Risk Of Arrhythmic Death Research Articles

ANMCO position paper: guide to the appropriate use of the wearable cardioverter defibrillator in clinical practice for patients at high transient risk of sudden cardiac death.

Extended risk stratification and optimal management of patients with a permanently increased risk of sudden cardiac death (SCD) are becoming increasingly important. There are several clinical conditions where the risk of arrhythmic death is present albeit only transient. As an example, patients with depressed left ventricular function have a high risk of SCD that may be only transient if there will be a significant recovery of function. It is important to protect the patients while receiving and titrating to the optimal dose the recommended drugs that may lead to an improved left ventricular function. In several other conditions, a transient risk of SCD can be observed even if the left ventricular function is not compromised. Examples are patients with acute myocarditis, during the diagnostic work-up of some arrhythmic conditions or after extraction of infected catheters while eradicating the associated infection. In all these conditions, it is important to offer a protection to these patients. The wearable cardioverter defibrillator (WCD) is of particular importance as a temporary non-invasive technology for both arrhythmia monitoring and therapy in patients with increased risk of SCD. Previous studies have shown the WCD to be an effective and safe therapy for the prevention of SCD caused by ventricular tachycardia/fibrillation. The aim of this ANMCO position paper is to provide a recommendation for clinical utilization of the WCD in Italy, based upon current data and international guidelines. In this document, we will review the WCD functionality, indications, clinical evidence, and guideline recommendations. Finally, a recommendation for the utilization of the WCD in routine clinical practice will be presented, in order to provide physicians with a practical guidance for SCD risk stratification in patients who may benefit from this device.

ANMCO Position paper: Wearable cardioverter defibrillator appropriate use guidance for the management of patients at high transient risk of sudden cardiac death

Extended risk stratification and optimal management of patients with a permanently increased risk of sudden cardiac death (SCD) is becoming increasingly important. There are several clinical conditions where the risk of arrhythmic death is present albeit only transient. As an example, patients with depressed left ventricular function have a high risk of SCD that may be only transient when there is a significant recovery of function. It is important to protect the patients while receiving the recommended measures and drugs that may either lead or not to an improved left ventricular function. In several other conditions a transient risk of SCD can be observed even if the left ventricular function is not compromised. Examples are patients with acute myocarditis, during the diagnostic work-up of some arrhythmic conditions or after extraction of infected catheters while eradicating the associated infection. In all these conditions it is important to offer a protection to these patients. The wearable cardioverter-defibrillator (WCD) is of particular importance as a temporary non-invasive technology for both arrhythmia monitoring and therapy in patients with increased risk of SCD. Previous studies have shown the WCD to be an effective and safe therapy for the prevention of SCD caused by ventricular tachycardia/fibrillation. The aim of this ANMCO position paper is to provide a recommendation for clinical utilization of the WCD in Italy, based upon current data and international guidelines. In this document we will review the WCD functionality, indications, clinical evidence as well as guideline recommendations. Finally, a recommendation for the utilization of the WCD in routine clinical practice will be presented, in order to provide physicians with a practical guidance for SCD risk stratification in patients who may benefit from this device.

Abstract 11630: Wearable Cardiac Defibrillator Use is Associated With Lower All-Cause Mortality in Patients With Ischemic Cardiomyopathy: A Systematic Review and Meta-Analysis

Introduction: Wearable cardiac defibrillators (WCD) have been shown to be effective for detection and treatment of ventricular tachyarrhythmias. However, their efficacy in improving survival or decreasing mortality in patients with newly diagnosed cardiomyopathy (CM) is uncertain. This study reviews the current available evidence. Method: We searched databases since inception to April 2022, without language and year of publication restriction for randomized trials and cohort studies that examined the difference between WCD use and non-use in mortality and survival among patients with ischemic and non-ischemic CM. Two independent investigators screened the abstracts and full texts and extracted the data. Data was analyzed using random effect model. Results: From 603 records identified by a librarian, only 4 randomized trials on WCD use in ischemic CM met the inclusion criteria. One of them was an abstract without any full text published. The total participants were 18,779 of which 2,408 were in the WCD group (mean age 65.12±11.5, 20.7% female) and the rest in control group (mean age 65.45±11.36, 28% female). The adjusted all-cause mortality at 3 months follow up was significantly lower in WCD group (RR 0.32, CI [0.11-0.97], including three studies, 2,360 patients in WCD group and 4,954 in control group) (heterogeneity score I 2 =86%)(figure). Adjusted all-cause mortality at 12 months was also significantly lower in WCD group (RR 0.43, CI [0.25-0.71], two studies, 857 patients in WCD group and 15,566 in control group) (heterogeneity score, I 2 =49%). Only one study reported adjusted risk for arrhythmic death, myocardial infarction, arrhythmia (atrial or ventricular), stroke and hospitalization. In addition, one study reported the difference in cost and healthcare use between the two groups. Conclusion: Our meta-analysis confirms significant reduction in all-cause mortality associated with WCD use in patients with newly diagnosed ischemic cardiomyopathy.

