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A three-axis accelerometer sensor is incorporated in a leadless pacemaker (Micra™, MedtronicInc ) for rate adaptation. 3 sensor setpoints at lower rate (LR), activity of daily living rate (ADLR) and upper rate (UR) are used to convert detected acceleration to a desired rate response. We describe inappropriate rate acceleration at rest and during chest physiotherapy in a sedentary elderly patient with leadless pacemaker. The underlying mechanism and various programming options are discussed. This article is protected by copyright. All rights reserved.

Leadless pacing is a major breakthrough in the management of bradyarrhythmia. Results of initial clinical trials that have demonstrated a significant reduction in acute and long-term pacing-related complications have been confirmed by real-world experience in a broader spectrum of patients. Nonetheless current use of a leadless pacemaker is hampered by its limited atrial sensing and pacing capability, as well as battery life-span and retrievability. We review the current clinical outcome data, indications and contraindications, implantation and retrieval techniques, synchronous ventricular pacing, and other clinical considerations. We also provide an overview of the latest advancements in leadless pacing technology including device-to-device communication and energy harvesting technology.

Tricuspid regurgitation (TR) is a well-known complication after permanent pacemaker implantation. The aim of this study was to compare the degree of TR and the relationship of lead position across the tricuspid valve (TV) between patients with right ventricular apical (RVA) and non-RVA pacing determined by three-dimensional echocardiography.Conventional and three-dimensional echocardiography was performed in 284 patients to determine the change in TR severity following permanent pacemaker implantation. Transvenous lead locations were based on fluoroscopic images. This was a retrospective study, and the selected pacing mode was not randomized.RVA pacing had more frequent severe TR (37.9% vs 25.7%, P = .03) compared with non-RVA pacing. Severe TR occurred in 9.7%, 12.6%, and 58.8% of patients when the lead passed through the middle, between the commissures, and impinging the TV leaflets, respectively. Non-RVA leads were more likely to be positioned in the middle of the TV (30.3% vs 12.1%, P .01) and had the lowest chance of leaflet impingement (33.6% vs 51.5%, P .01) compared with RVA leads. RVA pacing was associated with worsening of grade ≥2 TR severity compared with non-RVA pacing (42.4% vs 27.6%, P .01). A TV lead passage angle of -15° to 15° minimized TR.Pacing-induced TR is more prevalent with RVA than non-RVA pacing. Preferential lead impingement on the TV leaflet, as determined by TV lead passage angle, can explain the development and progression of pacing-induced TR.

Implementation of a critical care pathway (CCP) for acute coronary syndrome (ACS) has been shown to improve early compliance to guideline-directed therapies and reduce early mortality. Nevertheless its long-term impact on the compliance with medications or clinical outcomes remains unknown. Between 2004 and 2015, 2023 consecutive patients were admitted to our coronary care unit with ACS. We retrospectively compared the outcomes of 628 versus 1059 patients (mean age 66.1 ± 13.3 years, 74% male) managed before and after full implementation of a CCP. Compared with standard care, implementation of the CCP significantly increased coronary revascularization and long-term compliance with guideline-directed medical therapy (both P

Background The prognostic implication of statin in tolerance (SI) in those with stable CAD remains unclear. We hypothesized that SI is of higher prognostic significance in stable CAD patients with elevated high-sensitive cardiac troponin I (hs-cTnI). Methods A total of 952 stable CAD patients from the prospective Hong Kong CAD study who had complete clinical data, biomarker measurements and who were prescribed statin therapy were studied. Results We identified 13 (1.4%) and 125 (13.1%) patients with complete and partial SI, respectively. At baseline, patients with SI were more likely to have diabetes mellitus and a higher hs-cTnI level, but no difference in LDL-C level compared with those without SI. After 51 months of follow-up, patients with SI had a higher mean LDL-C level than those without SI. A total of 148 (15.5%) patients developed major adverse cardiovascular events (MACEs). Both SI (HR 1.52, 95% CI 1.06–2.19, P = 0.02) and elevated hs-cTnI (HR 3.18, 95% CI 2.07–4.89, P

Background Patients who survive non-ST-elevation myocardial infarction (NSTEMI) are at heightened risk of recurrent cardiovascular events. Data on long-term secondary atherothrombotic risk stratification are limited. Objectives To stratify post-NSTEMI patients for risk of recurrent cardiovascular events to maximise benefit from aggressive secondary prevention strategies using the TIMI Risk Score for Secondary Prevention (TRS 2°P) score in a real-world cohort of NSTEMI patients. Methods and results This was a single-centre observational study of 891 post-NSTEMI patients (73.7 ± 12.7 years; male: 54.2%). The TRS 2°P is a nine-point risk stratification tool to predict cardiovascular events in patients with established cardiovascular disease. The primary outcome was a composite endpoint of cardiovascular death, non-fatal MI and non-fatal ischaemic stroke. After a median follow-up of 31 months (IQR: 11.4 – 60.2), 281 patients (31.5%) had developed a primary outcome (13.3%/year) including 196 cardiovascular deaths, 94 non-fatal MIs and 22 non-fatal strokes. The TRS 2°P score was strongly associated with the primary outcome. The annual incidence of primary composite endpoint for patients with TRS 2°P score =0 was 1.6%, and increased progressively to 47.4% for those with a TRS 2°P score ≥6 (HR: 20.18, 95% CI: 4.85 to 84.05, p Conclusion The TRS 2°P score stratified post-NSTEMI patients for risk of future cardiovascular events and potentially help guide the selection of more aggressive secondary prevention therapy.

