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Introduction: Approximately 500.000 people in Europe sustain cardiac arrest (CA) every year, being myocardial infarction the main etiology. Interest has been raised in a new approach to refractory cardiac arrest (rCA) using extra-corporeal oxygenation (ECMO). In settings where it can be rapidly implemented, ECMO assisted resuscitation (ECPR) may be considered. Additionally, donation after circulatory death, which seeks to obtain solid organs donation from patients suffering rCA, has increased its role effectively increasing the pool of donors. Combined programs with integration of ECPR and uncontrolled donation after circulatory determination of death (uDCDD) are worldwide limited and experience integrating these two techniques is lacking. Methods: We report a 24 months experience of ECPR and uDCDD kidney transplantation based on a management protocol in a university teaching hospital in the urban area of Lisbon. Results: Over a period of 24 months, 58 patients were admitted to our ICU with rCA, 6 (10%) in the ECPR program and 52 (90%) in the uDCDD. Seventy-eight percent of patients were male, with an average age of 49 year-old. CA was witnessed in 83% of cases and initial rhythm was ventricular fibrillation in 20 cases (35%). 13 (25%) patients were effective organ donors. Refusal for effective donation was mainly due to prior comorbidities. Discussion: The development of an integrated program for ECPR and uDCDD is feasible and requires a well-established and efficient activation program. In an era of significant organ shortage, it provides a viable option for increasing the organ donation pool, with promising results. [ABSTRACT FROM AUTHOR]

Background and Aims Implantable cardioverter-defibrillators (ICDs) are critical for preventing sudden cardiac death (SCD) in arrhythmogenic right ventricular cardiomyopathy (ARVC). This study aims to identify cross-continental differences in utilization of primary prevention ICDs and survival free from sustained ventricular arrhythmia (VA) in ARVC. Methods This was a retrospective analysis of ARVC patients without prior VA enrolled in clinical registries from 11 countries throughout Europe and North America. Patients were classified according to whether they received treatment in North America or Europe and were further stratified by baseline predicted VA risk into low- (<10%/5 years), intermediate- (10%–25%/5 years), and high-risk (>25%/5 years) groups. Differences in ICD implantation and survival free from sustained VA events (including appropriate ICD therapy) were assessed. Results One thousand ninety-eight patients were followed for a median of 5.1 years; 554 (50.5%) received a primary prevention ICD, and 286 (26.0%) experienced a first VA event. After adjusting for baseline risk factors, North Americans were more than three times as likely to receive ICDs {hazard ratio (HR) 3.1 [95% confidence interval (CI) 2.5, 3.8]} but had only mildly increased risk for incident sustained VA [HR 1.4 (95% CI 1.1, 1.8)]. North Americans without ICDs were at higher risk for incident sustained VA [HR 2.1 (95% CI 1.3, 3.4)] than Europeans. Conclusions North American ARVC patients were substantially more likely than Europeans to receive primary prevention ICDs across all arrhythmic risk strata. A lower rate of ICD implantation in Europe was not associated with a higher rate of VA events in those without ICDs. [ABSTRACT FROM AUTHOR]

Out-of-hospital cardiac arrest (OHCA) continues to be a major global cause of death, affecting approximately 67 to 170 per 100,000 inhabitants annually in Europe, with a persisting high rate of mortality of up to 90% in most countries. Acute coronary syndrome (ACS) represents one of the most significant cause of cardiac arrest, and therefore invasive coronary angiography (CAG) with subsequent percutaneous coronary intervention (PCI) has emerged as a fundamental component in the management of OHCA patients. Recent evidence from large randomized controlled trials (RCTs) challenges the routine use of early CAG in the larger subgroup of patients with non-ST segment elevation myocardial infarction (NSTEMI). Additionally, emerging data suggest that individuals resuscitated from OHCA related to ACS face an elevated risk of thrombotic and bleeding events. Thus, specific invasive coronary strategies and anti-thrombotic therapies tailored to this unique setting of OHCA need to be considered for optimal in-hospital management. We sought to provide an overview of the prevalence and complexity of coronary artery disease observed in this specific population, discuss the rationale and timing for CAG after return of spontaneous circulation (ROSC), summarize invasive coronary strategies, and examine recent findings on antithrombotic therapies in the setting of ACS complicated by OHCA. By synthesizing the existing knowledge, this review aims to contribute to the understanding and optimization of care for OHCA patients to improve outcomes in this challenging clinical scenario. [ABSTRACT FROM AUTHOR]

Sudden deaths in competitive athletes are highly visible but potentially preventable events that generate great interest amongst the cardiovascular community and general public. Internet searches were performed using a combination of keywords and operators to produce search results for sudden death or cardiac arrest on the field in professional soccer players. We identified 35 male professional soccer players (mean age 26 ± 5 years) who experienced collapse and cardiac arrest on the field (most during matches) in Europe from December 2002 to February 2022 with 63% in the last 6 years. Twenty-five have died on the field or later in a hospital despite cardiopulmonary resuscitation. Of the 10 survivors, eight were implanted with cardioverter-defibrillators for secondary (n = 6) or primary (n = 2) prevention and returned to full competition; five of the 8 required successful device therapy during matches or training. Cardiac arrest and sudden death can occur not uncommonly in professional athletes highly trained over decades and participating at an elite sports level. Our observations also underscore the importance of targeted preparticipation cardiovascular screening, and availability of external defibrillators on the playing field. [ABSTRACT FROM AUTHOR]

The article discusses changes to the European Resuscitation Council guidelines for adult resuscitation. Topics include that about 8 percent of people having an out-of-hospital cardiac arrest survive to discharge; and the need to use a stepwise approach to airway management, moving on to more advanced techniques only if ventilation fails.

Objective: Most cardiac arrest patients who are successfully resuscitated are initially comatose due to hypoxic-ischemic brain injury. Quantitative electroencephalography (EEG) provides valuable prognostic information. However, prior approaches largely rely on snapshots of the EEG, without taking advantage of temporal information. Methods: We present a recurrent deep neural network with the goal of capturing temporal dynamics from longitudinal EEG data to predict long-term neurological outcomes. We utilized a large international dataset of continuous EEG recordings from 1,038 cardiac arrest patients from seven hospitals in Europe and the US. Poor outcome was defined as a Cerebral Performance Category (CPC) score of 3-5, and good outcome as CPC score 0-2 at 3 to 6-months after cardiac arrest. Model performance is evaluated using 5-fold cross validation. Results: The proposed approach provides predictions which improve over time, beginning from an area under the receiver operating characteristic curve (AUC-ROC) of 0.78 (95% CI: 0.72-0.81) at 12 hours, and reaching 0.88 (95% CI: 0.85-0.91) by 66 h after cardiac arrest. At 66 h, (sensitivity, specificity) points of interest on the ROC curve for predicting poor outcomes were (32,99)%, (55,95)%, and (62,90)%, (99,23)%, (95,47)%, and (90,62)%; whereas for predicting good outcome, the corresponding operating points were (17,99)%, (47,95)%, (62,90)%, (99,19)%, (95,48)%, (70,90)%. Moreover, the model provides predicted probabilities that closely match the observed frequencies of good and poor outcomes (calibration error 0.04). Conclusions and Significance: These findings suggest that accounting for EEG trend information can substantially improve prediction of neurologic outcomes for patients with coma following cardiac arrest. [ABSTRACT FROM AUTHOR]

