Higher Risk Of Arrhythmic Events Research Articles

Association between the number of altered late potential criteria and increased arrhythmic risk in Brugada syndrome patients.

Brugada syndrome (BrS) is associated with abnormal electrophysiological properties at right ventricular epicardium, consisting of fragmented electrograms extending well beyond QRS termination. We aimed to evaluate the utility of signal-averaged electrocardiogram (SA-ECG) for the noninvasive assessment of late potentials (LP) and risk stratification of BrS patients. A prospective, observational, single-center study of BrS patients is submitted to SA-ECG with the determination of the total filtered QRS duration (fQRS), root mean square voltage of the 40ms terminal portion of the QRS (RMS40), and duration of the low-amplitude electric potential component of the terminal portion of the QRS (LAS40). LP were considered positive when above standard cut-offs: fQRS > 114ms, RMS40 < 20µV, and LAS40 > 38ms. The rates of malignant arrhythmic events (MAEs), defined as sudden death or appropriate shocks, were compared in relation to clinical characteristics and SA-ECG findings. A total of 106 BrS patients (mean age, 48 ± 12years, 67.9% male) were studied, 49% with type-1 spontaneous pattern and 81% asymptomatic. During a median follow up of 4.7years, 10 patients (7.1%) suffered MAEs, including 4 sudden deaths. The presence of LP was significantly associated with the arrhythmic risk, which increased with the number of altered LP criteria. In comparison to the patients who had none or 1 altered LP criterium, MAE risk was 4.7 times higher in those with 2 altered criteria and 9.4 times higher in those with 3 altered LP criteria. SA-ECG may be a useful tool for risk stratification in BrS. The presence of 2 or 3 abnormal LP criteria could identify a subset of asymptomatic patients at high risk of arrhythmic events.

Asymptomatic Brugada patients: long-term prognosis from a large prospective study

Abstract Background One of the greatest challenges concerning the Brugada syndrome is how to stratify and manage asymptomatic patients, who represent the majority of patients with Brugada ECG pattern (BrECG). Purpose Aim of our study was to evaluate the long-term prognosis of a large population of asymptomatic Brugada patients. Methods One thousand one hundred and forty-nine asymptomatic Brugada patients were collected. Patients were treated as follows: in the 539 subjects with spontaneous type 1 BrECG documented on basal ECG or at 12-lead 24-hour Holter monitoring (12L-Holter) an electrophysiological study (EPS) was proposed and ICD implantation was proposed on the basis of the EPS results; in the 610 subjects with drug-induced-only type 1, clinical follow-up with multiple ECGs and 12L-Holter was suggested to search for spontaneous type 1 BrECG. Results Over a median follow-up of 6 (4-9) years there were 17 arrhythmic events (1.5%). Sixteen events occurred in the 539 patients with spontaneous type 1 (3%; 0.4% person-years) and only 1 in the 610 patients with drug-induced type 1 BrECG (0.16%; 0.03% person-years, p 0.001). Patients with spontaneous type 1 had a 15-time higher risk of arrhythmic events than patients with drug- induced type 1 BrECG. Patients with spontaneous type 1 BrECG and positive EPS had a 3-time higher risk of arrhythmic events than patients with negative EPS (6.8% vs 1.6%, p 0.035). An ICD was implanted in 163 patients: 8 (5%) received an appropriate intervention, while 23% experienced device-related complications, including 1 death. Conclusions Asymptomatic patients with spontaneous type 1 BrECG have an event rate of 3% at a median follow-up of 6 years. In this group, EPS represents a useful risk stratification procedure, as a positive EPS identifies patients with a 3-time higher event rate as compared to subjects with negative EPS. A negative EPS identifies a population at low although not zero-risk. Asymptomatic patients with drug-induced only Brugada ECG pattern are a group at very low arrhythmic risk. ICD implantation is burdened by a high incidence of complications, therefore alternative therapeutic strategies are needed.

Ventricular arrhythmias and sudden cardiac death caused by mitral valve prolapse: should we operate and when?

