Implantable Cardioverter Defibrillator Research Articles

An hiPSC-CM approach for electrophysiological phenotyping of a patient-specific case of short-coupled TdP

IntroductionA healthy young woman, age 26 without prior cardiac complications, experienced an out-of-hospital cardiac arrest caused by ventricular fibrillation (VF), which coincided with a fever. Comprehensive diagnostics including echo, CMR, exercise testing, and genetic sequencing, did not identify any potential cause. This led to the diagnosis of idiopathic VF and installment of an implantable cardioverter defibrillator, which six months later appropriately intervened another VF episode under conditions comparable to the first event. A second diagnostic opinion concluded short-coupled Torsade de Pointes (scTdP), and the patient was started on a verapamil treatment.MethodsFrom this patient, human induced pluripotent stem cell cardiomyocyte (hiPSC-CM) lines were generated to study cellular electrophysiology. Without a known genetic pathogenic variation, no isogenic control line could be produced, therefore a healthy age- and sex-matched control hiPSC-CM line was used. Cellular electrophysiology was studied in these cardiomyocytes using calcium- and voltage sensitive fluorescent dyes and measurements were carried out at 37 °C and 39 °C, to mimic the condition of hyperthermia in the patient. mRNA expression of electrophysiologically relevant genes were analyzed to identify a potential underlying mechanism.ResultsCalcium transients measured in patient lines at a physiological temperature indicated the occurrence of early after transients (EATs). Strikingly, at 39 °C the incidence of EATs further increased. Membrane potential data from the patient also revealed shorter action potentials that, combined with the EATs, indicate the premature release of calcium during diastole, which could be responsible for the extrasystoles in the patient. Gene expression profiles were mainly downregulated in the patient but could not clearly aid in unraveling a mechanism behind the occurrence of EATs. Pharmacological screening was performed to evaluate the treatment regimen and to determine a mechanism of action of the EATs. While verapamil, dantrolene, and flecainide did not decrease the incidence of EATs, calcium handling parameters were affected indicating functionality of the drugs.ConclusionThis patient-specific case of electrophysiological phenotyping resulted in a hypothesis of the possible mechanism behind the scTdP arrhythmias, but also accentuates the applicability of patient-specific hiPSC-CM disease modeling and phenotyping.

Anomalous Origin of The Left Coronary Artery from Pulmonary Artery Mimicking Antero-Lateral ST-Elevation Myocardial Infarction – A Case Report

Abstract Background Anomalous origin of the left coronary artery (LCA) from the pulmonary artery (PA) (ALCAPA) is a rare congenital abnormality. We present a case of an ALCAPA in a 25-year-old man. Case summary A 25-year-old male with no past medical history was admitted to our intensive cardiac care unit (ICCU) after sudden cardiac arrest due to ventricular fibrillation (VF) and suspected acute coronary syndrome (ACS). After being treated with shock by Automated External Defibrillator (AED), an electrocardiogram (ECG) demonstrated sinus tachycardia with antero-lateral ST-segment Elevation. Initial Transthoracic echocardiography (TTE) showed severe and diffuse left ventricular (LV) dysfunction and dilatation. Coronary angiography revealed anomalous origin of the LCA from the PA and extensive collateral circulation from a giant RCA. An ECG gated cardiac computed tomography (CT) confirmed the diagnosis of anomalous LM originating from the left pulmonary artery. Cardiac magnetic resonance (CMR) demonstrated an enlarged left ventricle with globally reduced function, and extensive sub-endocardial scarring of the anterior, anterolateral and lateral walls. Following a multidisciplinary heart team discussion, the patient successfully underwent repair of aberrant LCA with direct LCA re-implantation to the aorta and subcutaneous implantable cardioverter-defibrillator (S-ICD) implantation. Optimal medical therapy (OMT) for heart failure with reduced ejection fraction (HFrEF) was initiated and the patient was discharged home for a close clinical and echocardiographic follow up. In conclusion ALCAPA in the adulthood is a very rare congenital anomaly that clinicians should be aware of. The preferred treatment, when diagnosed in time, is direct re-implantation of the LCA to the aorta.

