Search

Focused echocardiography may be a useful tool in cardiopulmonary resuscitation for prognostication, to identify certain reversible causes of cardiac arrest, and to guide further management and procedures. Nonetheless, many clinicians have reservations regarding its widespread adoption due to evidence that it leads to prolonged interruption of cardiac compressions. Furthermore, the lack of a clear protocol for the inclusion of focused echocardiography into the rhythm check can lead to confusion in teams not familiar with incorporating the modality, as well as safety concerns for the echosonographer during delivery of a shock. We propose the protocol COACHRED to guide the use of focused echocardiography during rhythm check in a safe and timely manner. This approach incorporates the best strategies identified to date that minimise interruptions to chest compressions. We demonstrate that, in a simulation environment, it is achievable to incorporate focused echocardiography into the rhythm check while keeping the interruption to chest compressions within the timeframe prescribed by international guidelines. [ABSTRACT FROM AUTHOR]

Introduction: The electrophysiologic impact of cell‐based therapy on the injured myocardium remains highly controversial. We aimed to perform a meta‐analysis of studies comparing arrhythmia burden following transendocardial stem cell therapy vs placebo in patients with chronic ischemic heart disease (CIHD). Methods and Results: PubMed, Embase, and Cochrane Central Register of Controlled Trials were searched. No restriction of stem cell type was specified. The outcomes included sustained supraventricular or ventricular arrhythmias (VAs), sudden cardiac death (SCD), and resuscitated sudden cardiac arrest (SCA). Effect sizes were reported as odds ratio (OR) and 95% CI. Poisson regression was used to account for zero‐events data. Twelve randomized trials that included 736 patients (384 in the cell therapy group and 352 in the placebo group) were analyzed. Six different cell types were used. Follow‐up ranged from 6 to 12 months. There was a significant decrease in risk of SCD in the cell therapy group, (FE OR, 0.19 [0.04, 0.93]; P = .04). In subgroup analysis, there was a significantly lower risk of SCD or resuscitated SCA in the cell therapy group limited to studies that did not use skeletal myoblasts, (FE OR, 0.23 [0.06, 0.83]; P = .03). There was no significant difference in the incidence of sustained VA between groups (FE OR, 0.91 [0.47, 1.77]; P = .8), even after stratifying by cell type. There was no difference in supraventricular arrhythmias between groups. Conclusion: Nonskeletal myoblast transendocardial cell therapy was associated with a significantly lower risk of SCD or resuscitated SCA compared to control, with no proarrhythmic effects. [ABSTRACT FROM AUTHOR]

Introduction: There are conflicting data regarding the efficacy of implantable cardioverter‐defibrillator (ICD) in Chagas disease (CD) patients. This study aims to evaluate the short‐term outcome after ICD for secondary prevention, in a population where CD is a prevalent cause of heart failure (HF). Methods and Results: Consecutive patients with HF and reduced left ventricular ejection fraction (LVEF), who underwent ICD implantation for secondary prevention of SCD. Clinical and demographic data were collected to investigate mortality predictors at 1 year. During the study period, 117 patients underwent ICD implantation, of which 108 were included. The most frequent causes of HF was CD: 52 (48.1%) and ischemic cardiomyopathy: 20 (18.5%). Chagas and non‐Chagas patients were well balanced—male: 32 (61.5%) vs 38 (67.9%), P = .548; age: 59.2 (±10.9) vs 56.8 (±13.4), P = .681; and LVEF: 34.1 (±0.2) vs 31.3 (±8.7), P = .064, respectively. At the mean follow‐up of 15.7 months, overall mortality occurred in 14 (12.9%) patients, with a higher incidence in patients with CD cardiomyopathy, 11 (21.2%) vs 3 (5.4%), P = .021 (log‐rank). In the multivariate analysis, CD remained as an independent predictor for death (hazard ratio: 4.62, confidence interval [95% CI]: 1.27‐16.81, P = .021). Conclusion: CD was associated with a poor short‐term outcome in patients with HF submitted to ICD implantation for secondary prevention when compared with other HF etiologies. In this specific HF population, ICD indication should be individualized, considering the worst prognosis of these patients. [ABSTRACT FROM AUTHOR]

Objective: To describe incidence in pre‐hospital outcomes of adult out‐of‐hospital cardiac arrest (OHCA) of presumed cardiac aetiology, attended by Queensland Ambulance Service (QAS) paramedics between 2002 and 2014, by age, gender, geographical remoteness and socio‐economic status. Methods: The QAS OHCA Registry was used to identify cases, which was then linked with Queensland Hospital Admitted Patient Data Collection and Queensland Death Registry. Population data were obtained for each calendar year by age and gender from the Australian Bureau of Statistics in order to calculate incidence rates. Four mutually exclusive pre‐hospital outcomes were analysed: (i) no resuscitation (No‐Resus); (ii) resuscitation, no pre‐hospital return of spontaneous circulation (No‐ROSC); (iii) resuscitation, pre‐hospital return of spontaneous circulation not sustained to hospital (Unsustained‐ROSC); and (iv) resuscitation, pre‐hospital return of spontaneous circulation sustained to hospital (Sustained‐ROSC). Results: Over the 13 years, there were 30 560 OHCA cases for analyses. Incidence was significantly greater in males than females and incrementally increased with age, for each outcome. Incidence of total OHCA events generally increased as remoteness increased (major cities: 72.39 per 100 000 [95% CI 71.35–73.45]; very remote: 87.01 per 100 000 [95% CI 78.03–95.98]). There was an inverse association between incidence of OHCA events and socio‐economic status (SEIFA 1 and 2: 81.34 per 100 000 [95% CI 79.28–83.40]; SEIFA 9 and 10: 61.57 per 100 000 [95% CI 59.67–63.46]). Conclusion: Rural‐specific strategies should be continued. Prevention and management strategies for OHCA targeting lower socio‐economic groups require focus. [ABSTRACT FROM AUTHOR]

Introduction: Clinical trials did not provide conclusive evidence concerning the benefit of prophylactic implantable cardioverter‐defibrillators (ICDs) in patients with severe nonischemic cardiomyopathy (NICM). We aimed to compare incidence of appropriate sustained ventricular arrhythmia (SVA) and device therapy in ischemic cardiomyopathy (ICM) vs NICM ICD and/or cardiac resynchronization therapy (CRT‐D) patients. Methods and Results: We analyzed remote‐monitoring data from devices of the Home Monitoring Expert Alliance network. SVA recordings were adjudicated by three independent electrophysiologists. Our cohort included 1,946 patients who received either an ICD (55%) or a CRT‐D (45%) for primary prevention of sudden cardiac death. Median (interquartile range) age was 70 (62‐77) years, 81% were male, and 52% were in the ICM group. Patients were remotely monitored for a maximum follow‐up of 5 years. The 5‐year product‐limit estimate of SVA incidence in patients with an ICD was 47.3% (95% confidence interval [CI], 41.0%‐53.9%) in the ICM group and 44.7% (36.9%‐53.3%) in the NICM group. In patients with a CRT‐D, SVA incidence was 45.7% (37.3%‐55.0%) in ICM patients and 49.2% (40.4%‐58.7%) in NICM patients. The adjusted hazard ratio for SVA in the ICM vs NICM group was 0.96 (95% CI: 0.70‐1.30, P = .77) in ICD patients and 0.85 (95% CI: 0.61‐1.18, P = .34) in CRT‐D patients. SVAs triggered appropriate device therapies with similar incidence in all groups. Conclusion: In a large cohort of remotely monitored ICD and CRT‐D recipients, SVA incidence did not significantly differ in ICM and NICM patients. [ABSTRACT FROM AUTHOR]