Aims The European Association of Cardiovascular Imaging (EACVI) Scientific Initiatives Committee performed a global survey to evaluate current practice for the assessment and management of patients with hypertrophic cardiomyopathy (HCM). Methods and results A total of 213 centres from 38 different countries (87% European) responded to the survey. One hundred twenty-one (57%) centres followed HCM patients in a general cardiology outpatient clinic and 85 (40%) centres in a specialized HCM/cardiomyopathy clinic. While echocardiography was the primary imaging modality, cardiovascular magnetic resonance (CMR) has become an important complementary tool. Cardiac anatomy, left ventricular (LV) systolic, and diastolic function were assessed according to current European guidelines and recommendations. To evaluate LV obstruction, 49% of the centres performed bedside provocation manoeuvres in every patient and 55% of the centres used exercise stress echocardiography. The majority of centres used the 5-year risk assessment of sudden cardiac death (SCD) calculated with the HCM Risk-SCD score. However, 34% of the centres also used extensive non-infarct late gadolinium enhancement on CMR and 27% the presence of LV apical aneurysm to help select patients for primary prevention implantable cardioverter-defibrillator therapy. Ninety-nine percent of the responding centres performed regular imaging follow-up of HCM patients. Conclusion Most centres followed European guidelines and recommendations for the diagnosis and management of patients with HCM. The importance of bedside provocation manoeuvres and exercise stress echocardiography to diagnose LV outflow obstruction requires emphasis. Additional risk markers for SCD are used in many centres and might indicate the need for an update of current European recommendations. [ABSTRACT FROM AUTHOR]

Objective: Elucidate how physicians formulate a neurological prognosis after cardiac arrest and compare differences between experts and general providers.Methods: We performed semi-structured interviews with experts in post-arrest care and general physicians. We created an initial model and interview guide based on professional society guidelines. Two authors independently coded interviews based on this initial model, then identified new topics not included in it. To describe individual physicians' cognitive approach to prognostication, we created a graphical representation. We summarized these individual "mental models" into a single overall model, as well as two models stratified by expertise.Results: We performed 36 interviews (17 experts and 19 generalists), most of whom practice in Europe (23) or North America (12). Participants described their approach to prognosis formulation as complex and iterative, with sequential and repeated data acquisition, interpretation, and prognosis formulation. Eventually, this cycle results in a final prognosis and treatment recommendation. Commonly mentioned factors were diagnostic test performance, time from arrest, patient characteristics. Participants also discussed factors rarely discussed in prognostication research including physician and hospital characteristics. We found no substantial differences between experts and general physicians.Conclusion: Physicians' cognitive approach to neurologic prognostication is complex and influenced by many factors, including some rarely considered in current research. Understanding these processes better could inform interventions designed to aid physicians in prognostication. [ABSTRACT FROM AUTHOR]

Aims Sudden death is a leading cause of mortality in heart failure with reduced ejection fraction (HFrEF). In PARADIGM-HF, sacubitril/valsartan reduced the incidence of sudden death. The purpose of this post hoc study was to analyse the effect of sacubitril/valsartan, compared to enalapril, on the incidence of ventricular arrhythmias. Methods and results Adverse event reports related to ventricular arrhythmias were examined in PARADIGM-HF. The effect of randomized treatment on two arrhythmia outcomes was analysed: ventricular arrhythmias and the composite of a ventricular arrhythmia, implantable cardioverter defibrillator (ICD) shock or resuscitated cardiac arrest. The risk of death related to a ventricular arrhythmia was examined in time-updated models. The interaction between heart failure aetiology, or baseline ICD/cardiac resynchronization therapy-defibrillator (CRT-D) use, and the effect of sacubitril/valsartan was analysed. Of the 8399 participants, 333 (4.0%) reported a ventricular arrhythmia and 372 (4.4%) the composite arrhythmia outcome. Ventricular arrhythmias were associated with higher mortality. Compared with enalapril, sacubitril/valsartan reduced the risk of a ventricular arrhythmia (hazard ratio [HR] 0.76, 95% confidence interval [CI] 0.62-0.95; p = 0.015) and the composite arrhythmia outcome (HR 0.79, 95% CI 0.65-0.97; p = 0.025). The treatment effect was maintained after adjustment and accounting for the competing risk of death. Baseline ICD/CRT-D use did not modify the effect of sacubitril/valsartan, but aetiology did: HR in patients with an ischaemic aetiology 0.93 (95% CI 0.71-1.21) versus 0.53 (95% CI 0.37-0.78) in those without an ischaemic aetiology (p for interaction = 0.020). Conclusions Sacubitril/valsartan reduced the incidence of investigator-reported ventricular arrhythmias in patients with HFrEF. This effect may have been greater in patients with a non-ischaemic aetiology. [ABSTRACT FROM AUTHOR]

The aims of this centre-based survey, promoted and disseminated by the European Heart Rhythm Association (EHRA) was to investigate the current practice for the investigation of Sudden Unexplained Death in the Young (SUDY) amongst European countries. An online questionnaire composed of 21 questions was submitted to the EHRA Research Network, European Cardiac Arrhythmia Genetics (ECGen) Focus Group members, and European Reference Network GUARD-Heart healthcare partners. There were 81 respondents from 24 European countries. The majority (78%) worked in a dedicated clinic focusing on families with inherited cardiac conditions and/or SUDY or had easy access to a nearby one. On average, an autopsy was performed in 43% of SUDY cases. Macroscopic examination of the body and all organs were completed in 71% of cases undergoing autopsy, and expert cardiac examination in 32%. Post-mortem genetic testing was requested on average in 37% of Sudden Arrhythmic Death Syndrome (SADS) cases, but not at all by 20% of survey respondents. Psychological support and bereavement counselling for SADS/SUDY families were available for ≤50% of participants. Whilst electrocardiogram (ECG) and echocardiography were largely employed to investigate SADS relatives, there was an inconsistent approach to the use of provocative testing with exercise ECG, sodium channel blocking drugs, and/or epinephrine and genetic testing. The survey highlighted a significant heterogeneity of service provision and variable adherence to current recommendations for the investigation of SUDY, partly attributable to the availability of dedicated units and specialist tests, genetic evaluation, and post-mortem examination. [ABSTRACT FROM AUTHOR]

A 59-year-old male was found dead at home, with two empty vials of an oily preparation obtained from a manufacturer from East Europe. There was no label on the vial. The subject was a former weightlifter, also known as an anabolic steroids abuser. The local prosecutor ordered a body examination, which was unremarkable, and allowed collecting femoral blood, urine and scalp hair (6 cm, brown). He was treated for cardiac insufficiency with quinidine. Biological specimens were submitted not only to standard toxicological analyses including a screening with liquid chromatography (LC)–quadrupole time of flight, but also to a specific LC–tandem mass spectrometry method for anabolic steroids testing. Ethanol was not found in both blood and urine. Quinidine blood concentration (791 ng/mL) was therapeutic. No drug of abuse was identified. In blood, testosterone was less that 1 ng/mL and no other steroid was identified. In urine, testosterone/epitestosterone was 1.56 and boldenone was present at a concentration of 9 ng/mL. The hair test results, performed on the whole length, demonstrated repetitive steroids abuse, including not only testosterone (140 pg/mg), testosterone propionate (605 pg/mg) and testosterone decanoate (249 pg/mg), but also boldenone (160 pg/mg), trenbolone (143 pg/mg) and metandienone (60 pg/mg). Since forensic laboratories have limited access to steroid urinary metabolite reference material due to specific regulations (to avoid testing athletes before anti-doping verifications), hair analyses seem to be the best approach to document anabolic agents abuse. Indeed, in hair, the target drug is the parent compound; in addition, when compared to blood or urine, this matrix has a much larger window of detection. The pathologist concluded cardiac insufficiency in a context involving repetitive abuse of anabolic drugs. This case indicates that more attention should be paid to anabolic steroids, in a context of sudden cardiac death. [ABSTRACT FROM AUTHOR]

