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Background: Atrial fibrillation (AF) is the most common arrhythmia and has significant morbidity. A score composed of easily measured electrocardiographic variables to identify patients at risk of AF would be of great value in order to stratify patients for increased monitoring and surveillance. The purpose of this study was to develop an electrocardiographic risk score for new-onset AF., Methods: A total of 676 patients without previous AF undergoing coronary angiography were retrospectively studied. Points were allocated based on P-wave morphology in inferior leads, voltage in lead 1, and P-wave duration (MVP). Patients were divided into three risk groups and followed until development of AF or last available clinical appointment., Results: Mean age was 65 years, and 68% were male. The high- and intermediate-risk groups were more likely to develop AF than the low-risk group (odds ratio [OR] 2.4, 95% confidence interval [CI] 1.3-4.4; p = 0.006 and OR 2.1, 95% CI 1.4-3.27; p = 0.009, respectively). The high-risk group had a significantly shorter mean time to development of AF (258 weeks; 95% CI 205-310 weeks) compared to the intermediate- (278 weeks; 95% CI 252-303 weeks) and low-risk groups (322 weeks 95% CI 307-338 weeks), p = 0.005., Conclusions: A simple risk score composed of easy-to-measure electrocardiographic variables can help to predict new-onset AF. Further validation studies will be needed to assess the ability of this risk score to predict AF in other populations., (© 2019 Wiley Periodicals, Inc.)

Background: The association between advanced interatrial block (aIAB) and atrial fibrillation (AF) is known as "Bayes' Syndrome." There is little information on the prognostic role that new speckle tracking echocardiographic (STE) imaging techniques could play in it. We have examined the relationship between left atrial (LA) STE and the prediction of new-onset AF and/or stroke in IAB patients., Methods: This is an observational prospective and unicentric cohort study with 98 outpatients: 55 (56.2%) controls with normal ECG without IAB, 21 (21.4%) with partial IAB (pIAB) and 22 (22.4%) with aIAB. The end point was new-onset AF, ischemic stroke and the composite of both., Results: During a mean follow-up of 1.9 (1.7-2.3) years, 20 patients presented the end point (18 new-onset AF and two strokes): 8 (14.5%) in the control group, 3 (14.3%) in pIAB and 9 (40.9%) in aIAB, p = 0.03. In multivariable comprehensive Cox regression analyses, a decrease in absolute value of strain rate during the booster pump function phase (SRa) was the only variable independently related to the appearance in the evolution of the end point, in the first model (age, P-wave duration and SRa): HR 19.9 (95% CI, 3.12-127.5), p = 0.002 and in the second (age, presence of aIAB and SRa): HR 24.2 (95% CI, 3.15-185.4), p = 0.002., Conclusions: In patients with IAB, a decrease in absolute value of LA SRa with STE predicts new-onset AF and ischemic stroke. Future studies should confirm our results and assess the prognostic usefulness of LA STE in patients with IAB., (© 2019 Wiley Periodicals, Inc.)

Advanced interatrial block (IAB) (P-wave ≥120 ms and biphasic P-wave in leads II, III and aVF) is a prevalent ECG pattern frequently associated with supraventricular arrhythmias and stroke, especially in patients with structural heart disease. Intermittent IAB is a much more poorly defined electrocardiographic entity with uncertain clinical significance. In this case series, we review and analyze eight cases of second degree intermittent IAB. In six cases, there is normalization of advanced IAB after a premature supraventricular or ventricular contraction, suggesting a functional block that temporarily recovers post extra-systolic pause. Recognition of intermittent IAB (second degree) may help further characterize the prognostic and clinical implications of this ECG pattern., (Crown Copyright © 2019. Published by Elsevier Inc. All rights reserved.)

