Search

BACKGROUND: The development of left ventricular systolic dysfunction (LVSD) in hypertrophic cardiomyopathy (HCM) is rare but serious and associated with poor outcomes in adults. Little is known about the prevalence, predictors, and prognosis of LVSD in patients diagnosed with HCM as children. METHODS: Data from patients with HCM in the international, multicenter SHaRe Registry (Sarcomeric Human Cardiomyopathy) were analyzed. LVSD was defined as left ventricular ejection fraction RESULTS: We studied 1010 patients diagnosed with HCM during childhood ( CONCLUSIONS: Patients with childhood-diagnosed HCM have a significantly higher lifetime risk of developing LVSD, and LVSD emerges earlier than for patients with adult-diagnosed HCM. Regardless of age at diagnosis with HCM or LVSD, the prognosis with LVSD is poor, warranting careful surveillance for LVSD, especially as children with HCM transition to adult care.

Supplemental Digital Content is available in the text., Background: Cardiac involvement among hospitalized patients with severe coronavirus disease 2019 (COVID-19) is common and associated with adverse outcomes. This study aimed to determine the prevalence and clinical implications of COVID-19 cardiac involvement in young competitive athletes. Methods: In this prospective, multicenter, observational cohort study with data from 42 colleges and universities, we assessed the prevalence, clinical characteristics, and outcomes of COVID-19 cardiac involvement among collegiate athletes in the United States. Data were collected from September 1, 2020, to December 31, 2020. The primary outcome was the prevalence of definite, probable, or possible COVID-19 cardiac involvement based on imaging definitions adapted from the Updated Lake Louise Imaging Criteria. Secondary outcomes included the diagnostic yield of cardiac testing, predictors for cardiac involvement, and adverse cardiovascular events or hospitalizations. Results: Among 19 378 athletes tested for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, 3018 (mean age, 20 years [SD, 1 year]; 32% female) tested positive and underwent cardiac evaluation. A total of 2820 athletes underwent at least 1 element of cardiac triad testing (12-lead ECG, troponin, transthoracic echocardiography) followed by cardiac magnetic resonance imaging (CMR) if clinically indicated. In contrast, primary screening CMR was performed in 198 athletes. Abnormal findings suggestive of SARS-CoV-2 cardiac involvement were detected by ECG (21 of 2999 [0.7%]), cardiac troponin (24 of 2719 [0.9%]), and transthoracic echocardiography (24 of 2556 [0.9%]). Definite, probable, or possible SARS-CoV-2 cardiac involvement was identified in 21 of 3018 (0.7%) athletes, including 15 of 2820 (0.5%) who underwent clinically indicated CMR (n=119) and 6 of 198 (3.0%) who underwent primary screening CMR. Accordingly, the diagnostic yield of CMR for SARS-CoV-2 cardiac involvement was 4.2 times higher for a clinically indicated CMR (15 of 119 [12.6%]) versus a primary screening CMR (6 of 198 [3.0%]). After adjustment for race and sex, predictors of SARS-CoV-2 cardiac involvement included cardiopulmonary symptoms (odds ratio, 3.1 [95% CI, 1.2, 7.7]) or at least 1 abnormal triad test result (odds ratio, 37.4 [95% CI, 13.3, 105.3]). Five (0.2%) athletes required hospitalization for noncardiac complications of COVID-19. During clinical surveillance (median follow-up, 113 days [interquartile range=90 146]), there was 1 (0.03%) adverse cardiac event, likely unrelated to SARS-CoV-2 infection. Conclusions: SARS-CoV-2 infection among young competitive athletes is associated with a low prevalence of cardiac involvement and a low risk of clinical events in short-term follow-up.