The new guideline on acute coronary syndrome (ACS) of the European Society of Cardiology (ESC) replaces two separate guidelines on ST-elevation myocardial infarction (STEMI) and non-ST-elevation (NSTE) ACS. This change of paradigm reflects the experts view that the ACS is a continuum, starting with unstable angina and ending in cardiogenic shock or cardiac arrest due to severe myocardial ischemia. Secondary, partly non-atherosclerotic-caused myocardial infarctions ("type 2") are not integrated in this concept.With respect to acute care in the setting of emergency medicine and the chest pain unit structures, the following new aspects have to be taken into account:1. New procedural approach as "think A.C.S." meaning "abnormal ECG," "clinical context," and "stable patient"2. New recommendation regarding a holistic approach for frail patients3. Revised recommendations regarding imaging and timing of invasive strategy in suspected NSTE-ACS4. Revised recommendations for antiplatelet and anticoagulant therapy in STEMI5. Revised recommendations for cardiac arrest and out-of-hospital cardiac arrest6. Revised recommendations for in-hospital management (starting in the CPU/ED) and ACS comorbid conditionsIn summary, the changes are mostly gradual and are not based on extensive new evidence, but more on focused and healthcare process-related considerations., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Paliperidone palmitate (PP), a long‐acting intramuscular formulation of paliperidone, has been marketed in Europe within the last 10 years and provides an important treatment option for patients with schizophrenia. Our aim was to describe PP-related adverse drug reactions (ADRs) leading to death or life-threatening events, specifying their main clinical and pharmacological characteristics. This observational study was a retrospective review of PP-related ADRs in the French pharmacovigilance database between January 1, 2013, and December 31, 2019. Out of 473 PP-related ADRs, we identified 13 deaths and 14 life-threatening events. ADRs were primarily cardiorespiratory (n = 17; 63%). Other symptoms observed were mainly metabolic (n = 4), digestive (n = 4), and neurological (n = 4). Cardiorespiratory symptoms were generally observed within first 6 months after initiation of treatment (11 out of 17 cases), unlike metabolic disorders (all 4 cases 12–21 months after initiation). Cardiac arrests and sudden unexpected deaths occurred 10–14 days after the last PP once-monthly injection (23 cases) or 11–24 days after the last PP three-monthly injection (remaining 4 cases). No PP blood concentration assays were performed for these patients. In this study, PP-related ADRs leading to death or life-threatening events mainly presented with cardiorespiratory symptoms and tended to occur in the first 6 months after the initiation of treatment and within postadministration periods aligned with peak plasma PP concentrations. The hypothesis of supratherapeutic drug concentrations following intramuscular PP injection must be raised. PP-related ADRs leading to death or life-threatening events mainly presented with cardiorespiratory symptoms. Cardiac arrests and sudden unexpected deaths following initiation of PP treatment could be due to supratherapeutic drug concentrations. This study highlights the need to monitor blood concentrations of PP. Adverse reactions to paliperidone palmitate can lead to death or life-threatening events. It is hypothesized that cardiac arrests and sudden unexpected deaths following initiation of paliperidone palmitate treatment could be due to supratherapeutic drug concentrations. This paper proposes the need to monitor blood concentrations of paliperidone palmitate in future studies. [ABSTRACT FROM AUTHOR]

Out‐of‐hospital cardiac arrest (OHCA) is a major cause of death in the Western world with an estimated number of 275 000 treated with resuscitation attempts by the Emergency Medical Services (EMS) in Europe each year. Overall survival rates remain low, and most studies indicate that around 1 out 10 will survive to 30 days. Amongst the strongest factors associated with survival in OHCA is first recorded rhythm amendable to defibrillation, early defibrillation and prompt initiation of cardiopulmonary resuscitation (CPR). Overall, CPR started prior to EMS arrival has repeatedly been shown to be associated with survival rates 2–3 times higher compared with no such initiation. The primary goal of CPR is to generate sufficient blood flow to vital organs, mainly the brain and heart, until restoration of spontaneous circulation can be achieved. Barriers to the initiation of CPR by bystanders in OHCA include fear of being incapable, causing harm, and transmission of infectious diseases. Partly due to these barriers, and low rates of CPR, the concept of CPR with compression only was proposed as a simpler form of resuscitation with the aim to be more widely accepted by the public in the 1990s. But how reliable is the evidence supporting this simpler form of CPR, and are the outcomes after CO‐CPR comparable to standard CPR? [ABSTRACT FROM AUTHOR]

In this section of the European Resuscitation Council Guidelines 2021, key information on the epidemiology and outcome of in and out of hospital cardiac arrest are presented. Key contributions from the European Registry of Cardiac Arrest (EuReCa) collaboration are highlighted. Recommendations are presented to enable health systems to develop registries as a platform for quality improvement and to inform health system planning and responses to cardiac arrest. [ABSTRACT FROM AUTHOR]

Informed by a series of systematic reviews, scoping reviews and evidence updates from the International Liaison Committee on Resuscitation, the 2021 European Resuscitation Council Guidelines present the most up to date evidence-based guidelines for the practice of resuscitation across Europe. The guidelines cover the epidemiology of cardiac arrest; the role that systems play in saving lives, adult basic life support, adult advanced life support, resuscitation in special circumstances, post resuscitation care, first aid, neonatal life support, paediatric life support, ethics and education. [ABSTRACT FROM AUTHOR]

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Background: The American College of Cardiology Interventional Council published consensus-based recommendations to help identify resuscitated cardiac arrest patients with unfavorable clinical features in whom invasive procedures are unlikely to improve survival.Objectives: This study sought to identify how many unfavorable features are required before prognosis is significantly worsened and which features are most impactful in predicting prognosis.Methods: Using the INTCAR (International Cardiac Arrest Registry), the impact of each proposed "unfavorable feature" on survival to hospital discharge was individually analyzed. Logistic regression was performed to assess the association of such unfavorable features with poor outcomes.Results: Seven unfavorable features (of 10 total) were captured in 2,508 patients successfully resuscitated after cardiac arrest (ongoing cardiopulmonary resuscitation and noncardiac etiology were exclusion criteria in our registry). Chronic kidney disease was used in lieu of end-stage renal disease. In total, 39% survived to hospital discharge. The odds ratio (OR) of survival to hospital discharge for each unfavorable feature was as follows: age >85 years OR: 0.30 (95% CI: 0.15 to 0.61), time-to-ROSC >30 min OR: 0.30 (95% CI: 0.23 to 0.39), nonshockable rhythm OR: 0.39 (95% CI: 0.29 to 0.54), no bystander cardiopulmonary resuscitation OR: 0.49 (95% CI: 0.38 to 0.64), lactate >7 mmol/l OR: 0.50 (95% CI: 0.40 to 0.63), unwitnessed arrest OR: 0.58 (95% CI: 0.44 to 0.78), pH <7.2 OR: 0.78 (95% CI: 0.63 to 0.98), and chronic kidney disease OR: 0.96 (95% CI: 0.70 to 1.33). The presence of any 3 or more unfavorable features predicted <40% survival. Presence of the 3 strongest risk factors (age >85 years, time-to-ROSC >30 min, and non-ventricular tachycardia/ventricular fibrillation) together or ≥6 unfavorable features predicted a ≤10% chance of survival to discharge.Conclusions: Patients successfully resuscitated from cardiac arrest with 6 or more unfavorable features have a poor long-term prognosis. Delaying or even forgoing invasive procedures in such patients is reasonable. [ABSTRACT FROM AUTHOR]

Aim: Predicting the return of spontaneous circulation (ROSC) during cardiopulmonary resuscitation in victims of cardiac arrest (CA) remains challenging. Cerebral regional oxygen saturation (rSO2) measured during resuscitation is feasible, and higher initial and overall values seem associated with ROSC. However, these observations were limited to the analysis of few small single-centre studies. There is a growing number of studies evaluating the role of cerebral rSO2 in the prediction of ROSC.Methods: We conducted an updated meta-analysis aimed at investigating the association of initial and overall values of cerebral rSO2 with ROSC after CA. We performed subgroups analyses according to the location of CA and conducted a secondary analysis according to the country where the study was conducted (resuscitation practice varies greatly for out-of-hospital CA).Results: We included 17 studies. Higher initial rSO2 values (11 studies, n = 2870, 16.6% achieved ROSC) were associated with ROSC: Mean Difference (MD) -11.54 [95%Confidence Interval (CI)-20.96, -2.12]; p = 0.02 (I2 = 97%). The secondary analysis confirmed this finding when pooling together European and USA studies, but did not for Japanese studies (p = 0.06). One multi-centre Japanese study was an outlier with large influence on 95%CI. Higher overall rSO2 values during resuscitation (9 studies, n = 894, 33.7% achieving ROSC) were associated with ROSC: MD-10.38; [-13.73, -7.03]; p < 0.00001 (I2 = 77%). All studies were conducted in Europe/USA.Conclusions: This updated meta-analysis confirmed the association between higher initial and overall values of cerebral rSO2 and ROSC after CA. However, we found geographical differences, since this association was not present when Japanese studies were analysed separately. [ABSTRACT FROM AUTHOR]