Abstract Background Several autopsy and observational studies have investigated the link between mitral valve prolapse (MVP) and sudden cardiac death (SCD) due to the well accepted yet rare occurrence of complex ventricular arrhythmia (VA) in this cohort. Few studies however have investigated whether arrhythmia burden and more importantly SCD are reduced following surgical correction of MVP. Purpose To investigate the impact of mitral valve surgery (MVS) (replacement or repair) on VA and SCD in patients with MVP. Methods A systematic review of the current literature was conducted using an electronic search of the PubMed database in October 2021. Studies were included if subjects had undergone mitral valve (MV) repair or replacement with documented rates of arrythmias/SCD pre- and post-intervention. Small patient numbers in individual reports precluded formal meta-analysis and results were reported on a per study basis. Results 19 identified studies (10 cohort studies, nine case studies) comprised 1322 patients with a pooled mean age of 63.4 years and 38.9% were female. 748 of the 1322 patients underwent MVS: 263 MV repair, 18 MV replacement (one with leaflet and papillary muscle excision), two MV repair with Maze procedure, 177 percutaneous transcatheter MV repair, 45 annuloplasty with or without valve repair, and in 243 cases the surgical method was not specified. Of the 10 included cohort studies, seven of the eight which investigated rates of VA post MVS concluded there was a significant reduction, while one reported the predisposition to arrythmia persisted after relieving the abnormal mechanical effects of non-ischaemic MR (75% due to MVP). One study reported a reduction in SCD post MVS. Each of the nine included case studies showed a reduction in VA post MVS. One study showed mitral annular disjunction (MAD) was independently associated with a higher risk of arrhythmic events, this link persisting with time dependent MVS although reduced compared to medical management. Conclusions The underlying mechanisms for VA and SCD associated with MVP are not completely understood, and guidelines for the surgical correction of MVP based on arrhythmic and SCD risk are lacking. This systematic review illustrates a possible reduction in VA following MVS. Further identification of patients at risk of SCD, and potential use of risk stratification algorithms, would allow for consideration of earlier management and appropriate use of implantable cardioverter-defibrillators (ICD) placement / MVS with an expected survival benefit. Funding Acknowledgement Type of funding sources: None.

Cardiovascular Magnetic Resonance Imaging Phenotypes and Long-term Outcomes in Patients With Suspected Cardiac Sarcoidosis

In patients with sarcoidosis with suspected cardiac involvement, late gadolinium enhancement (LGE) on cardiovascular magnetic resonance imaging (CMR) identifies those with an increased risk of adverse outcomes. However, these outcomes are experienced by only a minority of patients with LGE, and identifying this subgroup may improve treatment and outcomes in these patients. To assess whether CMR phenotypes based on left ventricular ejection fraction (LVEF) and LGE in patients with suspected cardiac sarcoidosis (CS) are associated with adverse outcomes during follow-up. This cohort study included consecutive patients with histologically proven sarcoidosis who underwent CMR for the evaluation of suspected CS from 2004 to 2020 with a median follow-up of 4.3 years at an academic medical center in Minnesota. Demographic data, medical history, comorbidities, medications, and outcome data were collected blinded to CMR data. CMR phenotypes were identified based on LVEF and LGE presence and features. LGE was classified as pathology-frequent or pathology-rare based on the frequency of cardiac damage features on gross pathology assessment of the hearts of patients with CS who had sudden cardiac death or cardiac transplant. Composite of ventricular arrhythmic events and composite of heart failure events. Among 504 patients (mean [SD] age, 54.1 [12.5] years; 242 [48.0%] female and 262 [52.0%] male; 2 [0.4%] American Indian or Alaska Native, 6 [1.2%] Asian, 90 [17.9%] Black or African American, 399 [79.2%] White, 5 [1.0%] of 2 or more races (including the above-mentioned categories and Native Hawaiian or Other Pacific Islander), and 2 [0.4%] of unknown race; 4 [0.8%] Hispanic or Latino, 498 [98.8%] not Hispanic or Latino, and 2 [0.4%] of unknown ethnicity), 4 distinct CMR phenotypes were identified: normal LVEF and no LGE (n = 290; 57.5%), abnormal LVEF and no LGE (n = 53; 10.5%), pathology-frequent LGE (n = 103; 20.4%), and pathology-rare LGE (n = 58; 11.5%). The phenotype with pathology-frequent LGE was associated with a high risk of arrhythmic events (hazard ratio [HR], 12.12; 95% CI, 3.62-40.57; P < .001) independent of LVEF and extent of left ventricular late gadolinium enhancement (LVLGE). It was also associated with a high risk of heart failure events (HR, 2.49; 95% CI, 1.19-5.22; P = .02) independent of age, pulmonary hypertension, LVEF, right ventricular ejection fraction, and LVLGE extent. Risk of arrhythmic events was greater with an increasing number of pathology-frequent LGE features. The absence of the pathology-frequent LGE phenotype was associated with a low risk of arrhythmic events, even in the presence of LGE or abnormal LVEF. This cohort study found that a CMR phenotype involving pathology-frequent LGE features was associated with a high risk of arrhythmic and heart failure events in patients with sarcoidosis. The findings indicate that CMR phenotypes could be used to optimize clinical decision-making for treatment options, such as implantable cardioverter-defibrillators.

