Organic Heart Disease Research Articles

English

Echocardiography is one of the most important noninvasive tests in the evaluation, management and follows up of patient with congestive heart failure. It allows the accurate assessment of structural and functional abnormalities associated with congestive heart failure. Left ventricular ejection fraction (LV EF) is still the most common measurement in the evaluation of heart failure which differentiates heart failure into 2 groups: Heart failure with reduced ejection fraction (systolic heart failure: LV EF is less than 50%) and Heart failure with preserved or normal ejection fraction (Diastolic heart failure: LV EF is equal to or above 50%). LV EF measurement depends upon Left ventricular geometry 1 and diastolic indices are effected by heart rate, loading conditions. 2 Hence there is a need for an index which is affected to a limited extent by these factors and is easy to measure and accurate and easily reproducible. AIM: To evaluate the measurement of myocardial performance index (MPI) as method of evaluation of ventricular function in patients with heart failure secondary to systolic or diastolic dysfunction) in comparison with normal persons. METHODS: A Total of 170 individuals, 60 controls and 120 patients with heart failure who come for echocardiography examination are studied. Patients with organic valvular heart disease and other than sinus rhythm were excluded. Transthoracic echocardiography was done in all cases In addition to the standard echocardiographic measurements, MPI is measured as followed: The time interval from the cessation of onset of next mitral flow (period a: consists of ICT+ET+IVRT) and ventricular ejection time from Doppler outflow spectrum (period b: ET) were measured and MPI was calculated. Myocardial performance index (Tei index) is the ratio between the sum of isovolumic time intervals namely, isovolumic contraction time (ICT) plus isovolumic relaxation time (IVRT)) and ejection time (ET). MPI = (ICT+IVRT) / ET = (a-b)/b = (a/b) -1. Measurements were taken from three consecutive beats and averaged. RESULTS: LV-MPI in normal subjects was 0.32±0.07 and it is significantly increased in patients with both systolic and diastolic dysfunction, 0.95±0.26 and 0.59±0.13, respectively. RV MPI in normal individuals is 0.23±0.06 and significantly increased in patients with LVsystolic function 0.72 ± 0.28, but not in patients with diastolic heart failure0.34±0.15. LV MPI is significantly correlated with Left ventricular ejection fraction and left ventricular dilatation.

Therapeutic effect comparison between unipolar and bipolar radiofrequency ablation in treating atrial fibrillation in elderly patients

Objective To compare clinical effect of unipolar versus bipolar radiofrequency ablation in treating atrial fibrillation (AF) in elderly patients and discuss the correlated risk factors. Methods From October 2008 to December 2013, a total of 50 elderly patients with organic heart disease and AF underwent radiofrequency ablation surgery. All patients were divided into 2 groups of unipolar (group A, n= 20) and bipolar (group B, n=30 patients) radiofrequency ablations. The variations of electrocardiogram (ECG) and ultrasonic cardiogram (UCG) in patients were collected and the complications and the NYHA class of the patients were recorded at 3, 6 and 12 months after surgery. The total 43 elderly patients were divided into sinus group and non-sinus group according to their ECG at 12 months after surgery. Results The recovery rates of sinus rhythm at 3, 6 and 12 months after surgery were 73.7%(14/19), 66.7%(12/18) and 61.1% (11/18)respectively in group A and 82.8%(24/29), 85.2%(23/27)and 88.0%(22/25) respectively in group B. Two groups of the recovery rate of sinus rhythm had a statistically significant difference between the two groups (P<0.05) at 12 months after surgery. The complication rate in group A was higher than in group B 〔55.0% (11 cases) vs. 26.7% (8 cases), P<0.05〕. Preoperative history of AF and left atrial diameter were the influencing factors for the sinus rhythm recovery rates (P<0.05). Conclusions Bipolar radiofrequency ablation for AF is safe and has less complications and high success rate of restoring sinus rhythm. The patients with long preoperative history of AF and left atrium distension have a low success rate of restoring sinus rhythm with a high recurrence rate. Key words: Atrial fibrillation; Catheter ablation

Paroxysmal Supraventricular Tachycardia: A Complex Dilemma during Pregnancy

ABSTRACT The acute and chronic management of paroxysmal supraventricular tachycardia (PSVT) during pregnancy presents a challenging clinical situation as there are no evidence-based guidelines despite being the commonest arrhythmia found in pregnancy. We report a case of paroxysmal supraventricular tachycardia in a 25 years old antenatal woman with no organic heart disease, where she received verapamil followed by diltiazem as antiarrhythmics instead of adenosine for conversion into sinus rhythm. Since she had recurrent episodes in third trimester she received verapamil and metoprolol as prophylaxis with good fetal and maternal outcome. This case highlights the need to understand the complexities in diagnosis and management of paroxysmal supraventricular tachycardia during pregnancy. How to cite this article Kumare BD, Kawathalkar A, Vijay NR. Paroxysmal Supraventricular Tachycardia: A Complex Dilemma during Pregnancy. J South Asian Feder Obst Gynae 2015;7(1):44-47.