Artículo con numerosos autores, sólo se refleja el primero, que es además el de la UAM, This is a joint simultaneous publication initiative involving all interested National and Affiliated Cardiovascular Journals of the European Society of Cardiology., The Editorś Network of the European Society of Cardiology (ESC) provides a dynamic forum for editorial discussions and endorses the recommendations of the International Committee of Medical Journal Editors (ICMJE) to improve the scientific quality of biomedical journals. Authorship confers credit and important academic rewards. Recently, however, the ICMJE emphasized that authorship also requires responsibility and accountability. These issues are now covered by the new (fourth) criterion for authorship. Authors should agree to be accountable and ensure that questions regarding the accuracy and integrity of the entire work will be appropriately addressed. This review discusses the implications of this paradigm shift on authorship requirements with the aim of increasing awareness on good scientific and editorial practices

BACKGROUND Patients who survive myocardial infarction (MI) are at risk of recurrent cardiovascular (CV) events. This study stratified post-MI patients for risk of recurrent CV events using the Thrombolysis in Myocardial Infarction (TIMI) Risk Score for Secondary Prevention (TRS 2°P). Methods and Results: This was an observational study that applied TRS 2°P to a consecutive cohort of post-MI patients. The primary outcome was a composite endpoint of CV death, non-fatal MI, and non-fatal ischemic stroke. A total of 1,688 post-MI patients (70.3±13.6 years; male, 63.1%) were enrolled. After a mean follow-up of 41.5±34.4 months, 405 patients (24.0%) had developed a primary outcome (9.3%/year) consisting of 278 CV deaths, 134 non-fatal MI, and 33 non-fatal strokes. TRS 2°P was strongly associated with the primary outcome. The annual incidence of primary composite endpoint for patients with TRS 2°P 0 was 1.0%, and increased progressively to 39.9% for those with TRS 2°P ≥6 (HR, 27.6; 95% CI: 9.87-77.39, P

The Editors' Network of the European Society of Cardiology (ESC) provides a dynamic forum for editorial discussions and endorses the recommendations of the International Committee of Medical Journal Editors (ICMJE) to improve the scientific quality of biomedical journals. Authorship confers credit and important academic rewards. Recently, however, the ICMJE emphasized that authorship also requires responsibility and accountability. These issues are now covered by the new (fourth) criterion for authorship. Authors should agree to be accountable and ensure that questions regarding the accuracy and integrity of the entire work will be appropriately addressed. This review discusses the implications of this paradigm shift on authorship requirements with the aim of increasing awareness on good scientific and editorial practices.

Rheumatic heart disease results in significant remodeling of the atria that provides the milieu for maintaining atrial fibrillation. Some electrical remodeling is reversible and hence early intervention may prove useful. Active screening for atrial fibrillation in high-risk subset and instituting anticoagulation may reduce the devastating complications that follow. Age older than 50 years, NYHA functional class II symptoms, left atrial dimension >4.0 cm on echocardiogram in parasternal long-axis view, and gradients across the mitral valve >10 mm Hg are clinical indicators that identify the high-risk subset. Ablation strategy in this population may differ compared with the nonvalvular group.

BackgroundA high proportion of COVID-19 patients were reported to have cardiac involvements. Data pertaining to cardiac sequalae is of urgent importance to define subsequent cardiac surveillance.MethodsWe performed a systematic cardiac screening for 97 consecutive COVID-19 survivors including electrocardiogram (ECG), echocardiography, serum troponin and NT-proBNP assay 1–4 weeks after hospital discharge. Treadmill exercise test and cardiac magnetic resonance imaging (CMR) were performed according to initial screening results.ResultsThe mean age was 46.5 ± 18.6 years; 53.6% were men. All were classified with non-severe disease without overt cardiac manifestations and did not require intensive care. Median hospitalization stay was 17 days and median duration from discharge to screening was 11 days. Cardiac abnormalities were detected in 42.3% including sinus bradycardia (29.9%), newly detected T-wave abnormality (8.2%), elevated troponin level (6.2%), newly detected atrial fibrillation (1.0%), and newly detected left ventricular systolic dysfunction with elevated NT-proBNP level (1.0%). Significant sinus bradycardia with heart rate below 50 bpm was detected in 7.2% COVID-19 survivors, which appeared to be self-limiting and recovered over time. For COVID-19 survivors with persistent elevation of troponin level after discharge or newly detected T wave abnormality, echocardiography and CMR did not reveal any evidence of infarct, myocarditis, or left ventricular systolic dysfunction.ConclusionCardiac abnormality is common amongst COVID-survivors with mild disease, which is mostly self-limiting. Nonetheless, cardiac surveillance in form of ECG and/or serum biomarkers may be advisable to detect more severe cardiac involvement including atrial fibrillation and left ventricular dysfunction.

Contains fulltext : 238765.pdf (Publisher’s version ) (Closed access) With the global increase in device implantations, there is a growing need to train physicians to implant pacemakers and implantable cardioverter-defibrillators. Although there are international recommendations for device indications and programming, there is no consensus to date regarding implantation technique. This document is founded on a systematic literature search and review, and on consensus from an international task force. It aims to fill the gap by setting standards for device implantation.

Background Liver stiffness (LS) assessed by transient elastography is associated with adverse events in patients with heart failure. However, the predictive value of LS for adverse outcome is uncertain in patients undergoing tricuspid annuloplasty (TA). This study sought to evaluate the prognostic value and reversibility of LS in patients undergoing TA during left-sided valve surgery. Methods and results A total of 158 patients who underwent TA were prospectively evaluated. Patients were divided into three groups according to tertile of LS. Adverse outcome was defined as heart failure that required hospital admission or all-cause mortality following TA. The median LS was 13.9 (inter-quartile range 8.1–22.3) kPa and independently correlated positively with tricuspid regurgitation (TR) severity, inferior vena cava diameter and negatively with tricuspid annular plane systolic excursion. During a median follow-up of 31 months, 49 adverse events occurred. Multivariable Cox regression analysis revealed that LS was an independent predictor of adverse events. Significant improvement in LS at 1-year post-TA (13.1–7.8 kPa, P Conclusions This study demonstrated that LS is predictive of adverse outcome and is reversible in patients undergoing TA without TR recurrence at 1 year. These findings suggest that assessing LS, an integrative correlate of right heart condition, may aid the pre-operative risk assessment of candidate for heart surgery including TA.