LIDOCAINE IN VENTRICULAR TACHYCARDIA WITH HEMODYNAMICALLY UNSTABLE WHO REFUSE CARDIOVERSION, IS IT THE FIRST CHOICE OR NOT?

Sudden cardiac death (SCD) is a vital public health issue, accountable for almost 50% of all cardiovascular deaths. In the last three decades, SCD was the leading cause for almost 230000 to 350000 deaths per annum in the United States. Ventricular arrhythmias account for 25% to 36% of witnessed sudden cardiac arrests (SCA) at home and 38% to 79% of witnessed SCA in public. The goals of ventricular arrhythmia management include symptom relief, improving quality of life, reducing implantable cardioverter defibrillator shocks, preventing deterioration of left ventricular function, reducing risk of arrhythmic death, and potentially improving overall survival. Based on the ACLS guideline, each tachyarrythmia with a pulse should be given synchronized cardioversion, however, when such action could not be performed for various reasons, and showed wide QRS 0,12, intravenous or antiarrthytmia might serve as a possible treatment. If intravena antiarrhytmics are given, amiodarone may be considered. Amiodarone is also effective in preventing recurrence of monomorphic VT. Lidocaine is less effective in terminating VT than procainamide, sotalol and amiodarone. Lidocaine may be considered second-line antiarrthythmic therapy for monomorphic VT.

Survival Probability and Survival Benefit Associated With Primary Prevention Implantable Cardioverter-Defibrillator Generator Changes.

BackgroundAs patients derive variable benefit from generator changes (GCs) of implantable cardioverter‐defibrillators (ICDs) with an original primary prevention (PP) indication, better predictors of outcomes are needed.Methods and ResultsIn the National Cardiovascular Data Registry ICD Registry, patients undergoing GCs of initial non‐cardiac resynchronization therapy PP ICDs in 2012 to 2016, predictors of post‐GC survival and survival benefit versus control heart failure patients without ICDs were assessed. These included predicted annual mortality based on the Seattle Heart Failure Model, left ventricular ejection fraction (LVEF) >35%, and the probability that a patient's death would be arrhythmic (proportional risk of arrhythmic death [PRAD]). In 40 933 patients undergoing GCs of initial noncardiac resynchronization therapy PP ICDs (age 67.7±12.0 years, 24.5% women, 34.1% with LVEF >35%), Seattle Heart Failure Model–predicted annual mortality had the greatest effect size for decreased post‐GC survival (P<0.0001). Patients undergoing GCs of initial noncardiac resynchronization therapy PP ICDs with LVEF >35% had a lower Seattle Heart Failure Model–adjusted survival versus 23 472 control heart failure patients without ICDs (model interaction hazard ratio, 1.21 [95% CI, 1.11–1.31]). In patients undergoing GCs of initial noncardiac resynchonization therapy PP ICDs with LVEF ≤35%, the model indicated worse survival versus controls in the 21% of patients with a PRAD <43% and improved survival in the 10% with PRAD >65%. The association of the PRAD with survival benefit or harm was similar in patients with or without pre‐GC ICD therapies.ConclusionsPatients who received replacement of an ICD originally implanted for primary prevention and had at the time of GC either LVEF >35% alone or both LVEF ≤35% and PRAD <43% had worse survival versus controls without ICDs.

An overview of heart rhythm disorders and management in myotonic dystrophy type 1.

Myotonic dystrophy type 1 (DM1) is the most common adult form of muscular dystrophy, presenting with a constellation of systemic findings secondary to a CTG triplet expansion of the noncoding region of the DMPK gene. Cardiac involvement is frequent, with conduction disease and supraventricular and ventricular arrhythmias being the most prevalent cardiac manifestations, often developing from a young age. The development of cardiac arrhythmias has been linked to increased morbidity and mortality, with sudden cardiac death well described. Strategies to mitigate risk of arrhythmic death have been developed. In this review, we outline the current knowledge on the pathophysiology of rhythm abnormalities in patients with myotonic dystrophy and summarize available knowledge on arrhythmic risk stratification. We also review management strategies from an electrophysiological perspective, attempting to underline the substantial unmet need to address residual arrhythmic risks for this population.