Modern treatment of atrial fibrillation.

Atrial fibrillation (AF) is the most common type of arrhythmia and has a large global burden. In general, treatment of AF is based on medication and consists of rate and rhythm control together with anticoagulation. However, surgical treatment may be required in patients with AF combined with organic valvular heart diseases or who experience recurrence despite medication. In addition, surgical treatment plays a role in the treatment of lone AF. This article reviews the various surgical treatment options for AF.

ASSA14-03-45 Selective late sodium current inhibitor altered atrial electrical conduction but not atrial activation pattern

Objective Rhythm control is an important strategy to treat atrial fibrillation (AF). However, drugs currently used for rhythm control are neither sufficiently safe nor effective. Ranolazine (Ran) and dronedarone (Drone) are new drugs with efficacy to maintain sinus rhythm. Ran, a late sodium current inhibitor, but not Drone, caused no increase in mortality in patients with AF and organic heart disease. The objective of this study was to compare the effect of ranolazine and dronedarone on atrial activation pattern and interatrial conduction. Method Electrogram was recorded from two identical multielectrode recording arrays (48 channels each) placed against the left and right atria of Langendorff-perfused female rabbit isolated hearts. Continuous 5 s recordings were analysed offline. Isochronal maps were drawn from the recording data. Data were analysed with Prism version 5 and expressed as mean ± SEM. To compare values of measurements obtained from the same heart before and after a drug treatment, repeated measures one-way analysis of variance (ANOVA) was used to determine which pairs of group means was significantly different. Results Ran (1–30 μm) significantly prolonged intra-atrial activation conduction time and mean activation time in frequency- and concentration-dependent manners. At the frequency of 3.3 Hz, 4.0 Hz and 5.0 Hz, Ran (1–30 μm) increased left and right intraatrial conduction time by 5.22 ± 0.14, 7.33 ± 0.07, 9.78 ± 0.02 ms, and 6.89 ± 0.09, 8.83 ± 0.23 and 13.06 ± 0.96 ms, respectively. It also prolonged left and right atrial mean activation time by 2.85 ± 0.03, 3.92 ± 0.11, 5.23 ± 0.09 ms and 3.15 ± 0.14, 3.75 ± 0.15, 6.58 ± 0.40 ms, respectively (n = 9, p 0.05). Conclusion Compared with multichannel inhibitor dronedarone, selective late sodium current inhibitor ranolazine has obvious frequency dependence to slow the intra-atrial electrical conduction, which can partially explain the anti-AF mechanism of ranolazine.

Estudio clínico de 182 casos de infarto del miocardio

En 9.896 historias clínicas de varios servicios de Medicina Interna de los hospitales 2 de Mayo, Central de Policía y Arzobispo Loayza, hemos encontrado 1,724 cardiopatías orgánicas (16.51%), 474 esclerosis de las arterias coronarias (27.53% de las cardiopatías) y en éstas últimas 182 casos de infarto del miocardio (38.31%).

A Double-Blind, Placebo Controlled Trial, Evaluating the Effects of a Proprietary Blend of Plant Adaptogens on Sexual Satisfaction and Sexual Response in Adult Males