Ventricular Arrhythmias and Implantable Cardioverter-Defibrillator Use in Patients with Left-Ventricular Assist Device: Validation of the VT-LVAD Prediction Score

<h3>Purpose</h3> In the absence of proven survival benefit, <i>de novo</i> implantation of an implantable cardioverter defibrillator (ICD) in patients treated with a durable left ventricular assist device (LVAD) remains controversial. This study aims to assess the incidence of ventricular arrhythmias (VA) and ICD complications in patients stratified by VT-LVAD Score. <h3>Methods</h3> Patients implanted with a durable LVAD at our institution between 2010 and 2020 were reviewed (n=63). They were retrospectively classified into two groups according to the VT-LVAD prediction score: 27 patients were deemed at low/intermediate risk (<5) and 36 patients at high/very high arrhythmic risk (>5). Preoperative characteristics, outcomes, ICD-related complications and arrhythmic events were compared between the two groups. <h3>Results</h3> Mean follow-up was 43±35 months, and mean duration of support was 11±16 months. Patients in the low/intermediate risk group were generally healthier. They were younger (53 vs. 60 years old) and had less atrial fibrillation (18% vs. 64%) and VA (22% vs. 81%). In the low/intermediate risk group, 12 (44%) patients had an ICD prior to LVAD implantation, 8 (30%) patients had an ICD post LVAD implantation and 7 (26%) patients either died or underwent cardiac transplantation before consideration of an ICD. In the high/very high risk group, 28 (78%) patients had an ICD prior to LVAD implantation, 5 (14%) patients had an ICD post LVAD implantation and 3 (8%) patients either died before consideration of an ICD. Among patients with an ICD in the low/intermediate-risk group (n=20), 2 (10%) patients had an inappropriate shock secondary to supraventricular tachycardia (SVT). Two patients required appropriate antitachycardia pacing (ATP) without shock. In patients with an ICD in the high/very high risk group (n=33), 9 (27%) required appropriate ATP and 1 (3%) had an inappropriate shock secondary to SVT. There was no other ICD complication. <h3>Conclusion</h3> Our analysis showed that patients with LVAD do not seem to derive a mortality benefit from a primary prevention strategy for ICD implantation. Nevertheless, the rate of ICD-associated complications was low. The VT-LVAD score may be useful to discriminate amongst LVAD patients at high risk of arrhythmic events. However, a large, randomized trial is needed to validate this strategy.

The Mitral Annulus disjunction in mitral valve prolapse: Presentation and outcome

Clinical knowledge regarding mitral annulus disjunction (MAD) of mitral-valve-prolapse (MVP) remains limited, controversial and its potential link with untoward outcomes unsubstantiated. To assess in MVP-patients, MAD prevalence, phenotypic characteristics and long-term outcome (clinical arrhythmic events and excess-mortality). A cohort of 595 (278 female, age 61 ± 16 years) consecutive patients with isolated MVP, with comprehensive clinical, rhythmic, Doppler-echocardiographic and consistent MAD assessment, was examined. MAD prevalence, associated MVP-phenotype and outcome (survival, clinical arrhythmic events) were analyzed in overall and matched cohort. MAD presence was common (186–31%) in MVP, generally in younger patients and independently associated with severe myxomatous disease ( P ≤ 0.0002). MAD presence was also independently associated with larger left ventricle ( P = 0.005). Age-matched-cohort survival after MVP diagnosis was not worse with MAD (10-year 93 ± 2% for no-MAD and 97 ± 1% for MAD, P = 0.4), even adjusted-comprehensively for MVP characteristics ( P = 0.8). During follow-up, 170 patients had clinical arrhythmic events [ventricular tachycardia-VT ( n = 159), arrhythmia ablation ( n = 14), Cardioverter-defibrillator implantation ( n = 14) and sudden cardiac death ( n = 3)]. MAD was independently associated with higher risk of arrhythmic events [adjusted-hazard-ratio 2.60(1.87–3.62), P < 0.0001]. MAD link to arrhythmic events was weaker post-mitral-surgery [adjusted-hazard-ratio 2.07 (1.24–3.43), P = 0.005] ( Fig. 1 ). MAD is frequent at MVP diagnosis and strongly linked to advanced-myxomatous-degeneration. MAD presence is independently associated with long-term excess-incidence of clinical arrhythmic events. However, within the first 10 years post-diagnosis MAD is not linked to excess-mortality and while reassurance should be provided from the survival point of view, careful monitoring for arrhythmias is in order with MAD.