Introduction: Safety of vigorous exercise for individuals with appropriately-treated HCM remains debated. Physical activity practices in this population have not been described. The objective of this report is to describe physical activity pattern in HCM patients. Long term follow up which is ongoing will determine safety of vigorous exercise. Methods: The NIH-funded LIVE-HCM study prospectively enrolled individuals age 8-60 years with clinically overt HCM or patients with a positive genetic test for sarcomeric HCM. Participants (or parents, for children) answered surveys describing activity patterns. Vigorous exercise was defined as > 6 METS for > 60 hours per year. Clinical and demographic data were derived from medical record review. Results: Among 1798 participants, 745 (41%) reported exercising vigorously, including 296 competitive athletes, with 59 at high-school or college varsity level, 770 (43%) were exercising at moderate, and 283 (16%) at low levels. Of those working, 6% described jobs more active than walking, including 16 in protective services, and 11 in sports/coaching. Clinical/demographic data including imaging characteristics and treatments, are shown in Table, and were mostly similar amongst the exercise-groups. Conclusions: Many patients with HCM are engaged in vigorous exercise including competitive athletics. Prospective follow-up of this cohort is ongoing. Comparison of arrhythmic outcomes outcomes in vigorous exercisers vs moderate/low level exercisers will help determine the safety of exercise in HCM patients.

Introduction: The safety of vigorous exercise for individuals with appropriately-treated LQTS remains unproven, and physical activity practices in this population have not been described. Methods: LIVE-LQTS prospectively enrolled individuals age 8-60 years with overt LQTS or gene mutation carriers. Participants (or parents, for children) answered surveys describing activity patterns. Vigorous exercise was defined as > 6 METS for > 60 hours per year. Clinical and demographic data were derived from medical record review. Results: Among 1554 participants, 804 (52%) reported exercising vigorously, 473 of these competitively, 577 (37%) exercising at moderate, and 173 (11%) at low levels. Seven percent of those working describe jobs more active than walking, including 10 in protective services and 19 in sports/coaching. Over 90% are genotype positive, 57% are phenotype positive at rest and an additional 16% have exercise-induced QT prolongation. Forty four percent have had documented ventricular arrhythmias or syncope. Eighty-four percent are appropriately treated with either beta-blockers, ICD, and/or sympathectomy, although among beta-blocked patients, only 60% are on the most effective agents. Among adults, BMI was significantly lower among the vigorous exercisers. Conclusion: While the high percentage of vigorous exercisers seen in this study may not represent all patients with LQTS due to self-selection for study participation, many patients with LQTS are engaged in vigorous exercise or competitive athletics. Prospective follow up of this cohort is ongoing and will determine safety of vigorous exercise through comparison of arrhythmic outcomes in vigorous exercisers vs moderate/low level exercisers.

More than 8 million young men and women participate in competitive high school or collegiate sports in the United States annually. For the vast majority of these young men and women, sport participation plays an invaluable role in promoting healthy physical, emotional, and cognitive development. In rare cases, however, seemingly healthy athletes with occult cardiovascular disease (CVD) die suddenly during sport participation. Strategies to reduce these highly visible tragedies, including preparticipation screening and medical oversight of training and competition, are well established and can lead to the identification of athletes with undiagnosed CVD. For the competitive athlete diagnosed with CVD, determination of future athletic eligibility is a critical step in a care continuum that begins with diagnosis and continues through long-term treatment. Fundamentally, eligibility determination is a quest to reduce the risk of future sudden death while simultaneously avoiding unnecessary sport restriction. This process may be challenging for the patient and family, clinicians, and schools or sporting organizations. Accordingly, the American College of Cardiology (ACC), the American Heart Association (AHA), and the Heart Rhythm Society (HRS) provide eligibility recommendations for competitive athletes with established CVD. Until recently, the 2005 update of the 36th Bethesda Conference statement, an encyclopedic compendium of CVD diagnoses with binary yes-or-no eligibility recommendations for each diagnosis, served as the standard of care.1 This binary approach to eligibility inherently facilitated paternalistic decision making, in which doctors, schools, and athletic organizations were encouraged/expected to permit or restrict sport participation with little or no input …

Background—The risks of sports participation for implantable cardioverter-defibrillator (ICD) patients are unknown. Methods and Results—Athletes with ICDs (age, 10–60 years) participating in organized (n=328) or high-risk (n=44) sports were recruited. Sports-related and clinical data were obtained by phone interview and medical records. Follow-up occurred every 6 months. ICD shock data and clinical outcomes were adjudicated by 2 electrophysiologists. Median age was 33 years (89 subjects