564 Controversial role of intracardiac eletrophysiology study in Brugada syndrome: analysis of a single-centre retrospective cohort study

Abstract Aims According to European guidelines, aborted sudden cardiac death (SCD) in Brugada syndrome (BrS) is regarded as a I class recommendation for secondary prevention implantable cardioverter defibrillator (ICD). However, the risk stratification of BrS patients for primary prevention ICD still represents a clinical conundrum. Although intracardiac electrophysiology (EP) study proved useful for the selection of high-risk patients in this setting. Therefore, aim of this study was to assess all clinical and EP variables associated with the induction of VA at EP study and the rate of appropriate/inappropriate ICD interventions and/or clinical SCD events in these patients occurring at follow-up. Methods and results From 2001 to 2021, all EP studies performed in symptomatic/asymptomatic patients (46 ± 14 years, M 88%) with/without family history of SCD spontaneous/drug-induced type I pattern (TIP) on ECG and no spontaneous ventricular arrhythmias were retrospectively considered at our study centre. Clinical variables, BrS pattern, EP study data (including right ventricular site and type of stimulation protocol), and ICD interventions (DC-shocks or Anti-Tachycardia Pacing events, ATP) and/or SCD events occurring at follow-up were all evaluated. EP study was deemed positive for any polymorphic VA induced during programmed ventricular stimulation; non-sustained episodes included. ICD was routinely implanted in all patients with a positive EP study. Follow-up data were detected by the collection of medical and home-monitoring recordings at study-site level. Follow-up data were available in 50 patients (9 ± 6 years on average). Patients were generally young with few cardiovascular comorbidities. SCD history was known in 21 (42%) with a significant number of asymptomatic patients (48%). Br patterns were equally distributed in the investigated population (spontaneous and drug-induced TIP in 52% and 48%, respectively) and AF history was fairly common (16%). In the study population, EP study tested positive in 30 patients (60%): spontaneous TIP (P = 0.0518), few extrastimuli during programmed ventricular stimulation (P = 0.0015), and right ventricular stimulation at the apical site (P ≤ 0.0001) were the only variables to be clearly associated with a positive EP study in the appraised patients. At follow-up, appropriate ICD shocks were documented in 4 out of 30 implanted patients (13%) at generally 5 ± 7 years from EP study evaluation. Although three ICD interventions (75%) occurred in patients with spontaneous TIP, one patient with drug-induced TIP pattern and positive EP study referred to Emergency Department for unrelenting VT storm after roughly 13 years from ICD implantation. Inappropriate ICD interventions for fast rate AF were detected in 10% of cases. Finally, no SCD events were documented at follow up in patients with a negative EP study. Conclusions In a retrospective analysis, EP study proved useful in the risk stratification of SCD in BrS patients. A few ventricular extrastimuli delivered at the right ventricular apex seem sufficient to prompt the induction of life-threatening VA in high-risk BrS patients during EP study. Moreover, in this setting, a negative EP study seems protective against the development of VA/SCD events at follow-up. However, not only is spontaneous TIP associated with an increased risk of arrhythmic death, but a drug-induced TIP, generally regarded as a low-risk condition, might also be associated with a long-term hazard of SCD in these patients.

Cardiac biomarkers for risk stratification of arrhythmic death in patients with heart failure and reduced ejection fraction

