Symptomatic Arrhythmias Research Articles

Quality of life in patients with long-standing persistent atrial fibrillation after surgical ablation and simultaneous coronary artery bypass grafting

Aim. To analyze quality of life (QOL) of patients with coronary artery disease (CAD) in combination with long-standing persistent atrial fibrillation (AF) in the long-term postoperative period, depending on chosen surgical strategy for concomitant pathology.Material and methods. The analysis of QOL changes in the long-term postoperative period (12 and 24 months) in 116 patients with CAD and concomitant long-term persistent AF who selectively underwent biatrial (BA) or isolated left atrial (LA) ablation with simultaneous on-pump coronary artery bypass grafting. To assess QOL, a non-specific Medical Outcomes Study 36-Item Form Health Status Survey (SF-36) questionnaire was used. Patients were questioned in preoperative and long-term postoperative periods (12 and 24 months).Results. All SF-36 parameters significantly improve after open surgical treatment in the long-term postoperative period (24 months) with both treatment strategies (BA and LA ablation) for AF. In the BA ablation group, 74% of patients did not have arrhythmia after 12 months, and only 38,5% of patients in the LA ablation group belonged to European Heart Rhythm Association (EHRA) score class 1 (p=0,001). After 24 months, a comparison revealed a significant diff erence between the two groups in arrhythmia symptoms (p=0,014), with maintaining the advantage of the BA ablation group. After 12 and 24 months, none of the patients in both compared groups had severe class IV angina.Conclusion. SF-36 parameters were improved 24 months after surgical treatment of CAD and long-standing persistent AF, regardless of the ablation strategy. Elimination of angina symptoms and long-term maintenance of sinus rhythm can improve the QOL of patients in the long-term postoperative period.

Geriatric depression and quality of life in atrial fibrillation: the geriatric population analysis

Abstract Background and purpose Arrhythmias such as atrial fibrillation (AF) is often associated with depression, with vague anxiety about symptom and the risk of serious complication such as stroke or heart failure. In the geriatric population, geriatric depression often occurs with an increase of physical illness and has substantial costly and quality of life implications for functionality and life satisfaction. However, few studies have investigated relationship between geriatric depression and Quality of Life (QoL), and arrhythmia symptoms (palpitation, dyspnea and chest discomfort). Method Between November 2019 and October 2020, elderly people (≥65 years) who participated in the AF awareness symposium were enrolled in this study. They were divided into 4 groups according to the presence or absence of chest symptom and AF, and were examined geriatric depression by Geriatric depression scale (GDS)-15 and Quality of Life (QoL) by the 12-item Short- Form Health Survey (SF-12) including physical and mental health status. Results Of the 1511 subjects, 1364 were analyzed after excluding 147 with missing values. Among them, 911 were in the non-AF group without symptom (Group A), 43 in the AF group without symptom (group B), 323 in the non-AF group with symptom (group C), and 87 in the AF group with symptom (group D). Geriatric depression rates (defined as GDS-15 ≥10) were 2.7% in non-symptomatic group (2.7% in A [n=25] and 2.3% in B [n=1]) and 7.8% in symptomatic group (7.4% in C [n=24] and 9.2% in D [n=8]). (P<0.05) In multivariate regression analysis, an increased risk of geriatric depression was observed in groups C and D (group C: odds ratio [OR]=2.54, CI: 1.40, 4.61, P<0.01 and group D: OR=3.13 CI: 1.16, 7.57, P=0.02). The mean values of physical and mental health status in SF-12 were 48.5 (±7.9) and 56.7 (±6.8) in A, 44.6 (±10.7) and 57.3 (±7.3) in B, 45.0 (±9.9) and 53.8 (±7.7) in C, and 43.4 (±10.8) and 54.8 (±8.6) in D, respectively. Physical health status in SF-12 was associated with group C (C vs A: estimate −2.95 [CI: −4.03, −1.87], p<0.01) and D (D vs A: estimate −2.93 [CI: −4.88, −0.97], p<0.01), other than heart failure, older age and female. Mental health status in SF-12 was associated with group C (C vs A: estimated −2.34 [CI: −3.72, −1.42], p<0.01), heart failure, hypertension, older age, female and group D (D vs A: estimate −1.63 [CI: −3.31, 0.05], p=0.06), but not statistically significant. Individuals with arrhythmia symptom (group C and D) had lower physical and mental health status than those without (group A and B) (P<0.05). Conclusion Older adults with arrhythmia symptoms were more likely to have geriatric depression and low QoL, especially those with symptomatic AF, with a geriatric depressive complication rate of 9.2%. Further studies are needed to investigate whether improving physical health status can improve QoL and geriatric depression. Funding Acknowledgement Type of funding sources: None.