Objective: Atrial fibrillation (AF) rhythm gives rise to an irregular response in ventricular activity, preventing the use of standard ECG-derived risk markers based on ventricular repolarization heterogeneity under this particular condition. In this study, we proposed new indices to quantify repolarization variations in AF patients, assessing their stratification performance in a chronic heart failure population with AF., Methods: We developed a method based on a selective bin averaging technique. Consecutive beats preceded by a similar RR interval were selected, from which the average variation within the ST-T complex for each RR range was computed. We proposed two sets of indices: 1) the 2-beat index of ventricular repolarization variation, ( I V2 ), computed from pairs of stable consecutive beats; and 2) the 3-beat indices of ventricular repolarization variation, computed in triplets of stable consecutive beats ( I V3 )., Results: These indices showed a significant association with sudden cardiac death (SCD) outcome in the study population. In addition, risk assessment based on the combination of the proposed indices improved stratification performance compared to their individual potential., Conclusion: Patients with enhanced ventricular repolarization variation computed in terms of the proposed indices were successfully associated to a higher SCD incidence in our study population, evidencing their prognostic value., Significance: using a simple ambulatory ECG recording, it is possible to stratify AF patients at risk of SCD, which may help cardiologists in adopting most effective therapeutic strategies, with a positive impact in both the patient and healthcare systems.

Objective: We proposed and evaluated a method for correcting possible phase shifts provoked by the presence of ventricular premature contractions (VPCs) for a better assessment of T-wave alternans (TWA).  Methods: First, we synthesized ECG signals with artificial TWA in the presence of different noise sources. Then, we assessed the prognostic value for sudden cardiac death (SCD) of the long-term average of TWA amplitude (the index of average alternans, ) in ambulatory ECG signals from congestive heart failure (CHF) and evaluated whether it is sensitive to the presence of VPCs., Results: The inclusion of the phase correction after VPC in the processing always improved estimation accuracy of the under different noisy conditions and regardless of the number of the VPCs included in the sequence. It also presented a positive impact on the prognostic value of with increased hazard ratios (from 17% to 29%, depending of the scenario) in comparison to the noninclusion of this step., Conclusion: The proposed methodology for estimation, which corrects for the possible phase reversal on TWA after the presence of VPCs, represents a robust TWA estimation approach with a significant impact on the prognostic value of for SCD stratification in CHF patients., Significance: An accurate TWA estimation has a potential direct clinical impact on noninvasive SCD stratification, allowing better identification of patients at higher risk and helping clinicians in adopting the most appropriate therapeutic strategy.

Background: Data are lacking on the characteristics of atrial activity in centenarians, including interatrial block (IAB)., Objective: The aim of this study was to describe the prevalence of IAB and auricular arrhythmias in subjects older than 100 years and to elucidate their clinical implications., Methods: We studied 80 centenarians (mean age 101.4 ± 1.5 years; 21 men) with follow-ups of 6-34 months. Of these 80 centenarians, 71 subjects (88.8%) underwent echocardiography. The control group comprised 269 septuagenarians., Results: A total of 23 subjects (28.8%) had normal P wave, 16 (20%) had partial IAB, 21 (26%) had advanced IAB, and 20 (25.0%) had atrial fibrillation/flutter. The IAB groups exhibited premature atrial beats more frequently than did the normal P wave group (35.1% vs 17.4%; P < .001); also, other measurements in the IAB groups frequently fell between values observed in the normal P wave and the atrial fibrillation/flutter groups. These measurements included sex preponderance, mental status and dementia, perceived health status, significant mitral regurgitation, and mortality. The IAB group had a higher previous stroke rate (24.3%) than did other groups. Compared with septuagenarians, centenarians less frequently presented a normal P wave (28.8% vs 53.5%) and more frequently presented advanced IAB (26.3% vs 8.2%), atrial fibrillation/flutter (25.0% vs 10.0%), and premature atrial beats (28.3 vs 7.0%) (P < .01)., Conclusion: Relatively few centenarians (<30%) had a normal P wave, and nearly half had IAB. Our data suggested that IAB, particularly advanced IAB, is a pre-atrial fibrillation condition associated with premature atrial beats. Atrial arrhythmias and IAB occurred more frequently in centenarians than in septuagenarians., (Copyright © 2016 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: Even if atrial fibrillatory rate (AFR) has been related to clinical outcome in patients with atrial fibrillation (AF), its relation with ventricular response has not been deeply studied. The aim of this study was to investigate the relation between AFR and RR series variability in patients with AF., Methods: Twenty-minute electrocardiograms in orthogonal leads were processed to extract AFR, using spatiotemporal QRST cancellation and time frequency analysis, and RR series in 127 patients (age 69 ± 11 years) with congestive heart failure (NYHA II-III) enrolled in the MUSIC study (MUerte Subita en Insufficiencia Cardiaca). Heart rate variability and irregularity were assessed by time domain parameters and entropy-based indices, respectively and their correlation with AFR investigated., Results: Variability measures seem not to be related to AFR, while irregularity measures do. A significant correlation between AFR and variability parameters of heart rate variability during AF was found only in patients not treated with antiarrhythmics drugs (correlation = 0.56 P < 0.05 for pNN50), while this correlation was lost in patients taking rate- or rhythm-control drugs. A significant positive correlation between AFR and indices of RR irregularity was found, showing that a higher AFR is related to a less organized RR series (correlation = 0.33 P < 0.05 for regularity index for all patients, correlation increased in subgroups of patients treated with the same drug)., Conclusions: These results suggest that a higher AFR is associated with a higher degree of irregularity of ventricular response that is observed regardless of the use of rate-controlling drugs., (©2012, Wiley Periodicals, Inc.)