Gender related differences in brugada syndrome

Abstract Background Brugada syndrome (BS) is a heritable channelopathy with male predominance. Males (M) seem to have a higher risk of arrhythmic events, although, there is limited data regarding gender differences in BS. Aim To compare the differences between genders in a Portuguese sample of BS patients (pts). Methods Single-center retrospective study of BS pts followed by the Arrhythmology Department. Pts were divided according to gender and compared regarding baseline characteristics and electrocardiographic (ECG) parameters that possibly predict the arrhythmic risk (significative S wave in DI, R wave sign, Tpeak-Tend interval and fragmented QRS). The events during follow-up were syncope of probable arrhythmic origin, ventricular tachycardia/ventricular fibrillation (VT/VF) and sudden cardiac death (SCD). Results A total of 165 pts were included; 64 (39%) were female (F) and the mean age at diagnosis was 47±15 years. The diagnosis was made by family screening (FS) in 72 (44%) pts. Sixty-seven pts (41%) had spontaneous type 1 pattern, 59 (36%) had history of syncope and 5 (3%) had history of aborted SCD. A positive genetic test was identified in 41 (25%) pts. Sixty-three (38%) pts were referred for an electrophysiological study (EEF) which was positive in 17 (27%) pts. A cardioverter-defibrillator was implanted in 45 (27%) pts. Females were more often diagnosed by FS (64% vs 31%, p &amp;lt;.001), had less type 1 spontaneous pattern (22% vs 53%, p&amp;lt;.001) and had no atrial fibrillation (0% vs 7%, p=.043). They performed EEF less frequently (22% vs 49%, p&amp;lt;.001) and had less spontaneous pattern during treadmill stress test (8% vs 33%, p=.004). Regarding ECG parameters, females had shorter QRS interval (104±12 vs 115±18 ms, p&amp;lt;0.001), less frequent aVR sign (3% vs 27%, p&amp;lt;0.001), less significative S wave in DI (31% vs 55%, p=0.004), and a tendency for a shorter Tp-Te interval (80 vs 100 ms, p=0.051). Corrected QT interval was longer in females (396 vs 392ms, p=0.044). During a median follow-up of 28 (IQR 16–41) months, 7 pts had VT/VF (2F, 5M) and 3 had syncope (3M), with no differences between gender (p=0.287). There were no cardiovascular deaths. Conclusion In BS, female pts are more often diagnosed by FS and have less spontaneous type 1 pattern. Gender appears to affect basal ECG characteristics in BS, namely in parameters that may predict arrhythmic risk. Further studies are important to clarify the role of gender in prognosis and risk stratification of BS pts. Funding Acknowledgement Type of funding sources: None.

The mitral annulus disjunction of mitral valve prolapse: Presentation and outcome

To assess in MVP-patients, MAD prevalence, phenotypic characteristics and long-term outcome. A cohort of 595 (278 female, age 61 ± 16 years) patients with isolated MVP, clinical, rhythmic, Doppler-echocardiographic and MAD assessment was examined. MAD prevalence, phenotype and outcome (survival, clinical arrhythmic events) starting at diagnostic echocardiogram were analyzed. To balance important baseline differences, we also propensity-score matched patients with and without MAD (no-MAD). MAD presence was common (186–31%) in MVP, generally in younger patients and independently associated with severe-myxomatous-MVP and larger-LV ( P ≤ 0.005). Age-matched-cohort survival after MVP diagnosis was not worse with MAD (10-year 93 ± 2% for no-MAD and 97 ± 1% for MAD, P = 0.4), even adjusted-comprehensively for MVP-characteristics ( P = 0.8) and accounting for time-dependent (TD) mitral-surgery ( P = 0.6). During follow-up, 170 patients had clinical-arrhythmic-events [ventricular tachycardia ( n = 159), arrhythmia-ablation (n = 14), Cardioverter-defibrillator-implantation ( n = 14) and sudden-cardiac-death ( n = 3)]. MAD was independently associated with higher risk of arrhythmic-events [adjusted-HR 2.60(1.87–3.62), P < 0.0001]. MAD link to arrhythmic-events persisted with TD mitral-surgery [adjusted-HR 2.54(1.84–3.50), P < 0.0001], was strong under medical-management [adjusted-HR 3.21 (2.03–5.06), P < 0.0001] but was weaker post-mitral-surgery ( Fig. 1 ). This large cohort with MVP comprehensively characterized, shows that MAD is frequent at MVP diagnosis and strongly linked to advanced-myxomatous-degeneration. MAD presence is independently associated with long-term excess-incidence arrhythmic-events. However, within the first 10 years post-diagnosis MAD is not linked to excess-mortality and while reassurance should be provided from the survival point of view careful monitoring for arrhythmias is in order with MAD.

Pathogenesis of Ventricular Arrhythmias and Its Effect on Long-Term Prognosis in Patients With Takotsubo Cardiomyopathy.