Background: We conducted a rapid review of current international and Australian advanced life support (ALS) guidelines for cardiac arrest associated with anaphylaxis to (1) assess the variation and (2) determine if a systematic review update of ALS guideline recommendations is warranted.Method: A search and comparison of key recommendations was conducted for major international and Australian clinical guidelines, including member societies and councils of the World Allergy Organisation and the International Liaison Committee on Resuscitation (ILCOR). Systematic database searches (Medline, Cochrane Database of Systematic Reviews, PROSPERO international register of systematic reviews and ClinicalTrials.gov databases) was conducted to identify existing and in-progress research published on the topic of anaphylaxis and cardiac arrest.Results: Eight international guidelines were identified from Australia/New Zealand, Europe, United States and Canada, and 5 national guidelines were identified for Australia. There was general consensus across all guidelines for the use of adrenaline, oxygen, patient positioning and glucagon. There was variation across international and Australian guidelines for adrenaline dosing and frequency, antihistamines and corticosteroid recommendations. Most recommendations were based on low-level evidence, and the review of published systematic reviews and clinical trials identified new evidence in the last decade.Conclusions: We found significant variation between current ALS guideline recommendations for treating anaphylaxis. While there is no new evidence to suggest a systematic review of guideline recommendations is needed, there may be an opportunity to produce more consistent international guideline recommendations and educational materials. [ABSTRACT FROM AUTHOR]

To describe current practices in European Paediatric Intensive Care Units (PICUs) regarding neuro-prognostication in comatose children after cardiac arrest (CA). An anonymous online survey was conducted among members of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC) and the European Paediatric Neurology Society (EPNS) throughout January and February 2019. The survey consisted of 49 questions divided into 4 sections: general information, cardiac arrest, neuro-prognostication and follow-up. The survey was sent to 1310 EPNS and 611 ESPNIC members. Of the 108 respondents, 71 (66%) (23 countries, 45 PICUs) completed the "neuro-prognostication" section. Eight PICUs (20%) had a local neuro-prognostication guideline. The 3 methods considered as most useful were neurological examination (92%), magnetic resonance imaging (MRI) (82%) and continuous electroencephalography (cEEG) (45%). In 50% a Pediatric Cerebral Performance Category (PCPC) score ≥ 4 was considered as poor neurological outcome. In 63% timing of determining neurological prognosis was based on the individual patient. Once decided that neurological prognosis was futile, 55% indicated that withdrawing life-sustaining therapy (WLST) was (one of) the options, whereas 44% continued PICU treatment (with or without restrictions). In 28 PICUs (68%) CA-survivors were scheduled for follow-up visits. Local guidelines for neuro-prognostication in comatose children after CA are uncommon. Methods to assess neurological outcome were mainly neurological examination, MRI and cEEG. Consequences of poor outcome differed between respondents. Inaccuracies in neuro-prognostication can result in premature WLST, thereby biasing outcome research and creating a self-fulfilling cycle. Further research is needed to develop scientifically based international guidelines for neuro-prognostication in comatose children after CA. • Neuro-prognostication guidelines in comatose cardiac arrest survivors are uncommon. • Neurologic exam, MRI and cEEG are considered most useful in order to prognosticate. • Once decided the prognosis is futile, treatment consequences differed across Europe. [ABSTRACT FROM AUTHOR]

The electrocardiogram (ECG) is cheap and widely available but its use as a screening tool for early identification of athletes with a cardiac disease at risk of sudden cardiac death is controversial because of presumed low specificity. In the last decade, several efforts have been made to improve the distinction between physiological and pathological ECG findings in the athlete, leading to continuous evolution of the interpretation criteria. The most recent 2017 International criteria grouped ECG changes into three categories: normal, borderline, and abnormal. Borderline findings warrant further investigations only when two or more are present while abnormal changes should always be considered as the sign of a possible underlying disease. This review encompasses the evolution of the athlete's ECG interpretation criteria and highlights areas of uncertainty that will need to be addressed by further studies. [ABSTRACT FROM AUTHOR]

Background: In-hospital cardiac arrest is a major cause of death in European countries, and survival of patients remains low ranging from 20% to 25%. Aims: The purpose of this study was to assess healthcare professionals' knowledge on cardiopulmonary resuscitation among university hospitals in 12 European countries and correlate it with the return of spontaneous circulation rates of their patients after in-hospital cardiac arrest. Methods and results: A total of 570 healthcare professionals from cardiology, anaesthesiology and intensive care medicine departments of European university hospitals in Italy, Poland, Hungary, Belgium, Spain, Slovakia, Germany, Finland, The Netherlands, Switzerland, France and Greece completed a questionnaire. The questionnaire consisted of 12 questions based on epidemiology data and cardiopulmonary resuscitation training and 26 multiple choice questions on cardiopulmonary resuscitation knowledge. Hospitals in Switzerland scored highest on basic life support (P =0.005) while Belgium hospitals scored highest on advanced life support (P <0.001) and total score in cardiopulmonary resuscitation knowledge (P =0.01). The Swiss hospitals scored highest in cardiopulmonary resuscitation training (P <0.001). Correlation between cardiopulmonary resuscitation knowledge and return of spontaneous circulation rates of patients with in-hospital cardiac arrest demonstrated that each additional correct answer on the advanced life support score results in a further increase in return of spontaneous circulation rates (odds ratio 3.94; 95% confidence interval 2.78 to 5.57; P <0.001). Conclusion: Differences in knowledge about resuscitation and course attendance were found between university hospitals in 12 European countries. Education in cardiopulmonary resuscitation is considered to be vital for patients' return of spontaneous circulation rates after in-hospital cardiac arrest. A higher level of knowledge in advanced life support results in higher return of spontaneous circulation rates. [ABSTRACT FROM AUTHOR]

Positive selection causes beneficial alleles to rise to high frequency, resulting in a selective sweep of the diversity surrounding the selected sites. Accordingly, the signature of a selective sweep in an ancestral population may still remain in its descendants. Identifying signatures of selection in the ancestor that are shared among its descendants is important to contextualize the timing of a sweep, but few methods exist for this purpose. We introduce the statistic SS-H12, which can identify genomic regions under shared positive selection across populations and is based on the theory of the expected haplotype homozygosity statistic H12, which detects recent hard and soft sweeps from the presence of high-frequency haplotypes. SS-H12 is distinct from comparable statistics because it requires a minimum of only two populations, and properly identifies and differentiates between independent convergent sweeps and true ancestral sweeps, with high power and robustness to a variety of demographic models. Furthermore, we can apply SS-H12 in conjunction with the ratio of statistics we term H2Tot and H1Tot to further classify identified shared sweeps as hard or soft. Finally, we identified both previously reported and novel shared sweep candidates from human whole-genome sequences. Previously reported candidates include the well-characterized ancestral sweeps at LCT and SLC24A5 in Indo-Europeans, as well as GPHN worldwide. Novel candidates include an ancestral sweep at RGS18 in sub-Saharan Africans involved in regulating the platelet response and implicated in sudden cardiac death, and a convergent sweep at C2CD5 between European and East Asian populations that may explain their different insulin responses. [ABSTRACT FROM AUTHOR]