Common genetic variants improve risk stratification after atrial switch operation for transposition of the great arteries

Abstract Background Current clinical risk scores are able to predict late complication risk in adults after atrial switch operation (AtrSO) for transposition of the great arteries (TGA), but a large heterogeneity in clinical course remains. Purpose To study whether common genetic factors are predictive of outcome and provide added value to an existing clinical risk score in TGA-AtrSO patients. Methods This multicenter study examined the association of genome-wide single-nucleotide polymorphisms (SNPs) in TGA-AtrSO patients with a combined clinical endpoint: time to symptomatic ventricular arrhythmia, heart failure hospitalization, ventricular assist device implantation, heart transplantation, or mortality. Furthermore, we evaluated whether a polygenic risk score (PRS) constructed of independent single-nucleotide polymorphisms (SNPs) with a p<1x10–5 could be of added value to a recently published clinical risk score (included clinical factors: age >30 years, prior ventricular arrhythmia, age >1 year at repair, ≥moderate right ventricular dysfunction, severe tricuspid regurgitation, and ≥mild left ventricular dysfunction). Results We followed 133 patients (age at inclusion 28 [IQR 24–35] years, 59% male) for 13 [IQR 8–16] years. Thirty-two patients (24%) reached the endpoint. The genome-wide association study yielded one locus that reached genome-wide significance (p<1x10–8) and 18 loci marked by 20 SNPs that reached the suggestive threshold (p<1x10–5). The constructed PRS remained an independent predictor after correction for the clinical score (HR=1.21/point increase [95% CI 1.13–1.29], p=3x10–10). While the clinical risk score indicated intermediate (5–20%) 5-year risk of events in 52 patients (39%), the combined risk score (clinical score + PRS) reclassified 35 patients to low (<5%) and 6 to high (>20%) risk. Observed 5-year event-free survival based on the combined score remained 100% for low-risk patients, compared to 23% and 64% in intermediate and high-risk patients, respectively. This resulted in improved risk stratification with the combined risk score vs the clinical risk score alone (p=2x10–16, C-statistic 0.95 vs 0.85). Conclusions Genetic factors explain some of the variation in clinical course of TGA-AtrSO patients and improve risk stratification. In the heterogeneous group of patients with a clinical score indicating intermediate risk, the combined model could classify 67% of patients more accurately to <5% or >20% risk. These data argue for more research into the impact of genetics on clinical outcome in adult congenital heart disease. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): Dutch Heart Foundation Figure 1. Risk stratification of predicted 5-year risk of events based on the clinical model versus the combined model (clinical risk score + polygenic risk score).

Assessment of ECG during hybrid comprehensive telerehabilitation in heart failure patients – subanalysis of the TELEREHabilitation in heart failure patients – TELEREH-HF randomized clinical trial

Abstract Background Exercise training in heart failure (HF) patients (pts) should be monitored to ensure patients safety. That is why we use ECG telemonitoring during hybrid comprehensive telerehabilitation (HCTR). Purpose Assessment of frequency of cardiac arrhythmias during telerehabilitation in HF patients. Methods The present analysis formed part of TELEREH-HF multicenter, randomized (1:1), controlled trial that enrolled 850 HF pts with New York Heart Association class I, II, or III and left ventricular ejection fraction (LVEF) of 40% or less. Patients were randomized 1:1 to 9 week HCTR plus usual care or usual care only. This subanalysis focuses on 386 pts (aged 62±11 years, LVEF 31±7%) randomized to HCTR based on Nordic walking training 5 times/week. HCTR was tele-monitored with an EHO mini device adjusted to record 16-second fragments of ECG (from three precordial leads) and to transmit the data via mobile phone network to the monitoring center. The timing of automatic ECG recording were pre-set and coordinated with exercise training. Results In all, 16622 HCTR sessions were registered and 66488 ECGs transmitted fragments were evaluated (four 16-second recording per patient per one session were recorded). A sinus rhythm was present in 320 (83%) pts, permanent atrial fibrillation in 66 (17%) pts. Assessment of ECG during HCTR procedure is presented in Table 1. Conclusions Telerehabilitation in heart failure patients is safe without evidence for symptomatic cardiac arrhythmias requiring discontinuation of training. Non-sustained ventricular tachycardia and paroxysmal atrial fibrillation episodes were rare but have required adjustment of the telerehabilitation regimen. The most common arrhythmias were ventricular and supraventricular premature beats. These arrhythmias did not result in any changes in rehabilitation and therapy regimens. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): The National Centre for Research and Development, Warsaw, Poland.

