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Introduction: Carotid sinus syndrome (CSS), characterized by exaggerated vagal responses leading to asystolic pauses with carotid sinus massage (CSM), often necessitates pacemaker implantation. This study investigates cardioneuroablation (CNA) as an alternative strategy for CSS., Methods: Prospective study of consecutive patients referred for CNA due to CSS. All patients underwent CSM, atropine test and 24-h Holter monitoring before the procedure and at 6 months. The primary objective was the absence of any cardioinhibitory response to CSM following CNA. Secondary objectives included the combined endpoint of syncope and presyncope-free survival, pacemaker-free survival, differences in heart rate variation (HRV), as well as differences in the pre- and postprocedure atropine tests and in the SF-36 quality-of-life questionnaire., Results: A total of 13 consecutive patients (84.6% male, mean age 63.8 ± 12.3 years) were included. CSM revealed a symptomatic asystolic pause in all patients before CNA (7.3 [5.6-10.5] s). After the procedure, all the patients had a negative CSM, and only one patient (7.7%) had a positive CSM at 6 months. After a median follow-up of 11.2 (10.6-16.3) months, syncope or presyncope-free survival was 84.6%, and none required pacemaker implantation. There was an improvement in the energy and health change items in the SF-36 questionnaire. There was a reduction in HR increase in the atropine test at 6 months (pre-CNA: 66% [52-84] vs. post-CNA 26.0% (19.8-29.3]; p = .008) and in HRV parameters., Conclusions: In this proof-of-efficacy study, performed in patients affected by asystolic CSS, CNA was effective in reducing the rate of cardioinhibitory responses, suggesting a potential efficacy in also reducing syncopal recurrences. Controlled trials are warranted to corroborate clinical findings., (© 2024 Wiley Periodicals LLC.)

Background/Objectives : Hyperkalemia is a common electrolyte disorder in patients with heart failure and reduced ejection fraction (HFrEF). Renin-angiotensin-aldosterone system inhibitors (RAASi) have been shown to improve survival and decrease hospitalization rates, although they may increase the serum potassium levels. Hyperkalemia has significant clinical and economic implications, and is associated with increased healthcare resource utilization. The objective of the study was to analyze the management of hyperkalemia and the associated medical costs in a cohort of patients with HFrEF. Methods : An observational, longitudinal, retrospective, single-center retrospective study was conducted in patients with HFrEF who started follow-up in a heart failure unit between 2010 and 2021. Results : The study population consisted of 1181 patients followed-up on for 64.6 ± 38.8 months. During follow-up, 11,059 control visits were conducted, documenting 438 episodes of hyperkalemia in 262 patients (22.2%). Of the hyperkalemia episodes, 3.0% required assistance in the Emergency Department, 1.4% required hospitalization, and only 0.2% required admission to the Intensive Care Unit. No episode required renal replacement therapy. Reduction or withdrawal of RAASi was necessary in 69.9% of the hyperkalemia episodes. The total cost of the 438 hyperkalemia episodes was €89,178.82; the expense during the first year accounted for 48.8% of the total cost. Conclusions : Hyperkalemia is frequent in patients with HFrEF. It is often accompanied by a modification of treatment with RAASi. Hyperkalemia generates substantial costs in terms of healthcare resources and medical care, especially during the first year.