BACKGROUND: Leadless pacemakers (LPs) provide ventricular pacing without the risks associated with transvenous leads and device pockets. LPs are appealing for patients who need pacing, but do not need defibrillator or cardiac resynchronization therapy. Most implanted LPs provide right ventricular pacing without atrioventricular synchrony (VVIR mode). The Mode Selection Trial in Sinus Node Dysfunction Trial (MOST) showed similar outcomes in patients randomized to dual chamber (DDDR) vs ventricular pacing (VVIR). We compared outcomes by pacing mode in LP-eligible patients from MOST. METHODS: Patients enrolled in the MOST study with an LVEF >35%, QRSd

Aims Little is known about the relative importance of body volume and haemodynamic parameters in the development of worsening of renal function in acutely decompensated heart failure (ADHF). To study the relationship between haemodynamic parameters, body water content and worsening of renal function in patients with heart failure with reduced ejection fraction (HFrEF) hospitalised for ADHF. Methods and results This prospective observational study involved 51 consecutive patients with HFrEF (age: 73±14 years, male: 60%, left ventricular ejection fraction: 33.3%±9.9%) hospitalised for ADHF. Echocardiographic-determined haemodynamic parameters and body volume determined using a bioelectric impedance analyser were serially obtained. All patients received intravenous furosemide 160 mg/day for 3 days. There was a mean weight loss of 3.95±2.82 kg (p Conclusions Normal body volume and lower serum BNP on admission were associated with worsening of renal function in patients with HFrEF hospitalised for ADHF.

Background Little is known about the impact of the provision of handheld point-of-care ultrasound (POCUS) devices on physical examination skills of medical students. Methods We describe an educational initiative that comprised a POCUS workshop followed by allocation of a POCUS device to medical students for use over the subsequent 8 weeks. They were encouraged to scan patients and correlate their physical examination findings. A mobile instant messaging group discussion platform was set to provide feedback from instructors. Physical examination skills were assessed by means of clinical examination. Results 210 final-year medical students from the University of Hong Kong participated in the programme. 46.3% completed the end of programme electronic survey: 74.6% enjoyed using the POCUS device, 50.0% found POCUS useful to validate physical examination findings and 47.7% agreed that POCUS increased their confidence with physical examination. 93.9% agreed that the programme should be incorporated into the medical curriculum and 81.9% would prefer keeping the device for longer time from 16 weeks (45.6%) to over 49 weeks (35.3%). Medical students who participated in the POCUS programme had a higher mean score for abdominal examination compared with those from the previous academic year with no POCUS programme (3.65±0.52 vs 3.21±0.80, p=0.014), but there was no statistically significant difference in their mean score for cardiovascular examination (3.62±0.64 vs 3.36±0.93, p=0.203). Conclusion The POCUS programme that included provision of a personal handheld POCUS device improved students’ attitude, confidence and ability to perform a physical examination.

Background: The Asymptomatic Atrial Fibrillation and Stroke Evaluation in Pacemaker Patients and the Atrial Fibrillation Reduction Atrial Pacing Trial (ASSERT) demonstrated that subclinical atrial fibrillation (SCAF) was associated with a 2.5-fold increased risk of stroke. However, the absolute stroke rate was only 1.7% per year and fewer than 20% patients with stroke had SCAF in the preceding 30 days. This raises the possibility that SCAF is merely a risk marker for stroke rather than the cause. Systematic characterization of stroke subtypes among patients with SCAF would help clarify this issue.Methods: All ischemic strokes that occurred in the ASSERT trial were blindly adjudicated by stroke neurologists, classified as cortical versus subcortical, and subtyped using modified TOAST criteria. Stroke severity was measured using the modified Rankin Score.Results: Of the 44 participants who had an ischemic stroke, 14 had SCAF before stroke. Among patients with SCAF who had stroke, 57% of strokes (n=8) were judged to be cardioembolic, 36% to be lacunar (n=5), and 7% (n= 1) to be large artery disease. However, of 5 patients who had SCAF detected within 30 days before their index stroke, 4 patients had a cardioembolic stroke. The average duration of SCAF in these 4 patients was 6.0 +/- 6.1 h/d. The modified Rankin score at 30 days was similar between patients with (2.7 +/- 2.3) and without SCAF (2.3 +/- 2.0; P =.68).Conclusions: In patientswith SCAF and stroke, SCAF seems probably causal inmany cases; however, in more than 40%, it seems to be acting only as a risk marker. (C) 2018 Elsevier Inc. All rights reserved.

The prognostic implication of early ventricular tachyarrhythmias (VTs) after acute coronary syndrome (ACS) remains unclear.We sought to investigate the clinical outcomes of early monomorphic and non-monomorphic VTs that occur within 48 hours in patients after ACS.We retrospectively reviewed the clinical outcomes of 2033 [mean age 67.0 ± 13.4 years; 1486 (73.1%) men] consecutive patients who presented with ACS from 2004 to 2015.A total of 67 (3.3%) and 90 (4.4%) patients developed early monomorphic or non-monomorphic VT, respectively. Killip class IV (odds ratio [OR] 3.05; 95% confidence interval [CI] 1.47-6.36; P.01), creatine kinase level (OR 1.01; 95% CI 1.00-1.02 per 100 IU/L; P = .01), and left ventricular ejection fraction (OR 0.96; 95% CI 0.94-0.99; P.01) were independently associated with early monomorphic VT, whereas age (OR 0.98; 95% CI 0.97-0.99; P = .04), ST elevated myocardial infarction (OR 3.53; 95% CI 1.71-7.27; P.01), Killip class IV (OR 4.91; 95% CI 2.76-8.74; P.01), diabetes mellitus (OR 0.48; 95% CI 0.28-0.81; P.01), and left ventricular ejection fraction (OR 0.97; 95% CI 0.95-0.99; P.01) were independently associated with early non-monomorphic VT. More patients with early monomorphic VT (n = 22 [32.8%]) died in hospital than those with non-monomorphic VT (n = 16 [17.8%]) or without early VT (n = 133 [7.1%]; P.01). After a mean follow-up of 67.8 ± 43.2 months, 21 patients with early monomorphic VT (46.7%), 22 patients with early non-monomorphic VT (29.7%), and 552 patients without early VT (31.7%) died. Both early monomorphic and non-monomorphic VTs were associated with a long-term increase in sudden arrhythmic deaths and recurrent VTs. Nevertheless, only early monomorphic VT was shown to independently predict overall survival (hazard ratio 1.62; 95% CI 1.03-2.55; P = .04).Early monomorphic VT, but not early non-monomorphic VT, independently predicted all-cause mortality in patients with ACS who survived to hospital discharge.