New Onset of AV- Nodal Reentrant Tachycardia (AVNRT) in the elderly – an uncommon diagnosis?

Abstract Background Arrhythmias in elderly patients (>70 years) are common in daily clinical practice. Most frequently, they are based on atrial fibrillation or other atrial tachycardia with an indication for oral anticoagulation and specific antiarrhythmic medications. The electrographic (ECG) documentation related to symptoms is essential before therapy initiation. In case of suspected AVNRT based on surface ECG, an electrophysiological study (EP) with ablation as curative strategy should be planned. Methods We analysed all patients >70 years with AVNRT diagnosed by electrophysiologic (EP) studies between May 2018 and December 2020. Results An EP study for suspected AVNRT was performed in 27 patients >70 years. The diagnosis of AVNRT was confirmed in 20 patients (75%). From all EP- studies with the diagnosis of AVNRT (n=93) in this period, 20 patients (22%) were older than 70 years (mean age 77 years with a range of 70–85 years), 12 were women. In most of the patients, the duration of symptoms was short (3 month). Only 4 patients had symptoms of paroxysmal tachycardia longer than 10 years. Except for 2 patients, all patients had at least one ECG- documentation (12- lead- ECG, Holter- ECG, telemetric ECG and/or in the loop recorder). In 12 patients, a 12- lead- ECG- documentation was available, in 5 patients the tachycardia has been registered in the Holter-ECG and in 1 in a loop recorder. In the 12- lead- ECG before ablation in sinus rhythm the PQ interval was with 196 (120- 300) ms in the upper range. In 16/ 20 patients was during the EP- study a sustained AVNRT (CL 410, 314- 538 ms) inducible. In the others, up to 3 typical AV- nodal- echo beats were induced in the EP- study. A slow pathway ablation/ modification was performed in all patients in typical position. In 2 patients, the implantation of a dual- chamber- pacemaker was necessary due to intermittent high- degree AV-nodal-block during the same hospital stay. In both patients, a first degree AV-block with PQ- interval of 250 and 300 ms was pre-existing. Discussion Especially for the elderly patients with new onset of clinical symptoms of arrhythmia, clinical anamnesis including an ECG- documentation is required for planning the therapeutic strategy. A borderline long PQ- interval as sign of an age- dependent fibrosis in the AV- node and, therefore, altered conduction properties in the AV node can be a cause of AVNRT in these older patients. In patients with pre-existing long PQ- interval (>250 ms), the risk of pacemaker implantation after successful ablation is higher. In this group of patients, medical therapeutic options are limited and often associated with the need of pacemaker implantation. Funding Acknowledgement Type of funding sources: None.

Assessment of ECG during hybrid comprehensive telerehabilitation in heart failure patients-Subanalysis of the Telerehabilitation in Heart Failure Patients (TELEREH-HF) randomized clinical trial.

BackgroundExercise training in heart failure (HF) patients should be monitored to ensure patients’ safety. Electrocardiographic (ECG) telemonitoring was used to assess the safety of hybrid comprehensive telerehabilitation (HCTR).ObjectiveAnalysis of ECG recorded during HCTR in HF patients.MethodsThe TELEREH‐HF multicenter, randomized, controlled trial enrolled 850 HF patients with New York Heart Association class I‐III and left ventricular ejection fraction of ≤40%. This subanalysis focuses on 386 patients (aged 62 ± 11 years, LVEF 31 ± 7%) randomized to HCTR. HCTR was telemonitored with a device allowing to record 16‐s fragments of ECG and to transmit the data via mobile phone network to the monitoring center.ResultsIn 386 patients, 16,622 HCTR sessions were recorded and 66,488 ECGs fragments were evaluated. Sinus rhythm was present in 320 (83%) and permanent atrial fibrillation (AF) in 66 (17%) patients, respectively. The most common arrhythmias were ventricular and atrial premature beats, recorded in 76.4% and 27.7% of the patients, respectively. Non‐sustained ventricular tachycardia (21 episodes in 8 patients) and paroxysmal AF episodes (6 in 4 patients) were rare. None of the analyzed demographic and clinical characteristics was predictive for onset of the new arrhythmias on exercise.ConclusionTelerehabilitation in HF patients was safe without the evidence for symptomatic arrhythmias requiring discontinuation of telerehabilitation. Only one mildly symptomatic paroxysmal AF episode led to the short‐term suspension of the training program. The most common arrhythmias were atrial and ventricular premature beats. These arrhythmias did not result in any changes in rehabilitation and therapy regimens.