ABSTRACT Objectives. Patients with heart failure and reduced left ventricular ejection fraction (HFrEF) are prone to ventricular tachyarrhythmias. We tested whether biomarkers C-terminal Endothelin 1 (CT-ET1), midregional pro atrial natriuretic peptide (MR-proANP) and midregional pro adrenomedullin (MR-proADM) might improve risk stratification for arrhythmic death. Methods: This prospective observational study included 160 heart failure patients with ischaemic cardiomyopathy (ICM) or non-ischaemic, dilated cardiomyopathy (DCM) and 30 control patients without heart disease. Primary endpoint was arrhythmic death (ArD) or resuscitated cardiac arrest (resCA). Results: A total of 61 patients died during the median follow-up of 7.0 [5.2–8.4] years. An ArD or resCA was observed in 48 patients. Plasma levels of CT-ET1 (p = 0.002), MR-proANP (p < 0.001) and MR-proADM (p = 0.013) were significantly higher in ICM or DCM patients compared to controls. MR-proANP levels in ICM patients were associated with a significantly increased risk for ArD or resCA (hazard ratio (HR) = 1.42, [95%CI: 1.08–1.85], p = 0.011) in a multivariable Cox regression model. Plasma levels of CT-ET1 (HR = 1.07 [0.98–1.17], p = 0.113) and MR-proADM (HR = 1.80 [0.92–3.55], p = 0.087) were not associated with ArD or resCA in ICM patients. No significant association with ArD or resCA was found in DCM patients. Multivariable Cox regression showed that CT-ET1 (HR = 1.14 [1.07–1.22], p < 0.001), MR-proANP (HR = 1.64 [1.29–2.08], p < 0.001) and MR-pro ADM (HR = 2.06 [1.12–3.77], p = 0.020) were associated with a higher risk for overall mortality. Conclusion: Patients with HFrEF had elevated levels of CT-ET1, MR-proANP and MR-proADM. Plasma levels of MR-proANP are useful as predictor for arrhythmic death in patients with ICM.

Cardiac magnetic resonance imaging and electrocardiography in sudden arrhythmic death risk stratification

Cardiac magnetic resonance imaging and electrocardiography in sudden arrhythmic death risk stratification

Who is shocked and who survives? A multi-state analysis of the NORDIC ICD trial

Abstract Background/Purpose The interaction between the risk of arrhythmic death and a competing non-arrhythmic risk of death in patients suitable for implantable cardioverter defibrillator (ICD) implantation is not well understood. Commonly, identification of subpopulations with the largest benefit of ICD implantation has been performed by separate risk models for the outcomes death and appropriate shock therapy. The interrelation between the outcomes was not sufficiently studied. Methods Data were derived from the safety population of the multinational, prospectively randomized NORDIC ICD trial (N=1067) with real-word patients implanted with a single, dual or triple chamber ICD for primary or secondary prevention. Since all outcome adjudication was performed by an independent Clinical Event Committee supported by full telemonitoring data transmission, a high validity of ICD interventions could be achieved. To investigate the impact of baseline characteristics on time to first appropriate shock, death without prior appropriate shock therapy and death after appropriate shock therapy, a multi-state Cox model was computed. Missing data have been multiply imputed before analysis. Results At 36 months follow-up, 86.4% of the patients were alive (7.8% after appropriate shock). 11.0% and 2.6% patients died without or after a foregoing appropriate shock, respectively. The primary randomization allocation showed no significant effect on the 3 outcome types. Higher age (per 5 years) and NYHA functional class (≥III vs. ≤II) were associated with an increased risk of death without appropriate shock (HR 1.31, 95% CI 1.14–1.50, p&amp;lt;0.001, and HR 2.17, 95% CI 1.26–3.74, p=0.005, fig.1, accordingly). The presence of diabetes mellitus at baseline was associated with the reduced risk of the occurrence of an appropriate shock (HR 0.57, 95% CI 0.35–0.92, p=0.022). Patients with secondary prevention indication for an ICD had very high risk for an appropriate shock after ICD implantation (HR 3.21, 95% CI 2.02–5.11, p&amp;lt;0.001), but not for death without or with previous appropriate shock (HR 1.42, 95% CI 0.72–2.79, p=0.306, or HR 0.73, 95% CI 0.23–2.34, p=0.594 after ICD shock). Renal insufficiency and ischemic vs. nonischemic disease showed a significantly increased global effect on all three transitions (HR 1.63, 95% CI 1.18–2.24, p=0.003 and HR 1.53, 95% CI 1.06–2.20, p=0.025, respectively). Conclusion The new multi-state model shows the interrelation between appropriate shocks and death, as well a remarkable variation of risk factors for the transitions. Specifically, the presence of higher age and NYHA functional class ≥III at baseline were strong prognostic factors for all-cause mortality without a foregoing shock therapy, but were not predictive for an appropriate shock therapy. In this all-comer study, a significant discriminator predictive for appropriate shock therapy, but not for death was an indication for secondary prevention of sudden cardiac death. Multi-state graph for NYHA class Funding Acknowledgement Type of funding source: Private company. Main funding source(s): This work was supported by Biotronik SE &amp; Co. KG (Berlin, Germany)