Introduction: The death of young athletes is devastating to families and communities. Despite routine pre-participation screening, 80–100/yr die or suffer cardiac arrest, with 65% occurring in high school athletes. AHA/ACC recommendations for pre-participation screening do not include routine electrocardiogram (ECG), in contrast to some international guidelines. Methods: We designed a pilot study to test feasibility of a larger trial, scaled to 1% of the estimated 800,000 participants required to power for detection of sudden death/arrest. Athletes and band members enrolled in eight high schools in two Texas school districts were randomized in block fashion to standard screening alone versus the addition of ECG. ECGs were interpreted using CardeaScreen software, over-read by an independent expert. Students with abnormal ECGs received cardiology evaluation at no cost. Text messages assessing for cardiac events or hospitalizations were sent to both groups biannually. Results: Of the ~8,000 eligible students, the intervention group enrolled 847 students who received ECG (21%); the non-intervention group enrolled 655 students (16%). CardeaScreen identified 20 of 847 ECGs as abnormal (2.4%) and the expert identified 19 as abnormal (2.2%) Six of 20 ECGs (30%) identified as abnormal by CardeaScreen were over-read as normal, and 5 of 827 ECGs (0.6%) identified as normal by CardeaScreen were over-read as abnormal (PPV 70%, NPV 99.4%). Twenty-five follow up visits were attempted, 22 were completed (88%), and specialist referrals were sent for 6 (29%). New diagnoses included Wolf-Parkinson-White syndrome, coronary anomaly, and depressed LV function. Follow up with SMS surveys yielded 737 responses at 6 months and 441 responses at 16 months. No sudden cardiac death or arrest was reported. Conclusion: Randomized ECG testing and follow-up of high school students is feasible, though with low enrollment and relatively low yield. Automated ECG interpretation is viable but leads to significant false + results. Low participation in enrollment and follow up present challenges to a large-scale ECG screening study powered for clinical events. Possible solutions include an “opt-out” enrollment strategy and use of alternate follow up methods such as social media.

We appreciate the interest of Dr d’Aloja and colleagues in our recent Perspective delineating the role of shared decision making in the care of athletes with cardiovascular disease.1 We concur with their assertion that decision making for competitive sport participation among athletes with heart disease is indeed a “troublesome issue.” This trouble stems in large part from the historical dominance of paternalistic decision making in the absence of adequate science to justify a 1-sided, clinician-dominated approach to health and longevity. d’Aloja and colleagues raise concerns about our call to engage key individuals other than the patient in the shared decision-making process. They cite …

Introduction: Mental Stress-Induced Myocardial Ischemia (MSIMI) can occur in patients with coronary artery disease (CAD) during acute mental stress challenge and is associated with an increased risk of adverse cardiovascular events. Adverse dynamic changes in repolarization with stress may also be particularly important when assessing risk of MSIMI. Hypothesis: In subjects with CAD, dynamic ECG repolarization changes during stress and recovery are associated with MSIMI. Methods: We studied 419 individuals with CAD who underwent mental stress challenge via a standardized speech stressor. Digital 12-lead ECGs were collected at baseline during resting , 1 minute after speech started, immediately after speech, and during recovery (5 minutes after speech ended). Repolarization metrics, including QRS-T angle, T-axis, ST depression, and T wave area were quantified in all 12 leads. Heart rate was also included. Subjects with baseline artifact were excluded. Changes amongst baseline, stress, and recovery were analyzed. Forward selection with alpha=0.01 was used to help guide the final model. MSIMI was assessed via Tc99m myocardial perfusion imaging (read by experienced clinicians). Results: The mean (SD) age was 56 (10), 38% were women, and 17% had MSIMI. The most significant predictors of MSIMI, based on the multivariate model, are summarized in the table. The C-statistic was 0.73, but reduced to 0.71 after leave-one-out cross validation. Goodness of fit was adequate. No significant race or gender differences were noted. Conclusion: Baseline and dynamic ECG repolarization changes in recovery (but not peak stress) contribute to MSIMI classification, and may be useful for risk stratification of arrhythmia risk due to emotional triggers. While the mechanisms regarding the relationship of MSIMI and ECG metrics during recovery are unknown, they could be due to hysteresis phenomena and/or known autonomic changes during recovery from stress.