Introduction: Adaptogens are plant substances that offer resistance of the organism to stressors. The human genome is able to utilize these plant derived substance to increase cellular defense in-vivo. Previous studies which validated adaptogens benefit in athletic training and performance also demonstrated subjective reports of improved male sexual performance. It is the objective of this trial is to isolate and report the human male sexual response to a proprietary blend of adaptogens, androgenic herbs combined and select amino acids (Admax®/Potenter®) and compare it to placebo, over a 14 day period when compared to placebo. Methods: Subjects were randomized into two cohorts to compare study compound (n=42) with placebo (n=21). Exclusion criteria eliminated individuals with organic impotence and organic heart disease as well as those unable to give informed consent or unable to adhere to study protocol. Participants completed the International Index of Erectile Function (IIEF) prior to dosing and instructed to attempt sexual intercourse a minimum of twice per week during the study period. They also were instructed to complete a sexual satisfaction diary, which became part of the source documents upon completion of the trial. Each participant was provided 50 capsules of either study compound or placebo (8 capsules per day with 2 additional capsules). Participants completed the IIEF upon completion of the study as well. Results: 63 healthy adult males (age range 30-58, mean = 42.4, ± 3), were consented and enrolled in a placebo controlled, double blind, study of the male sexual experience and satisfaction in response to a proprietary blend of adaptogens (Admax/Potenter®). All participants completed the trial and submitted both pre &amp; post self assessment utilizing the International Index of Erectile Function (IIEF). Participants on study compound (n=42) improved in all 5 measured parameters, compared to no change in the placebo group (n=21). All data was validated utilizing 2-tailed Student – T. Erectile function improved from 11.5 to 22.7 (p≤0.04) compared to placebo (decreased from11.7 to 10.8). Intercourse satisfaction improved from 5.6 to 11.1 (p≤0.05) compared to placebo (decreased from 5.5 to 5.2). Orgasmic function improved from 4.6 to 8.7 (p≤0.05) compared to placebo (increased from 4.7 to 4.8, not statistically significant). Sexual desire improved from 5.4 to 8.6 (p≤0.1) compared to placebo (decreased from 5.3 to 5.2). Overall sexual satisfaction improved from 3.1 to 9.1 (p≤0.01) compared to placebo (decreased from 3.3 to 2.9). Discussion: This data demonstrates that the male sexual experience is markedly enhanced with the utilization of this adaptogenic compound (Admax®/Potenter®), when taken 3-6 hours prior to anticipation of sexual intercourse. Subjectively, the data would also indicate that the effect is relatively short acting (lasting 6-24 hours) and moderate onset of action (taken 3-6 hours prior to event). Pharmacokinetic studies were not performed. There were no side effects reported by any of the participants as is consistent with its use in previous clinical trials. All early indications would suggests, that this proprietary blend of adaptogens is an excellent supplement to increase the male sexual experience and can safely be used up to 14 days without demonstrated side effects.

Association between neutrophil–lymphocyte ratio and mitral annular calcification

Mitral annular calcification (MAC) is closely related to cardiovascular disorders including coronary artery disease, atherosclerosis, heart failure, and stroke. The clinical risk factors for cardiovascular diseases, including age, obesity, hypertension, hyperlipidemia, and diabetes mellitus, are the same for MAC and atherosclerosis. The aim of this study was to assess the neutrophil-lymphocyte ratio (NLR), an inflammatory marker, in patients with MAC. The study group consisted of 117 patients with MAC. Age and sex-matched control group was composed of 38 patients who were admitted to echocardiography laboratory due to suspicion of organic heart disease and eventually found to be free of MAC. We measured hematological indices in patients and control individuals. NLR ratio was significantly higher in patients with MAC than in control individuals (3.3 ± 1.8 vs. 1.6 ± 0.4, respectively; P < 0.001), and NLR ratio was positively correlated with MAC (P < 0.001, r = 0.58). Red cell distribution width was also significantly higher in patients with MAC than in control individuals (16.2 ± 3.3 vs. 13.4 ± 0.9%, respectively; P < 0.001). We have shown that NLR was significantly elevated in patients with MAC and it was correlated with MAC.

An interesting case of straight back syndrome and review of the literature

Straight back syndrome is characterized by loss of the normal upper thoracic kyphosis, leading to a reduced anteroposterior diameter and squashing of the heart. Most patients are asymptomatic; if symptomatic, chest pain and palpitations are most common. On examination, the abnormal clinical findings simulate organic heart disease that needs to be ruled out by echocardiography and cardiac catheterization. A lateral chest radiograph is diagnostic. This condition is commonly associated with mitral valve prolapse and bicuspid aortic valve. We describe an interesting case of straight back syndrome with all the classic and rarely reported clinical findings.

Sodium channelopathy underlying familial sick sinus syndrome with early onset and predominantly male characteristics.