Wearable Cardioverter Defibrillator as a Treatment in Patients with Heart Failure of Various Aetiologies—A Series of Ten Cases Within the BIA-VEST Registry

Background/Objectives: Sudden cardiac death (SCD) remains a major global health concern and represents one of the most common causes of mortality due to cardiovascular diseases. The wearable cardioverter–defibrillator (WCD) is an innovative, non-invasive medical device designed to provide continuous heart monitoring and immediate defibrillation in patients at risk for SCD. The study aimed to assess the efficacy of WCD usage in patients awaiting decision on therapy with implantable cardioverter–defibrillators (ICDs). Methods: We explored the clinical applications, benefits, and limitations of WCD usage within the BIA-VEST registry in Poland over the years 2021–2023. The study included 10 patients with a mean age of 49.1 ± 12.02 years. Results: All patients demonstrated good tolerance and compliance with the LifeVest WCD, wearing it for an average of 93.1 days, about 22.8 h per day (95.7% of the time). No interventions from LifeVests were recorded, and there were no effective, ineffective, or inadequate discharges. After the first follow-up echocardiography, five patients still required ICDs. Due to improved LVEF and overall condition in six out of ten patients undergoing WCD bridge therapy, ICD implantation was finally waived. Conclusions: The WCD acts as a bridge to therapy, such as ICD implantation or cardiac surgery, and may be particularly beneficial for patients with transient or evolving conditions, such as structural heart diseases and life-threatening ventricular arrhythmias.

Validation Against Polysomnography of a Transthoracic Impedance Sensor for Screening of Sleep Apnea in Heart Failure Patients: A Pooled Analysis of AIRLESS and UPGRADE

Background/Introduction: Cardiac implantable electronic devices and their integrated thoracic impedance sensors have been used to detect sleep apnea for over a decade now. Despite their usage in daily clinical practice, there are only limited data on their diagnostic accuracy. Methods: AIRLESS and UPGRADE were prospective investigator-driven trials meant to validate the AP scan® (Boston Scientific, Marlborough, MA, USA) in heart failure cohorts. Patients, who either fulfilled the criteria for implantation of an implantable cardioverter-defibrillator (ICD), cardiac resynchronization therapy (CRT), or upgrading to CRT according to most recent guidelines at the time of study conduction, were eligible for enrolment. Sleep apnea and its severity, measured by apnea–hypopnea index (AHI), were assessed by polysomnography. For direct comparison, the apnea sensor-derived AP scan® was used from the identical night. Results: Overall, 80 patients were analyzed. Median AHI was 21.6 events/h (7.1–34.7), while median AP scan® was 33.0 events/h (26.0–43.0). In the overall cohort, the sensor-derived AP scan® correlated significantly with the AHI (r = 0.61, p < 0.001) with a mean difference (MD) of −12.6 (95% confidence interval (CI) −38.2 to 13.0). Furthermore, the AP scan® was found to correlate well with the AHI in patients with obstructive sleep apnea r = 0.73, p = 0.011, MD −5.2, 95% CI −22.7 to 12.3), but not central sleep apnea (r = 0.28, p = 0.348, MD −10.4, 95% CI −35.4 to 14.6). Conclusions: In an exclusive heart failure cohort, the AP scan® correlated well with the PSG-derived AHI. A similar correlation was found in most subgroups except for patients suffering from central sleep apnea.

Revisiting ICD Therapy for Primary Prevention in Patients With HeartFailure and Reduced Ejection Fraction.

Implantable cardioverter-defibrillators (ICDs) are recommended to reduce the risk of sudden cardiac death (SCD) in patients with heart failure with reduced ejection fraction (HFrEF). The landmark studies leading to the current guideline recommendations preceded the 4 pillars of guideline-directed medical therapies (GDMTs). Therefore, some have questioned the role of ICDs for primary prevention in current clinical practice. In this paper, the authors provide an overview of the current ICD recommendations, including the instrumental clinical trials, the risk of SCD as observed in clinical trials vs real-world scenarios, disparities in ICD use among different patient populations, the impact of contemporary GDMT on outcomes, and ongoing and future trials and methodologies to help identify patients who are at an increased risk of SCD and who may benefit from an ICD. The authors also propose a pragmatic guidance for clinicians when they engage in the shared decision-making discussions for primary ICD implantation.

