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Stroke remains one of the most serious complications in atrial fibrillation (AF) patients and has been linked to disturbances of the autonomic nervous system. The purpose of this study was to test the hypothesis that impaired cardiac autonomic function might be associated with an enhanced stroke risk in AF patients. A total of 1922 AF patients who were in either sinus rhythm (SR group; n = 1121) or AF (AF group; n = 801) on a 5-minute resting electrocardiographic (ECG) recording were enrolled in the study. Heart rate variability triangular index (HRVI), standard deviation of normal-to-normal intervals, root mean square root of successive differences of normal-to-normal intervals, mean heart rate, 5-minute total power, and power in the high-frequency, low-frequency, and very-low-frequency ranges were calculated. Cox regression models were constructed to examine the association of heart rate variability (HRV) parameters with the composite endpoint of stroke or systemic embolism. Mean age was 71 ± 8 years in the SR group and 75 ± 8 years in the AF group. Thirty-seven patients in the SR group (3.4%) and 60 patients in the AF group (8.0%) experienced a stroke or systemic embolism during follow-up of 5 years. In patients with SR, HRVI <15 was the strongest HRV parameter to be associated with stroke or systemic embolism (hazard ratio 3.04; 95% confidence interval 1.3–7.0; P =.009) after adjustment for multiple confounders. In the AF group, no HRV parameter was found to be associated with the composite endpoint. HRVI measured during SR on a single 5-minute ECG recording is independently associated with stroke or systemic embolism in AF patients. HRV analysis in SR may help to improve risk stratification in AF patients. [ABSTRACT FROM AUTHOR]

Atrial fibrillation (AF) and heart failure frequently coexist. Prediction of left ventricular ejection fraction (LVEF) recovery after catheter ablation (CA) for AF remains difficult. The purpose of this study was to evaluate the value of biomarkers, alone and in combination with the Antwerp score, to predict LVEF recovery after CA for AF. Patients undergoing CA for AF with depressed LVEF (<50%) were included. Plasma levels of 13 biomarkers were measured immediately before CA. Patients were categorized into "responders" and "nonresponders" in a similar fashion to the Antwerp score performance derivation and validation cohorts. The predictive power of the biomarkers alone and combined in outcome prediction was evaluated. A total of 208 patients with depressed LVEF were included (median age 63 years; 39–19% female; median indexed left atrial volume 42 (33–52) mL/m2; median LVEF 43 (38–46)%). At a median follow-up time of 30 (20–34) months, 161 (77%) were responders and 47 (23%) were nonresponders. Of 13 biomarkers, –4—angiopoietin 2 (ANG2), growth differentiation factor 15 (GDF15), fibroblast growth factor 23, and myosin binding protein C3—were significantly different between responders and nonresponders (P ≤.001) and their combination could predict the end point with an area under the curve of 0.72 (95% confidence interval [CI] 0.64–0.81) overall, 0.69 (95% CI 0.59–0.78) in heart failure with mildly reduced ejection fraction, and 0.88 (95% CI 0.77–0.98) in heart failure with reduced ejection fraction. Only ANG2 and GDF15 remained significantly associated with LVEF recovery after adjustment for age, sex, and Antwerp score and significantly improved the accuracy of the Antwerp score predictions (P <.001). The area under the curve of the Antwerp score in the outcome prediction improved from 0.75 (95% CI 0.67–0.83) to 0.78 (95% CI 0.70–0.86). A biomarker panel (ANG2 and GDF15) significantly improved the accuracy of the Antwerp score. [Display omitted] [ABSTRACT FROM AUTHOR]

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Background: The occurrence of congestive heart failure (CHF) hospitalization among patients with atrial fibrillation (AF) is a poor prognostic marker.Objective: The purpose of this study was to assess whether insulin-like growth factor-binding protein 7 (IGFBP-7), a marker of myocardial damage, identifies AF patients at high risk for this complication.Methods: We analyzed 2 prospective multicenter observational cohort studies that included 3691 AF patients. Levels of IGFBP-7 and N-terminal pro-brain natriuretic peptide (NT-proBNP) were measured from frozen plasma samples at baseline. The primary endpoint was hospitalization for CHF. Multivariable adjusted Cox regression analyses were constructed.Results: Mean patient age was 69 ± 12 years, 1028 (28%) were female, and 879 (24%) had a history of CHF. The incidence per 1000 patient-years across increasing IGFBP-7 quartiles was 7, 10, 32, and 85. The corresponding multivariable adjusted hazard ratios (aHRs) (95% confidence interval [CI]) were 1.0, 1.05 (0.63-1.77), 2.38 (1.50-3.79), and 4.37 (2.72-7.04) (P for trend <.001). In a subgroup of 2812 patients without pre-existing CHF at baseline, the corresponding aHRs were 1.0, 0.90 (0.47-1.72), 1.69 (0.94-3.04), and 3.48 (1.94-6.24) (P for trend <.001). Patients with IGFBP-7 and NT-proBNP levels above the biomarker-specific median had a higher risk of incident CHF hospitalization (aHR 5.20; 3.35-8.09) compared to those with only 1 elevated marker (elevated IGFBP-7 aHR 2.17; 1.30-3.60); elevated NT-proBNP aHR 1.97; 1.17-3.33); or no elevated marker (reference).Conclusion: Higher plasma levels of IGFBP-7 were strongly and independently associated with CHF hospitalization in AF patients. The prognostic information provided by IGFBP-7 was additive to that of NT-proBNP. [ABSTRACT FROM AUTHOR]