Background and Purpose: This scientific statement provides an interprofessional, comprehensive review of evidence and recommendations for indications, duration, and implementation of continuous electro cardiographic monitoring of hospitalized patients. Since the original practice standards were published in 2004, new issues have emerged that need to be addressed: overuse of arrhythmia monitoring among a variety of patient populations, appropriate use of ischemia and QT-interval monitoring among select populations, alarm management, and documentation in electronic health records. Methods: Authors were commissioned by the American Heart Association and included experts from general cardiology, electrophysiology (adult and pediatric), and interventional cardiology, as well as a hospitalist and experts in alarm management. Strict adherence to the American Heart Association conflict of interest policy was maintained throughout the consensus process. Authors were assigned topics relevant to their areas of expertise, reviewed the literature with an emphasis on publications since the prior practice standards, and drafted recommendations on indications and duration for electrocardiographic monitoring in accordance with the American Heart Association Level of Evidence grading algorithm that was in place at the time of commissioning. Results: The comprehensive document is grouped into 5 sections: (1) Overview of Arrhythmia, Ischemia, and QTc Monitoring; (2) Recommendations for Indication and Duration of Electrocardiographic Monitoring presented by patient population; (3) Organizational Aspects: Alarm Management, Education of Staff, and Documentation; (4) Implementation of Practice Standards; and (5) Call for Research. Conclusions: Many of the recommendations are based on limited data, so authors conclude with specific questions for further research.

Implantable cardioverter defibrillators (ICDs) save lives in patients at risk for sudden death attributable to ventricular arrhythmias, pacemakers (PMs) have been improving symptoms in patients with bradyarrhythmias for decades, and, more recently, cardiac resynchronization devices have improved mortality, morbidity, and quality of life for patients with heart failure.1 However, these devices can also be life-changing for the patients receiving them. The need for long-term follow-up, concerns regarding malfunction, and lifestyle restrictions all affect patients with any implanted device. For patients with ICDs, receiving shocks, both appropriate and inappropriate, can impact quality of life (QOL). Lead or device malfunction can result in unnecessary shocks, and recalls can cause anxiety. Shocks at the end of life can be particularly devastating. However, with careful attention by the healthcare team, both shocks and their impact can be reduced. In addition to shocks, restrictions imposed by the ICD can also impact QOL. The possibility of syncopal arrhythmias and loss of control attributable to shocks, as well, has led to concerns regarding the safety of driving and of sports participation for some individuals, a further burden. Remote monitoring increases the ease of follow-up for patients and physicians and may improve timeliness of management. However, a consequence of remote follow-up has been a decrease in the amount of time electrophysiologists may spend face-to-face with patients, emphasizing the importance of communication between electrophysiologist and primary cardiologist. This article will review ways in which electrophysiologists, general cardiologists, and patients can work together to minimize the burdens that can accompany these devices, often weighing issues of patient QOL, safety, and autonomy. Studies of overall QOL for patients with ICDs have shown mixed results. Some studies have found no significant differences in overall QOL between ICD patients and other cardiac patients,2,3 PM patients, or the general population. …

Background— Data are scarce on outcomes of pacemaker implantation in nonagenarians (age≥90 years). Methods and Results— We identified patients >70 years of age (n=115 683) who underwent initial pacemaker implantation in the 2004 to 2008 Healthcare Cost and Utilization Project–Nationwide Inpatient Sample. Outcomes included in-hospital mortality, complications, length of stay, and charges. Unadjusted outcomes were compared using χ 2 and Mantel-Haenszel tests. Multivariate hierarchical logistic models and stepwise linear regression models adjusted for case-mix variation and clustering. Eleven percent (12 917) were >90 years of age. Relative to patients aged 70 to 79 years, patients >90 years of age were more likely to have moderate/severe comorbidity (Charlson score >1; 43.2% versus 40.1%) and less likely to be admitted electively (17.5% versus 29.9%), all P 90 years were 1.87% (CI, 1.63–2.11%) and 6.31% (CI, 5.89–6.72%). Length of stay and charges in patients aged 70 to 79 years were 3.22 days (CI, 3.20–3.24 days) and $38 871 (CI, $38 700–$39 043), and in patients aged >90 years, 4.27 days (CI, 4.25–4.30 days) and $41 373 (CI, $41 190–$41 556). Multivariable analysis revealed severe comorbidity (odds ratio, 5.00; 95% CI, 4.05–6.17) was a greater predictor of mortality than increasing age (odds ratio, 2.81 per decade; CI, 2.35–3.35), all P 5) was more strongly associated with complications, length of stay, and charges than age. Conclusions— Although increasing age predicts worsening outcomes in the elderly, the absolute rates are modest, even in nonagenarians, and comorbidity is a stronger predictor.