Midterm outcomes of patients with native heart recovery after Impella 5+ for cardiogenic shock

AbstractAimsLeft ventricular unloading by percutaneous microaxial flow‐pump devices has been shown to improve survival in patients with cardiogenic shock (CS). The objective of the study is to examine whether Impella 5.0/5.5 (5+) support is effective in facilitating heart recovery, overall survival, and quality of life.Methods and resultsThis single‐centre retrospective study examined midterm (180 days) outcomes of patients with CS supported by Impella 5+ who achieved heart recovery. The primary endpoint was survival at 180 days and freedom from implantable cardioverter‐defibrillator (ICD), heart transplant/left ventricular assist device (LVAD), or readmission for heart failure. Functional status was assessed with New York Heart Association (NYHA) classification. Between June 2022 and April 2024, 20 patients with CS (64 ± 8.9 years, 80% male) received Impella 5+ and discharged with heart recovery. Before Impella placement, mean left ventricular ejection fraction (LVEF) was 19.2 ± 5.2%, 7 (35%) patients were SCAI stage C, 9 (45%) SCAI stage D, and 4 (20%) SCAI stage E, and the mean vasoactive‐inotropic score was 23.2 ± 38.0. The average duration of Impella support was 10.5 ± 8 days. At 180 days, 19 (95%) patients were alive, no patient received a heart transplant/LVAD, 40% were implanted with an ICD and there were two admissions for heart failure. The mean LVEF was 33.5 ± 10.7%, 5 (26.3%) patients were NYHA class I, 9 (47.4%) were NYHA class II, and 5 (26.3%) were NYHA class III. One patient died from a non‐cardiac cause.ConclusionImpella 5+ represents a promising treatment strategy for CS, providing high rates of sustained native heart recovery. A comprehensive platform of mechanical and pharmacological unloading is key.

Long-Term Results of Stereotactic Arrhythmia Radioablation for Refractory Ventricular Arrhythmias—A Taiwanese Population Study

BackgroundStereotactic arrhythmia radioablation (STAR) has proven to be effective in refractory ventricular tachyarrhythmia (VT). We report the long-term results in first Asian series of STAR for refractory VT in a group of Taiwanese. MethodsThis study prospectively enrolled patients with treatment-failure VT. 3D electroanatomic maps, delayed enhancement magnetic resonance imaging and dual energy computed tomography were used to identify scar substrates. The main target volume was treated with a single radiation dose of 25 Gy delivered by Varian/Edge TrueBeam System. Efficacy was assessed by VT events recorded by implantable cardioverter defibrillator. ResultsFrom February 2019 to Feburary 2023, 11 patients were enrolled and followed up for at least 1 year. Ten male and one female patient received the treatment. During the median follow-up of 53 months, VT episodes decreased by 88% in post-treatment first 6 months. Late VT recurrence was observed in most of patients. Five patients received repeated catheter ablation for recurrent VTs. One-year survival rate was 83%. Among surviving patients, 1 received heart transplant and 2 had HeartMate III implantation. ConclusionsIn patients with medication and catheter ablation refractory VT, STAR is associated with a marked acute reduction in the burden of VT. The acute response of VT burden reduction helps to bridge patients to the next treatment step of heart failure, including medical optimization or surgical management, and enhance clinical outcomes.

Life-Threatening Ventricular Tachyarrhythmia in Isolated Cardiac Sarcoidosis Compared With Cardiac Sarcoidosis With Extracardiac Involvement.