Incidence prevalence and management of different types of arrhythmia in patients with ischemic heart disease in Taif city

Background: Despite considerable progress in management over the recent years, coronary artery disease (CAD) remains the leading cause of death. Objectives: to assess the different types of arrhythmias in patients with ischemic heart diseases in Taif city. Methods: A retrospective study was done on 529 patients from Taif, Saudi Arabia aged 30 to >75 years, of both genders and who had CAD, through the review of medical records of cardiac patients in AL Hada armed forces hospital. A checklist was used that included demographic features and risk factors for ischemic heart disease, symptoms of heart failure, medications that patients who had CAD used and types of arrhythmias. Results: All patients had a type of arrhythmia during their hospital stay. The main types of arrhythmias were AF (26.8 %), conduction disturbance (38.2%) and first-degree heart block (9.1 %). Patients who had STEMI with symptoms of heart failure and arrhythmias had a significantly higher percentage for the need of DC shock compared to other patients. Patients with UA who developed low EF were shown to be significant as regards arrhythmias rather than normal EF. The number of affected vessels had no effect on the development of arrhythmias during the acute stage. The development of arrhythmia that required DC shock was more common in STEMI patients especially those who developed heart failure symptoms. Conclusion: The need of assessment of heart failure symptoms and EF in patients with UA is essential to determine the need for implantable device insertion. Also, early administration of b-blocker decreases the risk of development of arrhythmia during an acute ischemic event. Key words: arrhythmias, patients, ischemic, heart, disease, Taif

Assessing and Managing Asymptomatic Ventricular Preexcitation in the Young Athlete

Assessing and Managing Asymptomatic Ventricular Preexcitation in the Young Athlete

Ablation of cardiac arrhythmias using a three-dimensional electro-anatomical mapping system in the Instituto Nacional Cardiovascular - INCOR

To describe the initial experience in ablation of cardiac arrhythmias using 3D mapping at the Instituto Nacional Cardiovascular INCOR (Lima, Peru). A retrospective descriptive study was carried out. During February 2020, data was collected from the medical records of all patients in whom ablation was performed using 3D mapping from July 2017 to December 2019. This procedure was performed in patients with symptomatic arrhythmia refractory to antiarrhythmic therapy. Data were collected from 123 patients (median age: 46 years, 64.2% male), who had a median time of illness of 6 years. Among the arrhythmias treated, 19% had atrial fibrillation, 17.5% atrial tachycardia, 17.5% idiopathic ventricular arrhythmias, 16.6% Wolf Parkinson White syndrome / Atrioventricular reentrant tachycardia, 11.1% ventricular arrhythmias of the His-Purkinje conduction system, 9.5% scar related ventricular tachycardia associated, 6.4% atrial flutter and 2.4% intranodal tachycardia. The median fluoroscopy time was 26 minutes. Ablation was acutely successful in 95.9% of cases, acute complications were observed in 4.8%, and recurrence-free survival during the first year of follow-up was 74%. Our experience in ablation of cardiac arrhythmias using 3D mapping had a high acute success rate, low frequency of complications, and one-year recurrence-free survival of 74 %.

A left lateral body position increases pulmonary vein stress in healthy humans.

Pulmonary vein (PV) stretch is proarrhythmic for atrial fibrillation (AF). AF patients often report that a left lateral (LL) body position can trigger arrhythmia symptoms. Because the PV myocardium is thought to trigger AF, we hypothesized that the LL compared to the supine body position increases PV wall stress. Functional cardiac magnetic resonance imaging was performed in supine and LL recumbent body position in awake condition in healthy human volunteers (n = 20). Following a change from supine to LL position, the heart moved in an anterior‐LL direction in the thorax. The right superior PV diameter was increased by 19% (24.6 ± 3.1 vs. 20.7 ± 3.2 mm, p = 0.009) and left atrial (LA) volume was larger by 17% (61.7[15.4] vs. 51.0[17.8] ml, p = 0.015) in LL than supine position, respectively. The passive LA conduit fraction (normalized difference between maximum and pre‐contraction LA volume) increased by 25% in LL compared to supine position (19.6 ± 9.0 vs. 15.7 ± 7.6%, respectively, p = 0.016). Local wall stress in the PV regions increased in LL compared to supine position (overall mean: 1.01 ± 0.12 vs. 1.10 ± 0.10 arb. unit, LL vs. supine, position effect p = 0.041), whereas this was not the case in the LA walls (overall mean: 1.18 ± 0.31 vs. 1.21 ± 0.21 arb. unit, LL vs. supine, position effect p = 0.381). In conclusion, a left lateral body position increases PV myocardial stress during the atrial relaxation phase of healthy volunteers. These results have implications for the mechanisms of posture‐triggered AF.