Introduction In Hong Kong, the prevalence of atherosclerotic cardiovascular disease has increased markedly over the past few decades, and further increases are expected. In 2008, the Hong Kong Cardiovascular Task Force released a consensus statement on preventing cardiovascular disease in the Hong Kong population. The present article provides an update on these recommendations. Participants A multidisciplinary group of clinicians comprising the Hong Kong Cardiovascular Task Force-10 cardiologists, an endocrinologist, and a family physician-met in September 2014 and June 2015 in Hong Kong. Evidence Guidelines from the American College of Cardiology/American Heart Association, the European Society of Hypertension/European Society of Cardiology, and the Eighth Joint National Committee for the Management of High Blood Pressure were reviewed. Consensus process Group members reviewed the 2008 Consensus Statement and relevant international guidelines. At the meetings, each topical recommendation of the 2008 Statement was assessed against the pooled recommendations on that topic from the international guidelines. A final recommendation on each topic was generated by consensus after discussion. Conclusions It is recommended that a formal risk scoring system should be used for risk assessment of all adults aged 40 years or older who have at least one cardiovascular risk factor. Individuals can be classified as having a low, moderate, or high risk of developing atherosclerotic cardiovascular disease, and appropriate interventions selected accordingly. Recommended lifestyle modifications include adopting a healthy eating pattern; maintaining a low body mass index; quitting smoking; and undertaking regular, moderate-intensity physical activity. Pharmacological interventions should be selected as appropriate after lifestyle modification.

Background Chinese patients with atrial fibrillation (AF) and a low CHA 2 DS 2 -VASc have a disproportionately high ischemic stroke risk; nonetheless, little is known about the impact of age on ischemic stroke risk in this population. In this study, we aimed to examine the age-related ischemic stroke risk in Chinese patients with nonvalvular AF without other risk factors for stroke. Methods This was a hospital-based observational registry. Results A total of 1198 Chinese patients with AF (mean age, 73.6 ± 16.5 years; male sex, 53.3%) were included in this analysis. The mean CHA 2 DS 2 -VASc and HAS-BLED score were 1.81 ± 1.00 and 1.32 ± 0.77, respectively, and none of the patients was prescribed antiplatelet or anticoagulation therapy. After a mean follow-up of 2.95 years, there were 234 ischemic strokes (19.5%), with an annual ischemic stroke incidence of 6.62%/y. The overall annual ischemic stroke risk was 0.43%/y, 5.87%/y, 7.49%/y, and 8.04%/y for age groups P for trend Conclusions Chinese patients with AF and a low CHA 2 DS 2 -VASc were at a disproportionally high risk of ischemic stroke. Chinese patients between 50 and 64 years have a high risk for stroke despite a low CHA 2 DS 2 -VASc and a low bleeding risk. Only patients aged

BACKGROUND: Osteogenic circulating endothelial progenitor cells (EPC) play a pathogenic role in cardiovascular system degeneration through promulgating vasculature calcification, but its role in conduction disorders as part of the cardiovascular degenerative continuum remained unknown. AIM: To investigate the role of osteocalcin (OCN)‐expressing circulating EPCs in cardiac conduction disorders in the unique clinical sample of rheumatoid arthritis (RA) susceptible to both abnormal bone metabolism and cardiac conduction disorders. METHODS: We performed flow cytometry studies in 134 consecutive asymptomatic patients with rheumatoid arthritis to derive osteogenic circulating OCN‐positive (OCN+) CD34+KDR+ vs. CD34+CD133+KDR+ conventional EPC. Study endpoint was the prespecified combined endpoint of electrocardiographic conduction abnormalities. RESULTS: Total prevalence of cardiac conduction abnormality was 9% (n = 12). All patients except one had normal sinus rhythm. One patient had atrial fibrillation. No patient had advanced atrioventricular (AV) block. Prevalence of first‐degree heart block (>200 ms), widened QRS duration (>120 ms) and right bundle branch block were 6.7%, 2.1%, and 2.2% respectively. Circulating osteogenic OCN(+)CD34(+)KDR(+) EPCs were significantly higher among patients with cardiac conduction abnormalities (p = 0.039). Elevated OCN(+)CD34(+)KDR(+) EPCs> 75th percentile was associated with higher prevalence of cardiac conduction abnormalities (58.3% vs. 20.02%, p = 0.003). Adjusted for potential confounders, elevated OCN(+)CD34(+)KDR(+ )EPCs> 75th percentile remained independently associated with increased risk of cardiac conduction abnormalities (OR = 4.4 [95%CI 1.2–16.4], p = 0.028). No significant relation was found between conventional EPCs CD34+CD133+KDR+ and conduction abnormalities (p = 0.36). CONCLUSIONS: Elevated osteogenic OCN(+)CD34(+)KDR(+ )EPCs are independently associated with the presence of electrocardiographic conduction abnormalities in patients with rheumatoid arthritis, unveiling a potential novel pathophysiological mechanism.

Background Little is known about the comparative effectiveness and safety of non–vitamin K antagonist oral anticoagulants (NOAC) compared to warfarin in Chinese atrial fibrillation (AF) patients. Our aim was to compare the ischemic stroke risk reduction and incidence of intracranial hemorrhage (ICH) of warfarin in relation to quality of anticoagulation control (as reflected by time in therapeutic range [TTR]), and to dabigatran and rivaroxaban in a real-world cohort of Chinese AF patients. Hypothesis NOAC, rather than warfarin, is preferred in Chinese AF patients. Methods Of 2099 patients studied (73.1 ± 12.3 years, female: 44.6%, CHA2DS2-VASc 3.7 ± 1.9 and HAS-BLED 2.0 ± 1.0) with nonvalvular AF, 963 patients (45.9%) were on warfarin (only 16.3% had TTR ≥65%), 669 patients were on rivaroxaban, and 467 patients were on dabigatran. Results After a mean follow-up of 21.7 ± 13.4 months, there were 156 ischemic strokes (annual incidence of 4.10%/year), with the incidence of ischemic stroke being highest in patients on warfarin with TTR

Background Epidemiological data for heart failure (HF) in the Chinese population is scarce. In this study, we described the clinical characteristics and outcomes of new-onset HF in our population. Methods and Results We conducted a retrospective, observational study on consecutive Chinese patients hospitalized for new-onset HF between 2005 and 2012 in our center. A total of 1940 patients (mean age, 78.2 ± 11.8 years, 54.2% female) were identified. The rate of new HF hospitalization was 0.59 per 1000 population. The most prevalent comorbidities were hypertension (69.8%) and coronary artery disease (29.3%), and 52.3% had HF with preserved ejection fraction (HFpEF). The all-cause mortality was 19.5% at 1 year, 32.1% at 2 years, and 54% at 5 years. Cardiovascular mortality was 7.2% at 1 year, 11.8% at 2 years, and 20.7% at 5 years. No difference in all-cause mortality or cardiovascular mortality was observed between those with HF with reduced ejection fraction than HFpEF. Conclusions Our patients with new-onset HF shared similar clinical characteristics with the Caucasian population. The prognosis was poor with high all-cause mortality for both HFpEF and HF with reduced ejection fraction.