• Data on atrial fibrillation (AF) recurrence after multiple-procedure pulmonary vein isolation (PVI) are rare. • After up to two procedures (PVI only), left atrial volume predicts AF recurrence. • Burden based classification (AF burden score) predicts AF recurrence as well. • But conventional classification (paroxysmal or persistent) does not. Catheter ablation of atrial fibrillation (AF) by means of pulmonary vein isolation (PVI) focuses on the PVs as the putative trigger of AF. However, which classification should be used to identify patients that are most suitable for PVI is uncertain. The aim of the study was to evaluate rhythm-, burden-, and anatomically-based classification schemes to predict success rates after up to two procedures of an ablation strategy strictly aimed at isolation of the PVs. Patients with paroxysmal or non-longstanding persistent AF undergoing PVI-only ablation with the option of one repeat PVI in case of AF recurrence were included. An AF burden score (AFB) was determined based on frequency, episode duration, and number of previous cardioversions and then categorized as minimal, mild, moderate, or severe. Two- and three-dimensional anatomical assessment of the left atrium (LA) was performed based on pre-interventional imaging by computed tomography or magnetic resonance imaging. Of 195 patients analyzed, 24 presented with recurrence after the last intervention (12%, median follow up: 16 ± 11 months). In multivariable analysis, a more than 6-fold increase of risk for AF recurrence was identified for patients with a severe compared to a mild AFB [hazard ratio: 6.241 (95% confidence interval: 1.914–20.167, p = 0.002)]. In contrast to univariable analysis, no other parameter was associated with recurrence in multivariable analysis. Burden-based (AFB) classification was identified as a significant predictor for AF recurrence even after repeat PVI, while neither anatomical parameters nor the established rhythm-based classification of paroxysmal and persistent AF did. [ABSTRACT FROM AUTHOR]

Background: Cardiac resynchronization therapy (CRT) reduces morbidity and mortality in selected heart failure patients, but decision-making regarding selection of CRT-defibrillator or CRT-pacemaker is an ongoing debate.Objective: The purpose of this study was to construct predictive models and scoring systems for implantable cardioverter-defibrillator (ICD) therapy and death without ICD therapy (prior death).Methods: We pooled 2 prospective cohorts of CRT-D patients with primary prevention indication and used Fine and Gray models to develop independent prognostic models for time to first ICD therapy (event of interest) or death without prior ICD therapy (competing event). We defined CRT-D benefit as a high probability of ICD therapy combined with moderate/low probability of prior death.Results: Seven hundred twenty patients were included. Median follow-up was 7.2 years, and 247 patients (34%) died. Cumulative incidence of ICD therapy/prior death at 5 years was 24%/17%. In multivariable models, higher New York Heart Association classes, diuretic use, and ischemic cardiomyopathy were predictors of ICD therapy (hazard ratio 1.89 [1.30-2.75], 1.91 [1.12-3.24], and 1.40[1.02-1.92], respectively) but not of prior death. Males with comorbidities (cancer, renal failure, peripheral artery disease, body mass index >30) or systolic blood pressure ≤100 were at higher risk for prior death. Higher age was associated with lower risk of ICD therapy but higher risk of prior death. One-quarter of patients had low predicted benefit from CRT-D implantation using a scoring system for the dual prediction of appropriate ICD therapy and death without appropriate ICD-therapy.Conclusion: Different factors predict ICD therapy or prior death in CRT-D patients using competing risk models. Scoring allows identifying patients with predicted low benefit of CRT-D (low chance of ICD therapy, high chance of prior death). [ABSTRACT FROM AUTHOR]