Takotsubo cardiomyopathy (TTC), also known as broken heart syndrome, stress cardiomyopathy (SCM), or apical ballooning syndrome, is a non-ischemic cardiac disease with an initial clinical presentation that is very similar to acute coronary syndrome (ACS). Ventricular arrhythmias (VAs) contribute significantly to an increase in the rates of death in patients with TTC, especially during the acute phase, in which patients with TTC are more susceptible to develop life-threatening arrhythmias (LTA) such as ventricular tachycardia (VT), ventricular fibrillation (VF), torsades de pointes (TdP), and sudden cardiac death (SCD). However, the pathophysiology of TTC and how VA occurs are still a mystery. We aim to review previous literature and discuss the possible mechanisms of VA in TTC patients.VA usually complicates the acute phase of the disease and worsens the long-term prognosis. Alterations of repolarization (negative T wave, prolonged QTc) indicate a high risk of arrhythmic events (TdP, VT, VF, and SCD). Catecholamine effect on myocardial cells and myocardial edema can create a substrate for the development of VA. Some of the most commonly proposed mechanisms for the development of VA in patients with TTC are coronary vasospasm, myocardial stunning due to catecholamines, re-entry, and triggered activity. Further prospective studies, including a more significant number of patients, are required to understand the disease's pathophysiology better and improve LTA management in patients with TTC.

Prolonged left ventricular contraction duration in apical segments as a marker of arrhythmic risk in patients with long QT syndrome.

Long QT syndrome (LQTS) is an inherited cardiac ion channelopathy predisposing to life-threatening ventricular arrhythmias and sudden cardiac death. The aim of this study was to investigate left ventricular mechanical abnormalities in LQTS patients and establish a potential role of strain as a marker of arrhythmic risk. We included 47 patients with genetically confirmed LQTS (22 LQT1, 20 LQT2, 3 LQT3, and 2 SCN3B) and 25 healthy controls. A history of cardiac events was present in 30 LQTS subjects. Tissue Doppler and speckle tracking echocardiography were performed and contraction duration was measured by radial and longitudinal strain. The radial strain characteristic was subdivided into two planes - the basal and the apical. Left ventricular ejection fraction and global longitudinal strain were normal in LQTS patients. Mean contraction duration was longer in LQTS patients compared with controls in regard to basal radial strain (491 ± 57 vs. 437 ± 55 ms, P < 0.001), apical radial strain (450 ± 53 vs. 407 ± 53 ms, P = 0.002), and longitudinal strain (445 ± 34 vs. 423 ± 43 ms, P = 0.02). Moreover, contraction duration obtained from apical radial strain analysis was longer in symptomatic compared with asymptomatic LQTS mutation carriers (462 ± 49 vs. 429 ± 55 ms, P = 0.024), as well as in subject with mutations other than LQT1 considered to be at higher risk (468 ± 50 vs. 429 ± 49 ms, P = 0.01). Myocardial contraction duration is prolonged for both radial and longitudinal directions in LQTS patients. Regional left ventricular function analysis may contribute to risk stratification. Apical radial deformation seems to select subjects at higher risk of arrhythmic events.

A Pooled Analysis of the Prognostic Significance of Brugada Syndrome with Atrial Fibrillation.

Guidelines have previously suggested that atrial fibrillation (AF) is associated with an increased risk of arrhythmic death in Brugada syndrome (BrS) patients. However, only two articles consisting of 17 AF patients with BrS supported these views. The risk stratification of BrS patients with AF remains controversial. Thus, a meta-analysis is used to estimate the risk stratification of BrS patients with AF. We searched for relevant studies published from 2000 to December 30, 2018. A total of 1712 patients with BrS from five studies were included: 200 patients (12%) were reported with AF, among whom 37 patients (19%) had arrhythmic events. BrS patients with AF in all studies (OR 1.92, 95% CI:0.91to 4.04, P =0.09; Heterogeneity: P = 0.03, I2=61%) and some European studies (OR 1.12, 95% CI: 0.18 to 6.94, P=0.91; Heterogeneity: P = 0.006, I2=80%) did not display a higher risk of arrhythmic events than those without AF, but BrS patients with AF in Japanese studies (OR 2.32, 95% CI: 1.37 to 3.93, P=0.002; Heterogeneity: P = 0.40, I2=0%) had a higher risk of arrhythmic events than those without AF. The proportion of BrS patients with AF was greater in Japanese studies than in some European studies (16% vs. 9%, P<0.001). On the whole, BrS patients with AF showed no higher risk of arrhythmic events than those without AF, but BrS patients with AF in Japan had a higher risk of arrhythmic events than those without AF.

Association of QT dispersion with mortality and arrhythmic events-A meta-analysis of observational studies.

BackgroundThe risk stratification of coronary heart disease (CHD) and/or heart failure (HF) patients with easily measured electrocardiographic markers is of clinical importance. The aim of this meta‐analysis is to indicate whether increased QT dispersion (QTd) is associated with fatal and nonfatal outcomes in patients with CHD and/or HF.MethodsWe systematically searched MEDLINE and Cochrane databases without restrictions until August 15, 2018 using the keyword “QT dispersion”. Studies including data on the association between QTd and all‐cause mortality, sudden cardiac death (SCD) or arrhythmic events in patients with HF and/or CHD were classified as eligible.ResultsIn the analysis including patients with CHD and/or HF, we found that QTd did not differ significantly in patients with SCD compared to no SCD patients while QTd was significantly greater in the group of all‐cause mortality patients and in patients who experienced a sustained ventricular arrhythmia. Subgroup analysis showed that in myocardial infarction studies, QTd was significantly higher in patients with an arrhythmic event compared to arrhythmic event‐free patients while a nonsignificant difference was found in QTd in patients who died from any cause compared to survivors. Similarly, in HF patients, the QTd was significantly greater in patients with an arrhythmic event while a nonsignificant difference was found regarding all‐cause mortality and SCD outcomes.ConclusionsQTd has a prognostic role for stratifying myocardial infarction or HF patients who are at higher risk of arrhythmic events. However, no prognostic role was found regarding all‐cause mortality or SCD in this patient population.