Entirely leadless cardiac pacemakers that are delivered transvenously required the use of large-diameter delivery sheath and femoral venous approach. The complexity of external femoral and iliac venous anatomy may limit their implantation. We describe a hemodialysis patient without subclavian venous access and a conventional pacemaker with a failed right ventricular lead, who had difficult iliac venous anatomy that was also compressed by an external endovascular abdominal aortic stent. Successful leadless pacing using a Micra™ (Medtronic Inc., Minneapolis, MN, USA) was accomplished with a strong support wire, hydrophilic delivery sheath, and guided by venography.

The aim of the study was to evaluate the relation between tricuspid regurgitation (TR) severity and liver stiffness (LS) in patients with TR. A total of 131 patients with various degrees of TR secondary to left-sided heart valve disease were enrolled. Severity of TR was quantitatively assessed by proximal isovelocity surface area-derived effective regurgitant orifice (ERO). Patients were divided into 2 groups: 48 with mild-moderate TR (ERO0.4 cm(2)) and 83 with severe TR (ERO ≥0.4 cm(2)). Transient elastography was used to measure the level of LS, an established marker of liver fibrosis, with the threshold of significant LS set at ≥12.5 kPa. Patients with severe TR had a higher LS and prevalence of significant LS than those with mild-moderate TR. Furthermore, LS and significant LS independently correlated with TR-ERO, right atrial pressure and inferior vena cava (IVC) diameter. The presence of a large TR-ERO (≥0.4 cm(2)) and IVC diameter (2.15 cm(2)) provided a high specificity of 78% for significant LS. In conclusion, the present study demonstrates that TR-ERO, right atrial pressure, and IVC diameter are important parameters associated with LS in patients with TR.

Cremation of implanted cardiac electronic devices can be associated with explosion from rapid gas formation causing potential hazard to the crematoria staffs and facilities. We present four patients who had undergone cremation with a leadless pacemaker (MicraTM , Medtronic Inc., Minneapolis, MN, USA) left inside their bodies. There was neither reported explosion nor damage to the cremation chamber during the cremation process. In this small series, cremation of MicraTM is not associated with noticeable explosion.

Background The major risk of implanting a leadless pacemaker at the right ventricular (RV) apex is cardiac perforation. Objective The purpose of this study was to describe and prospectively evaluate the safety and feasibility of a technique for midseptal implantation of the Micra leadless pacemaker. Methods We positioned the device at the center of the cardiac silhouette in the right anterior oblique (RAO) view, toward the left in the left anterior oblique (LAO) view, and away from the sternum in the left lateral view. Results Among the 51 patients (mean age 81.3 ± 9.3 years; 47% men) included in the study, 29 (57%) were >80 years old, 7 (14%) had body mass index Conclusion In this high-risk patient cohort, midseptal implantation of a leadless pacemaker as guided by RAO, LAO, and left lateral views was achieved in 90% of patients, with a low risk of complications.

Background and Purpose—Little is known about the impact of quality of anticoagulation control, as reflected by time in therapeutic range (TTR), on the effectiveness and safety of warfarin therapy in Chinese patients with atrial fibrillation. We investigated the risks of ischemic stroke and intracranial hemorrhage (ICH) in relation to warfarin at various TTRs in a real-world cohort of Chinese patients with atrial fibrillation receiving warfarin and compared with those on dabigatran, aspirin, and no therapy.Methods—This is an observational study.Results—Of 8754 Chinese patients with atrial fibrillation and CHA2DS2-VASc ≥1 (79.5±9.2 years; CHA2DS2-VASc, 4.1±1.5; and Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile International Normalized Ratio, Elderly (>65 years), Drugs/Alcohol Concomitantly [HAS-BLED], 2.2±0.9), 16.3% received warfarin, 41.1% aspirin, 4.5% dabigatran, and 38.1% received no therapy. The incidence of ischemic stroke was highest in patients with no therapy (10.38%/y), followed by patients on aspirin (7.95%/y). The incidence of stroke decreased progressively with increasing TTR quartiles (56.2%) from 7.34%/y (first quartile) to 3.10%/y (fourth quartile). Patients on dabigatran had the lowest incidence of stroke among all groups (2.24%/y). The incidence of ICH was lowest in patients on dabigatran (0.32%/y) compared with those on warfarin (0.90%/y), aspirin (0.80%/y), and no therapy (0.53%/y). ICH incidence decreased with increasing TTR from 1.37%/y (first quartile) to 0.74%/y (fourth quartile).Conclusions—In Chinese patients with atrial fibrillation, the benefits of warfarin therapy for stroke prevention and ICH risk are closely dependent on the quality of anticoagulation, as reflected by TTR. Even at the top TTR quartile, warfarin was associated with a higher stroke and ICH risk than dabigatran.