Elevated plasma levels of asymmetric dimethylarginine and the risk for arrhythmic death in ischemic and non-ischemic, dilated cardiomyopathy – A prospective, controlled long-term study

IntroductionElevated plasma levels of asymmetric dimethylarginine (ADMA), an inhibitor of NO synthase, are associated with adverse outcome. There is no data available, whether ADMA levels are associated with arrhythmic death (AD) in patients with ischemic cardiomyopathy (ICM) or non-ischemic, dilated cardiomyopathy (DCM). Methods and resultsA total of 110 ICM, 52 DCM and 30 control patients were included. Primary outcome parameter of this prospective study was arrhythmic death (AD) or resuscitated cardiac arrest (RCA). Plasma levels of ADMA were significantly higher in ICM (p < 0.001) and in DCM (p < 0.001) patients compared to controls. During a median follow-up of 7.0 years, 62 (32.3%) patients died. AD occurred in 26 patients and RCA was observed in 22 patients. Plasma levels of ADMA were not associated with a significantly increased risk of AD or RCA in ICM (hazard ratio (HR) = 1.37, p = 0.109) or in DCM (HR = 1.06, p = 0.848) patients. No significant association was found with overall mortality in ICM (HR = 1.39, p = 0.079) or DCM (HR = 1.10, p = 0.666) patients. Stratified Kaplan-Meier curves for ADMA levels in the upper tertile (>0.715 µmol/l) or the two lower tertiles (≤0.715 µmol/l) did not show a higher risk for AD or RCA (p = 0.221) or overall mortality (p = 0.548). In patients with left ventricular ejection fraction ≤ 35%, ADMA was not associated with AD or RCA (HR = 1.35, p = 0.084) or with overall mortality (HR = 1.24, p = 0.162). ConclusionsPlasma levels of ADMA were elevated in patients with ICM or DCM as compared to controls, but were not significantly predictive for overall mortality or the risk for arrhythmic death.

Evaluation of the cardioprotection efficiency in the treatment of patients with acute myocardial infarction and stable angina pectoris by means of digital processing of ECG (digitalization) with subsequent expert assesment

The aim of the work is to investigate the influence of cardiocytoprotection on heart rate variability (HRV) in the treatment of patients with acute Q wave myocardial infarction and stable angina pectoris by digital processing of the ECG and its digitization with a subsequent expert assessment.Material and methods. 124 patients with acute Q-MІ and SAP admitted to regional clinical cardiology center of Chernivtsi during the period 2017-18 were examined. The treatment was held in accordance with the unified records of the Ministry of Healthcare of Ukraine with the evaluating of effectiveness of the implementation of metabolic therapy by using medications Tivortin, Tivorel, Korvityn and Tiotryzolin in comparison with Amiodarone and Bisoprolol in the conditions of the acute test with the registration of the second derivations of the standard ECG for 30 s by using electrocardiograph «Easy ECG MonitorPrince180B» («HealForce» PRC) before using the drugs which were examined and at the height of their effect on patients with Q-IM in comparison with the SAP group.Results. During the research with integrated analysis of impacts of cardiocytoprotection therapy in patients with the Q-IM, in contrast to the SAP group, it was found that arginine chloride reduces the rate of SDNN and activates a sympathetic contour, but the positive is the reduction of the duration and dispersion of QT interval in these patients after using it, arginine chloride and quercetin also reduce the variance of ST segment when MI, and therefore reduce the risk of ischemia and does not indicate the increase of the risk of arrhythmic death, indicated antiarrhythmic direction of the indicator of the maximum rate of differential T wave on the background of using of Corvityn and Tivortin, which is more showed in the case with Tivortin. The possibility of effective quantitative evaluation of the electrocardiogram by digital processing (digitization) by using its own security software «Smart ECG» (certificate of registration of copyright N73687 from 05.09.2017 g.) in the selected groups of patients was proved.Conclusion. Early diagnostic and timely prescription of adequate therapy with inclusion of Bisoprolol, Amiodarone, and medicines with metabolic focus allow us to achieve rapid clinical effect and to prevent the progression of the main pathological process and the development of complications.

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.

Importance of Diastolic Function for the Prediction of Arrhythmic Death: A Prospective, Observer-Blinded, Long-Term Study.

