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Sudden cardiac arrest (SCA) is the most common cause of death in the world. This manuscript highlights the various challenges in prevention and early management of SCA and also discusses the current state of SCA awareness. The manuscript also outlines the various national and international initiatives in improving SCA awareness and their impact on improving outcomes in SCA. Various campaigns have strived for widespread dissemination of cardiopulmonary resuscitation training and advocated for broader public access defibrillator availability. Finally, the manuscript describes future directions including harnessing technology with voice command and artificial intelligence to allow lay person deliver effective CPR, to improve EMS response times, and to allow wider CPR knowledge dissemination in schools and places of employment. Future research should be focused on optimizing SCA outcomes among vulnerable populations and minorities. Advancements in resuscitation science and use of big data for improvement of EMS services will improve outcomes in SCA.

Many widely used medications may cause or exacerbate a variety of arrhythmias. Numerous antiarrhythmic agents, antimicrobial drugs, psychotropic medications, and methadone, as well as a growing list of drugs from other therapeutic classes (neurological drugs, anticancer agents, and many others), can prolong the QT interval and provoke torsades de pointes. Perhaps less familiar to clinicians is the fact that drugs can also trigger other arrhythmias, including bradyarrhythmias, atrial fibrillation/atrial flutter, atrial tachycardia, atrioventricular nodal reentrant tachycardia, monomorphic ventricular tachycardia, and Brugada syndrome. Some drug-induced arrhythmias (bradyarrhythmias, atrial tachycardia, atrioventricular node reentrant tachycardia) are significant predominantly because of their symptoms; others (monomorphic ventricular tachycardia, Brugada syndrome, torsades de pointes) may result in serious consequences, including sudden cardiac death. Mechanisms of arrhythmias are well known for some medications but, in other instances, remain poorly understood. For some drug-induced arrhythmias, particularly torsades de pointes, risk factors are well defined. Modification of risk factors, when possible, is important for prevention and risk reduction. In patients with nonmodifiable risk factors who require a potentially arrhythmia-inducing drug, enhanced electrocardiographic and other monitoring strategies may be beneficial for early detection and treatment. Management of drug-induced arrhythmias includes discontinuation of the offending medication and following treatment guidelines for the specific arrhythmia. In overdose situations, targeted detoxification strategies may be needed. Awareness of drugs that may cause arrhythmias and knowledge of distinct arrhythmias that may be drug-induced are essential for clinicians. Consideration of the possibility that a patient’s arrythmia could be drug-induced is important.

Sudden cardiac arrest (SCA) is the most common cause of death in the world. This manuscript highlights the various challenges in prevention and early management of SCA and also discusses the current state of SCA awareness. The manuscript also outlines the various national and international initiatives in improving SCA awareness and their impact on improving outcomes in SCA. Various campaigns have strived for widespread dissemination of cardiopulmonary resuscitation training and advocated for broader public access defibrillator availability. Finally, the manuscript describes future directions including harnessing technology with voice command and artificial intelligence to allow lay person deliver effective CPR, to improve EMS response times, and to allow wider CPR knowledge dissemination in schools and places of employment. Future research should be focused on optimizing SCA outcomes among vulnerable populations and minorities. Advancements in resuscitation science and use of big data for improvement of EMS services will improve outcomes in SCA.

Coronavirus disease 2019 (COVID-19) is a global pandemic that is wreaking havoc on the health and economy of much of human civilization. Electrophysiologists have been impacted personally and professionally by this global catastrophe. In this joint article from representatives of the Heart Rhythm Society, the American College of Cardiology, and the American Heart Association, we identify the potential risks of exposure to patients, allied healthcare staff, industry representatives, and hospital administrators. We also describe the impact of COVID-19 on cardiac arrhythmias and methods of triage based on acuity and patient comorbidities. We provide guidance for managing invasive and noninvasive electrophysiology procedures, clinic visits, and cardiac device interrogations. In addition, we discuss resource conservation and the role of telemedicine in remote patient care along with management strategies for affected patients.

Pulmonary vein isolation is the cornerstone for atrial fibrillation ablation. Effectiveness of pulmonary vein isolation during cryoablation is demonstrated by confirming entrance and exit block. Loss of pulmonary vein potentials during cryoablation demonstrates presence of entrance block. Exit block is confirmed by pacing from within the pulmonary veins and demonstrating lack of capture of the left atrium. Administration of adenosine can unmask dormant conduction in the pulmonary veins.