Sick sinus syndrome (SSS) is a common arrhythmia often associated with aging or organic heart diseases but may also occur in a familial form with a variable mode of inheritance. Despite the identification of causative genes, including cardiac Na channel (SCN5A), the pathogenesis and molecular epidemiology of familial SSS remain undetermined primarily because of its rarity. We genetically screened 48 members of 15 SSS families for mutations in several candidate genes and determined the functional properties of mutant Na channels using whole-cell patch clamping. We identified 6 SCN5A mutations including a compound heterozygous mutation. Heterologously expressed mutant Na channels showed loss-of-function properties of reduced or no Na current density in conjunction with gating modulations. Among 19 family members with SCN5A mutations, QT prolongation and Brugada syndrome were associated in 4 and 2 individuals, respectively. Age of onset in probands carrying SCN5A mutations was significantly less (mean±SE, 12.4±4.6 years; n=5) than in SCN5A-negative probands (47.0±4.6 years; n=10; P<0.001) or nonfamilial SSS (74.3±0.4 years; n=538; P<0.001). Meta-analysis of SSS probands carrying SCN5A mutations (n=29) indicated profound male predominance (79.3%) resembling Brugada syndrome but with a considerably earlier age of onset (20.9±3.4 years). The notable pathophysiological overlap between familial SSS and Na channelopathy indicates that familial SSS with SCN5A mutations may represent a subset of cardiac Na channelopathy with strong male predominance and early clinical manifestations.

English

BACKGROUND: The electrocardiographic finding of left axis deviation (LAD) occurs in wide variety of clinical conditions yet its significance has been debated. Paul-Wood stated its presence in 10% of healthy individuals while Pryor has quoted as low as 0.2%. OBJECTIVES: To study the incidence of LAD in various cardiac disorders. Conversely, to study the incidence of various cardiac disorders presenting as LAD. To make an attempt to find out how far it is of organic significance. METHOD: The study is based on the outcome of 70 cases with LAD out of 1180 cases attending the Medicine OPD or admitted in medicine wards of N.S.C.B. Medical College & Hospital, Jabalpur (M.P). RESULTS: LAD was found in only 5.9% of the cases examined. True LAD (-30 to –90 degrees) was found in 3.8%. Among various cardiovascular disorders the highest incidence of LAD was in cardiomyopathy (33.3%). Next being ischemic heart disease (15.5%) followed by hypertension and hypertensive heart disease (6.6%). No organic heart disease (3.6%), pulmonary heart disease (3.3%), congenital heart disease (3.1%), and rheumatic heart disease (2.1%), have contributed for a very small percentage. Among the LAD cases Myocardial infarction was most common seen in 21 cases (30%). CONCLUSIONS: LAD is uncommon and was found in only 5.9% of the cases examined. True LAD (-30 to –90 degrees) was found in 3.8% of cases and it reflected a definite pathological state. The ischemic factor was found to be more responsible for production of LAD rather than hypertrophy itself alone.

Prognostic value of T-wave alternans in survivors of ventricular fibrillation or hemodynamically unstable ventricular tachycardia

BackgroundT-wave alternans is useful for predicting the occurrence of ventricular tachyarrhythmias and sudden cardiac death in various heart diseases. However, little is known about the clinical significance of T-wave alternans measurement in survivors of ventricular fibrillation (VF) or hemodynamically unstable ventricular tachycardia (VT). MethodsWe studied 28 patients with organic heart disease who survived VF or hemodynamically unstable VT (20 males, mean age 63 years). Echocardiography, electrocardiogram (QRS duration and QTc intervals), and Holter monitoring (heart rate variability, heart rate turbulence and T-wave alternans) were performed before implantable cardioverter-defibrillator (ICD) implantation. Positive T-wave alternans was defined as >65μV. During the follow-up period (10.2±6.2 months), ventricular tachyarrhythmias requiring appropriate shock therapy occurred in eight patients (29%). The subjects were divided into two groups, based on whether appropriate shock therapy was required (n=8, Group A) or not (n=20, Group B). Parameters from echocardiography, electrocardiogram, and Holter monitoring were compared between the two groups in order to investigate their relationship with the incidence of shock therapy after ICD implantation. ResultsThe prevalence of positive T-wave alternans was significantly higher in Group A than in Group B (88% vs. 15%, P=0.004). Univariate Cox proportional hazard analysis showed that, among the variables measured, only T-wave alternans had predictive power for recurrent ventricular tachyarrhythmias (hazard ratio, 13.17; 95% confidence interval: 1.606–108.1, P=0.016). ConclusionsThese results suggest that T-wave alternans by Holter monitoring is useful for predicting recurrent ventricular tachyarrhythmias in survivors of VF or hemodynamically unstable VT.

Incidence and patterns of valvular heart disease in a tertiary care high-volume cardiac center: a single center experience.