Antiarrhythmic therapy for atrial fibrillation: current guidelines of the European Society of Cardiology and the European Association for Cardio-Thoracic Surgery (ESC/EACTS)

The treatment of atrial fibrillation (AF) remains one of the most difficult tasks in modern cardiology. In 2020, the European Society of Cardiology (ESC), together with the European Association for Cardio-Thoracic Surgery (EACTS), published guidelines for the diagnosis and management of AF, which include several new directives.ESC experts have formulated a novel concept for treatment of AF patients. The first component of treatment ‘A' (Anticoagulation/ Avoid stroke) is anticoagulant therapy in patients with increased risk of thromboembolic events. The second line of treatment ‘B' (Better symptom control) is the control of arrhythmia symptoms, selection of a rhythm control strategy or ventricular rate control. The third direction ‘C' includes cardiovascular risk factors and comorbid conditions management.The most challenging tasks in AF treatment are the control of arrhythmia symptoms. As in the previous version of 2016 guidelines, the latest ones identify 2 following strategies in treatment of AF: rhythm control and ventricular rate control.According to the current ESC/EACTS guidelines (2020), antiarrhythmic therapy continues to be one of the important directions in AF management. Early prescription f antiarrhythmic and anticoagulant agents with an increased risk of thromboembolic events, catheter ablation can not only improve the quality of life, but also the prognosis of patients with AF.

The difference between cystatin C- and creatinine-based eGFR is associated with adverse cardiovascular outcome in patients with chronic kidney disease

Background and aimsDecreased kidney function is an important risk factor for cardiovascular disease (CVD). However, assessing risk of CVD may be difficult when there is a gap between creatinine- and cystatin C-based estimated glomerular filtration rate (eGFR). We studied the association of the difference in eGFRs with major adverse cardiovascular events (MACE) in patients with chronic kidney disease (CKD). MethodsThis prospective cohort study was conducted in 2076 patients with CKD stages based on the KDIGO guideline (eGFR categories of G1: ≥90; G 2: 60–89; G3: 30–59; G4: 15–29; G5: <15 mL/min/1.73 m2 without kidney replacement therapy). The difference in eGFR (eGFRdiff) was calculated by subtracting the cystatin C-based eGFR (eGFRcys) from the creatinine-based eGFR (eGFRcreat). The primary outcome was MACE, defined as non-fatal acute myocardial infarction and unstable angina, stroke, congestive heart failure, symptomatic arrhythmia, and cardiac death. ResultsDuring a median follow-up of 4.1 years, MACE occurred in 147 patients (incidence rate, 15.0 per 1000 patient-years). When patients were categorized into baseline eGFRdiff tertiles, the highest tertile was associated with a significantly higher risk of MACE (hazard ratio, 2.12; 95% confidence interval [CI], 1.28–3.51) than the lowest tertile when adjusted for eGFRcreat, eGFRcys, or eGFR based on both creatinine and cystatin C. Patients in the highest tertile had more baseline coronary artery calcification (CAC) than those in the lowest tertile (odds ratio [OR], 1.38; 95% CI, 1.03–1.86). In addition, 978 patients had data for both baseline and follow-up CAC at year 4. In this subgroup, baseline eGFRdiff was significantly associated with accelerated CAC progression (≥50/year) (OR, 1.03; 95% CI, 1.01–1.05). ConclusionsA large positive difference between eGFRcreat and eGFRcys was associated with a higher risk of MACE and faster CAC progression in patients with CKD. Therefore, careful monitoring of CVD is needed for patients with a higher eGFRdiff.

Meta‐analysis of cryoballoon ablation versus antiarrhythmic drugs as initial therapy for symptomatic atrial fibrillation