Background: More sustained forms of atrial fibrillation (AF) are less amenable to treatment and associated with worse outcomes, but the incidence and predictors of AF progression are not well defined.Objective: The purpose of this study was to perform a systematic review and meta-analysis assessing the incidence and predictors of AF progression.Methods: PubMed, EMBASE, and the Cochrane Library were searched from inception to August 2017. AF progression was defined as progression from paroxysmal to persistent/permanent AF or as progression from persistent to permanent AF. Random effect models were used to calculate pooled cumulative incidence rates. Predictors related to between-study variability were assessed using meta-regression analyses.Results: We identified 47 studies with 27,266 patients who were followed for 105,912 patient-years. The pooled incidence of AF progression was 8.1 per 100 patient-years of follow-up (95% confidence interval [CI] 7.1-9.1 per 100 patient-years of follow-up; I2 = 98%; P < .0001). The incidence was 7.1 per 100 patient-years of follow-up (95% CI 6.2-8.0 per 100 patient-years of follow-up; across 42 studies) for progression from paroxysmal to non-paroxysmal AF as compared with 18.6 per 100 patient-years of follow-up (95% CI 8.9-28.3 per 100 patient-years of follow-up; across 5 studies) for progression from persistent to permanent AF. Higher age (β = 5.4; 95% CI 1.4-9.4; P = .01; R2 = 14.3%) and the prevalence of hypertension (β = 5.2; 95% CI 1.0-9.4; P = .02; R2 = 18.0%) were associated with a higher AF progression rate. Follow-up duration (β = -4.5; 95% CI -5.8 to -3.3; P < .0001; R2 = 68.0%) and the prevalence of paroxysmal AF (β = -9.5; 95% CI -18.7 to -0.3; P = .04; R2 = 4.4%) were inversely associated with AF progression. Together these variables explained 73.8% of the observed between-study heterogeneity.Conclusion: The incidence of AF progression appears to be relatively low, and the incidence seems to decrease with longer follow-up duration. Age, hypertension, baseline AF type, and follow-up duration explained a high percentage of the observed between-study heterogeneity. [ABSTRACT FROM AUTHOR]

Objectives The purpose of this study was to evaluate prevalence, progression, treatment, and outcome of silent coronary artery disease (CAD) in asymptomatic patients with diabetes (DM) at high coronary risk. Background Despite the close association of diabetes and CAD, general CAD screening in asymptomatic patients with DM is discouraged even though outcome data in patients at high coronary risk are lacking. Methods Prospective multicenter outcome study—with a pilot randomized treatment substudy. The study comprised 400 asymptomatic patients with DM (type 2) without history or symptoms of CAD at high CAD risk. They underwent clinical evaluation and myocardial perfusion single-photon emission computed tomography (MPS) at baseline and after 2 years. Patients with normal MPS received usual care; those with abnormal MPS received medical or combined invasive and medical management. Results An abnormal MPS was found in 87 of 400 patients (22%). In patients with normal MPS, MACE occurred in 2.9% and ischemia or new scar in 3.2%. Patients with abnormal MPS had more MACE (9.8%; hazard ratio: 3.44; 95% confidence interval [CI]: 1.32 to 8.95; p = 0.011) and ischemia or new scar (34.2%; odds ratio: 15.91; 95% CI: 7.24 to 38.03; p < 0.001) despite therapy, resulting in “overt or silent CAD progression” of 35.6% versus 4.6% (odds ratio: 11.53; 95% CI: 5.63 to 24.70; p < 0.001). Patients with abnormal MPS randomized to medical versus invasive-medical strategies had similar event rates (p = 0.215), but more ischemic or new scar findings (54.3% vs. 15.8%; p < 0.001). Conclusions High-risk asymptomatic patients with DM and normal MPS (78%) have a low rate of first manifestations of CAD. Patients with abnormal MPS at baseline (22%) have a 7-fold higher rate of progression to “overt or silent CAD,” despite therapy. Randomized patients’ outcomes suggest that a combined invasive and medical strategy for silent CAD may reduce scintigraphic but not symptomatic CAD progression versus medical therapy alone. (Trial of Invasive versus Medical therapy of Early coronary artery disease in Diabetes Mellitus ISRCTN87953632 ). [ABSTRACT FROM AUTHOR]