BACKGROUND: Veterans with post-traumatic stress disorder (PTSD) have higher risk of coronary heart disease (CHD) incidence and mortality. Psychological conditions may have an adverse effect on the autonomic nervous system, and may in part have genetic origins. Novel non-linear measures of heart rate variability (HRV), such as fractal dimension (FD) and power law slope have been associated with mortality and may signify autonomic dysfunction. We hypothesized that PTSD is associated with reduced FD and increased power law slope, suggesting higher mortality risk. METHODS: FD and power law slope were measured from 24-hour Holter recordings in 416 predominantly healthy middle-aged male twins from the Vietnam Era Twin Registry. Current (symptoms within the past month) and remitted (past history of) PTSD were measured using the Structured Clinical Interview for Psychiatry Disorders. Mixed-effect regression models were used to adjust for twin clustering and account for genetic/familial influences. RESULTS: The mean age was 56 ± 3 years, 35 had current PTSD, and 46 had remitted PTSD. In models that analyzed twins as individuals, current PTSD was significantly associated with 22% reduced FD and 18% increased power law slope. This association persisted for power law slope after adjustment for traditional risk factors, lifestyle factors, depression, and anti-depressant medication use (table). After controlling for genetic/familial factors by comparing twin brothers discordant for current PTSD within pairs (20 pairs), both measures remained significantly associated with current PTSD. Remitted PTSD did not influence HRV measures. No interaction by zygosity was found. CONCLUSIONS: Vietnam era veterans with PTSD have reduced FD and increased power law slope persisting after multivariable adjustment. This suggests that autonomic mechanisms, independent of genetic and familial effects, may contribute to increased CHD and mortality in veterans with PTSD.

Approximately 2.6 million troops have served or are serving overseas as part of Operation Iraqi Freedom/Operation New Dawn in Iraq and Operation Enduring Freedom in Afghanistan, as of September 2013.1 There have been 6664 casualties and 51 904 wounded as of February 2014.2 Although definitions of combat experience vary, 30% of veterans with service in Afghanistan and 71% to 86% of those serving in Iraq have participated in a firefight.3 The rising mental health problems of returning veterans are well documented,4 with ≤20% of returning veterans meeting diagnostic criteria for posttraumatic stress disorder (PTSD)5 and up to 17% meeting criteria for any psychological disorder (depression, anxiety, or PTSD).3 These mental health problems stem directly from combat, with a dose-response relationship–the more firefights the soldiers had experienced, the higher the rate of PTSD and depression.3 Article see p 1813 However, evidence is emerging for a role of combat in exerting not just a psychological but also a physiologic toll. Previous studies of the long-term physical consequences of combat have shown mixed results. In one prospective longitudinal study enrolling veterans shortly after World War II, those who had experienced combat were more likely to die or report physical decline over a 15-year period.6 In the Atherosclerotic Risk in Communities study, however, no increase in coronary heart disease (CHD) was seen in combat-exposed veterans compared with those who had not seen combat or who …

Large randomized trials have demonstrated unequivocally that implantable cardioverter defibrillators (ICDs) improve outcome for individuals with defined clinical characteristics known to be associated with a high risk of ventricular arrhythmias. However, less is known about outcomes of patients receiving ICDs in the “real world.” The National Cardiovascular Data Registry provides extensive and detailed clinical information about patients receiving ICDs at the time of implant, but does not include longitudinal data on mortality or shocks except in a small subset.1 Industry databases of ICD patients undergoing remote (transtelephonic) monitoring, which provide extensive information on therapies received, thus present a unique opportunity to fill this gap in knowledge. Article see p 2359 In this issue of Circulation , Saxon et al2 describe data on 69 556 patients followed remotely (in addition to in-office) and 124 450 patients followed in-office alone, which was generated by the Altitude project, a prospectively designed database generated by a single ICD manufacturer to store data regarding patients receiving its devices. Survival data are obtained through cross-referencing with the Social Security death index, and data on treated arrhythmias are obtained from the transtelephonic transmissions. The authors use this database to answer four distinct questions: (1) whether remote monitoring impacts survival; (2) whether shocks are associated with mortality; (3) how survival compares among patients receiving ICDs, ICDs with cardiac resynchronization (CRT) capability (CRT-D), and CRT devices without defibrillation capability; and (4) how survival of “real-world” patients compares with that of patients enrolled in trials. The study is limited by lack of detailed information about the patients' …