Background: Subcutaneous implantable cardioverter‐defibrillator (S‐ICD) is gaining in popularity for primary and secondary prevention of sudden cardiac death. The objective was to evaluate the safety and clinical effectiveness of the S‐ICD for prevention of sudden cardiac death compared to transvenous cardioverter‐defibrillator (TV‐ICD). Methods: A systematic review with meta‐analyses was performed. The electronic databases MEDLINE, EMBASE, SCI, and Cochrane Central Register of Controlled Trials were consulted in March 2018 with no restrictions on publication date. Predefined criteria were used to determine inclusion of studies and to assess their methodologic quality. Results: Ten longitudinal‐observational studies with comparison group presenting moderate methodologic flaws were included (N = 7820). The combination of results indicates that health‐related quality of life is not significantly different between S‐ICD and TV‐ICD groups (Physical health: MD = 2.90; 95% CI = −3.88, 9.68/Mental health: MD = 0.13; 95% CI = −2.11, 2.37). Mortality occurred in 4.4% of S‐ICD patients and 5.9% of TV‐ICD patients died (OR = 0.79; 95% CI = 0.50, 1.24). The incidence of infections (OR = 1.79; 95% CI = 0.93, 3.43) and inappropriate shocks (OR = 1.28, 95% CI = 0.91, 1.78) is not significantly different between both groups. The S‐ICD reduces complications related to electrodes/leads (OR = 0.13, 95% CI = 0.05, 0.29) and has lower electrodes/leads movement compared with TV‐ICD (OR = 0.26; 95% CI 0.10, 0.67). In contrast, pneumothorax is more likely in TV‐ICD than S‐ICD (OR = 0.17; 95% CI = 0.03, 0.97). Conclusions: S‐ICD reduces electrodes/leads movement, electrodes/leads related complications, and pneumothorax. Our study did not demonstrate a statistically significant difference in mortality, health‐related quality of life, and infection rate between S‐ICD and TV‐ICD. [ABSTRACT FROM AUTHOR]

Here, we describe the cases of two elite athletes, with a diagnosis of arrhythmogenic cardiomyopathy (ACM), in which a subcutaneous implantable cardioverter defibrillator (S‐ICD) has been implanted. Both patients experienced a ventricular tachycardia during exercise and received effective S‐ICD shocks that interrupted arrhythmias. This report reveals for the first time that the S‐ICD is effective in reverting arrhythmias in ACM patients, even during exercise. Moreover, these cases may confirm that competition/physical activity is associated with ICD shocks. [ABSTRACT FROM AUTHOR]

The article offers information on guidance for emergency front of neck access (eFONA) in airway management in Great Britain. Topics discussed include developing skills for identification of the cricothyroid membrane; reviewing techniques to improve making the transition to eFONA for airway management; and lifesaving intervention in airway management.

Background: The perioperative management of anticoagulation with the use of subcutaneous implantable cardioverter‐defibrillator (S‐ICD) implantation is still evolving. Objective: The purpose of this study was to assess whether it is safe to perform S‐ICD implantation with uninterrupted warfarin. Methods: This is a multi‐center retrospective review of patients undergoing S‐ICD implantation between October 1, 2012 and June 30, 2017. Forty‐eight patients underwent successful S‐ICD implantation during the study period. The most common indication for implantation was primary prevention of sudden cardiac death. In 23 (47.9%) patients, warfarin was continued without any interruption. In 25 (52.1%) patients, warfarin was interrupted prior to implantation. The incidence of clinically significant lateral pocket hematoma was compared in the two groups. Results: The mean international normalized ratio was 2.0 ± 0.4 in the uninterrupted group and 1.4 ± 0.4 for the interrupted group. A total of seven patients developed a hematoma at the lateral pocket. No patient developed a hematoma at the parasternal pockets. Six patients in the uninterrupted group (26.1%) and one patient in the interrupted group (0.04%) developed a significant lateral pocket hematoma (P = .04). The concomitant use of dual antiplatelet therapy did not increase the risk of hematoma. There was no significant difference between HASBLED and CHA2DS2VASc scores between the groups. None of the patients with a hematoma developed infection or required hematoma evacuation. Conclusions: The uninterrupted use of warfarin in the perioperative period of S‐ICD implantation is associated with an increased risk of lateral pocket hematoma. [ABSTRACT FROM AUTHOR]

Background: The benefits of implantable cardioverter‐defibrillators (ICDs) for the prevention of sudden cardiac arrest (SCA) are well established. However, a significant knowledge gap remains regarding current indications and utilization of ICDs in real‐world settings in Asia. Methods: Patients who underwent ICD implantation in South Korea from 2007 to 2015 were identified using the Health Insurance Review and Assessment Service database. We investigated trends in use of ICD for the prevention of SCA. Results: A total of 4649 ICDs were implanted during 9 years. ICDs were implanted in 1448 (31.2%) patients for primary prevention and in 3201 (68.8%) for secondary prevention. The proportion of ICDs for primary prevention increased from 6.1% in 2007 to 41.9% in 2015. Primary prevention was more frequent in older (≥40 years) recipients (34.4% vs. 14.6%, P < .0001). The rates of ICD implantation for primary prevention were highest for nonischemic dilated cardiomyopathy (55.1%) and lowest (9.7%) for inherited primary arrhythmia syndrome (IPAS). Conclusion: Our data showed a trend of progressively increasing rates of ICD implantation in Asia, especially for primary prevention of SCA. Primary prevention as an indication for ICD in patients with IPAS remained low. [ABSTRACT FROM AUTHOR]

The article reports on guidelines for cardiac screening in the preparticipation physical examination of athletes for the prevention of sudden cardiac death. The Science Advisory and Coordinating Committee of the American Heart Association has developed guidelines which involve key medical history questions that assess the risk for specific cardiac abnormalities. Risk factors for sudden cardiac death include congenital cardiac abnormalities, hypertrophic cardiomyopathy, and coronary anomaly.

Sudden cardiac death (SCD) is a devastating and all too common result of both acquired and genetic heart diseases. The profound sadness endured by families is compounded by the risk many of these deaths confer upon surviving relatives. For those with known cardiac disease, disease‐specific therapy and risk stratification are key to reducing sudden death. For families of a SCD victim, uncovering a definitive cause of death can help relieve the agonising uncertainty and is a vital first step in screening surviving relatives and instituting therapy to reduce SCD risk. Increasing knowledge about the molecular mechanisms and genetic drivers of malignant arrhythmias in the diverse clinical entities that can cause SCD is vital if we are to optimise risk stratification and personalise patient care. Advances in diagnostic tools, disease‐specific therapy and defibrillator technology are improving outcomes for patients and their families but there is still much progress to be made. [ABSTRACT FROM AUTHOR]

Background: Because sudden cardiac death (SCD) in the young mainly occurs in individuals with structurally normal hearts, improved screening techniques for detecting inherited arrhythmic diseases are needed. The QT interval is an important screening measurement; however, the criteria for detecting an abnormal QT interval are based on Bazett formula and older populations. Objective: To define the normal upper limits for QT interval from the electrocardiograms (ECGs) of healthy young individuals, compare the major correction formula and propose new QT interval thresholds for detecting those at risk of SCD. Methods: Young active individuals underwent ECGs as part of routine preparticipation physical examinations for competitive sports or community screening. This was a nonfunded study using de-identified data with no follow-up. Results: There were 31 558 subjects: 2174 grade school (7%), 18 547 high school (59%), and 10 822 college (34%). Mean age was 17 (12-35 years), 45% were female, 67% white, and 11% of African descent. Bazett performed least favorably for removing the effect of heart rate (HR), whereas Fridericia performed the best. Fridericia correction also closely fit the raw data best (R2 of 0.65), and at percentile values applicable to screening. The recommended risk cut points using Bazetts correction identified less than half of the athletes in the 99th or 99.5th percentiles of the uncorrected QT by HR range. Use of Fridericia correction increased capture rates by over 50%. Conclusion: Our results support the application of the Fridericia-corrected threshold of 460 for men and 470 milliseconds for women (and 485 milliseconds for marked prolongation) rather than Bazett correction for the preparticipation examination. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To determine whether burden of multiple chronic conditions (MCCs) influences the risk of receiving inappropriate vs appropriate device therapies. DESIGN: Retrospective cohort study. SETTING: Seven US healthcare delivery systems. PARTICIPANTS: Adults with left ventricular systolic dysfunction receiving an implantable cardioverter‐defibrillator (ICD) for primary prevention. MEASUREMENTS: Data on 24 comorbid conditions were captured from electronic health records and categorized into quartiles of comorbidity burden (0‐3, 4‐5, 6‐7 and 8‐16). Incidence of ICD therapies (shock and antitachycardia pacing [ATP] therapies), including appropriateness, was collected for 3 years after implantation. Outcomes included time to first ICD therapy, total ICD therapy burden, and risk of inappropriate vs appropriate ICD therapy. RESULTS: Among 2235 patients (mean age = 69 ± 11 years, 75% men), the median number of comorbidities was 6 (interquartile range = 4‐8), with 98% having at least two comorbidities. During a mean 2.2 years of follow‐up, 18.3% of patients experienced at least one appropriate therapy and 9.9% experienced at least one inappropriate therapy. Higher comorbidity burden was associated with an increased risk of first inappropriate therapy (adjusted hazard ratio [HR] = 1.94 [95% confidence interval {CI} = 1.14‐3.31] for 4‐5 comorbidities; HR = 2.25 [95% CI = 1.25‐4.05] for 6‐7 comorbidities; and HR = 2.91 [95% CI = 1.54‐5.50] for 8‐16 comorbidities). Participants with 8‐16 comorbidities had a higher total burden of ICD therapy (adjusted relative risk [RR] = 2.12 [95% CI = 1.43‐3.16]), a higher burden of inappropriate therapy (RR = 3.39 [95% CI = 1.67‐6.86]), and a higher risk of receiving inappropriate vs appropriate therapy (RR = 1.74 [95% CI = 1.07‐2.82]). Comorbidity burden was not significantly associated with receipt of appropriate ICD therapies. Patterns were similar when separately examining shock or ATP therapies. CONCLUSIONS: In primary prevention ICD recipients, MCC burden was independently associated with an increased risk of inappropriate but not appropriate device therapies. Comorbidity burden should be considered when engaging patients in shared decision making about ICD implantation. [ABSTRACT FROM AUTHOR]