Although isolated cardiac sarcoidosis (CS) is not uncommon, little is known about the risk of life-threatening ventricular tachyarrhythmia. We aimed to evaluate the incidence of ventricular tachyarrhythmia in patients with isolated CS. Ninety-four patients with CS were enrolled. Isolated CS was diagnosed by histological or clinical confirmation in the heart alone. The endpoint was sudden cardiac death, ventricular fibrillation, sustained ventricular tachycardia, or implantable cardioverter defibrillator (ICD) therapy for ventricular fibrillation or sustained ventricular tachycardia. Twenty-five patients were diagnosed with isolated CS, and 69 with CS with extracardiac involvement. As the initial cardiac manifestation leading to the CS diagnosis, 10 (40%) patients with isolated CS had ventricular tachyarrhythmia. Over the median follow-up of 48 months after the CS diagnosis, sudden cardiac death occurred in 2 (8%) patients with isolated CS. Ventricular fibrillation or sustained ventricular tachycardia, including ICD therapy, occurred in 15 (60%) patients with isolated CS and 13 (19%) with CS with extracardiac involvement. The rate of ventricular tachyarrhythmia was higher in patients with isolated CS than in those with CS with extracardiac involvement (log-rank, p < 0.01). Cox proportional hazard analysis showed that isolated CS was independently associated with ventricular tachyarrhythmia. Two or more ventricular tachyarrhythmias more frequently occurred in patients with isolated CS (52% vs 13%, p < 0.01). Electric storm more frequently occurred in patients with isolated CS (24% vs 6%, p = 0.01). In conclusion, patients with isolated CS have ventricular tachyarrhythmia at a higher rate, compared with those with CS with extracardiac involvement.

Cardiac MRI Pectoralis Muscle Thickness as a Measure of Sarcopenia: Prognostic Significance, Interreader Agreement, and Physiologic Correlation.

Purpose To evaluate pectoralis muscle thickness at routine cardiac MRI as a marker of sarcopenia, including prognostic significance for major adverse cardiac events (MACE), interobserver agreement, and correlation with physiologic parameters. Materials and Methods This retrospective cohort study included adult patients undergoing cardiac MRI for assessment of suspected cardiomyopathy between October 2018 and February 2020. Measurements of maximum pectoralis major thickness were performed by two experienced radiologists using axial images at the level of the carina. A random subset of 50 patients were re-evaluated to assess intra- and interobserver agreement. The primary end point was MACE, defined as a composite of cardiac death, resuscitated sudden cardiac death, appropriate implantable cardioverter defibrillator discharge, or hospitalization for heart failure. Prognostic significance of pectoralis major thickness measurements for MACE was assessed using Cox proportional hazard models, and correlation between muscle thickness measurements and cardiopulmonary exercise testing (CPET), performed within 1 year of MRI, was assessed using Spearman correlation. Results The study included 1045 patients (mean age, 50 years ± 17 [SD]; 642 male, 403 female). After median follow-up of 3.3 years (IQR: 2.3-3.9 years), MACE occurred in 66 patients. In multivariable models adjusted for patient age, left ventricular ejection fraction, late gadolinium enhancement, and cardiomyopathy cause, pectoralis major muscle thickness was predictive of MACE in both male (hazard ratio [HR], 0.89 [95% CI: 0.85, 0.94]; P < .001) and female patients (HR, 0.85 [95% CI: 0.76, 0.96]; P = .008), with improved model fit in nested models. Pectoralis muscle thickness measurements had excellent intra- and interobserver agreement (intraclass correlation coefficient, 0.99 and 0.95, respectively) and correlated with absolute peak oxygen uptake (r = 0.65, P < .0001) and oxygen uptake efficiency slope (r = 0.61, P < .001) in the subset who underwent CPET within 1 year of MRI (n = 258). Conclusion Pectoralis major muscle thickness at routine cardiac MRI is a simple, reproducible measure of sarcopenia that was associated with MACE occurrence in male and female patients and correlated with CPET parameters. Keywords: Cardiac, Cardiomyopathies, MR Imaging Supplemental material is available for this article. © RSNA, 2024.

Declining Trend of Sudden Cardiac Death in Younger Individuals: A 20-Year Nationwide Study.