Aim: In this study, we sought to quantitatively describe the survival outcomes, incidence rates, and predictors of survival after paediatric traumatic out-of-hospital cardiac arrest (OHCA).Methods: We systematically searched MEDLINE, EMBASE, EMCARE, and CINAHL to identify observational or interventional studies reporting relevant data for paediatric traumatic OHCA. The Joanna Briggs Institute critical appraisal tool for prognostic studies was used to assess study quality. We analysed the survival outcomes and pooled incidence rates per 100,000 person-years using random-effect models.Results: Nineteen articles met the eligibility criteria involving 705 Emergency Medical Service (EMS)-attended and 973 EMS-treated traumatic paediatric OHCAs across an estimated serviceable population of 15.2 million. Four studies were conducted in the Asia-pacific region, seven in Europe, and eight in North America. Nine studies were assessed as low quality. Overall pooled survival to hospital discharge or 30-day survival for the EMS-treated cases was 1.2% (n = 6 studies; 95% confidence interval (CI): 0.1%, 3.1%; I2 = 26.1%). The pooled rate of return of spontaneous circulation in four studies was 22.1% (95% CI: 18.4%, 26.1%; I2 = 0.0%), and the pooled rate of event survival was 18.8% (n = 3 studies; 95% CI: 15.2%, 22.7%; I2 = 0.0%). The pooled incidence of EMS-treated paediatric traumatic OHCA was 1.6 cases per 100,000 person-years (n = 10 studies; 95% CI: 1.1, 2.2; I2 = 98.1%). No study reported on the impact of epidemiological or clinical factors on survival.Conclusion: Survival outcomes of paediatric traumatic OHCA are poor and existing studies report varying incidence rates. The absence of large prospective and international registry data hinders the development of novel strategies to improve survival rates. [ABSTRACT FROM AUTHOR]

Aim: Survival is the most consistently captured outcome across countries for out-of-hospital cardiac arrests (OHCA), with return of spontaneous circulation (ROSC) representing the earliest endpoint for 'unbiased' initial resuscitation success. The ROSC after cardiac arrest (RACA) score was developed to predict ROSC and has been validated in several European countries. In this study, we aimed to evaluate the performance of RACA in a Pan-Asian population.Methods: We conducted a retrospective analysis of data collected in the Pan-Asian Resuscitation Outcomes Study (PAROS) registry. We included OHCA cases from seven communities (Japan, South Korea, Malaysia, Singapore, Taiwan, Thailand, and United Arab Emirates) between January 2009 and December 2012. Paediatric cases, cases that were conveyed by non-emergency medical services (EMS), and cases with incomplete records were excluded from the study.Results: The RACA score showed similar discrimination performance as the original German study and various European validation studies. However, it had poor calibration with the original constant regression coefficient, which was primarily due to the low ROSC rate (8.2%) in the PAROS cohort. The calibration performance of RACA significantly improved after the constant coefficient was modified to adjust for the disparity in ROSC rates between Asia and Europe.Conclusion: This is the largest validation study of the RACA score. RACA consistently performs well in both Pan-Asian and European communities and can thus be a valuable tool for evaluating EMS systems. However, to implement it, the constant coefficient has to be modified in the RACA formula with local historical data. [ABSTRACT FROM AUTHOR]

Background: The epidemiology and outcome after out-of-hospital cardiac arrest (OHCA) varies across Europe. Following on from EuReCa ONE, the aim of this study was to further explore the incidence of and outcomes from OHCA in Europe and to improve understanding of the role of the bystander.Methods: This prospective, multicentre study involved the collection of registry-based data over a three-month period (1st October 2017 to 31st December 2017). The core study dataset complied with the Utstein-style. Primary outcomes were return of spontaneous circulation (ROSC) and survival to hospital admission. Secondary outcome was survival to hospital discharge.Results: All 28 countries provided data, covering a total population of 178,879,118. A total of 37,054 OHCA were confirmed, with CPR being started in 25,171 cases. The bystander cardiopulmonary resuscitation (CPR) rate ranged from 13% to 82% between countries (average: 58%). In one third of cases (33%) ROSC was achieved and 8% of patients were discharged from hospital alive. Survival to hospital discharge was higher in patients when a bystander performed CPR with ventilations, compared to compression-only CPR (14% vs. 8% respectively).Conclusion: In addition to increasing our understanding of the role of bystander CPR within Europe, EuReCa TWO has confirmed large variation in OHCA incidence, characteristics and outcome, and highlighted the extent to which OHCA is a public health burden across Europe. Unexplained variation remains and the EuReCa network has a continuing role to play in improving the quality management of resuscitation. [ABSTRACT FROM AUTHOR]

Objective: While cardiac arrest (CA) patients discharged alive from intensive care unit (ICU) are considered to have good one-year survival but potential neurological impairment, comparisons with other ICU sub-populations non-admitted for CA purpose are still lacking. This study aimed to compare long-term outcome and health-related quality of life (HRQOL) between CA patients and patients admitted to ICU for all other causes.Methods: In 1635 patients discharged alive from 21 European ICUs in an ancillary analysis of a prospective multicentric cohort, we compared CA causes of ICU admission to all other causes of ICU admissions (named non-CAs). The primary endpoint was one-year survival rate after ICU discharge. Secondary endpoints included HRQOL at 3, 6 and 12 months after ICU discharge using the outcome survey short form-36 (SF36). Propensity score matching was used to consider the probability of having CA.Results: Of the 1635 patients, 1561 were included in this study comprised of 1447 non-CAs and 114 CAs. At one-year in the non-matched population, survival rate was greater in the CA group 89% versus the non-CA group 78% (log rank p = 0.0056). In the matched population, this difference persisted between CAs and non-CAs (log rank p = 0.049). The physical component summary of the SF36 scale was higher in the CA group than in the non-CA group at all time points in both non-matched and matched populations.Conclusions: CA patients discharged alive from ICU have a better one-year survival and a better HRQOL specifically on physical functions than patients admitted to ICU for other causes.Trial Registration: ClinicalTrials.gov NCT01367093; registered on June 6, 2011. [ABSTRACT FROM AUTHOR]

Students are an important part of the community response to an out-of-hospital cardiac arrest (OHCA). If even schoolchildren now know cardio-pulmonary resuscitation (CPR), even more the reason a young doctor should know how to treat an OHCA. The aim of our study was to assess medical students' knowledge of CPR and OHCA throughout Europe. An online survey was given to final-year students by the Medical Student Associations of different countries. 1012 medical students from 99 different universities and 14 different countries completed the questionnaire. A total of 82.2% attended a BLS or BLS/AED course, provided by the University in only 69.7% of cases. In 84.3% it was a mandatory part of their degree. A total of 78.6% felt able to rescue a person in OHCA. Only 49.3% knew that 'unresponsiveness' and 'absence of normal breathing' are sufficient for lay people to identify an OHCA, and less than half of those interviewed knew the incidence of OHCA in Europe and the decrease in chance of survival if CPR is not performed. The correct compression:ventilation ratio was known by 90.2%, the correct compression depth by 69.7%, whilst only 57.8% knew the right compression rate. In total, 69.7% knew that an AED must be used immediately when available, and only 57.2% recognized the AED symbol. Medical students' knowledge of cardiac arrest and CPR needs to be improved throughout Europe and we believe that BLS/AED training should be mandatory in all European Universities. • A survey was provided to final-year European students just before their graduation. • An important lack of knowledge about cardiac arrest and CPR was demonstrated. • Mandatory BLS/AED training should be introduced during medical school. [ABSTRACT FROM AUTHOR]

Aims: The European REMOTE-CIED study is the first randomized trial primarily designed to evaluate the effect of remote patient monitoring (RPM) on patient-reported outcomes in the first 2 years after implantation of an implantable cardioverter-defibrillator (ICD).Methods and Results: The sample consisted of 595 European heart failure patients implanted with an ICD compatible with the Boston Scientific LATITUDE® RPM system. Patients were randomized to RPM plus a yearly in-clinic ICD check-up vs. 3-6-month in-clinic check-ups alone. At five points during the 2-year follow-up, patients completed questionnaires including the Kansas City Cardiomyopathy Questionnaire and Florida Patient Acceptance Survey (FPAS) to assess their heart failure-specific health status and ICD acceptance, respectively. Information on clinical status was obtained from patients' medical records. Linear regression models were used to compare scores between groups over time. Intention-to-treat and per-protocol analyses showed no significant group differences in patients' health status and ICD acceptance (subscale) scores (all Ps > 0.05). Exploratory subgroup analyses indicated a temporary improvement in device acceptance (FPAS total score) at 6-month follow-up for secondary prophylactic in-clinic patients only (P < 0.001). No other significant subgroup differences were observed.Conclusion: Large clinical trials have indicated that RPM can safely and effectively replace most in-clinic check-ups of ICD patients. The REMOTE-CIED trial results show that patient-reported health status and ICD acceptance do not differ between patients on RPM and patients receiving in-clinic check-ups alone in the first 2 years after ICD implantation.ClinicalTrials.gov Identifier: NCT01691586. [ABSTRACT FROM AUTHOR]