Aims: To explore the motivation of family members of patients at high risk for sudden cardiac death for undertaking cardiopulmonary resuscitation (CPR) training. Background: Home cardiac arrests are associated with poor outcomes because few family members learn CPR. Little is known about factors that motivate family members to participate in CPR training. Design: We used grounded theory to establish a theoretical framework to explore the motivational factors for learning CPR among family members. Methods: Twelve participant observations and 42 semi‐structured interviews with family members of different behaviours towards CPR training were conducted from December 2013 ‐ November 2016. Data were analysed using constant‐comparisons, situational analysis, and encoding. Findings: A motivation‐behaviour theoretical framework for learning CPR was constructed. We identified meeting inner needs as the core category to demonstrate motivation. Security motivation and responsibility motivation emerged as main categories, which demonstrate that seeking a sense of security and shouldering family responsibility were important considerations for family members to learn CPR. These two motivations produced high‐engagement behaviours of family members to learn CPR. Conclusions: The motivations we identified—deriving from a sense of security and family responsibility—are the main reasons family members would learn CPR and, therefore, should be understood by medical professionals. Understanding these motivations may help in the formulation of customized CPR training that further meets the needs of family members. For example, motivational interventions that are integrated with a family‐based CPR course can be designed to improve the participation of family members and the sustainability of the course. [ABSTRACT FROM AUTHOR]

Introduction: The use of extracorporeal life support (ECLS) is increasing worldwide, in particular for the management of refractory cardiac arrest, cardiogenic shock and post cardiopulmonary bypass ventricular failure. Extubation of patients under extracorporeal membrane oxygenation (ECMO) for respiratory failure is a growing practice for adult and pediatric patients, especially for lung transplantation candidates. Because of potential complications and, specifically, accidental arterial decannulation, extubation of patients under ECLS is not standard practice. Our goal was to evaluate the interest in patient extubation under ECLS. Materials and methods: We performed a monocentric, retrospective study of all ECLS cases between January 2014 and January 2016. We excluded patients who died within the first 48 hours of ECLS. Results: We analyzed 57 of the initial 109 patients included in the study. The initial SOFA score was higher in the non-extubated group under ECLS, without significant difference (8.6 ± 2.8 vs 7.2 ± 2.1, p=0.065). Patients who were not extubated had a higher rate of acquired ventilator pneumonia (61.9% vs 26.7%, p=0.03). Moreover, patients who were extubated under ECLS had better 30-day survival rates (73.3% vs 40.5%, p=0.04). In multivariate analyses, the independent factors associated with mortality were age, duration of ECLS and the lack of extubation under ECLS. Conclusion: Extubation of patients under ECLS is safe and feasible. Furthermore, in extubated patients, we observed fewer cases of ventilator-associated pneumonia and better 30-day survival rates. [ABSTRACT FROM AUTHOR]

Defibrillator technology for sudden cardiac death (SCD) prevention now includes the transvenous implantable cardiac defibrillator (ICD), subcutaneous ICD (S-ICD) and wearable cardioverter defibrillator (WCD). ICD use improves survival in patients who survived previous sudden cardiac arrest (SCA) due to ventricular tachycardia (VT)/ventricular fibrillation (VF), as well as in patients who experienced haemodynamically significant VT. It is also currently indicated for primary prevention in ischaemic/non-ischaemic cardiomyopathies, certain congenital heart disease conditions and inherited channelopathies. In this review article, we hope to present an updated review on ICD use for SCD prevention, with a focus on contemporary issues affecting ICD selection. These include: the role of primary prevention ICD in patients with non-ischaemic cardiomyopathy (NICM) in light of the 2016 DANISH (Danish Study to Assess the Efficacy of ICDs in Patients with Non-Ischemic Systolic Heart Failure on Mortality) trial; the role of defibrillator component (CRT-D) in patients receiving cardiac resynchronisation therapy (CRT-P); and the emerging role of cardiac magnetic resonance imaging (cMRI) in particular, the presence of late gadolinium enhancement (LGE), as an important SCD risk predictor. The current use of S-ICD and WCD, including clinical indications, evidence for efficacy and limitations, will also be discussed. [ABSTRACT FROM AUTHOR]

Sudden Cardiac Death (SCD) is a major public health issue, accounting for half of all cardiovascular deaths world-wide. The implantable cardioverter-defibrillator (ICD) has been solidified as the cornerstone therapy in primary prevention of SCD in ischaemic and non-ischaemic cardiomyopathy. However, what has become increasingly clear is that the left ventricular ejection fraction (LVEF) is an inadequate tool to select patients for a prophylactic ICD, despite its widespread use for this purpose. Use of LVEF alone has poor specificity for arrhythmic versus non-arrhythmic death. In addition, the vast majority of sudden deaths occur in patients with more preserved cardiac function. Alternate predictors of sudden death include electrophysiology study, non-invasive markers of electrical instability, myocardial fibrosis, genetic and bio-markers. The challenge for the future is finding a risk stratification test, or combination of tests, that adequately select patients at high risk of SCD with low competing risk of non-sudden death. [ABSTRACT FROM AUTHOR]

Introduction Sudden cardiac arrest (SCA) is an acute medical condition in which the heart ceases its function and circulation of blood stops. Resuscitation should be started as soon as SCA is diagnosed. Medical staff are required to know the algorithms for both basic and advanced resuscitation procedures. Material and methods The aim of this study was to assess the knowledge of cardiopulmonary resuscitation among nurses from clinical departments. A questionnaire was used as a research tool. Due to the nature of the study, frequency analysis, the non-parametric Chi2 test, non-parametric equivalent of the Student's t-test, U Mann-Whitney, and the non-parametric equivalent of variance analysis (ANOVA) or the H Kruskal-Wallis test were used. Results Research has shown satisfactory knowledge of algorithms of conduct but insufficient knowledge about the use of AEDs. There was a statistically significant relationship between knowledge and time of completion of the CPR course (Kruskal- Wallis test: χ2 =9.41; p=0.024). [ABSTRACT FROM AUTHOR]

