clinical prediction tools for the estimation of total bleeding risk in clinical practice. The present review summarizes data on definition, risk prediction, prevention, and management of oral anticoagulation‑associated bleeding as reflected by the recent European Heart Rhythm Association consensus statement.