Objectives The aim of this study was to determine temporal trends, in-laboratory complications, mortality, and predictors of mortality among nonagenarians undergoing percutaneous coronary intervention (PCI). Background Nonagenarians (patients 90 years of age or older) undergoing PCI are often underrepresented in clinical trials, and their management remains challenging and controversial. Methods All veterans undergoing PCI with data recorded in the Veterans Affairs Clinical Assessment, Reporting, and Tracking program from 2005 to 2014 were evaluated. Temporal trends in the use of PCI, occurrence of in-laboratory complications, and 30-day and 1-year mortality were assessed. Using a frailty model, predictors of 30-day and 1-year mortality in nonagenarians were evaluated. Results Among all veterans undergoing PCI (n = 67,148) between 2005 and 2014, 274 (0.4%) were nonagenarians. The proportion of nonagenarians increased from 0.25% in 2008 to 0.58% in 2014. Compared with younger patients, nonagenarians had a greater risk for acute cardiogenic shock post-procedure (0.73% vs. 0.12%; p = 0.04) and no reflow (2.9% vs. 1.0%; p = 0.02). Unadjusted (10.6% vs. 1.4%; p Conclusions Nonagenarians were a small but growing population with worse 30-day and 1-year mortality. The National Cardiovascular Data Registry risk score was a strong predictor of mortality in these patients.

The choice of appropriate antithrombotic therapy in patients with atrial fibrillation (AF) undergoing percutaneous coronary interventions (PCI) should be approached prudently. Careful consideration is necessary, balancing the ischemic and bleeding risk. Traditionally, triple antithrombotic therapy comprising of aspirin, a P2Y12 inhibitor, and an oral anticoagulant is associated with high bleeding rates. Recent trials have evaluated the safety and effectiveness of dual antithrombotic therapy in AF patients undergoing PCI. These studies have shown a significant reduction in bleeding with no increase in ischemic events. Clopidogrel is the preferred P2Y12 agent in the dual antithrombotic regimens. The novel oral anticoagulants (NOAC) rivaroxaban and dabigatran have been evaluated as part of dual antithrombotic therapy and are preferred options for oral anticoagulation in AF patients undergoing PCI. Studies are in progress to evaluate the role of alternate NOACs in this clinical scenario. This review explores the contemporary management of antithrombotic therapy in AF patients undergoing PCI.

As the burden of cardiovascular disease in the United States continues to increase, uncertainty remains on how well-equipped the cardiovascular workforce is to meet the challenges that lie ahead. In a time when health care is rapidly shifting, numerous factors affect the supply and demand of the cardiovascular workforce. This Council Commentary critically examines several factors that influence the cardiovascular workforce. These include current workforce demographics and projections, evolving health care and practice environments, and the increasing burden of cardiovascular disease. Finally, we propose 3 strategies to optimize the workforce. These focus on cardiovascular disease prevention, the effective utilization of the cardiovascular care team, and alterations to the training pathway for cardiologists.

Background: The etiology of sudden cardiac death in patients with end-stage renal disease (ESRD) on hemodialysis (HD) is largely unknown, though there is evidence to suggest that metabolic alkalosis induced by HD with a high-bicarbonate dialysate/prescription may play a role. Methods: We investigated the effects of metabolic alkalosis induced by HD with an acetate-containing bicarbonate-buffered dialysate on frequency of ventricular arrhythmia in 47 patients with ESRD on chronic HD using 48-h Holter monitoring in 3 phases: intra-HD, post-HD day 1, and post-HD day 2. Serum levels of bicarbonate, calcium, and potassium along with hemodynamics were measured pre-HD, post-HD, 20-h post-HD, and 44-h post-HD. Correlations were performed to verify the association between bicarbonate prescription and change in serum bicarbonate levels post-HD and to determine if the HD-induced change in serum bicarbonate level (metabolic alkalosis) had any direct association with ambient ventricular arrhythmia (premature ventricular contractions per hour) or indirect associations with ambient ventricular arrhythmia by affecting electrolytes or hemodynamics that are known to increase the risk of ventricular arrhythmia. Results: Mean pre-HD serum bicarbonate level was 21.3 mEq/L. Dialysate bicarbonate prescription (mean of 36.4 mEq/L) correlated with changes in serum bicarbonate levels immediately post-HD 26.7 mEq/L (r = 0.46, p < 0.01), 20-h post-HD 25.2 mEq/L (r = 0.38), and 44-h post-HD 23.2 mEq/L (r = 0.35, p = 0.01). No statistically significant correlations were found between the post-HD change in serum bicarbonate levels (metabolic alkalosis) with ambient ventricular arrhythmia, changes in serum calcium, potassium, or hemodynamics in any phase. Conclusions: High-bicarbonate dialysate prescription is associated with metabolic alkalosis following the HD procedure. A mild metabolic alkalosis induced by HD with an acetate-containing bicarbonate-buffered dialysate solution had no direct association with ambient ventricular arrhythmia on Holter monitoring and was not associated with changes in hemodynamics or changes in serum total calcium or potassium levels. This study helps to provide guidance for the safe use of high bicarbonate dialysate/prescription in patients with ESRD on HD.