BackgroundThe optimal first‐line approach for patients with symptomatic atrial fibrillation (AF) remains unclear. We compared the efficacy and safety of cryoballoon ablation (CBA) and antiarrhythmic drugs (AADs) in the initial management of symptomatic AF.HypothesisCBA is superior to AAD as initial therapy for symptomatic AF.MethodsWe searched the EMBASE, PubMed, and Cochrane Library databases for randomized controlled trials (RCTs) that compared CBA with AAD as first‐line treatment for AF from the date of database establishment until March 18, 2021. The risk ratio (RR) with a 95% confidence interval (CI) was used as a measure of treatment effect.ResultsThree RCTs that enrolled 724 patients in total were included in this meta‐analysis. Majority of the patients were relatively young and had paroxysmal AF. CBA was associated with a significant reduction in the recurrence of atrial arrhythmia compared with AAD therapy, with low heterogeneity (RR, 0.59; 95% CI, 0.49–0.71; p < .00001; I 2 = 0%). There was a significant difference in the rate of symptomatic atrial arrhythmia recurrence (RR, 0.44; 95% CI, 0.29–0.65; p < .0001; I 2 = 0%); however, the rate of serious adverse events was similar between the two treatment groups (RR: 1.18; 95% CI: 0.71–1.97, p = .53; I 2 = 0%). Transient phrenic nerve palsy occurred in four patients after the CBA procedure.ConclusionThe current meta‐analysis suggests that CBA is more effective than AAD as initial therapy in patients with symptomatic paroxysmal AF. Serious iatrogenic adverse events are uncommon in CBAs.

Influence of frailty syndrome on anxiety and depression of patients with atrial fibrillation

Abstract Funding Acknowledgements Type of funding sources: None. Background. Atrial fibrillation (AF) is a chronic disease whose somatic symptoms cause patients to feel anxiety. Anxiety and depression are associated with recurrent episodes of AF and may exacerbate the symptoms of arrhythmia, increasing the risk of sudden complications and death. The evidence suggests that frailty leads to cognitive decline and increased prevalence of anxiety and depression. However, there is little information on what increases the risk of frailty syndrome in atrial fibrillation. The aim of the study was to determine the impact of frailty syndrome on anxiety and depression in patients with AF. Material and methods. The study was conducted on 158 patients with AF (including 78 women) aged 70.4 ± 7.6 years. Standardized tools were used: the Edmonton frailty scale (EFS) and the hospital anxiety and depression scale (HADS-M) to assess and compare anxiety, depression, and frail and non-frail patients with AF. Results. The average ESF score was 8.555.0. 53.2% had frailty syndrome, 10.1% were vulnerable and 36.7% had no frailty syndrome. Mean level of anxiety was 10.253.0 and depression was 9.83.85. In comparative analysis patients with frailty syndrome had more often high level of anxiety (73.8% vs. 18.9%, p &amp;lt; 0.001) and high level of depression (72.6% vs. 2.7%; p &amp;lt; 0.001) in comparison to patients without frailty syndrome. In multivariate analysis the independent determinants of frailty syndrome were longer duration of AF (β=4.649, p = 0.001), anxiety (β=2.4727, p = 0.036) and depression (β=5.5712, p &amp;lt; 0.001). Conclusions. Patients with AF have high level of FS and anxiety and depression, and FS exacerbates the symptoms of anxiety and depression. Independent determinants of frailty syndrome are longer duration of AF, anxiety and depression.

App based monitoring of heart rate via FibriCheck to facilitate teleconsultations: from COVID-19 to clinical practice?

Funding AcknowledgementsType of funding sources: Public Institution(s). Main funding source(s): Part of this project was realized with financial support from the city of Antwerp in the context of the call "Innovative solutions for Corona”BackgroundDuring the first peak of the COVID-19 pandemic, face-to-face cardiology visits had to be replaced by teleconsultations but lacking the standard performed electrocardiogram. Instead, app-based monitoring of patients’ heart rate and rhythm using photoplethysmography (PPG) technology was available as an alternative to aid these teleconsultations.PurposeEvaluation of the feasibility to initiate remotely PPG recordings with FibriCheck (Qompium, Hasselt, Belgium) and of the value of using FibriCheck before and after teleconsultation to substitute in-person arrhythmia consultations in three Belgian hospitals (Antwerp University Hospital, Heilig-Hart Hospital Lier and Jessa Hospital Hasselt).MethodsPatients known with AF or with suspected arrhythmia symptoms during teleconsultation were contacted for the activation of FibriCheck seven days before or after a teleconsultation respectively, as shown in Figure 1. Instructions and a QR code were sent to the patients to download and activate FibriCheck. The code automatically links the application to an online platform available for the treating physician. Patients were asked to record their heart rhythm three times a day and when they experienced symptoms.ResultsIn total, 92 patients (mean age: 64.7 ± 17.4) were contacted during the first COVID-19 peak, of which a total of 22 patients declined because not owing a smartphone or tablet (n = 11) or they were not willing or not capable to use FibriCheck (n = 11). A significant age difference was seen between the 22 non-participants versus the 70 participants (mean age 73.8 ± 18.7 vs. 61.9 ± 15.9; p = 0.004). Half of the patients, eligible for PPG monitoring (n = 38, 54.9%), were initiated before a planned (tele)consultation. Of these, four patients (10.5%) were diagnosed with an arrhythmia by using FibriCheck, of which two had frequent extrasystoles and two had a recurrence of AF and rate control was adapted. Of the 32 patients who used FibriCheck after a teleconsultation due to symptomatic palpitations, extrasystoles (n = 3) or high suspicion for a new AF diagnosis (n = 2) was established via FibriCheck. Early in-office evaluation was organised for the patients with a new diagnosis of AF, and rhythm control was initiated. In the majority of patients (57.1%), teleconsultation with FibriCheck was reassuring so that they could be followed-up according to their normal schedule.ConclusionDuring the COVID-19 pandemic, cardiologists were able to obtain important additional information using the FibriCheck application when performing teleconsultations. The possibility to successfully complete teleconsultations using the FibriCheck data, and its broad applicability, create opportunities to implement FibriCheck in standard clinical practice as an easy tool to monitor patients before or after in-person consultations or even hospitalisations. Figure.