Aim: Physical training and sport activity have a beneficial effect on cardiac autonomic activity. However, the exact impact of different types of sports disciplines on cardiac autonomic function is still unclear. The aim of this study was to evaluate the cardiac autonomic profile in different sports discplines and to determine their impact on cardiac autonomic function by using heart rate variability (HRV), a noninvasive electrocardiographic (ECG) analysis of the sympatho-vagal balance., Methods: Temporal and spectral HRV parameters determined from 24-hour continuous ECG monitoring were studied in 40 subjects, including 12 endurance athletes, 14 hockey players and 14 untrained male volunteers (control group). Each participant had to wear a Holter recorder during 24 hours and to continue his everyday activities. All HRV parameters were compared between the 3 study groups., Results: All heart rate values were lower and all parasympathetic-related time domain indices, including root mean square of successive differences (RMSSD) and pNN50 (NN50 count divided by the total number of all NN intervals), were higher in both athletes groups as compared with controls (P<0.05). However, standard deviation of all NN intervals (SDNN) values, which determine global HRV, were significantly higher only in endurance athletes (P<0.05). Furthermore, the power spectral components low frequency (LF), a mixture of both autonomic inputs, and HF (high frequency), a marker of vagal modulation, were significantly higher with a resulting lower LF/HF ratio in both athletes groups as compared to controls (P<0.05)., Conclusion: Both endurance and team playing athletic activity induce during all-day a high parasympathetic tone (higher RMSSD, pNN50 and HF, and lower LF/HF ratio). However, only endurance athletic activity has a particularly high global HRV (higher SDNN), indicating thereby that this type sports discipline may have a more substantially favorable effect on the cardiac autonomic profile.

Introduction: Repolarization dynamics, reflecting adaptation of QT to changing heart rate, is considered a marker of unfavorable prognosis in patients with heart diseases. We aimed to evaluate the prognostic value of QT/RR slope in predicting total mortality (TM) and sudden death (SD) in patients with congestive heart failure (CHF)., Methods and Results: In 651 sinus rhythm patients with CHF in NYHA class II-III enrolled in the MUSIC study, 24-hour Holter monitoring was performed at enrollment to assess slope of the QTa/RR (QT apex) and QTe/RR (QTend) during the entire 24-hour Holter recording and separately during day and night periods. Patients were followed for a median of 44 months, with the primary endpoint defined as TM and the secondary as SD. Analysis of repolarization dynamics was feasible in 542 patients (407M), mean age 63 years, 83% in NYHA class II, 49% with ischemic cardiomyopathy, with mean LVEF 37%. Mean value of QTa/RR slope was 0.172 and QTe/RR was 0.193. During the 44-month follow-up there were 119 deaths including 47 SD. Nonsurvivors were characterized by steeper QT/RR slopes. Increased QT/RR slopes during the daytime (>0.20 for QTa and >0.22 for QTe) were independently associated with increased TM in multivariate analysis after adjustment for clinical covariates with respective hazard ratios 1.57 and 1.58, P = 0.002. None of the dynamic repolarization parameters was associated with increased risk of SD in the entire population., Conclusions: Abnormal repolarization dynamics reflected as increased daytime QT/RR slopes is an independent risk stratifier of all-cause mortality in patients with chronic heart failure.