To investigate whether the CHADS2 and CHA2DS2-VASc scores have clinical utility for prediction of adverse vascular function and vascular dysfunction-mediated incident cardiovascular (CV) events among high-risk patients without atrial fibrillation (AF), and the additional value of incorporating PR prolongation to the scores.We analyzed 579 high-risk CV outpatients without clinical AF in a prospective cohort for new-onset ischemic stroke, myocardial infarction (MI), congestive heart failure (CHF), and CV death. Brachial flow-mediated dilation (FMD) and nitroglycerin-mediated dilatation (NMD), carotid intima-media thickness (IMT) and pulse wave velocity (PWV) were determined.Baseline CHADS2 score was associated with lower FMD (Pearson r = -0.16, P0.001) and NMD (r = -0.17, P0.001), higher carotid IMT (r = 0.30, P0.001) and PWV (r = 0.35, P0.001; similar for CHA2DS2-VASc score: All P0.05). After follow-up of 63 ± 11 months, 82 patients (14.2%) developed combined CV endpoint. ROC curve analysis showed that both CHADS2 and CHA2DS2-VASc scores were predictors for ischemic stroke (C-Statistic: CHADS2 0.70, P = 0.004; CHA2DS2-VASc 0.68, P = 0.010), MI (CHADS2 0.63, P = 0.030; CHA2DS2-VASc 0.70, P = 0.001), and CV death (CHADS2 0.63, P = 0.022; CHA2DS2-VASc 0.65, P = 0.011). Higher CHADS2 score was associated with reduced event-free survival from combined CV endpoints (log-rank = 16.7, P0.001) with differences potentiated if stratified by CHA2DS2-VASc score (log-rank = 29.2, P0.001). Incorporating PR prolongation, the CHA2DS2-VASc-PR score achieved the highest C-Statistic for CV death prediction (0.70, P0.001) superior to the CHADS2 score (chi-square: 12.1, P = 0.0005).The CHADS2 and CHA2DS2-VASc predict vascular dysfunction and cardiovascular events in high-risk CV patients without clinical AF, with further improved performance incorporating PR prolongation.

Tricuspid annuloplasty (TA) is increasingly being performed, but the clinical outcome is unsatisfactory. Acute kidney injury (AKI) is a common complication following cardiac surgery and predicts outcome. Nonetheless the occurrence rate and prognostic value of AKI after TA are unclear.This study reviewed 339 consecutive patients (age 65±11 years; male 42%) who underwent TA. The incidence of AKI was defined according to risk/injury/failure/loss/end stage (RIFLE), acute kidney injury network (AKIN), and kidney disease improving global outcomes (KDIGO) criteria, respectively. Major adverse cardiovascular events (MACE) was defined as death, heart failure, stroke, and myocardial infarction (MI). The influence of AKI on MACE was evaluated as a short-term outcome and outcome beyond 30 days.The incidence of AKI, defined according to RIFLE, AKIN, and KDIGO was 57%, 52%, and 53%, respectively. MACE occurred in 94 cases (21 deaths, 63 heart failure requiring hospitalization, 7 stroke, and 3 MI). For short-term outcome, AKI defined by all three scoring systems was independently associated with MACE and death (p0.01 for both), but not heart failure, stroke, or MI. For outcome beyond 30 days, AKI by all three criteria was associated with MACE and heart failure. Only AKI by AKIN and KDIGO, but not RIFLE, was independently associated with death.Our data suggest AKI affects over half of all patients who undergo TA, and has a major and long-lasting impact on survival, MACE, and heart failure. Use of AKIN and KDIGO is more useful than the RIFLE criteria when determining the prognostic value of AKI for mortality beyond 30 days.

Tricuspid regurgitation (TR) is common in patients referred for cardiac assessment. Nonetheless, current estimates of its prevalence and contributing factors are limited. The aim of the present study was to evaluate the prevalence and demographics of TR in patients referred for echocardiography assessment at two University-affiliated hospitals.A total of 6711 consecutive Chinese patients were recruited as part of the Chinese Valvular Heart Disease Study (CVATS).The most common valvular lesion was TR (54.7%), followed by mitral regurgitation (44.7%) and aortic regurgitation (26.5%). Clinically significant (moderate or severe) TR was identified in 8.4% with the proportion increased from 3.9% amongst those aged51 to 15.9% in those aged ≥81. Multivariable adjustment demonstrated that significant TR was associated with age, congenital heart disease, chronic obstructive pulmonary disease, left-sided valvular heart disease (VHD), impaired left ventricular ejection fraction50%, atrial fibrillation and pulmonary hypertension.Among all types of VHD, TR was the most common and was identified in over half of the subjects and clinically significant in 8.4%. These unique data provide contemporary clinical and epidemiological characteristics of TR in a large cohort of patients referred for cardiac assessment and confirm the increased burden of TR in the aged population.

Background Whether PR prolongation independently predicts new-onset ischemic events of myocardial infarction and stroke was unclear. Underlying pathophysiological mechanisms of PR prolongation leading to adverse cardiovascular events were poorly understood. We investigated the role of PR prolongation in pathophysiologically-related adverse cardiovascular events and underlying mechanisms. Methods We prospectively investigated 597 high-risk cardiovascular outpatients (mean age 66 ± 11 yrs.; male 67%; coronary disease 55%, stroke 22%, diabetes 52%) for new-onset ischemic stroke, myocardial infarction (MI), congestive heart failure (CHF), and cardiovascular death. Vascular phenotype was determined by carotid intima-media thickness (IMT). Results PR prolongation >200 ms was present in 79 patients (13%) at baseline. PR prolongation >200 ms was associated with significantly higher mean carotid IMT (1.05 ± 0.37 mm vs 0.94 ± 0.28 mm, P = 0.010). After mean study period of 63 ± 11 months, increased PR interval significantly predicted new-onset ischemic stroke (P = 0.006), CHF (P = 0.040), cardiovascular death (P 200 ms. Using multivariable Cox regression, PR prolongation >200 ms independently predicted new-onset ischemic stroke (HR 8.6, 95% CI: 1.9–37.8, P = 0.005), cardiovascular death (HR 14.1, 95% CI: 3.8–51.4, P 162 ms (C-statistic 0.70, P = 0.001; HR: 8.0, 95% CI: 1.65–38.85, P = 0.010). Conclusions PR prolongation strongly predicts new-onset ischemic stroke, MI, cardiovascular death, and combined cardiovascular endpoint including CHF in coronary patients or risk equivalent. Adverse vascular function may implicate an intermediate pathophysiological phenotype or mediating mechanism. Electronic supplementary material The online version of this article (doi:10.1186/s12872-017-0667-2) contains supplementary material, which is available to authorized users.