Diseases of the heart valves constitute a major cause of cardiovascular morbidity and mortality worldwide with rheumatic heart disease (RHD) being the dominant form of valvular heart disease (VHD) in developing nations. The current study was undertaken at a tertiary care cardiac center with the objective of establishing the incidence and patterns of VHD by Echocardiography (Echo). Among the 136,098 first-time Echocardiograms performed between January 2010 and December 2012, an exclusion criterion of trivial and functional regurgitant lesions yielded a total of 13,289 cases of organic valvular heart disease as the study cohort. In RHD, the order of involvement of valves was mitral (60.2%), followed by aortic, tricuspid and pulmonary valves. Mitral stenosis, predominantly seen in females, was almost exclusively of rheumatic etiology (97.4%). The predominant form of isolated MR was rheumatic (41.1%) followed closely by myxomatous or mitral valve prolapse (40.8%). Isolated AS, more common in males, was the third most common valve lesion seen in 7.3% of cases. Degenerative calcification was the commonest cause of isolated AS (65.0%) followed by bicuspid aortic valve (BAV) (33.9%) and RHD (1.1%). Multiple valves were involved in more than a third of all cases (36.8%). The order of involvement was MS+MR>MS+AR>MR+AR>AS+AR>MR+AS>MS+AS. Overall, 9.7% of cases had organic tricuspid valve disease. RHD contributed most to the burden of VHD in the present study with calcific degeneration, myxomatous disease and BAV being the other major forms of VHD. Multiple valves were affected in more than a third of all cases.

Right bundle branch block without overt heart disease predicts higher risk of pacemaker implantation: The study of atomic-bomb survivors

BackgroundWe investigated the clinical course of complete right bundle branch block (RBBB) or RBBB with axis deviation (AD) in terms of subsequent pacemaker implantation for high-degree atrioventricular (AV) block or sick sinus syndrome (SSS). Methods and resultsAmong the 16,170 atomic-bomb survivors in our biennial health examination between July 1967 and December 2010, we detected 520 newly-acquired RBBB subjects with no organic heart disease, and selected 1038 age- (at RBBB diagnosis) and sex-matched subjects without RBBB to serve as comparison subjects. Multivariate Cox regression analysis was used to estimate the hazard ratios (HRs) for the risk of pacemaker implantation due to all causes, AV block or SSS between RBBB and comparison subjects and between RBBB subjects with and without AD. The risk of pacemaker implantation for RBBB was 4.79 (95% confidence interval [CI] 1.89–12.58; P=0.001), 3.77 (95% CI, 1.09–13.07; P=0.036), and 6.28 (95% CI, 1.24–31.73, P=0.026) when implantation was for all causes, AV block and SSS, respectively. RBBB subjects with AD had a higher risk for all-cause pacemaker implantation than subjects without AD (HR, 3.03; 95% CI, 1.00–9.13, P=0.049). RBBB subjects with AD were younger than subjects without AD at the time of RBBB diagnosis (59.4±7.6 vs 74.4±3.1years old, P=0.019), and their progression from diagnosis to pacemaker implantation took longer (15.1±6.6 vs 6.4±3.0years, P=0.032). ConclusionsRBBB, especially with AD, progresses to AV block and SSS that requires pacemaker implantation; the mechanisms by which the conduction defect progresses differ among patients with and without AD.

Update on tricuspid regurgitation

Although commonly detected by transthoracic echocardiography, tricuspid regurgitation (TR) has been somehow neglected, and recent data have emerged on the need for careful examination of the tricuspid valve. Functional or secondary TR is the most frequent etiology of tricuspid valve pathology in western countries and is related to tricuspid annular dilation and leaflet tethering. The prognostic role of TR associated with organic left-sided valvular heart disease is well known. However, the value of functional TR in outcome stratification of patients with advanced left ventricular dysfunction is less clear. Surgical tricuspid repair has been avoided for years, because of the misconception that TR should disappear once the primary left-sided problem is treated; this results in a large number of untreated patients with functional TR. Over the past few years, many investigators have reported evidence in favor of a more aggressive surgical approach to functional TR. Consequently, interest has been growing in the pathophysiology and treatment of functional TR. The purpose of this article is to provide a comprehensive review of TR incorporating a description of valve anatomy, etiological factors, pathophysiology, epidemiological data, natural history, clinical evaluation, along with a discussion of the important role in prognostic stratification and a summary of management guidelines.