Background: Only few data are available on reproducibility over time in healthy young men and women and the corresponding gender-related changes of heart rate variability (HRV) measurements., Methods: We studied temporal and spectral HRV indices obtained from 24-hour Holter recordings in 32 healthy volunteers (14 men and 18 women, mean age 29 +/- 3 years) during 2 days of their usual all-day activity., Results: Time-domain measures and the spectral low-frequency (LF) and high-frequency (HF) components as well as the LF/HF ratio were comparable on both test days. Significantly higher values on test day 2 were observed only for the spectral very-low-frequency (VLF) component and for the resulting total power. Compared to men, women had higher day- and nighttime vagus-associated HRV indices, including root mean square of successive differences (RMSSD), pNN50 (NN50 count divided by the total number of all NN intervals), and HF power, and lower day- and nighttime VLF and LF power with lower LF/HF ratio and total power., Conclusions: Temporal indices and the LF and HF spectral HRV measures are reproducible over usual all-day activity in young healthy subjects. Young women have higher day-and nighttime vagal tone than men with similar age range.

Objective: Few trials report event-adjudication procedures in detail. Using data from the ACTION (A Coronary disease Trial Investigating Outcome with Nifedipine GITS) study, we compared the impact on event-rates of an adjudication strategy based on systematic screening of all reported serious adverse events (SAEs) with a strategy based on investigator diagnoses. The final diagnosis was always made by a critical events committee (CEC) using standard criteria., Methods: ACTION randomized 7665 patients with stable angina to either nifedipine or placebo. Pre-specified events included acute or procedural myocardial infarction (MI), refractory angina, heart failure and debilitating stroke. Clinically related SAEs including in-hospital procedures were combined into episodes independent from the investigator diagnoses entered on SAE reports. All fatal episodes and those episodes suggestive of pre-specified events were adjudicated by the CEC., Results: During follow-up, 17,081 episodes were reported in 5312 patients. The SAE descriptions ruled out the occurrence of a pre-specified event in 28%. The remaining 72% were adjudicated by the CEC and 616 cases of MI, 361 of refractory angina, 275 of heart failure and 190 of debilitating stroke were diagnosed (total=1442). Had adjudication by the CEC been limited to the 3924 episodes (2397 patients) that were fatal or for which the investigator had reported any of the diagnoses mentioned, 98 cases of MI, 35 of refractory angina, 81 of heart failure and 14 of debilitating stroke would have been missed (total=228)., Conclusion: Both the diagnostic criteria used and the adjudication process determine event-rates and conclusions about treatment effects in clinical trials. Published trial reports should always state if event-adjudication was independent of the diagnoses of investigators, and if all events of interest were adjudicated or only the first one.