Low vitamin D level is associated with atrial fibrillation (AF) and may be implicated in its pathogenesis.We studied single nucleotide polymorphisms (SNPs) of vitamin D mechanistic pathways and serum 25-hydroxyvitamin D [25(OH)D] levels in an age- and gender-matched case-control study (controls without AF: mean age 68.6 ± 8.7 years, female 25%; n = 1019; with AF: mean age 69.7 ± 9.5 years, female 30%; n = 156) recruited from a Chinese clinical cohort of patients with stable coronary artery disease. Twelve SNPs involved in the vitamin D mechanistic pathways were studied [biosynthetic: rs4646536, rs10877012, rs3829251, rs1790349; activation: rs2060793, rs1993116; vitamin D-binding protein (VBP)/group-specific component (GC): rs4588, rs7041, rs2282679, rs1155563; and vitamin D receptor: rs1544410, rs10735810]. A genetic risk score (GRS) (0-8) was constructed from SNPs associated with serum 25(OH)D as a proxy to lifelong vitamin D-deficient state. All 4 SNPs involved in the VBP/GC were significantly associated with serum 25(OH)D (rs4588, P 0.001; rs2282679, P 0.001; rs7041, P = 0.011; rs1155563, P 0.001; all other SNPs, P 0.05). Vitamin D GRS (points 0-8) generated from these 4 SNPs was independently predictive of serum 25(OH)D [B = 0.54, 95% confidence interval (CI) 0.30-0.79; P 0.001]. Genetically deprived vitamin D status as denoted by a low GRS (0-3) independently predicted an increased risk of AF, compared to a high GRS (4-8) (odds ratio = 1.848, 95% CI 1.217-2.805; P = 0.004).Genetically deprived vitamin D exposure predisposes to increased AF among patients with coronary artery disease. Whether VBP/GC may alter the risk of AF via alternative mechanisms warrants further studies.

Background ASSERT demonstrated that subclinical atrial fibrillation (SCAF) is common in pacemaker patients without prior AF and is associated with increased risk of ischemic stroke or systemic embolism. SCAF episodes vary in duration and little is known about the incidence of different durations of SCAF, or their prognosis. Methods and results ASSERT followed 2580 patients receiving a pacemaker or ICD, aged >65 years with hypertension, without prior AF. The effect of SCAF duration on subsequent risk of ischemic stroke or embolism was evaluated with time-dependent covariate Cox models. Patients in whom the longest SCAF was ≤6 min were excluded from the analysis (n=125). Among 2455 patients during mean follow-up of 2.5 years, the longest single episode of SCAF lasted >6 min to 6 h in 462 patients (18.8%), >6–24 h in 169 (6.9%), and >24 h in 262 (10.7%). SCAF duration >24 h was associated with a significant increased risk of subsequent stroke or systemic embolism (adjusted hazard ratio [HR] 3.24, 95% confidence interval [CI] 1.51–6.95, P=0.003). The risk of ischemic stroke or systemic embolism in patients with SCAF between 6 min and 24 h was not significantly different from patients without SCAF. Conclusions SCAF >24 h is associated with an increased risk of ischemic stroke or systemic embolism.

Background The World Heart Federation has undertaken an initiative to develop a series of Roadmaps to promote development of national policies and health systems approaches, and to identify potential roadblocks on the road to effective prevention, detection, and management of cardiovascular disease in low-and middle-income countries (LMICs) and develop strategies for overcoming these. This Roadmap focuses on atrial fibrillation (AF). AF is the most common, clinically significant arrhythmia and, among other clinical outcomes, is associated with increased risk of stroke. Methods Development of this Roadmap included a review of published guidelines and research papers, and consultation with an expert committee comprising experts in clinical management of AF and health systems research in LMICs. The Roadmap identifies 1) key interventions for detection, diagnosis, and management of AF; 2) gaps in implementation of these interventions (knowledge-practice gaps); 3) health system roadblocks to implementation of AF interventions in LMICs; and 4) potential strategies for overcoming these. Results More research is needed on determinants and primary prevention of AF. Knowledge-practice gaps for detection, diagnosis, and management of AF are present worldwide, but may be more prominent in LMICs. Potential barriers to implementation of AF interventions include long distances to health facilities, shortage of health care professionals with training in AF, including interpretation of ECG, unaffordability of oral anticoagulants for patient households, reluctance on the part of physicians to initiate oral anticoagulant (OAC) therapy, and lack of awareness of the importance of persistent adherence to OAC therapy. Potential solutions include training of nonphysician health workers and pharmacists in pulse-taking, use of telemedicine technologies to transmit electrocardiogram results, engagement of nonphysician health workers in OAC therapy adherence support, and country-specific support and education programs for noncardiologist health care professionals. Conclusions AF affects millions of people worldwide and, left untreated, increases the risk and severity of stroke and heart failure. Although guidelines for the detection, diagnosis, and management of AF exist, there are gaps in implementation of these guidelines globally, and in particular in LMICs. This Roadmap identifies some potential solutions that may improve AF outcomes in LMICs but require further evaluation in these settings.

Ictal asystole due to sinus node suppression is a cause of sudden unexplained death in epilepsy. Here, for the first time, we describe a complete atrioventricular nodal block in a patient with non-compressive traumatic subdural hematoma, who developed ictal asystole as a delayed presentation. A leadless VVI pacemaker (ventricular paced, ventricular sensed, and pacing inhibited in response to a sensed beat) was implanted as a preventive measure against seizure-related heart block.

The first cardiac implantable electronic device (CIED), the electronic pacemaker, maintains cardiac contraction during bradycardia. The implantable cardioverter-defibrillator (ICD) manages ventricular tachycardia (VT) or fibrillation (VF) and saves lives primarily through the use of high-energy shocks. The cardiac resynchronization therapy (CRT) device restores interventricular and intraventricular dyssynchrony in patients with heart failure (HF). Despite >50 years of pacing and 40 years of ICD therapy, the lead remains the weakest link between the device and the patient. Although CRT reduces mortality and morbidity in HF, it is applicable only to those patients with systolic left ventricular (LV) dysfunction and wide QRS complex, especially left bundle-branch block. At best, only 70% of such patients respond, and the majority of patients without left bundle-branch block or with nonsystolic HF derive no benefit from CRT. Early detection of worsening HF with implantable sensors enables corrective therapy to avert acute decompensated HF. Implantable cardiac monitors (ICMs) allow monitoring of arrhythmias such as atrial fibrillation (AF). Despite their efficacy at eliminating the risk of sudden cardiac death (SCD) in the highest-risk patient, ICDs currently have a limited role in reducing the overall burden of SCD, and ICM has the potential for early identification of asymptomatic subjects at risk of SCD to derive benefit from ICD. An increasing cause of SCD is pulseless electric activity (PEA), and alternative management other than defibrillation will be required. This review addresses the recent exciting development of CIEDs in response to these unmet clinical needs such as leadless and endocardial pacing, subcutaneous ICD (S-ICD), low-energy multistage electrotherapy for VT and AF, intermediate-strength stimulation for PEA, early detection of VT, sensors for HF monitoring, and novel therapies for arrhythmias and HF. ### Limitations of Cardiac Pacing With Current Pacemakers and CRT Despite the significant improvements in device longevity, reliability, size/profile, and ease of implantation over the last 50 years, implanting a pacemaker …