Declining cardiovascular mortality rates have been well-documented, yet temporal trends of sudden cardiac death (SCD) in young individuals remain unclear. We provide contemporary nationwide estimates of the temporal trends of SCD in young individuals (1-35 years of age) from 2000 through 2019 and correlate these trends to changes in out-of-hospital cardiac arrest (OHCA) patterns, rates of inherited cardiac diseases, and implantations of implantable cardioverter defibrillators (ICD). All individuals between 1 and 35 years of age living in Denmark from 2000 through 2019 were included, with annual re-evaluation of the at-risk population in regard to age. Adjudication of SCD cases relied on multiple sources, including death certificates, medical files, and autopsy reports. Information on OHCA, diagnostic rates, and ICD implantations were captured from nationwide administrative registries. Annual incidence rates of SCD were calculated, and temporal trends in SCD incidence were computed as percentage change annualized. Trends in OHCA survival and characteristics, diagnostic rates of inherited cardiac diseases, and ICD implantations were assessed. During the 20-year study period (47.5 million person-years), 1057 SCDs were identified (median age, 29 years; 69% male). The overall incidence of SCD was 2.2 per 100 000 person-years and declined by 3.31% (95% CI, 2.42-4.20) annually, corresponding to a 49% (95% CI, 38.7-57.6) reduction during the study. Rates of witnessed SCD declined markedly (percentage change annualized -7.03% [95% CI, -8.57 to -5.48]), but we observed no changes in the rate of unwitnessed SCD (percentage change annualized -0.09% [95% CI, -1.48 to 1.31]). Therefore, the proportion of unwitnessed SCD increased by 79% (P<0.001). Survival after OHCA in young individuals (1 to 35 years of age) increased from 3.9% to 28%, mainly because of increased bystander cardiopulmonary resuscitation and defibrillation rates. Diagnostic rates of inherited cardiac diseases increased 10-fold (incidence rate ratio, 10.4 [95% CI, 8.46-12.90]) and the ICD implantation rate increased 2-fold (incidence rate ratio, 1.97 [95% CI, 1.51-2.60]). SCD incidence rates in young individuals declined by 49% over the past 2 decades. The decline was paralleled by improved survival of OHCA, higher diagnostic rates of inherited cardiac diseases, and higher ICD implantation rates. However, rates of unwitnessed SCD were unchanged, which calls for new perspectives in preventive strategies.

Partnering RemoTe monitoring of Implanted Cardiac devices with Intelligent PATient Engagement – PARTICIPATE trial: a protocol for a randomised controlled trial

IntroductionCardiac implantable electronic devices (CIED) can transfer data to the healthcare team, remotely. National and international cardiac organisations recommend all patients use this technology, however patient engagement is suboptimal. Previously,...

Resting heart rate assessed within clinical practice demonstrates no prognostic relevance for defibrillator recipients in the German DEVICE registry

Resting heart rate (RHR) has prognostic implications in heart failure with reduced ejection fraction, where ≤ 70 bpm is targeted. Whether a RHR > 70 bpm assessed within clinical practice goes along with elevated cardiovascular risk in implantable cardioverter-defibrillator (ICD) / cardiac resynchronization therapy-defibrillator (CRT-D) recipients remains incompletely understood. A total of 1589 patients (ICD n = 1172 / CRT-D n = 417, median age 65 years, 22.6% female) undergoing ICD/CRT-D implantation or revision in the prospective German DEVICE multicenter registry were analyzed. RHR was assessed via a 12-channel electrocardiogram at enrollment. 1-year outcomes (all-cause mortality, major cardio- and cerebrovascular events (MACCE), all-cause hospital admission) were compared between patients with a RHR ≤ 70 bpm and > 70 bpm. 733 patients (46.1%) showed a RHR > 70 bpm. Median RHR was 63 (interquartile range 59; 68) bpm (≤ 70 bpm group) and 80 (75; 89) bpm (> 70 bpm group). Heart failure with reduced ejection fraction was present in 76.3%, a prior myocardial infarction in 32.4% and non-ischemic heart disease in 44.9%. One-year all-cause mortality was similar between RHR groups (≤ 70 bpm 5.4% vs. > 70 bpm 5.4%, p = 0.96), and subgroup analysis regarding patient characteristics and comorbidities revealed only a significantly higher rate of patients with dual chamber ICD in the > 70 bpm group (0.8% vs. 9.2%, p = 0.003). MACCE (5.9% vs. 6.1%, p = 0.87) and defibrillator shock rates (9.9% vs. 9.8%, p = 1.0) were similar. Higher all-cause hospital admission rates were observed in patients with > 70 bpm RHR (23.1% vs. 29.0%, p = 0.027) driven by non-cardiovascular events (6.0% vs. 11.7%, p = 0.001). In conclusion, in ICD and CRT-D recipients a RHR at admission > 70 bpm may indicate patients at increased risk of all-cause hospital admission but not of other adverse cardiovascular events or death at 1-year follow-up.