Importance: Patients with chronic kidney disease have impaired vitamin D activation and elevated cardiovascular risk. Observational studies in patients treated with hemodialysis showed that the use of active vitamin D sterols was associated with lower risk of all-cause mortality, regardless of parathyroid hormone levels.Objective: To determine whether vitamin D receptor activators reduce cardiovascular events and mortality in patients without secondary hyperparathyroidism undergoing hemodialysis.Design, Setting, and Participants: Randomized, open-label, blinded end point multicenter study of 1289 patients in 207 dialysis centers in Japan. The study included 976 patients receiving maintenance hemodialysis with serum intact parathyroid hormone levels less than or equal to 180 pg/mL. The first and last participants were enrolled on August 18, 2008, and January 26, 2011, respectively. The final date of follow-up was April 4, 2015.Interventions: Treatment with 0.5 μg of oral alfacalcidol per day (intervention group; n = 495) vs treatment without vitamin D receptor activators (control group; n = 481).Main Outcomes and Measures: The primary outcome was a composite measure of fatal and nonfatal cardiovascular events, including myocardial infarctions, hospitalizations for congestive heart failure, stroke, aortic dissection/rupture, amputation of lower limb due to ischemia, and cardiac sudden death; coronary revascularization; and leg artery revascularization during 48 months of follow-up. The secondary outcome was all-cause death.Results: Among 976 patients who were randomized from 108 dialysis centers, 964 patients were included in the intention-to-treat analysis (median age, 65 years; 386 women [40.0%]), and 944 (97.9%) completed the trial. During follow-up (median, 4.0 years), the primary composite outcome of cardiovascular events occurred in 103 of 488 patients (21.1%) in the intervention group and 85 of 476 patients (17.9%) in the control group (absolute difference, 3.25% [95% CI, -1.75% to 8.24%]; hazard ratio, 1.25 [95% CI, 0.94-1.67]; P = .13). There was no significant difference in the secondary outcome of all-cause mortality between the groups (18.2% vs 16.8%, respectively; hazard ratio, 1.12 [95% CI, 0.83-1.52]; P = .46). Of the 488 participants in the intervention group, 199 (40.8%) experienced serious adverse events that were classified as cardiovascular, 64 (13.1%) experienced adverse events classified as infection, and 22 (4.5%) experienced malignancy-related serious adverse events. Of 476 participants in the control group, 191 (40.1%) experienced cardiovascular-related serious adverse events, 63 (13.2%) experienced infection-related serious adverse events, and 21 (4.4%) experienced malignancy-related adverse events.Conclusions and Relevance: Among patients without secondary hyperparathyroidism undergoing maintenance hemodialysis, oral alfacalcidol compared with usual care did not reduce the risk of a composite measure of select cardiovascular events. These findings do not support the use of vitamin D receptor activators for patients such as these.Trial Registration: UMIN-CTR Identifier: UMIN000001194. [ABSTRACT FROM AUTHOR]

Background: Despite available evidence that implantable cardioverter defibrillators (ICDs) reduce all‐cause mortality among patients at risk for sudden cardiac death, utilization of ICDs is low especially in developing countries. Objective: To summarize reasons for ICD or cardiac resynchronization therapy defibrillator implant refusal by patients at risk for sudden cardiac arrest (Improve SCA) in developing countries. Methods: Primary prevention (PP) and secondary prevention (SP) patients from countries where ICD use is low were enrolled. PP patients with additional risk factors (syncope, ejection fraction < 25%, nonsustained ventricular tachycardia [NSVT], or frequent premature ventricular complexes) were further categorized as "1.5 PP patients." Candidates who declined implantation were asked for reasons for refusal. Baseline factors that may have influenced the implant decision were examined using logistic regression. Results: Among 3892 patients, the implant refusal rate was 46.5% among PP patients (n = 2700), and 10.3% among SP patients (n = 1192). The most common refusal reason was inability to pay for the device (53.8%), followed by not believing in the benefits of the ICD (19.4%). Among PP ICD candidates, those with no syncope, no NSVT, no premature ventricular contractions, shorter QRS duration, no atrial arrhythmias, and no left bundle branch block were more likely to refuse implant. Among SP candidates, a history of cardiovascular surgery and no sinus node dysfunction were significant predictors of ICD refusal. Additionally, countries had significant differences in patient refusal rates among PP and SP groups. Conclusion: Implant refusal among PP patients is high in many countries. Increased reimbursement and better awareness of the benefits of an ICD could increase their utilization. [ABSTRACT FROM AUTHOR]

Abstract Objectives To evaluate the effectiveness of wearable cardioverter defibrillator (WCD) use in protecting patients from sudden cardiac arrest (SCA) while they were treated in nonhospital settings until re-implantation of an Implantable cardioverter-defibrillator (ICD) was feasible. We sought to determine whether the WCD could be successfully utilized long term (≥1 year) after ICD extraction in patients at continued risk of SCD in which ICD re-implantation was not practical. Background ICDs have proven to improve mortality in patients for both secondary and primary prevention of SCA. Increased ICD implantation in older patients with comorbid conditions has resulted in higher rates of cardiac device infections. Currently, a wearable cardioverter defibrillator (WCD) is an alternative management for SCA prevention in specific cases. Methods This a retrospective analysis based on consecutive WCD patients who underwent ICD explant due to device-related infections or mechanical reasons between April 2007 and July 2014. A total of 102 patients were identified from the national database maintained by ZOLL (Pittsburgh, PA, USA). We analyzed the reason for WCD use, demographic information, device data, compliance and duration of WCD use, detected arrhythmias and therapies, and reason for discontinuing WCD use. Results In these long term WCD users, average length of WCD use was 638 ± 361 days. Nine patients (8.8%) had a sustained ventricular arrhythmia that was successfully resuscitated by the WCD. Six patients (5.8%) experienced inappropriate shocks. Two patients (1.9%) died of asystole events while wearing the WCD and an additional 10 patients died while not monitored by the WCD. Thirty-nine patients (38.2%) ended WCD use when a new ICD was implanted and 15 patients (14.7%) were still wearing the WCD at the time of analysis. Conclusions We found that extending use of the WCD to ≥1 year is a safe and effective alternative treatment for patients with explanted ICDs who are not pacemaker dependent. Highlights • Increased ICD implantation in older patients has resulted in higher rates of device infections. • Currently, a WCD is an alternative for outpatient management for ICD explant patients. • The extended use of WCD is a safe and effective alternative treatment for ICD explant patients. • WCD cannot treat asystole or patients who are pacemaker dependent. [ABSTRACT FROM AUTHOR]

Background and Purpose Sudden cardiac death causes an estimated 200,000 to 450,000 deaths per year in the USA. Although permanent implantation of an internal cardiac defibrillator offers a preventive intervention, the required assessment period for determining need creates vulnerability for patients who will benefit from this protection. The use of a wearable cardioverter defibrillator (WCD) for interim protection is rapidly increasing. There are no rehabilitation guidelines for patients wearing a WCD. This article reviews the WCD's purpose, considers implications and current challenges for use during rehabilitation, and illustrates this with a case report. Case Description A 51-year-old male with coronary artery disease following prolonged hospitalization was fitted with a WCD during evaluation for an internal cardiac defibrillator. During inpatient rehabilitation, the therapy plan required unique considerations because of the presence of the WCD. Outcomes Recapitulating the patient's rehabilitation course illustrates the WCD's challenges, the benefits to exercise progression, and the safety measures used. The patient gained functional independence, with uninterrupted care, in the presence of the WCD. Discussion Knowledgeable clinicians, attention to safety, and sufficient patient/caregiver education are essential for uninterrupted and successful rehabilitative care for WCD-wearing patients. Because of increasing clinical prevalence of WCDs in rehabilitation, it is critically important to share clinical experience and eventually conduct a systematic assessment. [ABSTRACT FROM AUTHOR]