Background— During follow-up of between 1 and 3 years in the Randomized Evaluation of Long-term Anticoagulation Therapy (RE-LY) trial, 2 doses of dabigatran etexilate were shown to be effective and safe for the prevention of stroke or systemic embolism in patients with atrial fibrillation. There is a need for longer-term follow-up of patients on dabigatran and for further data comparing the 2 dabigatran doses. Methods and Results— Patients randomly assigned to dabigatran in RE-LY were eligible for the Long-term Multicenter Extension of Dabigatran Treatment in Patients with Atrial Fibrillation (RELY-ABLE) trial if they had not permanently discontinued study medication at the time of their final RE-LY study visit. Enrolled patients continued to receive the double-blind dabigatran dose received in RE-LY, for up to 28 months of follow up after RE-LY (median follow-up, 2.3 years). There were 5851 patients enrolled, representing 48% of patients originally randomly assigned to receive dabigatran in RE-LY and 86% of RELY-ABLE–eligible patients. Rates of stroke or systemic embolism were 1.46% and 1.60%/y on dabigatran 150 and 110 mg twice daily, respectively (hazard ratio, 0.91; 95% confidence interval, 0.69–1.20). Rates of major hemorrhage were 3.74% and 2.99%/y on dabigatran 150 and 110 mg (hazard ratio, 1.26; 95% confidence interval, 1.04–1.53). Rates of death were 3.02% and 3.10%/y (hazard ratio, 0.97; 95% confidence interval, 0.80–1.19). Rates of hemorrhagic stroke were 0.13% and 0.14%/y. Conclusions— During 2.3 years of continued treatment with dabigatran after RE-LY, there was a higher rate of major bleeding with dabigatran 150 mg twice daily in comparison with 110 mg, and similar rates of stroke and death. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00808067.

Background and Purpose— Intracranial hemorrhage rates are higher in Asians than non-Asians, especially in patients receiving warfarin. This randomized evaluation of long-term anticoagulation therapy subgroup analysis assessed dabigatran etexilate (DE) and warfarin effects on stroke and bleeding rates in patients from Asian and non-Asian countries. Methods— There were 2782 patients (15%) from 10 Asian countries and 15 331 patients from 34 non-Asian countries. A Cox regression model, with terms for treatment, region, and their interaction was used. Results— Rates of stroke or systemic embolism in Asians were 3.06% per year on warfarin, 2.50% per year on DE 110 mg BID (DE 110), and 1.39% per year on DE 150 mg BID (DE 150); in non-Asians, the rates were 1.48%, 1.37%, and 1.06% per year with no significant treatment-by-region interactions. Hemorrhagic stroke on warfarin occurred more often in Asians than non-Asians (hazard ratio [HR], 2.4; 95% confidence interval [CI], 1.3–4.7; P =0.007), with significant reductions for DE compared with warfarin in both Asian (DE 110 versus warfarin HR, 0.15; 95% CI, 0.03–0.66 and DE 150 versus warfarin HR, 0.22; 95% CI, 0.06–0.77) and non-Asian (DE 110 versus warfarin HR, 0.37; 95% CI, 0.19–0.72 and DE 150 versus warfarin HR, 0.28; 95% CI, 0.13–0.58) patients. Major bleeding rates in Asians were significantly lower on DE (both doses) than warfarin (warfarin 3.82% per year, DE 110 2.22% per year, and DE 150 2.17% per year). Conclusions— Hemorrhagic stroke rates were higher on warfarin in Asians versus non-Asians, despite similar blood pressure, younger age, and lower international normalized ratio values. Hemorrhagic strokes were significantly reduced by DE in both Asians and non-Asians. DE benefits were consistent across Asian and non-Asian subgroups. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00262600.

Early identification of individuals who are at risk of developing atrial fibrillation (AF) and ischemic stroke may enable a closer surveillance and thus prompt initiation of oral anticoagulation for stroke prevention.This study sought to investigate whether congestive heart failure, hypertension, age ≥ 75 years, diabetes, previous stroke (CHADS2) and CHA2DS2-vascular disease, age 65-74 years, sex category (CHA2DS2-VASc) scores can predict new-onset AF and/or ischemic stroke in patients presenting with arrhythmic symptoms.We prospectively followed up 528 patients (68.5 ± 10.6 years, male 46.2 %) presented for assessment of arrhythmic symptoms but without any documented arrhythmia, including AF for development of new-onset AF and/or ischemic stroke. Their mean CHADS2 and CHA2DS2-VASc scores on presentation were 1.3 ± 1.3 and 2.3 ± 1.5, respectively. After 6.1 years, 89 patients (16.8 %, 2.77 per 100 patient-years) had documented AF, and 65 patients (12.3 %, 2.0 per 100 patient-years) suffered stroke. Both the CHADS2 (C statistic 0.63, 95 % confidence interval (CI) 0.58-0.67, P 0.0001, optimal cutoff at 1) and CHA2DS2-VASc (C statistic 0.63, 95 % CI 0.59-0.67, P 0.0001, optimal cutoff at 2) scores provided similar prediction for the new-onset AF. Similarly, CHADS2 (C statistic 0.69, 95 % CI 0.65-0.73, P 0.0001, optimal cutoff at 2) and CHA2DS2-VASc (C statistic 0.69, 95 % CI 0.65-0.73, P 0.0001, optimal cutoff at 2) have compatible efficacy for stroke prediction in this Chinese population.The CHADS2 and CHA2DS2-VASc scores can be used in patients who presented with arrhythmic symptoms to identify those who are at risk with developing new-onset clinical AF and ischemic stroke for close clinical surveillance and early intervention.