Risk of Recurrent Ventricular Tachyarrhythmia Following the Occurrence of a First Ventricular Arrhythmic Event in Patients with a Primary Prevention Implantable Cardioverter-Defibrillator

There are limited data on clinical and arrhythmic outcomes following a first ventricular tachyarrhythmia (VTA) in heart failure (HF) patients who receive a primary prevention implantable cardioverter-defibrillator (ICD). To quantify the burden and identify risk factors for recurrent VTA in this population, and to evaluate the risk of all-cause mortality associated with recurrent VTA. The study comprised 789 patients who experienced VTA following primary prevention ICD implantation in 5 ICD trials (MADIT-II, MADIT-RISK, MADIT-CRT, MADIT-RIT, RAID). Landmark analysis was used to quantify the burden and identify predictors of recurrent VTA. Time-dependent analysis was used to evaluate the association of VTA recurrence with subsequent mortality. Among the study patients, mean age was 63 years and 17% were women. The cumulative probability of experiencing at least one recurrent VTA episode at 3 years following a first VTA episode was 60%; the recurrent VTA burden after a first event over 3 years was 2.8 episodes per patient. The risk of recurrent VTA remained ≥56% at 3 years regardless of baseline clinical and echocardiographic risk factors. VTA recurrence was associated with a significant two-fold increased risk of subsequent all-cause mortality. Patients with a primary prevention ICD who experience an episode of VTA are at very high risk of recurrent VTA, regardless of baseline risk factors. Recurrent VTA is associated with a pronounced increase in the risk of death. These findings suggest a need for early intervention following a first VTA in patients who receive a primary prevention ICD.

Diagnosis and Prognosis of Isolated Cardiac Sarcoidosis: Multidisciplinary Diagnosis vs Japanese Circulation Society Criteria.

The prognosis of isolated cardiac sarcoidosis (ICS) has not been fully elucidated. The only diagnostic criteria available for ICS, the Japanese Circulation Society (JCS) criteria, have not been validated. Our objective was to study the prognosis of ICS, according to 2 different diagnostic strategies. We prospectively included patients with high suspicion for cardiac sarcoidosis (CS) by a multidisciplinary sarcoidosis team from November 2016 to June 2021. We included only incident cases. We applied the JCS ICS criteria and our multidisciplinary diagnosis (MDD) ICS criteria. We included 198 incident patients who had a final diagnosis of cardiac sarcoidosis. Median follow up time was 2.4 years (p25-p75 1.2-3.7). The prevalence of ICS was 7% (14/198) per the JCS criteria, and 29% (57/198) per our MDD criteria. Compared to non-isolated CS, patients with ICS per either criteria had similar rates of major cardiovascular outcomes (progression of atrioventricular block, worsening EF ≥ 10%, appropriate implantable cardioverter defibrillator [ICD] therapies, heart transplant, and death). Kaplan-Meier analyses showed similar prognosis for ICS and non-isolated CS in all outcomes, except for an association between ICS by MDD criteria and a shorter time to cardiac hospitalization. Multivariable Cox regression analyses showed that ICS was not an independent predictor of death, heart transplant, or clinical worsening. In conclusion, our MDD ICS criteria were more inclusive than the JCS ICS criteria. The prognosis was similar between ICS and non-isolated CS patients, regardless of which criteria were used.

To prevent sudden death in m.3243A>G carriers, comprehensive neurologic, cardiac, and pulmological examinations are required.

The interesting study has limitations that put the results and their interpretation into perspective. m.3243A>G carriers should undergo prospective testing for multisystem disease to avoid missing subclinical multisystem involvement. m.3243A>G carriers with hypertrophic cardiomyopathy require long-term electrocardiogram recordings to determine whether implantable cardioverter defibrillator implantation is necessary or not. To assess the outcome of m.3243A>G carriers, knowledge of heteroplasmy rates and mtDNA copy numbers is required. It is tempting to assign pathogenicity when any pathogenic variant is seen with genotype-phenotype correlation. However, double hits are possible and if genetic information is to be used to screen or risk-stratify other family members, the standard of care would be to ensure that post-mortem genetic autopsy is performed for a panel of causative genes, and that an autopsy is done to exclude other causes of death, if possible.