Recently, the American College of Cardiology, the American Heart Association, and the Heart Rhythm Society published an updated guideline on the management of atrial fibrillation (AF). This document is a complete revision of the 2006 guideline. Prominent changes in the 2014 guideline include the use of the CHA2DS2-VASc score for risk stratification of stroke, recommendations on when and how to use newer oral anticoagulants for thromboprophylaxis, downgrading of the use of aspirin for thromboprophylaxis of moderate-risk patients, and the use of catheter ablation in selected patients as first-line therapy for paroxysmal AF. In regard to rate control, the 2014 guideline reverts back to a previous recommendation for stricter targets for mean and maximum heart rate on therapy. The current guideline incorporates many recent trials in updating existing recommendations from the 2006 guideline. The 2014 guideline will be a vital tool in guiding physicians in the management of AF.

The field of adult and pediatric interventional cardiology (PIC) has expanded considerably over the last decade. Given the recent advances like transcatheter aortic valve replacement, percutaneous mitral valve repair, and left atrial appendage closure, many cardiology training programs are offering

Lifelong learning is essential for the practicing cardiologist. Present lifelong learning mechanisms are stagnant and at risk for not meeting the needs of currently practicing cardiologists. With the increasing burden of cardiovascular disease, growing complexity of patient care, and ongoing pressures of nonclinical responsibilities, educational programming must evolve to meet the demands of the contemporary cardiovascular professional. A paradigm shift, replete with modern and practical educational tools, is needed in the lifelong learning armamentarium. Emerging evidence of novel educational strategies in graduate medical education supports the promise of broader application of these tools to different stages of professional life. In this commentary from the Fellows-in-Training Section Leadership Council, the authors propose 3 novel educational tools-personalized learning, adaptive learning, and the flipped classroom-to improve lifelong learning to meet the educational needs of fellows-in-training to practicing cardiologists alike.

With the development of newer drugs and improvements in established treatment protocols, prognosis for many types of cancer has improved dramatically. Some cancers that were historically associated with high fatality rates now have high cure rates or successful palliation, turning the malignancy into a chronic disease. Given this improved prognosis, more patients will face the adverse effects of cancer treatment. Cancer therapy can result in cardiac toxicity, such as cardiomyopathy. Cardiotoxicity with chemotherapeutic agents in the form of cardiomyopathy was first described in 1966 in patients receiving anthracyclines.1 However, cancer treatment–induced arrhythmia (CTIA) has not attracted specific attention until recently.2 CTIA is a complex entity with multiple factors involved in its pathogenesis. It can be divided into primary CTIA (caused by a drug disrupting specific molecular pathways critical for the development of a specific arrhythmia) and secondary CTIA (caused by damage to the endocardium/myocardium/pericardium through ischemia, inflammation, or radiation therapy (RT), with arrhythmia as a secondary phenomenon). Secondary CTIA is much more common. The distinction between primary and secondary CTIA is not well defined, with many contributing and confounding factors, and the exact mechanisms for many drugs are still to be elucidated (Figure). Figure. Mechanisms of arrhythmias in cancer patients. AC indicates anthracyclines; ATO, arsenic trioxide; HA, histamine; hERG, human Ether-a-go-go -Related Gene; PI3K, phosphotidyl inositol 3–kinase; PKI, protein kinase inhibitors; SB, sinus bradycardia; and 5-FU, 5-fluorouracil. Heart image reprinted with permission from Marieb and Hoehn.3 Copyright © 2013, Pearson Education, Inc. The incidence of CTIA with many chemotherapeutic agents is yet to be firmly established as most chemotherapy trials have not had adequate numbers of patients enrolled to study this problem. In addition, most cancer treatment trials have excluded patients with preexisting cardiac disease, which is the most vulnerable population for CTIA. The National Cancer Institute …