Implantable cardioverter-defibrillators (ICDs) are well documented to save lives in many patient groups for primary and secondary prevention; however, although the ICD is highly effective at preventing sudden death, everyone will die eventually, whether of underlying heart disease or other terminal illness such as malignancy. As the population of patients living with ICDs expanded, case reports began appearing in the palliative care literature such as, “Death and defibrillation: a shocking experience”1 and “And it can go on and on and on.”2 ICD shocks are painful, described by patients as “a punch in the chest,” “being kicked by a mule,” and “putting a finger in a light socket,”3 and it is not surprising that receiving shocks at the end of life would be a distressing experience for the dying patient as well as his or her family. How often this actually happened was first described by our group in 2004. Interviewing family members of deceased patients from our practice, we found that 20% were reported to have received shocks in the last weeks, days, or hours of their lives.4 More recently, Sherazi et al5 reviewed charts of 98 patients receiving ICDs in the Multicenter Automatic Defibrillator Implantation Trial II (MADIT-2) who later died, finding that only 15% had had their ICDs deactivated, many after receiving shocks in the last week of life. The true frequency of ICD shocks in dying patients, however, was likely underestimated by both of these studies, because neither family nor healthcare providers may have been aware of all shocks received, and in many cases, the only individuals who could have provided the accurate answer may have carried it with them to the grave. Article see p 422 The study by Kinch Westerdahl et al6 in this issue of Circulation provides a …

Background— The ICD Registry was established in 2006 in part to measure quality of care in patients undergoing implantation of implantable cardioverter-defibrillators (ICDs); however, whether outcomes have improved since initiation of the registry is unknown. Our objective was to examine changes over time in 3 quality metrics available from the registry. Methods and Results— We performed an observational study of 367 153 patients who received new ICD implants from April 2006 to March 2010. Three quality metrics were selected: Adverse events (in-hospital complications or mortality), optimal medical therapy (OMT), and cardiac resynchronization therapy (CRT). OMT was defined as prescription of β-blocker and either angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in eligible patients. CRT eligibility was determined by QRS ≥120 ms, left ventricular ejection fraction ≤35%, and New York Heart Association class III/IV. Observation periods were divided into four 12-month intervals. We analyzed changes over time and used hierarchical logistic regression to adjust for potential confounders. Adverse events decreased over time (3.7% to 2.8%, P P P Conclusions— Since initiation of the ICD Registry, adverse events have been decreasing, and rates of OMT and CRT among eligible patients have been increasing, although there is still significant room for improvement.

Background— The risks of sports participation for implantable cardioverter-defibrillator (ICD) patients are unknown. Methods and Results— Athletes with ICDs (age, 10–60 years) participating in organized (n=328) or high-risk (n=44) sports were recruited. Sports-related and clinical data were obtained by phone interview and medical records. Follow-up occurred every 6 months. ICD shock data and clinical outcomes were adjudicated by 2 electrophysiologists. Median age was 33 years (89 subjects Conclusions— Many athletes with ICDs can engage in vigorous and competitive sports without physical injury or failure to terminate the arrhythmia despite the occurrence of both inappropriate and appropriate shocks. These data provide a basis for more informed physician and patient decision making in terms of sports participation for athletes with ICDs.