Objective: This study sought to evaluate the prognostic value of routine stress myocardial perfusion scintigraphy (MPS) 5 years after percutaneous coronary intervention (PCI). Background: Current appropriate use criteria define routine cardiac stress imaging <2 years after PCI as inappropriate and >2 years as uncertain in asymptomatic patients. Methods: All 339 of 683 BASKET (Basel Stent Kosteneffektivitäts Trial) 5-year survivors (55%) consenting to undergo protocol-mandated MPS and subsequent evaluation irrespective of symptoms were followed for major adverse cardiac events (MACE) (cardiac death, myocardial infarction [MI], or revascularization). For MPS, summed perfusion scores were calculated and perfusion defects were related to treated-vessel or remote myocardial areas. Results: Patients were 72 ± 10 years of age, 18% were female, and 90% were free of angina. MPS findings were abnormal in 205 of 339 patients (60%) with complete follow-up. During 3.7 ± 0.3 years, there were 7 cardiac deaths, 18 MIs, and 47 revascularizations, resulting in a MACE rate of 4.4% and a cardiac mortality rate of 0.6% per year. Patients with abnormal MPS findings had higher hazard ratios (HR) for MACE (HR: 1.95; 95% confidence interval [CI]: 1.06 to 3.59; p = 0.032), and cardiac death/MI (HR: 2.50; 95% CI: 0.93 to 6.69; p = 0.066) than patients with normal MPS finding. MACE rates were similar in patients with symptomatic and silent ischemia (p = 0.61) but higher than in patients with normal MPS findings (p < 0.05 for both comparisons). MACE rates were independently predicted by remote ischemia but not by treated-vessel ischemia or scar. Conclusions: Abnormal MPS findings 5 years after PCI are frequent irrespective of symptoms. The predictive power of abnormal MPS lies more in the detection of persistent or progressing coronary artery disease in remote vessel areas than in the diagnosis of late intervention-related problems in treated vessels. [Copyright &y& Elsevier]

Background: Good catheter–tissue contact force (CF) is critical for transmural and durable lesion formation during radiofrequency (RF) ablation but is difficult to assess in clinical practice. Tissue heating during RF application results in an impedance decrease at the catheter tip. Objective: The purpose of this study was to correlate achieved CF and initial impedance decreases during atrial fibrillation (AF) ablation. Methods: We correlated achieved CF and initial impedance decreases in patients undergoing ablation for AF with two novel open-irrigated CF-sensing RF catheters (Biosense Webster SmartTouch, n = 647 RF applications; and Endosense TactiCath, n = 637 RF applications). We then compared those impedance decreases to 691 RF applications with a standard open-irrigated RF catheter (Biosense Webster ThermoCool). Results: When RF applications with the CF-sensing catheters were analyzed according to an achieved average CF <5 g, 5–10 g, 10–20 g, and >20 g, the initial impedance decreases during ablation were larger with greater CF. Corresponding median values at 20 seconds were 5 Ω (interquartile range [IQR] 2–7), 8 Ω (4–11), 10 Ω (7–16), and 14 Ω (10–19) with the SmartTouch and n/a, 4 Ω (0–10), 8 Ω (5–12), and 13 Ω (8–18) with the TactiCath (P <.001 between categories for both catheters). When RF applications with the SmartTouch (CF-sensing catheter, median achieved CF 12 g) and ThermoCool (standard catheter) were compared, the initial impedance decrease was significantly greater in the CF-sensing group with median decreases of 10 Ω (6–14 Ω) vs 5 Ω (2–10 Ω) at 20 seconds (P <.001 between catheters). Conclusion: The initial impedance decrease during RF applications in AF ablations is larger when greater catheter contact is achieved. Monitoring of the initial impedance decrease is a widely available indicator of catheter contact and may help to improve formation of durable ablation lesions. [Copyright &y& Elsevier]

Background: Biomarkers may help to monitor and tailor treatment in patients with acute heart failure (AHF). Methods and Results: Levels of ST2, a novel biomarker integrating hypervolemic cardiac strain and proinflammatory signals, were measured at presentation to the emergency department (ED) and after 48 hours in 207 patients with AHF. Patients were stratified according to their early ST2 response (responders: ST2 decrease ≥25%; nonresponders: ST2 decrease <25%) and beta-blocker, renin-angiotensin-aldosterone system (RAAS) blockade, or diuretic treatment status at hospital discharge. We assessed the utility of ST2 levels and its changes to predict long-term mortality and the interaction between ST2 levels, treatment at discharge, and 1-year mortality. ST2 levels were higher in nonsurvivors than in survivors (median 108 vs 69 ng/mL; P < .01) and decreased significantly during the 1st 48 hours (median decrease 33%). ST2 decrease was less in nonsurvivors compared with survivors (median -25% vs -42%; P < .01). In Cox regression, early ST2 changes independently predicted 1-year mortality (hazard ratio 1.07 for every increase of 10%; P = .02). RAAS blockers at discharge were associated with survival independently from ST2 response, whereas the association of beta-blockers with survival differed markedly according to ST2 response, with beneficial effects restricted to ST2 nonresponders (P interaction = .04). A similar, albeit nonsignificant, trend was observed for diuretics (P interaction = .11). Conclusions: ED and serial ST2 measurements are independent predictors of 1-year mortality in AHF. [ABSTRACT FROM AUTHOR]