Introduction and Objectives: We report the results of the 2023 Spanish catheter ablation registry., Methods: Procedural data were collected and incorporated into the REDCap platform by all participating centers through a specific form., Results: There were 104 participating centers in 2023 compared with 103 in 2022. In 2023, the total number of ablation procedures was 26 207, indicating a stabilization of the increase observed in 2022 following the pandemic. The increase was mainly due to procedures for atrial fibrillation (AF), with a total of 9942 ablations, representing 38% of all substrates. Notably, pulse-field ablation represented 10.3% of all AF ablation procedures, leading single-shot ablation strategies to outnumber point-by-point AF ablation for the first time in the history of the registry. Cavotricuspid isthmus ablation remained the second most targeted substrate (19% of all substrates, n=5067). The overall acute success rate remained high (97%), with a downward trend in the complication rate (1.6% vs 1.8% in 2022) and mortality rate (0.03%; n=7). Compared with 2022, there was a significant increase in procedures performed using electro-anatomical mapping and zero-fluoroscopy techniques for cavotricuspid isthmus ablation (52% vs 26%), AV node re-entrant tachycardia (48% vs 34%), and accessory pathways (62% vs 22%). We registered 466 ablations in pediatric patients., Conclusions: The data indicate a stabilization in the post-pandemic increase in ablation procedures, with an absolute and relative increase in AF as the predominant substrate. Success rates remained stable with a modest reduction in complication and mortality rates., (Copyright © 2024 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Cardioneuroablation (CNA) represents a promising therapy for recurrent vasovagal syncope (VVS), extrinsically driven atrioventricular block (AVB) and sinus node dysfunction (SND). However, effectiveness in patients aged 50 and above is not well-established. In this prospective study of patients referred for CNA, we compared syncope and pacemaker implantation free survival, heart rate (HR) variability (HRV) and quality of life between two age groups: group A (< 50 years) and B (≥ 50 years). A total of 50 patients were included (17 Group A and 33 Group B). The etiologies comprised VVS (56%), AVB (22%), and SND (22%). After a median follow-up of 17.0 (12.5-26.0) months, there were no differences of the combined endpoint of syncope or pacemaker implantation free-survival between groups (29.4.% vs. 21.2%; p-log-rank = 0.736). 84% of the entire cohort remained free from syncope, with a better but not significant syncope free survival in the older group (23.5% vs. 12.1%; p-log rank = 0.486). There were no differences in pacemaker implantation rate (A 5.9% vs. B 17.6%; p log-rank = 0.658). Notably, older patients had lower HR values post-procedure compared to younger patients (68.9 ± 13.3 vs. 80.4 ± 16.3 bpm; p = 0.012). Both groups exhibited a decrease in HRV parameters and an improvement in quality of life. In conclusion, CNA has comparable clinical benefits for patients aged 50 and above in terms of syncope or pacemaker implantation free survival and HRV reduction when compared to younger patients., Competing Interests: Declarations Competing interests The authors declare no competing interests., (© 2024. The Author(s).)

(1) Background: Hyperkalemia is a common finding in patients with heart failure and reduced ejection fraction (HFrEF), though its prognostic significance is controversial. There is no consensus on optimal potassium levels in these patients. The primary endpoint of this study was to determine the 5-year incidence of hyperkalemia in a cohort of patients with HFrEF. Secondary endpoints were to determine predictors of hyperkalemia and its impact on overall 5-year mortality; (2) Methods: retrospective, longitudinal, single-center observational study of patients with HFrEF followed-up in a specialized unit between 2011 and 2019. Hyperkalemia was considered as potassium concentration > 5.5 mEq/L; (3) Results: Hyperkalemia was observed in 170 (16.8%) of the 1013 patients. The 5-year hyperkalemia-free survival rate was 82.1%. Hyperkalemia was more frequent at the beginning of follow-up. Factors associated with hyperkalemia in the multivariate analysis were baseline potassium (HR 3.13, 95%CI 2.15-4.60; p < 0.001), creatinine clearance (HR 0.99, 95%CI 0.98-0.99; p = 0.013), right ventricular function (HR 0.95, 95%CI 0.91-0.99; p = 0.016) and diabetes mellitus (HR 1.40, 95%CI 1.01-1.96; p = 0.047). The overall survival rate at 5 years was 76.4%. Normal-high potassium levels (5-5.5 mEq/L) were inversely associated with mortality (HR 0.60, 95%CI 0.38-0.94; p = 0.025); (4) Conclusions: Hyperkalemia is a common finding in patients with HFrEF with an impact on the optimization of neurohormonal treatment. In our retrospective study, potassium levels in the normal-high range seem to be safe and are not associated with increased mortality.