Background: The AHA/ACC released guidelines in 2006 recommending the use of ICDs in patients with EF less than 35%, congestive heart failure and/or myocardial infarction. Several studies have suggested that ICDs for primary prevention are underutilized. We sought to determine if use of a screening tool would increase adherence to guidelines. Methods: Data were collected prospectively at the Yale Cardiology Group office during September and October 2007 (screening period). All patients’ charts were flagged with a screening tool that asked if the EF was less than 35%; if they were referred to an electrophysiologist (EP) and if not, why not. Clinical and demographic data were collected by chart review to determine appropriateness of referral. Control data were obtained through retrospective review of charts corresponding to all patient visits during March and April 2007 (control period). Results: As shown in the table , the screening tool increased appropriate referral, from 39% of appropriate patients in the control group, to 72% during the screening period (p=0.06). More patients had been evaluated by an EP prior to the visit in the screening period (71%) than in the control period (47%). Approximately 2/3 of patients offered referral declined in both time periods. Conclusions: In this study, the first to investigate if a screening tool in the outpatient setting would increase the rate of appropriate patient referral for ICD as recommended by current ACC/AHA guidelines, utilization of a screening tool showed a trend toward increased physician adherence to guidelines. Surprisingly, over half of patients offered EP referral for ICD declined. Patient education regarding the benefits of ICDs may also increase appropriate use of this life-saving device.

Small case-series suggest the possibility of “adrenergically-mediated” atrial fibrillation (AF) in humans, and pharmacological autonomic manipulations can alter atrial electrophysiology. Whether AF can be triggered by emotional arousal is unknown. In this prospective, controlled, electronic-diary-based study of emotions preceding AF, patients with a history of paroxysmal or persistent AF, (N=75, mean age 58 years, 60% male, 60% taking beta-blocking medications) recorded their rhythm on event-monitor at the time of AF symptoms, and completed a diary entry querying mood states for the preceding 30 minutes (pre-AF “case period”) over a one-year follow-up. Also, patients underwent monthly 24-hour holter-monitoring, and were prompted by the diary to complete an entry twice per hour. Diaries recorded during sinus comprise the controls. Further, patients completed a diary each night. Patients’ exposure to each emotion was compared between the pre-AF case period and control periods using GEE modeling. Similarly, emotion on a nightly diary preceding AF on the following day was compared to that emotion on other nightly diaries. 119 AF episodes, (in 23 subjects), and 5796 holter-confirmed sinus rhythm control-periods had associated diary data. 95 pre-AF nightly diaries and 9306 control nightly diaries were completed. The likelihood of an AF episode was increased by negative emotions and decreased by happiness whether reported immediately preceding an AF episode, or the night before (table ). Impact of emotion was gender-specific: anger increased the odds of subsequent AF for men, worry for women. In stratified analysis, emotion triggered AF only in those not taking beta-blockers (data not shown). Negative emotions can trigger AF, while happiness is protective. Whether interventions aimed at reducing the physiological effects of emotional stress may lessen AF burden requires further study.

Current guidelines recommend cardiac resynchronization therapy (CRT-D) in appropriate patients undergoing ICD implantation. However, not all physicians who implant ICDs are trained to perform CRT-D. We examined the ICD Registry to assess whether use of CRT-D implantation varied by physician certification. We determined the certification of 2128 physicians who had submitted >=10 cases between April 2006 and June 2007. We excluded patients with a prior ICD, an epicardial lead, or aged ≤18 years, leaving 111,293 patients. Physicians were grouped into mutually exclusive categories reflecting highest current certification- Electrophysiology (EP), Cardiovascular Disease (CVD), Thoracic Surgery (TS), Internal Medicine (IM), Heart Rhythm Society alternative pathway (HRS), and Other. Patients were considered eligible for CRT-D if they met the following criteria: QRS duration >=120ms, LVEF ≪26>35%, and NYHA Class III-IV. We examined crude rates of CRT-D across physician categories and developed a logistic regression model to assess the association of physician certification and CRT-D implantation. Candidate variables included demographics, cardiac status, comorbidities, and physician volume. Odds ratios were converted to relative risks. 35,851 patients met all three eligibility criteria for CRT-D, and 28,932 (80.7%) had a CRT-D implanted. EP physicians implanted the majority of CRT-D (73.6%), with fewer CRT-D placed by CVD (20.6%), TS (0.9%), IM (0.8%), HRS (1.1%), or Other (3.1%). The crude rate of CRT-D implantation was highest among EP physicians and lower in all other categories: EP- 83.1%, CVD-75.8%, TS- 57.9%, IM- 76.5%, HRS- 77.1%, Other- 73.5% (p