B-PO03-184 REDUCTION IN URGENT HEALTHCARE VISITS BY USING A MOBILE ELECTROCARDIOGRAPHIC DEVICE

Mobile electrocardiogram (mECG) devices are being used increasingly, supplying recordings to providers and providing automatic rhythm interpretation. Given the intermittent nature of certain cardiac arrhythmias, mECGs allow instant access to a recording device. In the COVID-19 pandemic, ways to limit in-person patient interactions and avoid overwhelming emergency and inpatient services would add value. Our goal was to evaluate whether a mECG device would reduce healthcare utilization overall, particularly those of urgent nature. To evaluate whether the use of a mobile ECG device would lead to decreased urgent healthcare utilization in individuals with symptomatic arrhythmias. We identified a cohort of KardiaMobile (AliveCor, USA) mECG users and compared their healthcare utilization 1 year prior to obtaining the device and 1 year after device activation. 128 patients were studied (mean age 64, 47% female). Mean duration of follow-up pre-intervention was 9.78 months. 123 of 128 individuals completed post-intervention follow-up. Patients were less likely to have cardiac monitors ordered (30 vs 6; p<0.01), outpatient office visits (525 vs 382; p<0.01), cardiac-specific ED visits (51 vs 30; p<0.01), arrhythmia related ED visits (45 vs 20; p<0.01), and unplanned arrhythmia admissions (34 vs 11; p<0.01) in the year after obtaining a KardiaMobile device compared to the year prior. Mobile technology is available for heart rhythm monitoring and can give feedback to the user. This study showed a reduction of in-person healthcare utilization with mECG device use. In light of the ongoing COVID-19 pandemic, strategies to limit unnecessary patient contact have value. The use of mECG devices can decrease the risk of exposure to patient and provider from COVID-19, avoid overwhelming emergency and inpatient services during the pandemic, and may decrease healthcare costs. Given the increases in healthcare costs in recent years, methods to safely and effectively limit cost are needed. One possible strategy could be the use of mECG devices.

B-PO03-198 AMBULATORY RHYTHM MONITORING IN POSTURAL ORTHOSTATIC TACHYCARDIA SYNDROME AND ORTHOSTATIC INTOLERANCE: ARRHYTHMIAS BEYOND SINUS TACHYCARDIA