Arrhythmias in patients with acute ST elevation myocardial infarction

Purpose: Arrhythmias and conduction disturbances are common during acute myocardial infarction (AMI) and a major cause of death in the pre-hospital phase. The aim of this study was to investigate common predictors for all arrhythmias in patients with ST elevation AMI (STEMI) during in-hospital phase. Materials and Methods: Ninety patients (74 male, 55 ±11 years) with acute STEMI were included. Clinical charesteristics were recorded and laboratory parameters including serum C- reactive protein (CRP), creatinine kinase MB (CKMB) and potassium levels were measured. The patients were divided into two groups according to development of arrhythmias.Results: Group 1 (n=42) patients had new onset arrhythmias and Group 2 (n=48) patients had without arrhythmias. Median baseline CRP levels were significantly higher in group 1 (36.6 (21.8-77) mg/dl vs. 21.8 (24.2-30.7) mg/dl), especially in patients with atrial fibrillation and ventricular arrhythmias. Logistic regression analysis showed that baseline higher CRP level, peak CKMB level and inferior localization of AMI were significantly associated with the development of arrhythmia following AMI. Conclusion: Levels of CRP and CKMB and inferior infarct localization have predictive values for all the arrhythmic events during AMI. CRP levels were found to be associated with both atrial and ventricular arrhythmias. The assessment of CRP levels can be used to detect patients at high risk for arrhythmic events after STEMI.

Association of Genetic and Clinical Aspects of Congenital Long QT Syndrome With Life-Threatening Arrhythmias in Japanese Patients

ImportanceLong QT syndrome (LQTS) is caused by several ion channel genes, yet risk of arrhythmic events is not determined solely by the responsible gene pathogenic variants. Female sex after adolescence is associated with a higher risk of arrhythmic events in individuals with congenital LQTS, but the association between sex and genotype-based risk of LQTS is still unclear.ObjectiveTo examine the association between sex and location of the LQTS-related pathogenic variant as it pertains to the risk of life-threatening arrhythmias.Design, Setting, and ParticipantsThis retrospective observational study enrolled 1124 genotype-positive patients from 11 Japanese institutions from March 1, 2006, to February 28, 2013. Patients had LQTS type 1 (LQT1), type 2 (LQT2), and type 3 (LQT3) (616 probands and 508 family members), with KCNQ1 (n = 521), KCNH2 (n = 487) and SCN5A (n = 116) genes. Clinical characteristics such as age at the time of diagnosis, sex, family history, cardiac events, and several electrocardiographic measures were collected. Statistical analysis was conducted from January 18 to October 10, 2018.Main Outcomes and MeasuresSex difference in the genotype-specific risk of congenital LQTS.ResultsAmong the 1124 patients (663 females and 461 males; mean [SD] age, 20 [15] years) no sex difference was observed in risk for arrhythmic events among those younger than 15 years; in contrast, female sex was associated with a higher risk for LQT1 and LQT2 among those older than 15 years. In patients with LQT1, the pathogenic variant of the membrane-spanning site was associated with higher risk of arrhythmic events than was the pathogenic variant of the C-terminus of KCNQ1 (HR, 1.60; 95% CI, 1.19-2.17; P = .002), although this site-specific difference in the incidence of arrhythmic events was observed in female patients only. In patients with LQT2, those with S5-pore-S6 pathogenic variants in KCNH2 had a higher risk of arrhythmic events than did those with others (HR, 1.88; 95% CI, 1.44-2.44; P < .001). This site-specific difference in incidence, however, was observed in both sexes. Regardless of the QTc interval, however, female sex itself was associated with a significantly higher risk of arrhythmic events in patients with LQT2 after puberty (106 of 192 [55.2%] vs 19 of 94 [20.2%]; P < .001). In patients with LQT3, pathogenic variants in the S5-pore-S6 segment of the Nav1.5 channel were associated with lethal arrhythmic events compared with others (HR, 4.2; 95% CI, 2.09-8.36; P < .001), but no sex difference was seen.Conclusions and RelevanceIn this retrospective analysis, pathogenic variants in the pore areas of the channels were associated with higher risk of arrhythmic events than were other variants in each genotype, while sex-associated differences were observed in patients with LQT1 and LQT2 but not in those with LQT3. The findings of this study suggest that risk for cardiac events in LQTS varies according to genotype, variant site, age, and sex.