The aim of this study was to evaluate the association between heart rate turbulence (HRT) parameters and clinical, biochemical, echocardiographic, and electrocardiographic measures of heart failure (HF) in a large, prospectively enrolled population of patients with HF to determine whether HRT could be considered a marker of HF advancement and progression, giving insight into hemodynamic changes as well as changes of the autonomic nervous system. In 487 patients with HF (mean age 63 years), the following tests were performed: 12-lead surface electrocardiography, echocardiography, chest x-rays, N-terminal-pro-brain natriuretic peptide levels, and 24-hour Holter monitoring for HRT and heart rate variability analyses. Most patients were in New York Heart Association class II (82%) and had a mean left ventricular (LV) ejection fraction of 37 +/- 14%. Both HRT parameters, but especially turbulence slope, were significantly correlated with clinical indexes of HF (the third heart sound, peripheral edemas, jugular distension, and pulmonary congestion). Patients in New York Heart Association class III had significantly lower turbulence slopes and greater turbulence onset values than those in class II. Significant correlations were found between HRT parameters and the LV ejection fraction as well as with LV diameters. HRT parameters were significantly correlated with N-terminal-pro-brain natriuretic peptide levels (r = -0.47, p <0.001 for turbulence slope). Multivariate analyses showed that abnormal HRT parameters were independent predictors of HF severity measured by New York Heart Association class III and a LV ejection fraction <40%. In conclusion, the findings indicate that in patients with HF, HRT reflects well the severity of HF and associated LV dysfunction, which were verified in this study by a series of established clinical, echocardiographic, and biochemical parameters.

Aims: Effective prevention of recurrent pericarditis remains an important yet elusive goal. Corticosteroid therapy often needs to be continued for a prolonged period and causes severe side effects. We performed a multi-centre all-case analysis to investigate the efficacy of colchicine in preventing subsequent relapses of pericarditis, and addressed the hypothesis that pretreatment with corticosteroids may attenuate the beneficial effect of colchicine., Methods and Results: One hundred and forty published and unpublished cases of patients treated with colchicine after at least two relapses of pericarditis were aggregated from European centres. Of those, 119 were included in the study group. Only 18% of the patients had relapses under colchicine therapy, and 30% after its discontinuation. There were significantly more relapses among male patients after colchicine treatment (36 vs. 17%, P=0.046), and those with previous corticosteroid treatment (43 vs. 13%, P=0.02). Multivariate logistic regression analysis identified previous corticosteroid therapy (OR 6.68, 95% CI: 1.65-27.02) and male gender (OR 4.20, 95% CI: 1.16-15.21) as independent risk factors for recurrence following colchicine therapy., Conclusion: Treatment with colchicine is highly effective in preventing recurrent pericarditis, while pretreatment with corticosteroids exacerbates and extends the course of recurrent pericarditis.

A study of nonlinear dynamics of the heart rate variability (HRV) was performed using hidden Markov models (HMM) and Mutual Information (MI). A methodology based on HMM has been developed in the present work. Cardiac RR series were analyzed in the three frequency bands: HF (0.15-0.45Hz), high frequency band; LF (0.04-0.15Hz), low frequency band; VLF (0.003-0.04Hz), very low frequency band. These series (0, observations) were modeled using HMM. The model &#955;=(A,B,&#8719;) was selected so that P(O/&#955;) was locally maximized. Ergodic topology and N=10 states were also considered for this analysis. Different measures based on HMM were defined and obtained from RR time series of 37 Idiopathic Dilated Crdiomyopathy (IDC) patients and 46 healthy subjects (NRM), during awake and sleep stages. Two groups of IDC patients were considered: 11 high risk (HR) patients, after aborted sudden cardiac death (SCD) or who died during the follow up; 26 low risk (LR) patients, without SCD. Some HMM measures showed high percentages (up to 100%) of well classified subjects in all groups.

Background: Moderate consumption of red wine has been epidemiologically associated with a reduction in cardiovascular disease, but its mechanism of action is not fully understood. The objective was to study whether the protective effects of a daily intake of red wine (Tempranillo, 12.8% alcohol vol/vol) could be related to inhibition of thrombosis in an experimental model of diet-induced hyperlipemia., Methods and Results: For 100 days, animals were fed a western-type proatherogenic diet containing 2% cholesterol and 20% saturated fat. Three doses of red wine were studied (20, 30, and 40 g wine-ethanol/d) and compared with placebo-control animals not taking any wine. Thrombosis under flow conditions was evaluated by radioisotopic quantification of deposited platelets on damaged arteries. Changes in RhoA translocation in platelets and monocyte tissue factor expression were also analyzed. Mural platelet deposition was significantly reduced in animals ingesting red wine with their food. Expression of RhoA in the platelet cytoplasm (inactive form) was increased in wine-fed animals. Tissue factor mRNA expression in lipopolysaccharide-stimulated monocytes was reduced in wine-fed animals. Total cholesterol levels were not significantly different among groups., Conclusions: Moderate red wine intake significantly reduces platelet deposition triggered by damaged vessel wall, partially explained by inhibition of RhoA translocation to the platelet membrane. Hence, a daily moderate intake of wine seems to inhibit different pathways that converge in a reduced thrombotic risk on vessel wall injury.