Background: Clinically significant deterioration of patients admitted to general wards is a recognized complication of hospital care. Rapid Response Systems (RRS) aim to reduce the number of avoidable adverse events. The authors aimed to develop a core quality metric for the evaluation of RRS.Methods: We conducted an international consensus process. Participants included patients, carers, clinicians, research scientists, and members of the International Society for Rapid Response Systems with representatives from Europe, Australia, Africa, Asia and the US. Scoping reviews of the literature identified potential metrics. We used a modified Delphi methodology to arrive at a list of candidate indicators that were reviewed for feasibility and applicability across a broad range of healthcare systems including low and middle-income countries. The writing group refined recommendations and further characterized measurement tools.Results: Consensus emerged that core outcomes for reporting for quality improvement should include ten metrics related to structure, process and outcome for RRS with outcomes following the domains of the quadruple aim. The conference recommended that hospitals should collect data on cardiac arrests and their potential predictability, timeliness of escalation, critical care interventions and presence of written treatment goals for patients remaining on general wards. Unit level reporting should include the presence of patient activated rapid response and metrics of organizational culture. We suggest two exploratory cost metrics to underpin urgently needed research in this area.Conclusion: A consensus process was used to develop ten metrics for better understanding the course and care of deteriorating ward patients. Others are proposed for further development. [ABSTRACT FROM AUTHOR]

Objective: In 2014, the European Society of Cardiology (ESC) recommended the use of a novel risk prediction model (HCM Risk-SCD) to guide use of implantable cardioverter defibrillators (ICD) for the primary prevention of sudden cardiac death (SCD) in patients with hypertrophic cardiomyopathy (HCM). We sought to determine the performance of HCM Risk-SCD by conducting a systematic review and meta-analysis of articles reporting on the prevalence of SCD within 5 years of evaluation in low, intermediate and high-risk patients as defined by the 2014 guidelines (predicted risk <4%, 4%-<6% and ≥6%, respectively).Methods: The protocol was registered with PROSPERO (registration number: CRD42017064203). MEDLINE and manual searches for papers published from October 2014 to December 2017 were performed. Longitudinal, observational cohorts of unselected adult patients, without history of cardiac arrest were considered. The original HCM Risk-SCD development study was included a priori. Data were pooled using a random effects model.Results: Six (0.9%) out of 653 independent publications identified by the initial search were included. The calculated 5-year risk of SCD was reported in 7291 individuals (70% low, 15% intermediate; 15% high risk) with 184 (2.5%) SCD endpoints within 5 years of baseline evaluation. Most SCD endpoints (68%) occurred in patients with an estimated 5-year risk of ≥4% who formed 30% of the total study cohort. Using the random effects method, the pooled prevalence of SCD endpoints was 1.01% (95% CI 0.52 to 1.61) in low-risk patients, 2.43% (95% CI 1.23 to 3.92) in intermediate and 8.4% (95% CI 6.68 to 10.25) in high-risk patients.Conclusions: This meta-analysis demonstrates that HCM Risk-SCD provides accurate risk estimations that can be used to guide ICD therapy in accordance with the 2014 ESC guidelines.Registration Number: PROSPERO CRD42017064203;Pre-results. [ABSTRACT FROM AUTHOR]

Aortic valve stenosis (AS) is the most common heart valve disease in North America and Europe leading to an increased risk of heart failure and death. A multidisciplinary evaluation of symptoms, individual risk profile, echocardiographic parameters, biomarkers assessment is required for an appropriate clinical and therapeutic management of AS. The natriuretic peptides (NPs) represent an important biomarker for diagnostic, prognostic and therapeutic purposes in several cardiovascular diseases. The present review article provides an overview of the current knowledge on the role of NPs in the pathogenesis, diagnosis, risk stratification and potential therapeutic implications in AS. C-type natriuretic peptide (CNP) level is reduced in AS, favoring the formation of calcified aggregates and an increased expression of bone-related transcripts and proteins (Runx2, osteonectin, osteocalcin, alkaline phospahatase). Consistent results were obtained through the inhibition of the type A and B natriuretic peptide receptors (NPRA, NPRB) and of the proprotein convertase furin expression. Increased plasma B-type natriuretic peptide (BNP) level contributes to monitor the progression of AS and to identify patients who would most benefit from an early therapeutic intervention, such as surgical or transcatheter aortic valve replacement. Moreover, a risk stratification of AS patients that takes into account the NPs level has a major impact toward the occurrence of heart failure, syncope and sudden cardiac death. Finally, the development of novel therapeutic strategies, such as the neprilysin inhibition, may represent a suitable pharmacological approach for the treatment of AS. Due to the above mentioned multiple roles, NPs represent key players in AS development, management and treatment. • Natriuretic peptides are important biomarkers for diagnostic, prognostic, therapeutic purposes in cardiovascular diseases. • C-type natriuretic peptide contributes to AS development by preventing calcium deposition and osteoblast differentiation. • B-type natriuretic peptide level correlates with the severity of AS and helps in monitoring the progression of the disease. • B-type natriuretic peptide level helps in identifying patients who would most benefit from an early therapeutic intervention. • Targeting the natriuretic peptides system may offer a valuable therapeutic tool in patients affected by AS. [ABSTRACT FROM AUTHOR]

Despite advancements in prevention and treatment, sudden cardiac death (SCD) remains a leading cause of mortality and is responsible for approximately half of all deaths from cardiovascular disease. Outcomes continue to remain poor following a sudden cardiac arrest, with most individuals not surviving. Although coronary heart disease remains the dominant underlying condition, our understanding of SCD is improving through greater knowledge of clinical risk factors, cardiomyopathies, and primary arrhythmic disorders. However, despite a growing wealth of information from studies in North America, Europe, and Japan, data from other global regions (and particularly from low-and middle-income countries) remains scarce. [ABSTRACT FROM AUTHOR]

Background: Polymer-free amphilimus-eluting stents (PF-AES) represent a novel elution technology in the current era of drug-eluting stents. The clinical safety and efficacy of PF-AES as compared with latest-generation permanent-polymer zotarolimus-eluting stents (PP-ZES) have not yet been investigated in a large randomized trial.Methods: In this physician-initiated, prospective, multicenter, randomized, noninferiority trial, an all-comers population requiring percutaneous coronary intervention was enrolled across 3 European sites. Randomization (1:1 ratio) to PP-ZES or PF-AES was performed after stratification for troponin status and diabetes mellitus. In both treatment arms, troponin-positive patients were planned for 12-month dual antiplatelet therapy, whereas troponin-negative patients were planned for 1-month dual antiplatelet therapy. Outcome assessors were blinded to the allocated treatment. The device-oriented primary end point of target-lesion failure was defined as cardiac death, target-vessel myocardial infarction, or target-lesion revascularization at 12-months as analyzed by modified intention-to-treat (80% power, and a 3.5% noninferiority margin).Results: In total, 1502 patients were randomized and 1491 treated with the assigned stent and available for follow-up. The primary end point occurred in 42 (5.6%) of the 744 patients receiving PP-ZES versus 46 (6.2%) of the 747 patients receiving PF-AES. PF-AES were clinically noninferior to PP-ZES (risk difference, 0.5%; upper limit 1-sided 95% confidence interval, 2.6%; Pnoninferiority=0.0086). Cardiac death occurred in 10 (1.3%) versus 10 patients (1.3%; P value for difference, 1.00), target-vessel myocardial infarction occurred in 18 (2.4%) versus 17 patients (2.3%; P value for difference, 0.87), and target-lesion revascularization occurred in 22 (2.9%) versus 20 patients (2.6%; P value for difference, 0.75) for PF-AES as compared with PP-ZES. Overall, definite or probable stent thrombosis occurred in 1.0%.Conclusions: PF-AES were noninferior to PP-ZES regarding target-lesion failure at 12 months. Findings regarding the secondary end point and prespecified subgroups were generally consistent with that of the primary end point.Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT02328898. [ABSTRACT FROM AUTHOR]