Background. Wearable cardioverter-defibrillators (WCD, LifeVest, ZOLL) can protect from sudden cardiac death bridging a vulnerable period until a decision on implantable cardioverter-defibrillator (ICD) implantation can be reached. WCD is commonly used for 3 months or less. It is unknown, which patients use WCD longer and which patients are most likely to benefit from it. Hypothesis. Extended use of WCD is reasonable in selected cases based on underlying heart disease and overall patient risk profile. Methods. We conducted a systematic and comprehensive research of all published clinical studies on PubMed reporting on the use of the WCD. Only original articles reporting on wear times and time to appropriate shocks were included in our analysis. Results. The search resulted in 127 publications. 14 parameters were reported necessary for inclusion in our analysis. Median wear times ranged from 16 to 394 days. The median wear time was especially long for patients suffering from nonischemic cardiomyopathy (NICM) (range: 50–71 days) and specifically peripartum cardiomyopathy (PPCM) (120 days) and for heart transplant candidates. There was a large variation of appropriate shocks according to indication for WCD use. In contrast to NICM in general, the number of appropriate shocks was particularly high in patients with PPCM (0 in 254 patients and 5 in 49 patients, respectively). The median and maximal time periods to the first appropriate shock were longest in patients with PPCM (median time to the first appropriate shock: 68 days). Conclusions. Prolonged use of WCD is not uncommon in available literature. Patients suffering from NICM and specifically PPCM seem most likely to have longer therapy duration with WCD with success. Careful patient selection for prolonged use may decrease the need for ICD implantation in the future; however, prospective data are needed to confirm this hypothesis. [ABSTRACT FROM AUTHOR]

Distinguishing between adaptive and maladaptive cardiovascular response to exercise is crucial to prevent the unnecessary termination of an athlete’s career and to minimize the risk of sudden death. This is a challenging task essentially due to the substantial phenotypic overlap between electrical and structural changes seen in the physiological athletic heart remodeling and pathological changes seen in inherited or acquired cardiomyopathies. Stress testing is an ideal tool to discriminate normal from abnormal cardiovascular response by unmasking subtle pathologic responses otherwise undetectable at rest. Treadmill or bicycle electrocardiography, transthoracic echocardiography, and cardiopulmonary exercise testing are common clinical investigations used in sports cardiology, specifically among participants presenting with resting electrocardiographic abnormalities, frequent premature ventricular beats, or non-sustained ventricular arrhythmias. In this setting, as well as in cases of left ventricular hypertrophy or asymptomatic left ventricular dysfunction, stress imaging and myocardial tissue characterization by cardiovascular magnetic resonance show promise. In this review, we aimed to reappraise current diagnostic schemes, screening strategies and novel approaches that may be used to distinguish adaptive remodeling patterns to physical exercise from early phenotypes of inherited or acquired pathological conditions commanding prompt intervention. [ABSTRACT FROM AUTHOR]

Background: A wearable cardioverter defibrillator (WCD) is an alternative for patients who are not immediate candidates for an implantable cardioverter defibrillator (ICD). Methods: Retrospective analysis of 242 patients prescribed a WCD from January 2014 through March 2015 with 1‐year follow‐up. Results: A WCD was prescribed to 242 patients during the 15‐month period. Forty‐one patients were excluded due to lack of complete follow‐up. The remaining 201 patients received a WCD for primary or secondary prevention of SCD. Seventy‐nine percent of WCDs were prescribed by nonelectrophysiologists. Underlying etiologies for the WCD prescription included: 38% nonischemic cardiomyopathy, 25% recent myocardial infarction, 16% newly diagnosed ischemic cardiomyopathy, 12% documented ventricular arrhythmia, 6% ICD lead extraction, and 3% had high risk conditions for sudden cardiac death. During 1‐year follow‐up, 96 patients (48%) received an ICD and five patients (2.5%) received appropriate shocks and one patient (0.5 %) received an inappropriate shock. Other 105 (52%) patients subsequently did not require an ICD due to either improvement in ejection fraction, refusal of ICD therapy, or death. Conclusions: About half of patients prescribed a WCD subsequently receive an ICD and the rate of appropriate shock therapy from the WCD is 2.5%. [ABSTRACT FROM AUTHOR]

Abstract Background Sudden cardiac arrest (SCA) may be the sentinel expression of a sudden cardiac death-predisposing genetic heart disease (GHD). Although shown to underlie many unexplained SCAs in the young, the contribution of GHDs to sentinel SCA has never been quantified across the age spectrum. Thus, we sought to determine the contribution of GHDs in single-center referral cohort of non-ischemic SCA survivors. Methods and results Retrospective analysis of 3037 patients was used to identify all individuals who experienced a sentinel event of SCA. Following exclusion of patients with ischemic or complex congenital heart disease, cases were classified by clinical diagnoses. Overall, 180 (5.9%) referral patients experienced a sentinel SCA (average age at SCA 28 ± 15 years, 99 females). An etiology was identified in 113/180 patients (62.8%) including channelopathies in 26.7%, arrhythmogenic bileaflet mitral valve prolapse in 10.6%, cardiomyopathies in 9.4%, other etiologies in 6.7%, acquired long QT syndrome in 6.7%, and multiple disorders in 2.8%. The remaining 67/180 (37.2%) cases were classified as idiopathic ventricular fibrillation (IVF). Interestingly, the contribution of GHDs declined precipitously after the first decade of life [90.0% (age 0–9; n = 20), 58.7% (age 10–19; n = 46), 28.1% (age 20–29; n = 32), 23.8% (age 30–39; n = 42), 16.7% (age 40–49; n = 24), and 12.5% (age 50+; n = 16)]. Conclusions Within a referral population enriched for GHDs, the ability of a comprehensive cardiac evaluation, including genetic testing, to elucidate a root cause in non-ischemic SCA survivors declined with age. Although rare, GHDs can underlie SCA into adulthood and merit consideration across the age spectrum. Highlights • The diagnostic yield in non-ischemic cardiac arrest survivors is age-dependent. • The yield of genetic testing in unexplained sudden cardiac arrest is low. • Arrhythmic mitral valve prolapse is a frequent cause of non-ischemic SCA in adults. [ABSTRACT FROM AUTHOR]

Abstract Background In patients with repaired Tetralogy of Fallot (ToF), implantable cardioverter defibrillators (ICD) are considered reasonable in selected adults with multiple risk factors for sudden cardiac death. Patients and methods We performed a retrospective cohort study of all 174 patients with repaired ToF who are followed at the University Hospital of Muenster. We analyzed data according to the risk score previously proposed by Khairy and coworkers and patient outcome. We analyzed data separately for patients without previous sustained ventricular tachycardia (VT) (risk stratification group, n = 157) and patients with VT/secondary prevention ICD (n = 17). Results In the risk stratification group, a mean of 4 ± 1 risk score parameters were available. All six risk parameters were known in 10%, five in 14%. Risk score increased with availability of parameters. 15 patients with secondary prevention ICD had a mean risk score of 6.3 ± 2.2 (range 2–10). 11 patients of the risk stratification group with primary prevention ICD had a mean risk score 5.8 ± 2.4 (range 3–8). During follow-up of up to 14 years, five patients died (3%): at age 58, two at 69 and two at 76 years. Conclusion In the majority of patients risk score variables were incomplete, severely limiting its applicability because the true score cannot be calculated. Risk scores were not different between patients with secondary prevention ICD and patients with ICD for primary prevention based on current guidelines. Standardization of follow-up and prospective evaluation of these standards in large prospective patient cohorts is desirable to improve risk stratification in patients with ToF. Highlights • Risk score increases with known risk factors, but follow-up is not standardized. • Invasive tests are seldom indicated, preventing complete risk score calculation. • Risk score was similar in patients with primary and secondary prevention ICD. • Long-term outcome was favorable in the majority of patients. • Proposal of a follow-up protocol [ABSTRACT FROM AUTHOR]

Abstract: Background: Guideline‐directed medical therapy (GDMT) for patients with heart failure with reduced ejection fraction (HFrEF) has been challenging to achieve universally. Healthcare providers who seek to achieve optimal medical therapy frequently consider either a wearable cardioverter defibrillator (WCD) or an implantable cardioverter defibrillator (ICD) as indicated. The dynamic process of communication and physician recommendations marks a setting to study the relative interdependence of medical therapies and best practice. The purpose of this study was to examine the long‐term impact of the WCD on GDMT. We hypothesized the WCD serves as a “gateway” therapy, likely impacting other optimal strategies such that successful use of WCD improves GDMT adherence. Methods: Electronic medical records (EPIC) were manually reviewed to extract data elements in this observational study of 1289 HFrEF patients from 2013‐2015. Data included demographics, comorbidities, and use of GDMT including an ICD use in persistently low ejection fraction (≤36%) patients after 90 days. Results: WCD use was significantly associated with prescribing adherence to GDMT, χ2 (1, N = 981) = 33.36, P < 0.001. Further, WCD use was significantly associated with recommendations for follow‐up echocardiographic study, χ2 (1, N = 865) = 66.94, P < 0.001 and use of primary prevention ICD, χ2 (1, N = 1093) = 19.00, P < 0.001. Conclusions: This study demonstrates the use of the WCD correlates with improved clinician use of GDMT, follow‐up echocardiographic studies, and appropriate use of primary prevention ICD. Thus, the potential benefits of the WCD and its care processes may extend beyond prevention of sudden cardiac death to enhanced optimization of GDMT. [ABSTRACT FROM AUTHOR]