Introduction and Objectives: Multiparametric scores have been designed for better risk stratification in Brugada syndrome (BrS). We aimed to validate 3 multiparametric approaches (the Delise score, Sieira score and the Shanghai BrS Score) in a cohort with Brugada syndrome and electrophysiological study (EPS)., Methods: We included patients diagnosed with BrS and previous EPS between 1998 and 2019 in 23 hospitals. C-statistic analysis and Cox proportional hazard regression models were used., Results: A total of 831 patients were included (mean age, 42.8±13.1; 623 [75%] men; 386 [46.5%] had a type 1 electrocardiogram (ECG) pattern, 677 [81.5%] were asymptomatic, and 319 [38.4%] had an implantable cardioverter-defibrillator). During a follow-up of 10.2±4.7 years, 47 (5.7%) experienced a cardiovascular event. In the global cohort, a type 1 ECG and syncope were predictive of arrhythmic events. All risk scores were significantly associated with events. The discriminatory abilities of the 3 scores were modest (particularly when these scores were evaluated in asymptomatic patients). Evaluation of the Delise and Sieira scores with different numbers of extra stimuli (1 or 2 vs 3) did not substantially improve the event prediction c-index., Conclusions: In BrS, classic risk factors such as ECG pattern and previous syncope predict arrhythmic events. The predictive capabilities of the EPS are affected by the number of extra stimuli required to induce ventricular arrhythmias. Scores combining clinical risk factors with EPS help to identify the populations at highest risk, although their predictive abilities remain modest in the general BrS population and in asymptomatic patients., (Copyright © 2021 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Objective: This study is aimed at investigating the changes in serum CypC levels and their relationship with cardiovascular events at 12 months of follow-up in coronary artery disease (CAD) patients., Methods: The study included a total of 125 subjects (40 patients with acute CAD, 40 patients with chronic CAD, and 45 control volunteers) and we analyzed plasma CypC levels from baseline to 6 and 12 months for a better understanding of its behavior in atherosclerosis., Results: Serum CypC levels were shown to be gradually increased in CAD patients (30.63 pg/mL ± 3.77 at baseline, 38.70 pg/mL ± 6.41 at 6 months [p = 0.25], and 47.27 pg/mL ± 5.65 at 12 months [p = 0.007]). In addition, serum CypC levels during the follow-up were a significant predictor of CAD (c-statistic 0.76 at 6 months and 0.89 at 12 months; p < 0.001). Despite it, there was no significant association between CypC and cardiovascular events, but serum CypC levels tended to be higher in patients suffering cardiovascular events during the follow-up (29.02 pg/mL ± 6.39 vs. 79.96 pg/mL ± 22.18; p = 0.029). In this regard, plasma levels of high-sensitivity C-reactive protein (hsCRP) > 2.3 mg/L plus NT-proBNP > 300 pg/mL together were significant predictors of cardiovascular events during the follow-up in CAD patients with CypC levels >17.5 pg/mL (p = 0.048)., Conclusions: Taken together, our results suggest that serum CypC levels increase during the follow-up in CAD patients and could be a novel biomarker with a possible prognostic value in combination with hsCRP and NT-proBNP.

To analyze the clinical profile and therapeutic strategy in atrial fibrillation (AF) according to gender in a contemporaneous patient cohort a prospective, multicenter observational study was performed on consecutive patients diagnosed with AF and assessed by cardiology units in the region of Galicia (Spain). A total of 1007 patients were included, of which 32.3% were women. The mean age of the women was significantly greater than that of the men (71.6 versus 65.7 years; p < 0.001), with a higher prevalence of hypertension (HTN) and valve disease. Women more often reported symptoms related to arrhythmia (28.2% in EHRA class I versus 36.4% in men), with a poorer level of symptoms (EHRA classes IIb and III). Thromboembolic risk was significantly higher among women (CHA 2 DS 2 -VASc 3 ± 1.3 versus 2 ± 1.5), in the same way as bleeding risk (HAS-BLED 0.83 ± 0.78 versus 0.64 ± 0.78) ( p < 0.001), and women more often received anticoagulation therapy (94.1% versus 87.6%; p = 0.001). Rhythm control strategies proved significantly less frequent in women (55.8% versus 66.6%; p = 0.001), with a lesser electrical cardioversion (ECV) rate (18.4% versus 27.3%; p = 0.002). Perceived health status was poorer in women. Women were older and presented greater comorbidity than men, with a greater thromboembolic and bleeding risk. Likewise, rhythm control strategies were less frequent than in men, despite the fact that women had poorer perceived quality of life and were more symptomatic.

Background: Syncope in a patient with a pacemaker is a serious event requiring urgent action to ascertain its cause. Around 5% of cases are due to a pacemaker system malfunction., Case Summary: An 82-year-old man underwent dual-chamber permanent pacemaker implantation due to intermittent high-degree atrioventricular block (AVB) in sinus rhythm. Nine months later, the patient reported episodes of syncope. The chest X-ray showed both leads to be at their expected positions. The electrocardiography (ECG) showed common atrial flutter. Ventricular capture during pacing in atrial demand pacing (AAI) mode confirmed cross-stimulation due to the switching of the atrial and ventricular leads at the pacemaker header., Discussion: Cross-stimulation is a rare possibility in a differential diagnosis of causes of syncope. The diagnosis is frequently made during the procedure or a few hours later. The lack of symptoms during 9 months in this case was likely due to the patient having normal sinus rhythm with preserved AV conduction most of the time, as well as ventricular capture from the atrial lead related to non-sensed P waves. When atrial arrhythmias occurred, the sensing of the F waves inhibited ventricular pacing. In order to avoid this complication, in patients with intermittent bradycardia, pacing at a slightly higher heart rate during implantation of the device should be recommended to see the chamber paced with the surface ECG connected to the device interrogator. The ECG and electrogram (EGM) should correlate during device interrogation in order to identify this complication.)., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.)