Abstract: Background: A novel method to estimate cardiac volumes based on impedance measurements using the leads of a resynchronization device has been developed. This study investigated the method in patients with ischemic cardiomyopathy and documented wall motion abnormalities. Method and Results: Fifteen postinfarction patients (age 68 ± 8 years, ejection fraction 27 ± 5%) with symptomatic heart failure and ≥1 akinetic or dyskinetic segment were included. During the implantation of a cardiac resynchronization therapy (CRT) device, acute impedance curves were recorded along with stroke volume determined by the arterial pulse contour method. In an overdrive protocol, the impedance parameter “stroke impedance” decreased in significant correlation with stroke volume in all patients. The median correlation coefficient between stroke volume and stroke impedance was 0.83 (interquartile range 0.70–0.89). Furthermore, the atrioventricular delay was optimized based on impedance and reference stroke volume. After optimization by the impedance method, it differed by 18 ± 15 ms from the figure after optimization by the invasive reference. Compared with a standard atrioventricular delay of 120 ms, stroke volume was improved by 8.6 ± 9.8% with the use of invasive optimization and by 6.4 ± 10.8% with the use of impedance-based optimization. Conclusions: In CRT patients with chronic infarction and wall motion abnormalities, impedance is a valid parameter to estimate stroke volume and to guide optimization of CRT timing. [Copyright &y& Elsevier]

Background: The Achieve mapping catheter allows real-time recordings from the pulmonary veins (PVs) during cryoballoon (CB) ablation of atrial fibrillation (AF). Objective: To assess the clinical applicability of the Achieve mapping catheter and the value of real-time recordings from the PVs during CB. Methods: Patients with paroxysmal AF undergoing CB ablation were studied. Recordings from the PVs were analyzed during (real-time recordings) and after CB ablation and validated by using a variable circumferential mapping catheter (Achieve group; n = 20). A comparison was made by using a group of patients in whom CB ablation with a guidewire and a variable circumferential mapping catheter was performed (Guidewire group; n = 20). Results: Forty patients (age 58±11 years; ejection fraction 0.59±0.07; left atrial size 40±6 mm) with paroxysmal AF were included. In the Achieve group, real-time recordings from the PVs could be obtained in 40 of 80 (50%) PVs and could be seen more often at the left-sided PVs (25 of 39, 64%) than at the right-sided PVs (15 of 41, 37%; P = .02). Validation with a standard circumferential mapping catheter confirmed PV isolation in 75 of 80 (93%) PVs. After a single procedure and a follow-up of 14±4 months, 25 of 40 (63%) patients were in sinus rhythm with no significant difference between groups. Conclusions: The Achieve catheter can be used as a substitute for a guidewire during CB ablation, but real-time recordings can be obtained only in half of the PVs and are not sufficient to accurately confirm isolation of all PVs. [ABSTRACT FROM AUTHOR]

Background: Cryoballoon ablation has emerged as a novel treatment strategy for patients with atrial fibrillation (AF). Objective: The purpose of this study was to compare pulmonary vein isolation (PVI) using cryoballoon ablation versus RF ablation with regard to myocardial injury, pulmonary vein (PV) reconnection patterns, and outcome. Methods: Fifty patients (age 59 ± 9 years, ejection fraction 0.59 ± 0.06, left atrial size 41 ± 5 mm) with paroxysmal AF were studied. Twenty-five patients underwent PVI using a 28-mm cryoballoon. A control group of 25 patients underwent PVI using an open-irrigation RF ablation catheter. Myocardial injury was determined by measuring troponin T (TnT). PV reconnection patterns were studied in case of repeat procedures. Results: Procedure duration was 166 ± 32 minutes in the cryoballoon group versus 197 ± 52 minutes in the RF group (P = .014), with similar ablation times (cryoballoon: 45 minutes [interquartile range 40–52.5 minutes]; RF: 47 minutes [interquartile range 44–65 minutes], P = .17). Postprocedural TnT in the RF group was 1.29 ± 0.41 μg/L versus 0.76 ± 0.55 μg/L in the cryoballoon group (P = .002). In 12 patients who underwent repeat ablation, 74% of PV reconnection sites were inferiorly located in the cryoballoon group compared to 17% in the RF group (P = .0004). With 1.2 ± 0.4 and 1.3 ± 0.6 procedures per patient, 88% of patients in the cryoballoon group and 92% in the RF group were in stable sinus rhythm after follow-up of 12 ± 3 months (P = NS). Conclusion: Differences in the extent of myocardial injury and patterns of PV reconnection were observed between cryoballoon ablation and RF ablation of paroxysmal AF. [ABSTRACT FROM AUTHOR]