Patients with ischemic or dilated cardiomyopathy and reduced left ventricular ejection fraction (LVEF) face a high risk for ventricular arrhythmias. Exact grading of diastolic function might improve risk stratification for arrhythmic death. We prospectively enrolled 120 patients with ischemic, 60 patients with dilated cardiomyopathy, and 30 patients with normal LVEF. Diastolic function was graded normal (N) or dysfunction grade I to III. Primary outcome parameter was arrhythmic death (AD) or resuscitated cardiac arrest (RCA). Normal diastolic function was found in 23 (11%) patients, dysfunction grade I in 107 (51%), grade II in 31 (14.8%), and grade III in 49 (23.3%) patients, respectively. After an average follow-up of 7.0±2.6 years, AD or RCA was observed in 28 (13.3%) and 33 (15.7%) patients, respectively. Nonarrhythmic death was found in 41 (19.5%) patients. On Kaplan-Meier analysis, patients with dysfunction grade III had the highest risk for AD or RCA (P<0.001). This finding was independent from the degree of LVEF dysfunction and was observed in patients with LVEF≤35% (P=0.001) and with LVEF>35% (P=0.014). Nonarrhythmic mortality was the highest in patients with dysfunction grade III. This was true for patients with LVEF≤35% (P=0.009) or >35% (P<0.001). In an adjusted model for relevant confounding factors, grade III dysfunction was associated with a 3.5-fold increased risk for AD or RCA in the overall study population (hazard ratio=3.52; P<0.001). Diastolic dysfunction is associated with a high risk for AD or RCA regardless if LVEF is ≤35% or >35%. Diastolic function grading might improve risk stratification for AD.

Effect of PCI on QTC Dispersion in Patients with Angina

Background:‘Coronary heart disease (CHD) is now the leading cause of death worldwide; it is on the rise and has become a true pandemic that respects no borders. For the diagnosis of coronary artery disease, the 12 leads electrocardiogram (ECG) is the most readily available noninvasive test by which, in addition of diagnosis, localizing and estimating the size of myocardial ischemia can be determined. Abnormally high QT dispersion has been correlated with risk of arrhythmic death in various cardiac diseases including CAD. An increase in QTd is reported to predict the occurrence of life-threatening ventricular tachyarrhythmias and sudden cardiac death in patients with ischemic heart disease.&#x0D; Materials and Methods: This Cross sectional analytical study was conducted in Department of Cardiology, National Institute of Cardiovascular Diseases, Dhaka from January 2013 to December 2013. A total of 100 consecutive patients with angina based on predefined enrollment criteria were included in the study. .All patients were evaluated by history, clinical examination, biochemical analysis, and coronary angiogram (CAG) which was performed during index hospital admission. PCI was done only if the vessel was significantly stenosed.i,e. for LMCA - e”50%, for LAD, LCX and RCA it was e”70% as significant stenosis. Severity of stenosis of the involved vessels were categorized as severe( e”90%) and moderate(&lt;90%).&#x0D; Results: Among the study population 76 (76%) patients were male and 24 (24%) patients were female. The left anterior descending artery (LAD) group comprised 37 patients and there were significant differences between before and after PCI QTc dispersion (90.5±38.9 vs 70.4±39.6 ms, p=0.001). The left circumflex artery (LCX) group was comprised of 6 patients and there were significant differences between before and after PCI QTc dispersion (62.2±41.9 vs 50.2±37.2 ms, p=0.001). The right coronary artery (RCA) group consisted of 18 patients, there being significant differences between before and after PCI QTc dispersion (84.9±40.7 vs 69.1±41.5 ms, p=0.001)&#x0D; Conclusion: PCI reduces QTc dispersion significantly among patients with angina. This QTc dispersion change is not influenced by sex, smoking, beta-blockers, hypertension, diabetes, renal impairment, stable or unstable angina but it depends upon the severity of coronary artery stenosis, involvement of coronary vessel and number of vessels.Reduction of QTc dispersion is a good sign of successful PCI that indicates successful reperfusion which carries an excellent prognostic value of revascularization.Further long term follow up will establish it.&#x0D; University Heart Journal Vol. 16, No. 1, Jan 2020; 33-39

Modeling defibrillation benefit for survival among cardiac resynchronization therapy defibrillator recipients