Abstract Background Although large randomized clinical trials have found that primary prevention use of an implantable cardioverter-defibrillator (ICD) improves survival in patients with cardiomyopathy and heart failure symptoms, patients who receive ICDs in practice are often older and have more comorbidities than patients who were enrolled in the clinical trials. In addition, there is a debate among clinicians on the usefulness of electrophysiological study for risk stratification of asymptomatic patients with Brugada syndrome. Aim Our analysis has 2 objectives. First, to evaluate whether ventricular arrhythmias (VAs) induced with programmed electrostimulation in asymptomatic patients with Brugada syndrome identify a higher risk group that may require additional testing or therapies. Second, to evaluate whether implantation of an ICD is associated with a clinical benefit in older patients and patients with comorbidities who would otherwise benefit on the basis of left ventricular ejection fraction and heart failure symptoms. Methods Traditional statistical approaches were used to address 1) whether programmed ventricular stimulation identifies a higher-risk group in asymptomatic patients with Brugada syndrome and 2) whether ICD implantation for primary prevention is associated with improved outcomes in older patients (>75 years of age) and patients with significant comorbidities who would otherwise meet criteria for ICD implantation on the basis of symptoms or left ventricular function. Results Evidence from 6 studies of 1138 asymptomatic patients were identified. Brugada syndrome with inducible VA on electrophysiological study was identified in 390 (34.3%) patients. To minimize patient overlap, the primary analysis used 5 of the 6 studies and found an odds ratio of 2.3 (95% CI: 0.63–8.66; p=0.2) for major arrhythmic events (sustained VAs, sudden cardiac death, or appropriate ICD therapy) in asymptomatic patients with Brugada syndrome and inducible VA on electrophysiological study versus those without inducible VA. Ten studies were reviewed that evaluated ICD use in older patients and 4 studies that evaluated unique patient populations were identified. In our analysis, ICD implantation was associated with improved survival (overall hazard ratio: 0.75; 95% confidence interval: 0.67–0.83; p<0.001). Ten studies were identified that evaluated ICD use in patients with various comorbidities including renal disease, chronic obstructive pulmonary disease, atrial fibrillation, heart disease, and others. A random effects model demonstrated that ICD use was associated with reduced all-cause mortality (overall hazard ratio: 0.72; 95% confidence interval: 0.65–0.79; p<0.0001), and a second "minimal overlap" analysis also found that ICD use was associated with reduced all-cause mortality (overall hazard ratio: 0.71; 95% confidence interval: 0.61–0.82; p<0.0001). In 5 studies that included data on renal dysfunction, ICD implantation was associated with reduced all-cause mortality (overall hazard ratio: 0.71; 95% confidence interval: 0.60–0.85; p<0.001). [ABSTRACT FROM AUTHOR]

Abstract: Background: The subcutaneous implantable cardioverter defibrillator (S‐ICD) has been established as a valuable alternative to transvenous ICD for prevention of sudden cardiac death. The system automatically chooses the optimal sensing vector. However, during follow‐up and especially after device replacement we observed a change of the suggested sensing vector in automatic setup. Therefore, we analyzed frequency and reasons of vector change and its impact on inappropriate shocks (IAS). Material and methods: Between June 2010 and December 2017, a total of 216 patients with S‐ICD® were included in this analysis. In all patients sensing vectors at the time of implantation, during follow‐up, and after device replacement were investigated. Median follow‐up time was 27.3 ± 25.3 months. Results: A change of the initial vector was seen in 77 patients (35.7%). The most frequent reason for vector change was the postoperative setup in supine and erect position in 54 patients (70.1%). In 12 patients (15.5%), the vector was manually changed due to inappropriate sensing and/or therapies. Routine setup during follow‐up led to automatic vector change in 10 cases (13.0%). In only 1 patient the vector was manually changed due to oversensing in an exercise treadmill test. In 27 patients, the device was replaced due to battery depletion and in 6 of these patients the sensing vector was changed by the automatic setup. Vector change did not have an impact for inappropriate therapies in the follow‐up; only 1 patient received an IAS due to an inadvertent vector change after device replacement. Conclusion: In the present study, a significant number of S‐ICD® patients had a manual or automatic vector change during follow‐up and after device replacement. The study underlines the importance of a thoroughly performed screening and at least two valuable sensing vectors preimplant. Further studies are needed to evaluate the necessity of a routine automatic setup during follow‐up. [ABSTRACT FROM AUTHOR]

The article discusses the guidelines for patients and families in remote monitoring of implanted cardiac devices. Topics include the healthcare team's access of information from the device, the setting up of the devices, the transmission of information from the device to the monitor and the challenges and benefits of remote monitoring.

Abstract: Background: Patient‐reported outcomes of implantable cardioverter defibrillator (ICD), such as those with shock anxiety, have emerged as important endpoints that are related to quality of life (QOL), but they have not been well studied in a sample of the Japanese population. Therefore, we prospectively examined changes in shock anxiety in a large sample of Japanese patients with an ICD. Methods: We recruited 214 consecutive patients with an ICD who visited the outpatient clinic. At registration and 12 months later, all patients completed the Florida Shock Anxiety Scale (FSAS) questionnaire to allow us to examine changes in shock anxiety over the course of the first year after registration. Results: During the 12‐month follow‐up period, 10.5% of the patients received ICD shock therapy. Female sex, secondary prevention, and experience of ICD shock therapy were associated with high FSAS scores at registration. The FSAS scores in both patients with appropriate and inappropriate shock were significantly higher at the 12‐month follow‐up interval than at registration, and there was no significant difference in the extent of changes in FSAS scores (Δ = 5.2 ± 5.1 and Δ = 6.3 ± 9.9, respectively, P = 0.62). Conclusions: Female sex, secondary prevention, and experience of ICD shock therapy are important risk factors affecting shock anxiety in Japanese patients. Attention should be paid to the after‐effects of ICD shock in these patients, regardless of the shock type, with particular attention to women and patients who require secondary prevention. [ABSTRACT FROM AUTHOR]

Local anesthetic systemic toxicity (LAST), although rare, can be a fatal complication after regional anesthesia. The use of intravenous (IV) fat emulsion as a treatment of LAST is controversial among clinicians worldwide. This literature review aims to identify existing data supporting the use of IV lipids in the management of LAST and current best evidence-based practice by anesthesia providers during a LAST event. More than 120 articles resulted from a systematic literature search that was conducted using major search engines. Of those articles, 25 were included in this literature review. The safe use of IV lipids for the treatment of LAST is supported in the literature. Yet, there is still lack of awareness on lipid rescue therapy despite the significant evidence of its positive outcome. In the setting of local-anesthetic toxicity, lipid rescue should be considered first-line treatment. Intravenous lipids must be readily available in all institutions performing regional anesthesia. Education on their use, storage, and dosage is vital among anesthesia departments in the United States and worldwide. [ABSTRACT FROM AUTHOR]