The aim of this study was to determine temporal trends, in-laboratory complications, mortality, and predictors of mortality among nonagenarians undergoing percutaneous coronary intervention (PCI).Nonagenarians (patients 90 years of age or older) undergoing PCI are often underrepresented in clinical trials, and their management remains challenging and controversial.All veterans undergoing PCI with data recorded in the Veterans Affairs Clinical Assessment, Reporting, and Tracking program from 2005 to 2014 were evaluated. Temporal trends in the use of PCI, occurrence of in-laboratory complications, and 30-day and 1-year mortality were assessed. Using a frailty model, predictors of 30-day and 1-year mortality in nonagenarians were evaluated.Among all veterans undergoing PCI (n = 67,148) between 2005 and 2014, 274 (0.4%) were nonagenarians. The proportion of nonagenarians increased from 0.25% in 2008 to 0.58% in 2014. Compared with younger patients, nonagenarians had a greater risk for acute cardiogenic shock post-procedure (0.73% vs. 0.12%; p = 0.04) and no reflow (2.9% vs. 1.0%; p = 0.02). Unadjusted (10.6% vs. 1.4%; p 0.0001) and adjusted 30-day mortality (odds ratio: 2.14; 95% confidence interval [CI]: 1.42 to 3.22) and unadjusted (16.3% vs. 4.2%; p 0.0001) and adjusted 1-year mortality (odds ratio: 1.82; 95% CI: 1.27 to 2.62) were higher among PCI patients who were nonagenarians. The National Cardiovascular Data Registry risk score was highly predictive of both 30-day (hazard ratio: 2.29; 95% CI: 1.86 to 2.82) and 1-year (hazard ratio: 1.43; 95% CI: 1.07 to 1.90) mortality among nonagenarians.Nonagenarians were a small but growing population with worse 30-day and 1-year mortality. The National Cardiovascular Data Registry risk score was a strong predictor of mortality in these patients.

Background— Low serum magnesium (Mg) levels are associated with an increased risk of atrial fibrillation. Some studies have shown a benefit of Mg in facilitating pharmacological cardioversion. The role of an intravenous infusion of Mg alone in facilitating electric cardioversion is not clear. Methods and Results— In a prospective, randomized, double-blind, placebo-controlled trial, we enrolled patients with atrial fibrillation who were scheduled for electric cardioversion. Patients were randomized to receive Mg or placebo before cardioversion using a step-up protocol with 75, 100, 150, and 200 J biphasic shocks. Patients with hypokalemia, hypermagnesemia, or postcardiac surgery atrial fibrillation were excluded. Patients on antiarrhythmic drugs were included as long as they were at steady state. All patients were monitored for 1 hour post procedure for the maintenance of sinus rhythm. A total of 261 patients (69% male, mean age 65.5±11.1 years) were randomized (132 and 129 patients receiving Mg and placebo, respectively). Baseline characteristics were similar between both the groups. There was no statistically significant difference in the success rate of cardioversion between the 2 groups (86.4% versus 86.0%; P =0.94), cumulative amount of energy required for successful cardioversion (123.3±55.5 versus 129.5±52.6 J; P =0.40), or the number of shocks required to convert to sinus rhythm (2.25±1.24 versus 2.41±1.22, P =0.31). No adverse events were noted in either group. Conclusions— In patients undergoing electric cardioversion for persistent atrial fibrillation, Mg infusion does not increase the rate of successful cardioversion. Clinical Trial Information— URL: https://clinicaltrials.gov . Unique identifier: NCT01597557.

Anomalous Left Coronary Artery from Pulmonary Artery (ALCAPA) is a rare and potentially fatal congenital cardiac anomaly. For adults diagnosed with ALCAPA, there is a prominent collateral system that supports the LAD when the ductus closes allowing them to survive. They may present with chest pain

Cardiac sarcoidosis (CS) is a granulomatous disease that could result in life threatening arrhythmias. Recent HRS expert consensus statement recommends prophylactic ICD implantation in patients with CS who requires a pacemaker implantation for high degree AV block. A 55-year-old Caucasian

The use of robotic valve surgery for mitral valve repair is steadily increasing. The complication rate is 1-2% in experienced centers, and much higher in less experienced centers. 73 year old Caucasian woman with a history of diabetes, hypertension, and severe mitral regurgitation underwent, what