Background— Observational studies have suggested that psychological stress increases the incidence of sudden cardiac death. Whether emotional or physical stressors can trigger spontaneous ventricular arrhythmias in patients at risk has not been systematically evaluated. Methods and Results— Patients with implantable cardioverter-defibrillators (ICDs) were given diaries to record levels of defined mood states and physical activity, using a 5-point intensity scale, during 2 periods preceding spontaneously occurring ICD shocks (0 to 15 minutes and 15 minutes to 2 hours) and during control periods 1 week later. ICD-stored electrograms confirmed the rhythm at the time of shock. A total of 107 confirmed ventricular arrhythmias requiring shock were reported by 42 patients (33 men; mean age, 65 years; 78% had coronary artery disease) between August 1996 and September 1999. In the 15 minutes preceding shock, an anger level ≥3 preceded 15% of events compared with 3% of control periods ( P Conclusions— Anger and physical activity can trigger ventricular arrhythmias in patients with ICDs. Future investigations of therapies aimed at blocking a response to these stressors may decrease ventricular arrhythmias and shocks in these patients.

Background —The incidence of sudden cardiac death increases in populations who experience disasters such as earthquakes. The physiological link between psychological stress and sudden death is unknown; one mechanism may be the direct effects of sympathetic arousal on arrhythmias. To determine whether mental stress alters the induction, rate, or termination of ventricular arrhythmias, we performed noninvasive programmed stimulation (NIPS) in patients with defibrillators and ventricular tachycardia (VT), which is known to be inducible and terminated by antitachycardia pacing, at rest and during varying states of mental arousal. Methods and Results —Eighteen patients underwent NIPS in the resting-awake state (nonsedated). Ten underwent repeat testing during mental stress (mental arithmetic and anger recall). Induced VT was faster in 5 patients ( P =0.03). VT became more difficult to terminate in 5 patients during mental stress; 4 required a shock ( P =0.03). There was no change in ease of induction with mental stress. There was no evidence of ischemia on ECG or continuous ejection fraction monitoring. Eight patients received a shock in the resting-awake state and did not perform mental stress. Four underwent repeat NIPS after sedation; 3 then had induced VT terminated with antitachycardia pacing. All patients with an increase in norepinephrine of >50% had alterations in VT that required shock for termination ( P Conclusions —Mental stress alters VT cycle length and termination without evidence of ischemia. This suggests that mental stress may lead to sudden death through the facilitation of lethal ventricular arrhythmias.

BACKGROUND While previous studies using epidemiological data and ambulatory ECG monitoring have shown peak occurrence of sudden death and nonsustained ventricular tachycardia in the morning, none have examined circadian variation of potentially life-threatening ventricular tachycardia (VT), nor has any study observed circadian behavior of any arrhythmias in individuals followed longitudinally. We used the event memory of multiprogrammable implantable cardioverter-defibrillators to evaluate the circadian pattern of sustained VT over time. METHODS AND RESULTS Data were reviewed from 32 consecutive patients with coronary artery disease and sustained VT who had received the Ventak PRX (CPI, Inc) cardioverter-defibrillator between May 1991 and August 1993 and had experienced at least one episode of VT terminated by their device. Mean follow-up was 14 +/- 7 months. Among the 2558 episodes recorded by the device logs, VT occurrence peaked between 6 AM and noon (P = .007 by ANOVA among four 6-hour time periods). Harmonic regression revealed a morning peak at 9 AM (P < .01). This morning peak occurred in patients with both frequent and infrequent events. Among 21 patients who experienced more than four VT events, 8 (38%) had an AM peak of VT occurrence (> 35% of VT between 6 AM and noon). Neither age, ejection fraction, event frequency, presenting arrhythmia, nor drug therapy distinguished patients who displayed the AM VT peak. CONCLUSIONS In patients with coronary artery disease, sustained VT displays circadian variation with peak frequency in the morning, similar to that for sudden death. Individual patients who display specific patterns of circadian variation over time can be identified using defibrillator logs. Investigation of circadian variation of other phenomena to elucidate mechanisms of VT should focus on these patients.