Background: Because the best possible device longevity is crucial (i.e., risk of infection with premature device exchange, current cost-effectiveness calculations depending on reasonable longevity, patient comfort), industry-independent real-life data are fundamental. However, only limited independent data on the longevity of implantable cardioverter-defibrillators (ICDs) are available. Objective: The purpose of this study was to determine ICD device longevity and influencing factors. Methods: From a prospective database, we studied overall device longevity and identified those devices with replacement for battery depletion or prolonged charge time. For every device, we determined factors that included averaged shocks, pacing percentage, pacing mode, device size, and time of implant. Survival probabilities at different time intervals were calculated, and Kaplan-Meier and Cox regression analyses were used. Observed longevity was compared to industry-projected longevity obtained from product performance reports. Results: A total of 644 ICDs (Medtronic 317, Guidant 189, St. Jude 118, Intermedics 20) were implanted in 499 patients. During follow-up, 163 (25.3%) ICDs were replaced. Manufacturer, time of implant, pacing mode, pacing percentage, and capacitor reformation interval influenced longevity, whereas device size and number of shocks did not. Median longevity was 7.6 years for Medtronic devices, 5.0 years for Guidant devices, and 3.8 years for St. Jude devices. After 5 years, only 70% of ICDs were still in service compared to the 80% projected by industry. Conclusion: Marked differences in device longevity among manufacturers cannot be explained by pacing mode, number of shocks, or pacing percentage only. Overall, device performance requires further improvement for the sake of patient health and cost. [Copyright &y& Elsevier]

Three patients with advanced systemic sclerosis and recurrent or incessant monomorphic ventricular tachycardia underwent cardiac electrophysiologic studies. Biventricular transcatheter mapping showed findings most compatible with a reentrant mechanism, which was effectively treated with transcatheter ablation. [ABSTRACT FROM AUTHOR]

Randomized controlled trials of pulmonary vein isolation (PVI) for treating atrial fibrillation (AF) have proven the procedure's efficacy. Studies assessing its empirical cost-effectiveness outside randomized trial settings are lacking. We aimed to evaluate the effectiveness and cost-effectiveness of PVI versus medical therapy for AF. We followed a target trial approach using the Swiss-AF cohort, a prospective observational cohort study that enrolled patients with AF between 2014 and 2017. Resource utilization and cost information were collected through claims data. Quality of life was measured with EQ-5D-3L utilities. We estimated incremental cost-effectiveness ratios (ICERs) from the perspective of the Swiss statutory health insurance system. Patients undergoing PVI compared with medical therapy had a 5-year overall survival advantage with a hazard ratio of 0.75 (95% CI 0.46-1.21; P =.69) and a 19.8% SD improvement in quality of life (95% CI 15.5-22.9; P <.001), at an incremental cost of 29 604 Swiss francs (CHF) (95% CI 16 354-42 855; P <.001). The estimated ICER was CHF 158 612 per quality-adjusted life-year (QALY) gained within a 5-year time horizon. Assuming similar health effects and costs over 5 additional years changed the ICER to CHF 82 195 per QALY gained. Results were robust to the sensitivity analyses performed. Our results show that PVI might be a cost-effective intervention within the Swiss healthcare context in a 10-year time horizon, but unlikely to be so at 5 years, if a willingness-to-pay threshold of CHF 100 000 per QALY gained is assumed. Given data availability, we find target trial designs are a valuable tool for assessing the cost-effectiveness of healthcare interventions outside of randomized controlled trial settings. • What is the real-world cost-effectiveness of pulmonary vein isolation (PVI) compared with standard medical therapy for patients with atrial fibrillation? • In this economic evaluation designed with a target trial approach including 2379 patients with real-world clinical, quality of life, and costing data, we estimate the incremental cost-effectiveness ratio of PVI compared with standard medical therapy to be 158 612 Swiss francs per quality-adjusted life-year gained (1 US dollar ∼ 0.93 Swiss francs) at 5 years and 82 195 per quality-adjusted life-year at 10 years. • In our target trial emulation-based cost-effectiveness assessment, PVI for the management of atrial fibrillation might be cost-effective over a 10-year period. [ABSTRACT FROM AUTHOR]

Abstract: A case of a professional ice-hockey with a blunt chest trauma is presented. A year after the first cardiac evaluation, he experienced sustained ventricular tachycardia after another slight chest trauma. An implantable cardioverter-defibrillator was implanted. The pathophysiological background of tachycardias after a blunt chest trauma and its management are discussed. [Copyright &y& Elsevier]