Gender Differences in Prognosis and Risk Stratification of Brugada Syndrome: A Pooled Analysis of 4,140 Patients From 24 Clinical Trials.

Background: Male gender has been consistently shown to be a risk factor for a greater number of arrhythmic events in patients with Brugada Syndrome (BrS). However, there have been no large-scale comprehensive pooled analyses to statistically and systematically verify this association. Therefore, we conducted a pooled analysis on gender differences in prognosis and risk stratification of BrS with a largest sample capacity at present.Methods: We searched PubMed, Embase, Medline, Cochrane Library databases, Chinese National Knowledge Infrastructure, and Wanfang Data for relevant studies published from 2002 to 2017. The prognosis and risk stratification of BrS and risk factors were then investigated and evaluated according to gender.Results: Twenty-four eligible studies involving 4,140 patients were included in the analysis. Male patients (78.1%) had a higher risk of arrhythmic events than female patients (95% confidence interval: 1.46–2.91, P < 0.0001). Among the male population, there were statistical differences between symptomatic patients and asymptomatic patients (95% CI: 2.63–7.86, P < 0.00001), but in the female population, no statistical differences were found. In the female subgroup, electrophysiological study (EPS) positive patients had a tendency toward a higher risk of arrhythmic events than EPS-negative patients (95% CI: 0.93–29.77, P = 0.06).Conclusions: Male patients are at a higher risk of arrhythmic events than female patients. Within the male population, symptomatic patients have a significantly higher risk profile compared to asymptomatic patients, but no such differences are evident within the female population. Consequently, in the female population, the risk of asymptomatic patterns cannot be underestimated.

Clinical implications of eicosapentaenoic acid/arachidonic acid ratio (EPA/AA) in adult patients with congenital heart disease.

Recent studies showed that a low ratio between the levels of eicosapentaenoic acid and those of arachidonic acid (EPA/AA) is associated with higher incidence of coronary artery disease and poor prognosis of heart failure, arrhythmia, and cardiac sudden death. However, the clinical implications of EPA/AA in adult patients with congenital heart disease remain unclear. We aimed to assess the prognostic value of EPA/AA regarding cardiac events in adult patients with congenital heart disease. We measured the serum levels of eicosapentaenoic acid and arachidonic acid in 130 adult patients (median age, 31years) stratified into two groups according to their EPA/AA (low, ≤0.22; high, >0.22). We prospectively analyzed the association between EPA/AA and incidence of cardiac events during a mean observation period of 15months, expressed in terms of hazard ratio (HR) with 95% confidence interval (95% CI). In the subgroup of patients with biventricular circulation (2VC) (n=76), we analyzed the same clinical endpoints. In our study population, EPA/AA was not associated with the incidence of arrhythmic events (HR, 1.52; 95% CI, 0.82-2.85; p=0.19), but low EPA/AA was a predictor of heart failure hospitalization (HR, 2.83; 95% CI, 1.35-6.30; p<0.01). Among patients with 2VC, an EPA/AA of ≤0.25 was associated with a significantly higher risk of arrhythmic events (HR, 2.55; 95% CI, 1.11-6.41; p=0.03) and heart failure hospitalization (HR, 5.20; 95% CI, 1.78-18.1; p<0.01). EPA/AA represents a useful predictor of cardiac events in adult patients with congenital heart disease.

A meta-analysis on the prognostic significance of inferolateral early repolarization pattern in Brugada syndrome.

The early repolarization (ER) pattern has been linked to an increased risk for arrhythmic death in various clinical settings. There are limited and conflicting data regarding the prognostic significance of ER pattern in Brugada syndrome (BS). The aim of this meta-analysis was to provide a detailed analysis of the currently available studies regarding the arrhythmic risk in patients with BS and ER pattern. Current databases were searched until May 2015. A random-effect meta-analysis of the effect of ER pattern on the incidence of arrhythmic events in patients with BS was performed. Five studies were included comprising a total of 1375 patients with BS. An ER pattern was reported in 177 patients (12.8%). During follow-up (44.9-93 months), 143 patients (10.4%) suffered an arrhythmic event. Overall, BS patients with ER pattern displayed an increased risk of arrhythmic events compared to patients without ER (OR 3.29, 95% CI: 2.06 to 5.26, P < 0.00001; Heterogeneity: P = 0.11, I2 = 48%). Three studies provided data regarding ER pattern location. Inferior, lateral, or inferolateral ER pattern location was observed in 20.3%, 32.2%, and 48%, respectively. An inferolateral ER location conferred the higher arrhythmic risk (OR 4.87, 95% CI: 2.64 to 9.01, P< 0.00001; Heterogeneity: P = 0.85, I2 = 0%). This meta-analysis suggests that the ER pattern is associated with a high risk of arrhythmic events in patients with BS. In particular, BS patients with inferolateral ER (global ER pattern) displayed the highest arrhythmic risk.