Non-Pharmacological Therapy in Heart Failure and Management of Heart Failure in Special Populations-A Review.

Non-pharmacological therapies play an essential role in the management of heart failure, complementing pharmacological treatments to mitigate disease progression and improve patient outcomes. This review provides an updated perspective on non-pharmacological interventions with a focus on lifestyle modifications, device therapies, and the management of heart failure in special populations, such as the elderly, women, and patients with comorbid conditions like renal dysfunction and diabetes. Key lifestyle interventions, including sodium and fluid restriction, dietary changes, and physical activity, are explored for their impact on symptom reduction, hospital readmissions, and quality of life. Device therapies like cardiac resynchronization therapy (CRT) and implantable cardioverter defibrillators (ICD) are also evaluated for their effectiveness in reducing mortality in patients with advanced HF. Special attention is given to vulnerable populations, emphasizing the need for individualized approaches tailored to specific pathophysiological mechanisms and socioeconomic factors. By integrating these strategies, healthcare providers can optimize care and enhance patient adherence, reducing the overall burden of heart failure.

Impact of implantable cardioverter defibrillators on mortality in heart failure receiving quadruple guideline-directed medical therapy: a propensity score-matched study

BackgroundIn the contemporary management of heart failure with reduced ejection fraction (HFrEF), the recommended quadruple guideline-directed medical therapy (GDMT) consists of angiotensin receptor-neprilysin inhibitor (ARNI), evidence-based beta-blockers (BB), mineralocorticoid receptor antagonists (MRA), and sodium-glucose cotransporter-2 inhibitors (SGLT-2i). This study explored the impact of adding implantable cardioverter-defibrillator (ICD) therapy to this comprehensive regimen in HFrEF patients.MethodsUtilizing deidentified data from the National Electronic Database of the Turkish Ministry of Health, we conducted a nationwide retrospective cohort study on 5450 HFrEF patients receiving quadruple GDMT, including ARNI. Among them, 709 patients underwent additional ICD or cardiac resynchronization therapy defibrillator (CRT-D) implantation. Propensity score matching ensured balanced baseline characteristics between groups. Primary endpoint was determined as all-cause mortality.ResultsIn the matched cohort, all-cause mortality occurred in 108 out of 619 patients (17.4%) in the GDMT group and 101 out of 619 patients (16.3%) in the ICD group, with a hazard ratio (HR) of 0.74 and a 95% confidence interval (CI) ranging from 0.57 to 0.98. The median follow-up time was 1365 days in the matched cohort, 1283 days in the GDMT group. Subgroup analyses consistently demonstrated benefits, particularly among individuals aged 61 years and older (HR: 0.60, 95% CI: 0.42–0.87, p = 0.006), those with sinus rhythm (HR: 0.55, 95% CI: 0.34–0.89, p = 0.013), individuals not using amiodarone (HR: 0.61, 95% CI: 0.42–0.89, p = 0.011), and those with an estimated glomerular filtration rate lower than 61.9 (HR: 0.66, 95% CI: 0.48–0.91, p = 0.011).ConclusionsThis study may offer a glimmer of hope that even after achieving the best current optimal medical therapy, the addition of device therapy could still yield positive outcomes in the management of patients with HFrEF.Graphical

Electrocardiographic Characteristics of Brugada Syndrome Type I During Exercise Stress Test.

Brugada syndrome (BS) is a genetic channelopathy characterized by an increased risk of sudden cardiac death (SCD) in the absence of structural heart disease. Prognostic stratification is necessary to determine which patients are candidates for implantable cardioverter defibrillator (ICD). The present study aims to evaluate EKG changes during exercise stress tests in patients with BS and to identify any poor prognosis variables. This was an observational, case-control study. Three comparison groups were created: patients with Type 1 BS with or without prior arrhythmic events (BE and BNoE subgroups) and age- and sex-matched healthy individuals. Patients underwent EST and electrocardiographic variables were analyzed. The study recruited 36 patients with type 1 BS, 12 with prior Event (BE) and 24 without (BNoE). Patients in the BE group, in all postexercise recordings, had lower heart rates, notably in the first minute. A significant difference was also observed in the HR drop in the recovery phase, with a greater drop in relation to maximum HR in the first minute in the group of patients who had events. BS patients with prior events had a lower capacity to increase heart rate at peak effort and a greater proportional drop in the recovery phase. No relationship was observed between the occurrence of arrhythmic events and ST-segment elevation during the exercise test.