Introduction There is compelling evidence for an association between influenza epidemics and major adverse cardiovascular events. However, the role of extreme influenza epidemics as a trigger of out-of-hospital cardiac arrest (OHCA) is unclear. Thus, we evaluated the potential association between extreme influenza epidemics and incidence of OHCA. Methods We used a quasi-experimental design with time-series analysis of national registry data for cases of OHCA from all 47 prefectures of Japan during influenza seasons between 2005 and 2014. A Poisson regression time-series model with a distributed lag non-linear model was used to estimate prefecture-specific effects of influenza epidemics on OHCA. A multivariate meta-analysis was conducted for nationally pooled estimates. Results In total, 481,516 OHCAs of presumed cardiac origin were reported during the study period. The minimum morbidity percentile (MMP) was estimated as the 0th percentile for influenza incidence. The overall cumulative relative risk versus the MMP was 1.25 (95% confidence interval, 1.16–1.34) for extreme influenza epidemics (at the 99th percentile of influenza incidence). The effect of extreme influenza epidemics was significant for lag periods of 1.5–7.1 and 17.9–21 days. Multivariate random-effects meta-analysis indicated significant spatial heterogeneity among prefectures (Cochran Q test, p  = 0.011; I 2  = 23.2%). Conclusion Extreme influenza epidemics are associated with higher risk of OHCA. Our findings suggest that several weeks' prevention for extreme influenza infections should be implemented to reduce the risk of OHCA. [ABSTRACT FROM AUTHOR]

Prediction of sudden cardiac death continues to gain universal attention as a promising approach to saving millions of lives threatened by sudden cardiac death (SCD). This study attempts to promote the literature from mere feature extraction analysis to developing strategies for manipulating the extracted features to target improvement of classification accuracy. To this end, a novel approach to local feature subset selection is applied using meticulous methodologies developed in previous studies of this team for extracting features from non-linear, time-frequency, and classical processes. We are therefore enabled to select features that differ from one another in each 1-min interval before the incident. Using the proposed algorithm, SCD can be predicted 12 min before the onset; thus, more propitious results are achieved. Additionally, through defining a utility function and employing statistical analysis, the alarm threshold has effectively been determined as 83%. Having selected the best combination of features, the two classes are classified using the multilayer perceptron (MLP) classifier. The most effective features would subsequently be discussed considering their prevalence in the rank-based selection. The results indicate the significant capacity of the proposed method for predicting SCD as well as selecting the appropriate processing method at any time before the incident. Graphical abstract ᅟ. [ABSTRACT FROM AUTHOR]

Background Acute myocardial infarction (AMI) is a server disease effecting a large population worldwide. The pathophysiological process of ischemic/reperfusion (I/R) plays an important role for heart tissue damage. VO-OHpic, a PTEN inhibitor, has been demonstrated to be cardiac protective in sudden cardiac arrest models, but its role in AMI remains unclear. Methods An isolated AMI model was induced by dissecting the rat heart in a Langendorff system. Cardiac myocytes were extracted and induced ischemia in vitro . VO-OHpic was added into the above systems. The area of infarcted tissue in the heart was measured. Cardiac myocyte apoptosis was assessed by flow cytometry. Activation of Akt and GSK3β was quantified by flow cytometry. IL-10 levels were determined by ELISA. Results VO-OHpic reduced infarcted areas in the isolated heart, and improved cultured cardiac myocyte survival. VO-OHpic induced apoptosis resistance in cardiac myocytes. Akt-GSK3β signaling was activated by VO-OHpic administration. IL-10 levels in the medium were elevated by VO-OHpic. Conclusion VO-OHpic protects heart tissue by apoptosis resistance via activating Akt-GSK3β signaling and increasing IL-10 levels. [ABSTRACT FROM AUTHOR]

The article highlights conditions under which a haemodynamic resuscitation can be guided by microcirculatory data. Topics discussed include microcirculatory failure; pathophysiological importance of the microcirculation in shock states; and challenges due to autoregulation malfunctions during septic shock.

Abstract: Background: Chagas heart disease (CHD) is a dilated cardiomyopathy characterized by malignant ventricular arrhythmias and increased risk of sudden cardiac death (SCD). Much controversy exists concerning the efficacy of implantable cardioverter‐defibrillator (ICDs) in CHD because of mixed results observed. We report our long‐term experience with ICDs for secondary prevention in CHD, with the specific aim of assessing the results in groups with preserved or depressed global left ventricular function. Methods: 111 patients (75 males; 60 ± 12 years) were followed for 1,948 ± 1,275 days after ICD. Time to death was the primary outcome; LVEF ≤ 45% the exposure; and age, gender, and ICD therapy delivery the potential confounders. We used time‐to‐event methods and Cox proportional models for analysis, censoring observations at time of death or at 5‐year follow‐up in survivors. Results: Seventy‐two percent of the patients presented at least one sustained ventricular arrhythmia requiring appropriate therapy, and only three patients received inappropriate therapy. Death occurred in 50 (45%) patients, with an annual mortality rate of 8.4%, mostly due to refractory heart failure or noncardiac causes. Unadjusted survival rates were significantly distinct between patients with left ventricular ejection fraction (LVEF) ≤ 45% (26 deaths), 50.5% (95% confidence interval [CI]: 36.2%–63.2%) when compared to patients with LVEF > 45% (10 deaths), 77.6% (95% CI: 62.3%–87.3%, P < 0.01). After adjusting for confounders, low LVEF (hazard ratio [HR]: 5.2, 95% CI: 2.3–11.6), age (HR: 1.04, 95% CI: 1.01–1.07), and female gender (HR: 3.97, 95% CI: 1.85–8.54) were independently associated with the outcome. Conclusions: ICDs successfully aborted life‐threatening arrhythmias in CHD patients. Impaired left ventricular function predicted higher mortality in CHD patients with an ICD for secondary prevention of SCD. [ABSTRACT FROM AUTHOR]

Objectives: Despite the well-documented benefit of implantable cardioverter defibrillator (ICD) in patients with severe left ventricular dysfunction, there is a large number of patients who had not been offered this therapy. The aim of this study is to evaluate the utility of a hybrid decision support system (hCDSS) to improve the adherence to indicate ICD therapy in our institution.Methods: We conducted a retrospective, observational and single-center study. An hCDSS focused on patients with severe deterioration of the left ventricular function was implemented, creating a mandatory field containing the value of left ejection fraction and three options to choose: >35%, ≤ 35% or unknown. When the option ≤ 35% is checked, an email is automatically sent to the electrophysiology section where the staff can contact the treating physician to discuss the indication of ICD therapy. We measured the number of ICDs implanted before the alert (month 1-21), immediate post and late post alert (month 22-27 and 28-48 months respectively) RESULTS: The rate of ICD implantation increased from 1.76% per month in the pre-intervention period to 4.48% after the intervention (p < 0.001). This increase in the rate of ICD implantation remained stable between the immediate and late post-intervention period (4.6 vs. 4.4; p = .8) CONCLUSION: The implementation of a hybrid decision support system was associated with improved adherence to clinical guidelines for prevention of sudden cardiac death, as evidenced by a rapid and sustained increase in the number of ICD implants in patients with severe left ventricular dysfunction. [ABSTRACT FROM AUTHOR]

Introduction: The role of implantable cardioverter-defibrillator (ICD) placement in the primary prevention of sudden cardiac death (SCD) in all consecutive patients with left ventricular ejection fraction (LVEF) ≤ 35% is still a matter of hot debate due to the fact that the population of these patients is highly heterogeneous in terms of the SCD risk. Nevertheless, reduced LVEF is still the only established criterion during qualification of patients for ICD implantation in the primary prevention of SCD, therefore identification of persons with particularly high risk among patients with LVEF ≤35% is currently of lesser importance. More important seems to be the selection of individuals with relatively low risk of SCD in whom ICD implantation can be safely postponed. The aim of the study was to determine whether well-known, non-invasive parameters, such as microvolt T-wave alternans (MTWA), baroreflex sensitivity (BRS) and short-term heart rate variability (HRV), can be helpful in the identification of low-arrhythmic risk patients with left ventricular systolic dysfunction. Methods: In 141 patients with coronary artery disease and LVEF ≤ 35%, MTWA testing, as well as BRS and short-term HRV parameters, were analysed. During 34 ± 13 months of follow-up 37 patients had arrhythmic episode (EVENT): SCD, non-fatal sustained ventricular arrhythmia (ventricular tachycardia [VT] or ventricular fibrillation [VF]), or adequate high-voltage ICD intervention (shock) due to a rapid ventricular arrhythmia ≥200/min. LVEF, non-negative MTWA (MTWA_non-neg), BRS and low frequency power in normalized units (LFnu) turned out to be associated with the incidence of EVENT in univariate Cox analysis. The cut-off values for BRS and LFnu that most accurately distinguished between patients with and without EVENT were 3 ms/mmHg and 23, respectively. The only variable that provided 100% negative predictive value (NPV) for EVENT was negative MTWA result (MTWA_neg), but solely for initial 12 months of the follow-up; the NPVs for other potential predictors of the EVENT were lower. The cut-off values for BRS and LFnu that provide 100% NPV for EVENT during 12 and 24 months were higher: 6.0 ms/mmHg and 73 respectively, but the gain in the NPV occurred at an expense of the number of identified patients. However, the number of identified non-risk patients turned out to be higher when the predictive model included MTWA_neg and the lower cut-off values for ANS parameters: 100% NPV for 12 and 24 months of follow-up was obtained for combination MTWA_neg and BRS ≥ 3 ms/mmHg, for combination MTWA_neg and LFnu ≥ 23 100% NPV was obtained for 12 months. Conclusion: Well-known, non-invasive parameters, such as MTWA, BRS and short-term HRV indices may be helpful in the identification of individuals with a relatively low risk of malignant ventricular arrhythmias among patients with ischemic left ventricular systolic dysfunction; in such persons, implantation of ICD could be safely postponed. [ABSTRACT FROM AUTHOR]