CHANGE OF ARRHYTHMIC EVENTS IN ACUTE MYOCARDIAL INFARCTION WITH ST-SEGMENT ELEVATION AFTER PHARMACOINVASIVE REVASCULARIZATION

Aim. To study changes in course of arrhythmias, depending on the efficacy of coronary blood flow restoration due to pharmacoinvasive revascularization in patients ST segment elevation myocardial infarction (STEMI). Material and methods. STEMI-patients (n=117) an effective (according to ECG criteria) thrombolytic therapy (TLT) and the subsequent (after 3-24 hours) percutaneous coronary intervention (PCI), were included into the study. Telemetry ECG was performed before and after PCI analysis of the arrhythmias and cardiac conduction disorders. Results. Patients (n=84; 71.8%) an effective TLT, confirmed by the coronary angiography (CAG), and subsequent effective PCI were included into the group without (RT(–)). Patients (n=33; 28.2%) CAG proven rethrombosis of the infarct-related coronary artery and subsequent effective PCI were included into the group with (RT(+)). Regardless of the stability of coronary blood flow restoration after the TLT, PCI was associated an increased incidence of ventricular tachycardia (VT) (p<0.01), sinus tachycardia (p=0.01), paroxysmal supraventricular tachycardia (SVT) (p<0.05) and paired ventricular extrasystoles (p<0.01). Compared to the RT(–) group, in the RT(+) group after PCI VT were recorded more frequently (44% vs 63.6%, respectively; p<0.05) as well as AV-block 3 degree (3.6% vs 12.1%, respectively; p<0.05). Episodes of sinus tachycardia were detected significantly more frequently before PCI in RT(–) group compared RT(+) group (67.9% vs 45.4% respectively; p<0.01). The number of patients episodes of sinus bradycardia increased (from 19% to 32.1%; p=0.02) after PCI in RT(–) group. Conclusion. The incidence of VT and SVT paroxysms, episodes of sinus tachycardia, atrioventricular conduction disturbances and ventricular extrasystoles increased in all patients after the effective PCI due to reperfusion. However, VT episodes and paroxysmal atrioventricular block grade 3 were more common in patients previous re-thrombosis of the infarct-related coronary artery. Considering a high risk of arrhythmic events, continuous ECG mon itoring automated alarm systems about life-threatening arrhythmias should be applied in STEMI patients regardless of tactics of coronary blood flow restoration and the reperfusion effectiveness.

Usefulness of Fragmented QRS Complex to Predict Arrhythmic Events and Cardiovascular Mortality in Patients With Noncompaction Cardiomyopathy

We aimed to evaluate the prevalence and prognostic role of fragmented QRS complex (fQRS) in predicting arrhythmic events and cardiovascular mortality in patients with noncompaction cardiomyopathy (NCC). A total of 88 patients (64.8% men, mean age 38.6 ± 17.7 years) with the diagnosis of NCC were enrolled. Median follow-up time was 42.4 months. The fQRS was defined as the presence of ≥1 additional R wave (R') or notch on the R/S waves in ≥2 contiguous leads representing anterior (V1 to V5), inferior (II, III, and aVF), or lateral (I, aVL, and V6) myocardial segments. Compared to patients without fQRS group, patients with fQRS (fQRS (+) group) showed higher rates for total arrhythmic events, ventricular tachycardia, bradyarrhythmia requiring pacemaker, sudden cardiac death, cardiovascular mortality, and all-cause mortality. The cut-off point of ≥3 leads for the fQRS was the optimal point discriminating an arrhythmic event and cardiovascular mortality. In Kaplan-Meier survival analysis, total arrhythmic events and cardiovascular mortality occurred more frequently in the fQRS (+) group. In multivariate Cox proportional hazard regression analysis, after adjusting for other confounding factors, the presence of fQRS were found to be as an independent predictor of arrhythmic events (hazard ratio 3.850, 95% CI 1.062 to 9.947, p = 0.002) and cardiovascular mortality (hazard ratio 2.719, 95% CI 1.494 to 9.262, p = 0.005). In conclusion, the presence of fQRS complex, as a simple and feasible electrocardiographic marker, seems to be a novel predictor of arrhythmic events and cardiovascular mortality in patients with NCC. This simple parameter may be used in identifying patients at high risk for arrhythmic events and so individualization of specific therapies can be applied.

Clinical characterisation and long-term prognosis of women with Brugada syndrome

ObjectivesBrugada syndrome (BS) in women is considered an infrequent condition with a more favourable prognosis than in men. Nevertheless, arrhythmic events and sudden cardiac death (SCD) also occur in this...