Background: Out-of-hospital cardiac arrests (OHCA) precipitated by drug overdose (OD) are becoming an increasing public health problem in developed countries. Empirical data on the global incidence and outcomes are needed to guide preventive and treatment strategies.Methods: We conducted a systematic review using MEDLINE, Embase, Emcare, All EBM Reviews and CINAHL to identify observational or interventional studies reporting the incidence or outcomes of adult OHCA precipitated by drug OD between 1990 and 2018. Pooled incidence rates per 100,000 person-years and survival outcomes were summarised using random-effects models.Results: Twelve articles met the eligibility criteria, of which six were from North America, four from Europe and two from Asia. Only two studies reported the incidence of EMS-attended cases. The pooled incidence of EMS-treated OHCA was 1.4 cases per 100,000 person-years. The pooled rate of survival to hospital discharge and survival with favourable neurological outcome was 9% (95% CI: 6%, 12%; I2 = 90%; p < 0.001) and 6% (95% CI: 2%, 13%; I2 = 81%; p < 0.001), respectively. The pooled rate of return of spontaneous circulation was 25% (95% CI: 11%, 41%; I2 = 97%; p < 0.001). Drug OD OHCA was associated with an improvement in the odds of survival to hospital discharge (pooled odds ratio 2.2, 95% CI: 1.7, 2.7; I2 = 0%; p = 0.45).Conclusion: The incidence and survival outcomes of drug OD OHCA varies substantially across regions. Effective strategies designed to reduce incidence and improve survival outcomes are needed. [ABSTRACT FROM AUTHOR]

Cases of drug-induced QT prolongation and sudden cardiac deaths resulted in market withdrawal of many drugs and world-wide regulatory changes through accepting the ICH guidelines E14 and S7B. However, because the guidelines were not comprehensive enough to cover the electrophysiological changes by drug-induced cardiac ion channel blocking, CiPA was initiated by experts in governments and academia in the USA, Europe, and Japan in 2013. Five years have passed since the launch of the CiPA initiative that aimed to improve the current ICH guidelines. This report reviews the current achievements of the CiPA initiative and explores unresolved issues. [ABSTRACT FROM AUTHOR]

Sudden cardiac death is a tragedy at any age and under any circumstances, but it is perhaps more tragic when it appears in the athlete, a person who has a healthy lifestyle. Regular physical activity and physical performance training ensure a good functioning of the cardiovascular system. However, there are situations of unfavorable evolution, which are diagnosed as sudden cardiac death (SCD) in athletes. Obstructive hypertrophic cardiomyopathy - in the US - and arrhythmogenic right ventricular cardiomyopathy - in Europe - are the two leading causes of sudden cardiac death to young athletes. Sudden cardiac death in athletes is the leading cause of medical death in this subgroup, with an estimated incidence of 1 in 50,000 to 1 in 80,000 athletes per year. [ABSTRACT FROM AUTHOR]

The population of patients with congenital heart disease (CHD) is continuously increasing with more and more patients reaching adulthood. A significant portion of these young adults will suffer from arrhythmias due to the underlying congenital heart defect itself or as a sequela of interventional or surgical treatment. The medical community will encounter an increasing challenge as even most of the individuals with complex congenital heart defects nowadays become young adults. Within the past 20 years, management of patients with arrhythmias has gained remarkable progress including pharmacological treatment, catheter ablation, and device therapy. Catheter ablation in patients with CHD has paralleled the advances of this technology in pediatric and adult patients with structurally normal hearts. Growing experience and introduction of new techniques like the 3D mapping systems into clinical practice have been particularly beneficial for this growing population of patients with abnormal cardiac anatomy and physiology. Finally, device therapies allowing maintanence of chronotropic competence and AV conduction, improving haemodynamics by cardiac resynchronization, and preventing sudden death are increasingly used. For pharmacological therapy, ablation procedures, and device therapy decision making requires a deep understanding of the individual pathological anatomy and physiology as well as detailed knowledge on natural history and long-term prognosis of our patients. Composing expert opinions from cardiology and paediatric cardiology as well as from non-invasive and invasive electrophysiology this position paper was designed to state the art in management of young individuals with congenital heart defects and arrhythmias. [ABSTRACT FROM AUTHOR]

Background: Plant poisonings are uncommon in adults, and rarely fatal. Oenantha crocata is a toxic plant growing in the humid grasslands of North America and Western Europe.Case Report: We report here two adults who ingested Oenantha crocata roots, having mistaken them for edible tuberous radish. One developed vomiting and needed only 24 h symptomatic treatment, whereas the other suffered prolonged convulsions, cardiac arrest, and severe metabolic acidosis, leading to a fatal outcome. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Cases of poisoning with Oenantha crocata are rare and destabilizing. With increased interest in "natural" foods and team building by survival training, medical teams should be aware of the management for such poisoning. [ABSTRACT FROM AUTHOR]

Background: Identification of people with hypertrophic cardiomyopathy (HCM) who are at risk of sudden cardiac death (SCD) and require a prophylactic implantable cardioverter defibrillator is challenging. In 2014, the European Society of Cardiology proposed a new risk stratification method based on a risk prediction model (HCM Risk-SCD) that estimates the 5-year risk of SCD. The aim was to externally validate the 2014 European Society of Cardiology recommendations in a geographically diverse cohort of patients recruited from the United States, Europe, the Middle East, and Asia.Methods: This was an observational, retrospective, longitudinal cohort study.Results: The cohort consisted of 3703 patients. Seventy three (2%) patients reached the SCD end point within 5 years of follow-up (5-year incidence, 2.4% [95% confidence interval {CI}, 1.9-3.0]). The validation study revealed a calibration slope of 1.02 (95% CI, 0.93-1.12), C-index of 0.70 (95% CI, 0.68-0.72), and D-statistic of 1.17 (95% CI, 1.05-1.29). In a complete case analysis (n= 2147; 44 SCD end points at 5 years), patients with a predicted 5-year risk of <4% (n=1524; 71%) had an observed 5-year SCD incidence of 1.4% (95% CI, 0.8-2.2); patients with a predicted risk of ≥6% (n=297; 14%) had an observed SCD incidence of 8.9% (95% CI, 5.96-13.1) at 5 years. For every 13 (297/23) implantable cardioverter defibrillator implantations in patients with an estimated 5-year SCD risk ≥6%, 1 patient can potentially be saved from SCD.Conclusions: This study confirms that the HCM Risk-SCD model provides accurate prognostic information that can be used to target implantable cardioverter defibrillator therapy in patients at the highest risk of SCD. [ABSTRACT FROM AUTHOR]