Patients with heart failure having a low expected probability of arrhythmic death may not benefit from implantable cardioverter defibrillators (ICDs). The objective was to validate models to identify cardiac resynchronization therapy (CRT) candidates who may not require CRT devices with ICD functionality. Heart failure (HF) patients with CRT-Ds and non-CRT ICDs from the National Cardiovascular Data Registry and others with no device from 3 separate registries and 3 heart failure trials were analyzed using multivariable Cox proportional hazards regression for survival with the Seattle Heart Failure Model (SHFM; estimates overall mortality) and the Seattle Proportional Risk Model (SPRM; estimates proportional risk of arrhythmic death). Among 60,185 patients (age 68.6 ± 11.3 years, 31.9% female) meeting CRT-D criteria, 38,348 had CRT-Ds, 11,389 had non-CRT ICDs, and 10,448 had no device. CRT-D patients had a prominent adjusted survival benefit (HR 0.52, 95% CI 0.50-0.55, P < .0001 versus no device). CRT-D patients with SHFM-predicted 4-year survival ≥81% (median) and a low SPRM-predicted probability of an arrhythmic mode of death ≤42% (median) had an absolute adjusted risk reduction attributable to ICD functionality of just 0.95%/year with the majority of survival benefit (70%) attributable to CRT pacing. In contrast, CRT-D patients with SHFM-predicted survival <median or SPRM >median had substantially more ICD-attributable benefit (absolute risk reduction of 2.6%/year combined; P < .0001). The SPRM and SHFM identified a quarter of real-world, primary prevention CRT-D patients with minimal benefit from ICD functionality. Further studies to evaluate CRT pacemakers in these low-risk CRT candidates are indicated.

P307Magnetic resonance, electroanatomical mapping, and endomyocardial biopsy to solve the diagnostic and sport eligibility dilemma in a cohort of competitive athletes with ventricular arrhythmias

Abstract Background Ventricular arrhythmias (VAs) are a frequent finding in agonist athletes (athl) at routine sport medicine visits. VAs impact on sport eligibility, their management, and the sudden arrhythmic death risk evaluation in athletes currently represents one of the greatest challenges across both the cardiology and sport medicine field. Purpose To describe how an advanced multi-methodical evaluation allowed diagnosis, risk stratification, targeted therapy and sport eligibility reassessment in a competitive athl cohort with ventricular arrhythmias and pathological findings at magnetic resonance (MR). Methods All consecutive competitive athl with denied sport eligibility due to ventricular arrhythmias that underwent an advanced invasive evaluation at our institute were enrolled. A baseline and stress ECG, and late gadolinium enhanced evaluation (LGE) at MR were performed prior to invasive evaluation in all athl. Invasive evaluation performed in all athl comprised of an electrophysiological study (EPS) to assess arrhythmic inducibility, an endo-cavitary electro-anatomical mapping (EAM), and a EAM and MR guided endo-myocardial biopsy (EMB). A defined diagnosis was postulated in all cases, specific therapeutic interventions were started and sport eligibility status reassessed after 6 months from discharge. Results Thirty-two competitive athl were enrolled in our study (32±6 y.o.; 77% male; 4±1 1h-training session/week); 26 (81%) athl practiced a mixed aerobic-anaerobic, 5 (16%) a pure-aerobic, while only 1 (3%) a pure anaerobic sport. Arrhythmic presentation leading to sport eligibility revoke was: in 13 (40%) athl frequent (&gt;2000/day) premature ventricular contractions (PVCs) at rest, in 2 (6%) PVCs during stress ECG, in 6 (18%) non-sustained ventricular tachycardia (VT), in 8 (25%) sustained VT, and in 3 (11%) ventricular fibrillation/cardiac arrest during sport practice. MR alterations were described in all cases, and LGE at MR was found in 31 (87%) athl; a definite radiological diagnosis was obtained in 13 (40%) athl. A normal myocardium at EMB was found only in 3 (8%) pts; in 15 (45%) a leukocyte infiltrate pattern compatible with myocarditis, in 11 (39%) fibro-fatty replacement, in 2 (5%) a mitochondrial disease and in 1 (3%) a sarcoidosis were proven, and diagnosis were consequently postulated. EPS showed complex VAs inducibility in 8 (25%) cases, while a trans catheter ablation was performed in 10 (31%) athl. A total of 9 (28%) implantable cardioverter devices (ICDs) were implanted, for primary or secondary prevention. According to invasive diagnostic findings and sport medicine guidelines, 8 (25%) athl had their sport eligibility statuts re-instated. Conclusion An invasive multi-methodical assessment allowed in all cases to reach a diagnosis and to start a targeted therapy in a cohort of competitive athl with VA and a pathological MR, granting in a significant (25%) percentage sport eligibility status re-instatement.