Background: It is unknown whether unstable angina (UA) results in previously nondetectable low-level myocardial necrosis. We compared the pattern of myocardial necrosis between patients with UA, acute myocardial infarction (AMI), and noncardiac chest pain (NCCP) using 3 high-sensitive cardiac troponin (hs-cTn) assays. Methods: In a multicenter study, we enrolled 842 unselected patients with acute chest pain in the emergency department. Roche hs-cTnT, Beckman Coulter hs-cTnI, and Siemens hs-cTnI were determined in a blinded fashion at presentation and after 1, 2, 3, and 6 hours. The final diagnosis was adjudicated by 2 independent cardiologists. Results: A change in hs-cTn of ≥2 ng/L within the first hour after presentation as assessed with Roche hs-cTnT, Beckman Coulter hs-cTnI, and Siemens hs-cTnI was observed in 26%, 31%, and 32% of patients with UA (n = 115) compared with 91%, 92%, and 96% in patients with AMI (n = 120) and 12%, 23%, and 16% in patients with NCCP (n = 415; P < .001 for all comparisons between UA and AMI, P > .05 for all comparisons between UA and NCCP). In patients with UA, such a 1-hour change in hs-cTn of ≥2 ng/L was associated with an increased risk of death or AMI during the 30-day follow-up (P = .003, .03, .03) and 2-year follow-up (P < .001, .002, and .006). Conclusions: In marked contrast to patients with AMI, most patients with UA do not exhibit relevant hs-cTn changes. The minority of UA with hs-cTn changes, however, has a significantly worse short- and long-term outcome. [Copyright &y& Elsevier]

Perioperative myocardial infarction/injury (PMI) is a frequent, often missed and incompletely understood complication of noncardiac surgery. The aim of this study was to evaluate whether patient- or procedure-related factors are more strongly associated to the development of PMI in patients undergoing repeated noncardiac surgery. In this prospective observational study, patient- and procedure-related factors were evaluated for contribution to PMI using: 1) logistic regression modelling with PMI as primary endpoint, 2) evaluation of concordance of PMI occurrence in the first and the second noncardiac surgery (surgery 1 and 2). and 3) the correlation of the extent of cardiomyocyte injury quantified by high-sensitivity cardiac troponin T between surgery 1 and 2. The secondary endpoint was all-cause mortality associated with PMI reoccurrence in surgery 2. Among 784 patients undergoing repeated noncardiac surgery (in total 1′923 surgical procedures), 116 patients (14.8%) experienced PMI during surgery 1. Among these, PMI occurred again in surgery 2 in 35/116 (30.2%) patients. However, the vast majority of patients developing PMI during surgery 2 (96/131, 73.3%) had not developed PMI during surgery 1 (phi-coefficient 0.150, p < 0.001). The correlation between the extent of cardiomyocyte injury occurring during surgery 1 and 2 was 0.153. All-cause mortality following a second PMI in surgery 2 was dependent on time since surgery (adjusted hazard ratio 5.6 within 30 days and 2.4 within 360 days). In high-risk patients, procedural factors are more strongly associated with occurrence of PMI than patient factors, but patient factors are also contributors to the occurrence of PMI. • Perioperative myocardial infarction/injury (PMI) detected by cardiac troponin is a frequent complication of noncardiac surgery. • Procedural factors are more strongly associated with occurrence of PMI than patient factors in contrast to spontaneous AMI. • Repeated PMI increased 1-year mortality considerably. Mortality was particularly high in the first weeks after surgery. [ABSTRACT FROM AUTHOR]

Sex-related electrocardiographic differences are a well-known phenomenon, but not their expression in patients with atrial fibrillation (AF). In this study we aim to assess the presence of significant sex-related differences in ECG features, with particular attention to P-wave parameters, of a large cohort of patients affected by different types of AF. A 5-min resting 16-lead ECG was evaluated for 1119 AF patients in sinus rhythm. The durations of the main ECG waves and intervals were measured for both atrial and ventricular activity. Moreover, the beat-to-beat P-wave variability was computed for lead II and for the first principal component (PC1) computed across the 16 leads. The percentage of variance explained by PC1 was computed. Males compared to females showed significantly longer RR interval (1.02 ± 0.16 s vs 0.97 ± 0.15 s, p <.001), PQ interval (191 ± 34 ms vs 183 ± 35 ms, p =.008), QRS duration (105 ± 17 ms vs 98 ± 13 ms, p =.021), significantly lower percentage of variance explained by PC1 and P-wave variability. Males with paroxysmal AF compared to females with paroxysmal AF had significantly longer RR interval (1.01 ± 0.17 s vs 0.96 ± 0.14 s, p <.001), shorter QTc (388 ± 27 ms vs 402 ± 27 ms, p <.001), lower P-wave variability in PC1. Males with persistent AF compared to females with persistent AF had significantly shorter QTc interval (396 ± 30 ms vs 407 ± 26 ms, p =.019), longer PQ interval (194 ± 35 ms vs 182 ± 30 ms, p =.037), higher V1 terminal force (2.1 ± 1.2 mV*ms vs 1.8 ± 1 mV*ms, p =.007), lower percentage of variance explained by PC1. AF patients present with several sex-related ECG differences. Consequently, sex should be taken into account when developing ECG algorithms identifying patients at risk for AF progression. • ECG parameters show significant differences between males and females with AF in SR. • Male AF patients had longer RR, PQ and QRS intervals than females during SR. • Male AF patients had significantly lower P-wave variability than females during SR. • Male/females differences were found also in paroxysmal and persistent AF groups. [ABSTRACT FROM AUTHOR]