Limited literature exists on the utility of ambulatory rhythm monitoring in patients with postural orthostatic tachycardia syndrome (POTS) and orthostatic intolerance (OI), as most are thought to have sinus tachycardia. Our aim was to determine the diagnostic yield of Holter (H) and Zio® (Z) monitoring in patients with POTS or OI. We examined H and Z data from all patients seen at Children’s National from 1/1/2001 - 12/31/2020 and diagnosed with POTS or OI. We defined “arrhythmia” as SVT, frequent PVCs, PVC couplets, VT, 3° AV block, or WPW. Using the binomial z-test for proportions, we compared our data to previous literature in healthy children and in children with arrhythmia symptoms. Out of 855 patients diagnosed with POTS/OI (mean age 14.3 years, SD 3.3, 77% female), a total of 296 H and 71 Z monitors were obtained. The frequency of arrhythmia in this group was 14% by H and 23% by Z. Additionally, a total of 170 H and 22 Z monitors were obtained in 357 patients with syncope, with a diagnostic yield of 15% by H and 27% by Z, not significantly different from the POTS/OI group. Both the H and Z yields are significantly higher than what is reported in healthy children. The H yield is similar to what is reported in patients presenting for primary evaluation of cardiac symptoms, and the Z yield is significantly higher in the POTS/OI group (see table). Our results suggest that a significant proportion of patients with POTS/OI may have underlying cardiac arrhythmias, at a frequency similar to syncope patients. In the appropriate clinical context, physicians caring for POTS/OI patients should consider evaluating for alternate arrhythmias beyond sinus tachycardia.Tabled 1Frequency of Arrhythmias in the POTS/OI group vs. Healthy Subjects vs. Symptomatic ChildrenStudyDiagnosis/SymptomsMonitor TypeFrequency of ArrhythmiaP-value (compared to POTS/OI group)Current studyPOTS/OIHolter40/296 (14%)N/ACurrent studyPOTS/OIZio16/71 (23%)N/ACurrent studySyncopeHolter25/170 (15%)0.719Current studySyncopeZio6/22 (27%)0.465Scott, O (1980); Southall, DP (1981); Nagashima, M (1987); and Massin, MM (2005)Healthy childrenHolter14/847 (1.7%)< 0.001Massin, MM (2005)Hospitalized children without cardiac symptomsHolter2/112 (1.8%)< 0.001Drago, F (1989); Hegazy, RA (2007); Aman, R (2017); and Pradhan, S (2019)Palpitations, syncope, or unspecified tachycardiaHolter146/1321 (11%)0.230Bolourchi, M (2015); and Pradhan, S (2019)Palpitations, syncope, or unspecified tachycardiaZio229/2285 (10%)< 0.001 Open table in a new tab

Catheter ablation as first-line treatment for paroxysmal atrial fibrillation: a systematic review and meta-analysis

ObjectiveTo assess the efficacy and safety of catheter ablation (CA) compared with antiarrhythmic drugs (AADs) as first-line treatment for symptomatic paroxysmal atrial fibrillation (AF).MethodsSystematic review and meta-analysis of randomised controlled...

Role of Imaging in the Diagnosis of Arrhythmogenic Right Ventricular Cardiomyopathy in Presence of Congenital Heart Disease

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an underdiagnosed entity manifesting with arrhythmia, heart failure and sometimes with sudden cardiac death. Rarely, congenital heart disease (CHD) can co-exist with ARVC which creates a diagnostic challenge. The presence of ARVC in a known case of CHD changes the management plan. We describe three patients with CHD having additional features of ARVC based on proposed criteria in the last 5 years in our institution. The mean age of the patients was 43 years. Two patients had atrial septal defect and one had Ebsteins's anomaly. Cardiac magnetic resonance imaging was done in two patients which showed characteristic features of ARVC and fulfilled the criteria of diagnosis. One patient was labeled as probable ARVC. Medical therapy helped the patients with symptoms of arrhythmia and heart failure. On short-term follow-up, they were doing well. Diagnosis of ARVC in a known case of CHD requires a high index of suspicion. The proposed imaging criteria and holistic approach may help with early diagnosis and appropriate management.

Kardia Mobile applicability in clinical practice: A comparison of Kardia Mobile and standard 12-lead electrocardiogram records in 100 consecutive patients of a tertiary cardiovascular care center.

Mobile devices are gaining a rising number of users in all countries around the globe. Novel solutions to diagnose patients with out-of-hospital onset of arrhythmic symptoms can be easily used to record such events, but the effectiveness of these devices remain unknown. In a group of 100 consecutive patients of an academic cardiology care center (mean age 68 ± 14.2 years, males: 66%) a standard 12-lead electrocardiogram (ECG) and a Kardia Mobile (KM) record were registered. Both versions were assessed by three independant groups of physicians. The analysis of comparisons for standard ECG and KM records showed that the latter is of lower quality (p < 0.001). It was non-inferior for detection of atrial fibrillation and atrial flutter, showed weaker rhythm detection in pacemaker stimulation (p = 0.008), and was superior in sinus rhythm detection (p = 0.02), though. The sensitivity of KM to detect pathological Q-wave was low compared to specificity (20.6% vs. 93.7%, respectively, p < 0.001). Basic intervals measured by the KM device, namely PQ, RR, and QT were significantly different (shorter) than those observed in the standard ECG method (160 ms vs. 180 ms [p < 0.001], 853 ms vs. 880 ms [p = 0.03] and 393 ms vs. 400 ms [p < 0.001], respectively). Initial and indicative value of atrial fibrillation and atrial flutter detection in KM is comparable to results achieved in standard ECG. KM was superior in detection of sinus rhythm than eye-ball evaluation of 12-lead ECG. Though, the PQ and QT intervals were shorter in KM as compared to 12-lead ECG. Clinical value needs to be verified in large studies, though.