PECULIARITIES OF THE METABOLIC THERAPY USE IN PATIENTS WITH ACUTE AND CHRONIC ISCHEMIC HEART DISEASE: ANALYSIS OF DIGITAL PROCESSING OF ELECTROCARDIOGRAM

Abstract. In order to determine the cardioprotective effect of metabolic therapy, the results of the digital processing of the standard using the own software Smart ECG with the evaluation of effects in patients with ischemic heart disease (stable angina II functional class in comparison with the group of acute Q-myocardial infarction) were analysed . The possibility of an effective quantitative evaluation of the during its digital processing (digitalization) using the own software Smart ECG in these patient groups was proved. In comparison with the results of the study at myocardial infarction, in contrast to stable angina, tivortin reduces the SDNN index and activates a sympathetic contour. It is positive to reduce the dispersion of the QT interval when using tivortin and corvitin. Also, these drugs reduce ST segment depression in myocardial infarction, and consequently reduce the risk of ischemia and do not increase the risk of arrhythmic death. The anti-ischemic direction of the ratio of the maximum velocities of the differentiated T wave is more pronounced in tivortin than in corvitin. Quantitative evaluation of with its digital processing can be recommended to increase the effectiveness of an individual approach in the treatment of patients with acute and chronic ischemic heart disease with objective cardioprotection.

Abstract P371: The Effects of Omega-3 Fatty Acid Ethyl Esters on QT Dispersion and Corrected QT Dispersion in Hypertensive Patients With Left Ventricular Hypertrophy

Background: Left ventricular hypertrophy (LVH) leads to arrhythmia such as atrial fibrillation, ventricular arrhythmias and known risk factor of sudden cardiac death. Recent study suggests that Omega-3 fatty acid ethyl esters have anti-arrhythmic effects and reduce sudden cardiac death among survivor of myocardial infarction. QT dispersion(QTD) reflects ventricular repolarization heterogeneity and prolonged QTD has been associated with the risk of arrhythmic death in coronary artery disease patients. However, no study has done to prove the effects of Omega-3 fatty acid ethyl esters on QTD and corrected QTD(cQTD) in hypertensive patients with LVH Objective: We tried to evaluate the effects of Omega-3 fatty acid ethyl esters on QTD and cQTD in hypertensive patients with LVH Design and Method: This study included 30 hypertensive patients who confirmed LVH by ECG voltage criteria. The patients were evaluated with 12-leads electrocardiography before and 3~6 months after treatment of Omega-3 fatty acid ethyl esters(1g/day). We measured QTD (maximal QT interval - minimal QT interval) and cQTD (maximal corrected QT interval - minimal corrected QT interval) by Bazett’s formula using electronic caliper before and after treatment. Results: QTD (before: 60.86±14, after: 51.84±13.95 P=0.003) and cQTD (before: 63.83±14.18, after: 51.83±13.94 P&lt;0.001) was significantly reduced after treatment of Omega-3 fatty acid ethyl esters Conclusions: The QTD and cQTD significantly reduced after treatment of Omega-3 fatty acid ethyl esters in hypertensive patients with LVH. It may partially explain the anti-arrhythmic effect of Omega-3 fatty acid ethyl esters.

Vasopressin in Heart Failure.

The nonapeptide hypothalamic hormone vasopressin (VP), exerts important effects on cardiovascular system via its receptors V1, V2 and V3. Patients with congestive heart failure (CHF) present elevated plasma VP levels. Aim of this paper is to review the role of vasopressin in CHF. We analyzed the best of published literature dealing with the role of VP in patients affected by CHF, identifying keywords and MeSH terms in Pubmed and then searching them. The last search was performed on August 2017. Scientific articles dealing with the relationship between VP and CHF show that circulating high VP levels found in CHF despite an exaggerated increase in circulatory blood volume can contribute to CHF exacerbation. In particular, the stimulation of V1R induces vascular constriction responsible for increased systemic vascular resistance and afterload, and, in addition, coronary vasoconstriction with consequent reduced coronary circulation and cardiac contractility, whereas the stimulation of V2R induces free water reabsorption and this is responsible of preload increase and congestion of pulmonary vascular bed with edema and hyponatremia, markers of advanced CHF. VP can play an important role among the derangements of the endocrine system in CHF even being a possible target in the treatment of this condition. Vaptans, antagonists of VP receptors, in fact, are able to increase urine output and plasma sodium levels without the increased risk of arrhythmic death induced by diuretics, even though, further studies are needed to establish a possible role of these drugs in the treatment of CHF.