Determining the Relationship Between Sleep Problems, Shock Pain, and Shock Anxiety in Patients With ICD.

This study aimed to determine the relationship between sleep problems, shock pain, and shock anxiety in patients with implantable cardioverter defibrillator (ICD) and the affecting factors. The population of this descriptive cross-sectional study consisted of all patients who underwent ICD implantation in university hospital (N = 200), and the sample consisted of patients who met the inclusion criteria of the study (n = 132). Data were obtained using a "General Information Form", the "Florida Shock Anxiety Scale (FSAS)", the "Epworth Sleepiness Scale (ESS)", the "Pittsburgh Sleep Quality Index (PSQI)", and the "Visual Pain Scale (VPS)". The mean age of the patients was 66.13 years. The VPS was 6.40±3.36; the mean FSAS score was 29.98±8.46; the mean PSQI score was 8.02±3.81; the mean ESS score was 7.59±4.10. PSQI had a statistically significant correlation with the total FSAS score (p<0.001) and a statistically insignificant correlation with ESS (p>0.001). Age, sex, marital status, smoking status, cohabitants, previous ICD shocks, the status of lying on ICD, and fear of dislocation of ICD affected the total FSAS score; sex, employment status, history of heart attack, defined sleep disorder, awakening from sleep due to nightmares, and cessation of breathing during sleep affected the total PSQI score; history of previously defined sleep disorder, history of heart attack, use of medication for a sleep disorder, the pain felt when lying on ICD, and pain experienced during ICD shocks affected the total ESS score. The mean shock VPS scores differed between patients who received an ICD shock during sleep and those who were awakened by nightmares. It was found that the shock anxiety and shock pain scores of ICD patients were above average, that they had poor sleep quality, and that their sleepiness was at the level of "normal but increased daytime sleepiness".

Catheter Ablation or Antiarrhythmic Drugs for Ventricular Tachycardia.

Patients with ventricular tachycardia and ischemic cardiomyopathy are at high risk for adverse outcomes. Catheter ablation is commonly used when antiarrhythmic drugs do not suppress ventricular tachycardia. Whether catheter ablation is more effective than antiarrhythmic drugs as a first-line therapy in patients with ventricular tachycardia is uncertain. In an international trial, we randomly assigned in a 1:1 ratio patients with previous myocardial infarction and clinically significant ventricular tachycardia (defined as ventricular tachycardia storm, receipt of appropriate implantable cardioverter-defibrillator [ICD] shock or antitachycardia pacing, or sustained ventricular tachycardia terminated by emergency treatment) to receive antiarrhythmic drug therapy or to undergo catheter ablation. All the patients had an ICD. Catheter ablation was performed within 14 days after randomization; sotalol or amiodarone was administered as antiarrhythmic drug therapy according to prespecified criteria. The primary end point was a composite of death from any cause during follow-up or, more than 14 days after randomization, ventricular tachycardia storm, appropriate ICD shock, or sustained ventricular tachycardia treated by medical intervention. A total of 416 patients were followed for a median of 4.3 years. A primary end-point event occurred in 103 of 203 patients (50.7%) assigned to catheter ablation and in 129 of 213 (60.6%) assigned to drug therapy (hazard ratio, 0.75; 95% confidence interval, 0.58 to 0.97; P = 0.03). Among patients in the catheter ablation group, adverse events within 30 days after the procedure included death in 2 patients (1.0%) and nonfatal adverse events in 23 patients (11.3%). Among the patients assigned to drug therapy, adverse events that were attributed to antiarrhythmic drug treatment included death from pulmonary toxic effects in 1 patient (0.5%) and nonfatal adverse events in 46 patients (21.6%). Among patients with ischemic cardiomyopathy and ventricular tachycardia, an initial strategy of catheter ablation led to a lower risk of a composite primary end-point event than antiarrhythmic drug therapy. (Funded by the Canadian Institutes of Health Research and others; VANISH2 ClinicalTrials.gov number, NCT02830360.).