Background: No practical tool quantitates the risk of circulatory-etiology death (CED) immediately after successful cardiopulmonary resuscitation in patients without ST-segment-elevation myocardial infarction. We developed and validated a prediction model to rapidly determine that risk and facilitate triage to individualized treatment pathways.Methods: With the use of INTCAR (International Cardiac Arrest Registry), an 87-question data set representing 44 centers in the United States and Europe, patients were classified as having had CED or a combined end point of neurological-etiology death or survival. Demographics and clinical factors were modeled in a derivation cohort, and backward stepwise logistic regression was used to identify factors independently associated with CED. We demonstrated model performance using area under the curve and the Hosmer-Lemeshow test in the derivation and validation cohorts, and assigned a simplified point-scoring system.Results: Among 638 patients in the derivation cohort, 121 (18.9%) had CED. The final model included preexisting coronary artery disease (odds ratio [OR], 2.86; confidence interval [CI], 1.83-4.49; P≤0.001), nonshockable rhythm (OR, 1.75; CI, 1.10-2.77; P=0.017), initial ejection fraction<30% (OR, 2.11; CI, 1.32-3.37; P=0.002), shock at presentation (OR, 2.27; CI, 1.42-3.62; P<0.001), and ischemic time >25 minutes (OR, 1.42; CI, 0.90-2.23; P=0.13). The derivation model area under the curve was 0.73, and Hosmer-Lemeshow test P=0.47. Outcomes were similar in the 318-patient validation cohort (area under the curve 0.68, Hosmer-Lemeshow test P=0.41). When assigned a point for each associated factor in the derivation model, the average predicted versus observed probability of CED with a CREST score (coronary artery disease, initial heart rhythm, low ejection fraction, shock at the time of admission, and ischemic time >25 minutes) of 0 to 5 was: 7.1% versus 10.2%, 9.5% versus 11%, 22.5% versus 19.6%, 32.4% versus 29.6%, 38.5% versus 30%, and 55.7% versus 50%.Conclusions: The CREST model stratified patients immediately after resuscitation according to risk of a circulatory-etiology death. The tool may allow for estimation of circulatory risk and improve the triage of survivors of cardiac arrest without ST-segment-elevation myocardial infarction at the point of care. [ABSTRACT FROM AUTHOR]

According to the European Resuscitation Council guidelines, the use of mechanical chest compression devices is a reasonable alternative in situations where manual chest compression is impractical or compromises provider safety. The aim of this study is to compare the performance of a recently developed chest compression device (Corpuls CPR) with an established system (LUCAS II) in a pig model. Methods. Pigs (n = 5/group) in provoked ventricular fibrillation were left untreated for 5 minutes, after which 15 min of cardiopulmonary resuscitation was performed with chest compressions. After 15 min, defibrillation was performed every 2 min if necessary, and up to 3 doses of adrenaline were given. If there was no return of spontaneous circulation after 25 min, the experiment was terminated. Coronary perfusion pressure, carotid blood flow, end-expiratory CO2, regional oxygen saturation by near infrared spectroscopy, blood gas, and local organ perfusion with fluorescent labelled microspheres were measured at baseline and during resuscitation. Results. Animals treated with Corpuls CPR had significantly higher mean arterial pressures during resuscitation, along with a detectable trend of greater carotid blood flow and organ perfusion. Conclusion. Chest compressions with the Corpuls CPR device generated significantly higher mean arterial pressures than compressions performed with the LUCAS II device. [ABSTRACT FROM AUTHOR]

Aim: Extracorporeal cardiopulmonary resuscitation (ECPR) is an emerging therapy for refractory cardiac arrest. The purpose of this study was to analyze and report characteristics and outcomes of adult patients treated with ECPR after out-of-hospital cardiac arrest (OHCA) in a large international registry.Methods: The Extracorporeal Life Support Organization's Extracorporeal Life Support Registry was queried for adult cardiac arrests with arrest location of "EMT Transport" or "Outside Hospital."Results: From 2010-2016, 217 cases of ECPR following OHCA were reported in Europe (47%), Asia-Pacific (29%), and North America (24%). The median age was 52 years (IQR 45-62, range 18-87); 73% were male. The median duration of ECPR was 47h (IQR 17-94, range 0-711). Reported complications included hemorrhage (31.3%), limb complications (11.1%), circuit complications (8.8%), infection (7.4%), and seizures (5.5%). The rate of percutaneous coronary intervention (PCI) was higher in Europe (35.6%) and Asia-Pacific (25.8%) than North America (9.4%; p<0.01). Survival to hospital discharge was 27.6% (95% CI 22.1-34.0%), and male gender was independently associated with mortality (adjusted odds ratio 2.1 [95% CI 1.1-4.2], p<0.05). Survival did not differ by region, race, age, or year. Brain death was reported in 16.6% [95% CI 12.2-22.1%]; organ donation rate was not reported.Conclusion: This international analysis of ECPR for refractory OHCA reveals a survival rate of 27.6%, demonstrates association of male gender with mortality, and highlights regional differences in PCI utilization. These results will help inform implementation and research of this potentially life-saving strategy for refractory OHCA. [ABSTRACT FROM AUTHOR]

"Donation after circulatory death (DCD) is increasing in Europe, yet there is widespread variability in practice. Insight into actual practice is difficult to acquire simply by analyzing protocols and laws from each individual country. For this reason, the 3 DCD vignettes in this article have been constructed to outline routine and standard DCD practice in the United Kingdom, the Netherlands, and Spain. These imagined vignettes reflect a ""typical"" case, based on the authors' extensive experience with DCD but are not real patient cases. They are a resource aimed at stimulating discussion regarding European organ donation practice and provide a knowledge bank for those wanting to establish a DCD program in their country. It is our hope that by providing these vignettes, the wider organ donation and transplant community, as well as philosophers and the public, will have a better understanding of what DCD really is and what it really isn't." [ABSTRACT FROM AUTHOR]

Background: Periodontitis is associated with cardiovascular mortality in the general population and adults with chronic diseases. However, it is unclear whether periodontitis predicts survival in the setting of kidney failure.Methods: ORAL-D was a propensity matched analysis in 3338 dentate adults with end-stage kidney disease treated in a hemodialysis network in Europe and South America designed to examine the association between periodontitis and all-cause and cardiovascular-related mortality in people on long-term hemodialysis. Participants were matched 1:1 on their propensity score for moderate to severe periodontitis assessed using the World Health Organization Community Periodontal Index. A random-effects Cox proportional hazards model was fitted with shared frailty to account for clustering of mortality risk within countries.Results: Among the 3338 dentate participants, 1355 (40.6%) had moderate to severe periodontitis at baseline. After using propensity score methods to generate a matched cohort of participants with periodontitis similar to those with none or mild periodontal disease, moderate to severe periodontitis was associated with a lower risk of all-cause (9.1 versus 13.0 per 100 person years, hazard ratio 0.74, 95% confidence interval 0.61 to 0.90) and cardiovascular (4.3 versus 6.9 per 100 person years, hazard ratio 0.67, 0.51 to 0.88) mortality. These associations were not changed substantially when participants were limited to those with 12 or more natural teeth and when accounting for competing causes of cardiovascular death.Conclusion: In contrast to the general population, periodontitis does not appear to be associated with an increased risk of early death in adults treated with hemodialysis. [ABSTRACT FROM AUTHOR]

Objective: Among primary prevention patients with heart failure receiving cardiac resynchronisation therapy (CRT), the impact of additional implantable cardioverter defibrillator (ICD) treatment on outcomes and its interaction with sex remains uncertain. We aim to assess whether the addition of the ICD functionality to CRT devices offers a more pronounced survival benefit in men compared with women, as previous research has suggested.Methods: Observational multicentre cohort study of 5307 consecutive patients with ischaemic or non-ischaemic dilated cardiomyopathy and no history of sustained ventricular arrhythmias having CRT implantation with (cardiac resynchronisation therapy defibrillator (CRT-D), n=4037) or without (cardiac resynchronisation therapy pacemaker (CRT-P), n=1270) defibrillator functionality. Using propensity score (PS) matching and weighting and cause-of-death data, we assessed and compared the outcome of patients with CRT-D versus CRT-P. This analysis was stratified according to sex.Results: After a median follow-up of 34 months (interquartile range 22-60 months) no survival advantage, of CRT-D versus CRT-P was observed in both men and women after PS matching (HR=0.95, 95% CI 0.77 to 1.16, p=0.61, and HR=1.30, 95% CI 0.83 to 2.04, p=0.25, respectively). With inverse-probability weighting, a benefit of CRT-D was seen in male patients (HR 0.78, 95% CI 0.65 to 0.94, p=0.012) but not in women (HR 0.87, 95% CI 0.63 to 1.19, p=0.43). The excess unadjusted mortality of patients with CRT-P compared with CRT-D was related to sudden cardiac death in 7.4% of cases in men but only 2.2% in women.Conclusions: In primary prevention patients with CRT indication, the addition of a defibrillator might convey additional benefit only in well-selected male patients. [ABSTRACT FROM AUTHOR]