Clinical diagnosis of cardiac tumours is often difficult. We present the case of a 17 year-old boy in whom a left ventricular tumour was discovered during on diagnostic work-up for a syncope. The tumour was removed and histology confirmed the diagnosis of myxoma.

On the basis of our reported experience with colchicine for recurrent pericarditis, we administered colchicine to two patients with large pericardial effusions complicating idiopathic pericarditis. The first was a 26-year-old male who showed clinical deterioration following emergency pericardiocentesis and aspirin (3 g/day) for 10 days; the second was a 2-year-old girl who was unsuccessfully treated with aspirin (100 mg/kg/day) for 2 weeks, followed by corticosteroids for 7 months. Administration of colchicine (1 mg/day) instead of aspirin in the first case, and with a rapid tapering-off of the corticosteroids in the second case, led to complete regression of the pericardial effusion on echocardiography within 1 week and 1 month, respectively. Colchicine was discontinued after 1 month in the first patient and was continued for 6 months in the child. Neither has had a recurrence at 24 and 6 months of follow-up, respectively. No side effects of colchicine were observed. We conclude that colchicine may be effective in the treatment of large pericardial effusion when therapy with nonsteroidal anti-inflammatory drugs and/or corticosteroids fails.

Patients with severe angina pectoris, refractory to medical treatment, in which conventional revascularization (PTCA or bypass surgery) is not possible because they present advanced coronary artery disease with a poor distal bed, account for an important clinical problem due to an increasing incidence, combined with poor quality of life, an elevated risk of severe complications, repeated hospital admissions and high mortality rate. Laser transmyocardial revascularization provides a new therapeutic alternative for these patients. Although up to now there are only a few published series, with a small number of patients, the results obtained in the two ongoing multicentric studies in Europe and the United States (including more than 500 patients at present) are quite promising. It is a simple surgical procedure, but its associated mortality is not to be dismissed (in the beginning 12% and currently 5%), because patients are in an advanced evolutionary stage. In Spain this procedure has been available since April 1996 and the results have been encouraging. In our small series we have noted a significant symptomatic improvement and better quality of life.

A randomized trial was conducted to assess the efficacy of amiodarone versus metoprolol or no antiarrhythmic treatment to suppress asymptomatic ectopic activity and improve survival in patients who have had myocardial infarction with a left ventricular ejection fraction of 20 to 45% and > or = 3 ventricular premature complexes per hour (pairs or runs). Patients (n = 368) were randomly assigned to receive amiodarone 200 mg/day (n = 115) 10 to 60 days after the acute episode, and metoprolol 100 to 200 mg/day (n = 130) or no antiarrhythmic therapy (n = 123). After a median follow-up of 2.8 years, mortality in the amiodarone-treated patients (3.5 +/- 2% SEM) did not differ significantly from that of untreated control subjects (7.7 +/- 2.5%, p = 0.19), but was lower than that in the metoprolol group (15.4 +/- 3.5%, p = 0.006). Patients treated with metoprolol had twice the mortality seen in control subjects, even though the differences were not statistically significant. Holter studies performed at 1, 6 and 12 months showed that both amiodarone and metoprolol were equally effective in reducing heart rate, whereas only amiodarone significantly reduced ectopic activity (p < 0.0001). Thus, long-term treatment with amiodarone was clearly safe in patients with an ejection fraction of 20 to 45%, was effective in suppressing arrhythmias, and was associated with a lower mortality than metoprolol; corroboration is required in a larger trial.