Direct oral anticoagulants (DOACs) have a favourable risk-benefit profile compared to vitamin K-antagonists (VKAs) in atrial fibrillation (AF). Dosing is based on age, weight and renal function, without need of routine monitoring. In two prospective, multicentre AF cohorts (Swiss-AF, BEAT-AF) patients were stratified as receiving VKAs or adequately-, under- or overdosed DOACs, according to label. Primary outcome was a composite of major adverse clinical events (MACE), defined as cardiovascular death, myocardial infarction (MI), ischaemic stroke and systemic embolism. Secondary outcomes included major bleeding. Adjustment for confounding was performed. Median follow-up was 4 years. Of 3236 patients, 1875 (58%) were on VKAs and 1361 (42%) were on DOACs, of which 1137 (83%) were adequately-, 134 (10%) over- and 90 (7%) under-dosed. Compared to adequately dosed individuals, overdosed patients were more likely to be older and female. Underdosing correlated with concomitant aspirin therapy and coronary artery disease. Both groups had higher CHA 2 DS 2 -VASc scores. Patients on overdosed DOACs had higher incidence of MACE (HR 1.75; CI 1.10–2.79; adjusted-HR: 1.22) and major bleeding (HR 1.99; CI 1.14–3.48; adjusted-HR: 1.51). Underdosing was not associated with a higher incidence of MACE (HR 0.94; CI 0.46–1.92; adjusted-HR 0.61) or major bleeding (HR 1.07; CI 0.46–2.46; adjusted-HR 0.82). After adjustment, all CIs crossed 1.0. Inappropriate DOAC-dosing was more prevalent in multimorbid patients, but did not correlate with higher risks of adverse events after adjusting for confounders. DOAC prescription should follow label. [ABSTRACT FROM AUTHOR]

Objective The novel high-sensitivity cardiac troponin (hs-cTn) 0 h/1 h-algorithm substantially improves the early triage of patient's assigned “rule-out” or “rule-in” of acute myocardial infarction (AMI), while diagnostic uncertainty remains in that 25–30% of patients assigned to “observe”. We aimed to better characterize these patients. Methods In a prospective multicenter diagnostic study, we applied the hs-cTnT 0 h/1 h-algorithm in 2213 unselected patients presenting with symptoms suggestive of AMI to the emergency department. The final diagnosis was adjudicated by two independent cardiologists using all available information. Survival at 720-days was the prognostic endpoint. Findings were validated using a hs-cTnI 0 h/1 h-algorithm. Results Twenty-four percent (n = 523) of patients were assigned to “observe” by the hs-cTnT 0 h/1 h-algorithm. These patients differed significantly in multiple characteristics from “rule-out” and “rule-in” patients: they were older, in 75% male, and very often (57%) had pre-existing coronary artery disease (CAD). Diagnostic uncertainty for the presence of an AMI/UA was high. Only 39% of patients were suitable for coronary computed tomography angiography (CCTA). The most common final adjudicated diagnoses were non-cardiac disease (38%), non-coronary cardiac disease (24%), unstable angina (UA, 21%), and AMI (15%). Absolute hs-cTnT-changes within 3 h had the highest diagnostic accuracy for AMI (AUC 0.86). Cumulative 720-day survival rate was 86%, which was significantly lower as compared to “rule-out” (p < 0.001) and comparable to “rule-in” (p = ns). Findings were similar for the hs-cTnI “observe” zone. Conclusion “Observe” patients are typically elderly men with pre-existing CAD and high long-term mortality. Absolute hs-cTn-changes within 3 h, functional stress imaging and coronary angiography are the key diagnostic modalities. [ABSTRACT FROM AUTHOR]