Complex right ventricular outflow tract ectopy in the absence of organic heart disease. Results οf a long-term prospective observational study

Complex right ventricular outflow tract ectopy in the absence of organic heart disease. Results οf a long-term prospective observational study☆ Konstantinos A. Gatzoulis ⁎, Stefanos Archontakis , Ioannis Vlasseros , Dimitris Tsiachris , Apostolis Vouliotis , Petros Arsenos , Polichronis Dilaveris , Skevos Sideris , George Karystinos , Ioannis Skiadas , Ioannis Kallikazaros , Christodoulos Stefanadis a

Predictors of recurrent sudden cardiac death in patients associated with coronary vasospasm

Even though coronary heart disease is the leading cause of sudden cardiac death (SCD), there is increasing evidence that SCD can be developed in the absence of organic heart disease. Coronary vasospasm or primary electrical disorder may play an important role in these circumstances. In aborted SCD patients associated with coronary vasospasm, medical treatment is recommended as the first line therapy. However, some patients experience recurrent SCD events despite medical treatment. Furthermore, although coronary vasospasm can cause life threatening arrhythmia, some patients did not have any ischemic symptoms before the index event.

Characteristics of intra-left atrial flow dynamics and factors affecting formation of the vortex flow – analysis with phase-resolved 3-dimensional cine phase contrast magnetic resonance imaging.

The intra-left atrial (LA) blood flow from pulmonary veins (PVs) to the left ventricle (LV) changes under various conditions and might affect global cardiac function. By using phase-resolved 3-dimensional cine phase contrast magnetic resonance imaging (4D-Flow), the intra-LA vortex formation was visualized and the factors affecting the intra-LA flow dynamics were examined. Thirty-two patients with or without organic heart diseases underwent 4D-Flow and transthoracic echocardiography. The intra-LA velocity vectors from each PV were post-processed to delineate streamline and pathline images. The vector images revealed intra-LA vortex formation in 20 of 32 patients. All the vortices developed during the late systolic and early diastolic phases and were directed counter-clockwise when viewed from the subjects' cranial side. The flow vectors from the right PVs lengthened predominantly toward the mitral valves and partly toward the LA appendage, whereas those from the left PVs directed rightward along the posterior wall and joined the vortex. Patients with vortex had less organic heart diseases, smaller LV and LA volume, and greater peak flow velocity and volume mainly in the left PVs, although the flow directions from each PV or PV areas did not differ. 4D-Flow can clearly visualize the intra-LA vortex formation and analyze its characteristic features. The vortex formation might depend on LV and LA volume and on flow velocity and volume from PVs.

Relationship between cardiopulmonary exercise testing parameters and heart failure risk (H2ARDD score) in atrial fibrillation

BackgroundA novel risk scoring system (H2ARDD) for estimating the incidence of heart failure (HF) events in atrial fibrillation (AF) has been developed, which represents points assigned for organic heart disease (2 points), anemia (1 point), renal dysfunction (1 point), diabetes (1 point), and diuretic use (1 point). We aimed to clarify whether H2ARDD score is related to cardiopulmonary exercise testing (CPX) parameters in patients with AF. MethodsThe study population included 344 consecutive patients with AF who underwent CPX as initial screening between June 2004 and March 2012. The association between 4 CPX parameters and the incidence of HF events was analyzed by using multiple linear regression models. ResultsThe peak O2 uptake (peak V̇O2), anaerobic (gas exchange) threshold (AT), and ratio of the increase in V̇O2 to the increase in work rate (ΔV̇O2/ΔWR) were lower and the slope of the increase in ventilation to the increase in CO2 output (V̇E–V̇CO2 slope) was higher in patients with than in those without each H2ARDD score component. Accordingly, the parameters significantly increased or decreased according to H2ARDD score. With the multiple linear regression models, H2ARDD score was independently associated with each CPX parameter even after adjustment for various cofactors. ConclusionsH2ARDD score was independently associated with the well-established CPX parameters in patients with AF, suggesting a potential pathophysiological basis for a risk stratification system for predicting HF events in patients with AF.

Syncope in Patients with Organic Heart Disease

Patients with syncope and organic heart disease remain a small but important subset of those patients who experience transient loss of consciousness. These patients require thoughtful and complete evaluation in an attempt to better understand the mechanism of syncope and its relationship to the underlying disease, and to diagnose and treat both properly. The goal is to reduce the risk of further syncope, to improve long-term outcomes with respect to arrhythmic and total mortality, and to improve patients’ quality of life.