Introduction: The aim of our study was to determine the risk factors for electrical storm (ES) and to assess the impact of ES on the long-term prognosis in patients after myocardial infarction (MI) with an implantable cardioverter-defibrillator (ICD) for secondary prevention of sudden cardiac death (SCD).Material and Methods: We retrospectively analyzed 416 patients with coronary artery disease after MI who had an implanted ICD for secondary prevention of SCD. Fifty (12%) patients had one or more incidents of an electrical storm - the ES (+) group. We matched the reference group of 47 patients from 366 ES (-) patients.Results: We analyzed 3,408 episodes of ventricular arrhythmias: 3,148 ventricular tachyarrhythmic episodes in the ES (+) group (including 187 episodes of ES) and 260 in the ES (-) group. Multivariate logistic regression showed that inferior wall MI (RR = 3.98, 95% CI: 1.52-10.41) and the absence of coronary revascularization (RR = 2.92, 95% CI: 1.18-7.21) were independent predictors of ES (p = 0.0014). During 6-year observation of 97 patients, there were 39 (40%) deaths: 25 (50%) subjects in the ES (+) group and 14 (30%) in the ES (-) group (p = 0.036). Independent predictors of death were: the occurrence of ES (HR = 1.93), older age (HR = 1.06), and lower left ventricular ejection fraction (HR = 0.95) (for all p < 0.001).Conclusions: Electrical storm in patients after MI with ICD for secondary prevention is a relatively common phenomenon and has a negative prognostic significance. Myocardial infarction of the inferior wall and the absence of coronary revascularization are predisposing factors for the occurrence of an ES. [ABSTRACT FROM AUTHOR]

A 19-year-old male collegiate wrestler was diagnosed with bicuspid aortic valve disease and aortic insufficiency due to the presence of an aortic-ventricular tunnel. The athlete underwent an electrocardiogram, transthoracic echocardiogram, transesophageal echocardiogram, as well as a diagnostic ultrasound of his carotid arteries and abdominal aorta in order to diagnose this underlying structural abnormality. This diagnosis resulted in the athlete being disqualified for the remainder of the wrestling season and undergoing open-heart surgery to repair his bicuspid aortic valve. This case study will explain the events surrounding the recognition of this disease as well as advocate for the use of cardiac screening in preparticipation exams (PPEs). It is imperative that we implement more advanced diagnostic testing in the PPEs of young athletes in order to diagnose underlying structural heart abnormalities that may lead to sudden cardiac death. [ABSTRACT FROM AUTHOR]

Aim: To quantify the physiologic effects of pre-arrest bolus dilute epinephrine in the pediatric intensive care unit.Methods: Patients <18 years old and ≥37 weeks gestation who received an intravenous bolus of dilute epinephrine (10 mcg/mL) in the pediatric intensive care units at our institution from January 2011 to March 2017 were retrospectively identified. Patients were excluded if doses exceeded 20 mcg/kg, or under the following circumstances: orders limiting resuscitation, extracorporeal membrane oxygenation, active chest compressions, simultaneous administration of other blood pressure-altering interventions or documented normotension prior to epinephrine. The primary outcome was change in systolic blood pressure within 5 min of epinephrine. Patients were categorized as non-responders if the change in systolic blood pressure was ≤10 mmHg.Results: One hundred forty-four patients were analyzed. The median index dose was 0.7 mcg/kg (IQR, 0.3-2.0), and the mean increase in systolic blood pressure was 31 mmHg (95% CI, 25-36; P < 0.001). Thirty-nine (27%) patients were classified as non-responders. Compared to responders, non-responders had higher rates of cardiac arrest or extracorporeal membrane oxygenation within 6 h (26% vs 10%; relative risk, 2.69; 95% CI, 1.21-5.97; P = 0.03), and had higher in-hospital mortality (51% vs 21%; relative risk, 2.45; 95% CI, 1.51-3.96; P < 0.001).Conclusions: In the majority of pre-arrest pediatric patients, bolus dilute epinephrine resulted in an increase in systolic blood pressure, and lack of blood pressure response was associated with poor outcomes. Optimal dosing of dilute epinephrine remains unclear. [ABSTRACT FROM AUTHOR]

Objectives: The benefit of implanting patients with nonischemic cardiomyopathy (NICMP) with an implantable cardioverter defibrillator (ICD) for primary prevention has not been demonstrated in any randomized controlled trial. This also holds true for the most recent study on the subject. This systematic review and meta-analysis aims to examine the effectiveness of primary prevention using an ICD in the NICMP population. Methods: We searched the literature for randomized controlled trials examining the effectiveness of ICD in reducing all-cause mortality in patients with NICMP. The primary outcome of our analysis was all-cause mortality. A fixed-effects model was used for the primary analysis. Results: A total of 5 randomized controlled trials focused on primary prevention of sudden cardiac death for patients with NICMP that met our inclusion and exclusion criteria. They have individually failed to consistently show a benefit for the use of an ICD in this population. However, the cumulative effect of ICD implantation in patients with NICMP demonstrated a 21% relative risk reduction in mortality (Relative risk [RR]: 0.79; confidence interval: 0.66-0.95). Conclusion: There is a decrease in mortality with the use of ICD for primary prevention in patients with NICMP having left ventricular ejection fraction <35%. [ABSTRACT FROM AUTHOR]

Background: Understanding the epidemiological characteristics of anaphylaxis-associated out-of-hospital cardiac arrest (OHCA) is the first step toward developing preventative strategies and optimizing care systems. We aimed to describe and compare epidemiological features and clinical outcomes among patients with anaphylaxis-associated OHCAs according to causative agent groups. Methods: We identified emergency medical service (EMS)-treated anaphylaxis-associated OHCA patients from a nationwide OHCA registry between 2008 and 2015. We compared epidemiological characteristics and outcomes according to causal agents (a natural agents group and an iatrogenic agents group) and evaluated temporal variability in incidence. Multivariate logistic regression analysis was performed to compare survival to discharge between causative agent groups. Results: During the study period (8 years), the total number of anaphylaxis-associated OHCAs was 233. A total of 224 eligible cases were included in the analysis. There were 192 patients (85.6%) in the natural agents group and 32 patients (14.3%) in the iatrogenic agents group. There was significant diurnal and seasonal variability in the frequency of anaphylaxis-associated OHCAs (p values<0.01 for both), with the highest incidences occurring during the day (7:01 am to 3 pm; 64.6%) and in summer (June to August, 48.7%). Compared with the natural agents group, the adjusted odds ratio (AOR) for survival to discharge in the iatrogenic agents group was statistically insignificant (AOR 3.61, 95% CI 0.86 to 15.06). Conclusion: The incidence of anaphylaxis-associated OHCA is considerably low, and significant temporal variability, with a peak during the day and in summer, is evident. Anaphylaxis-associated OHCA is more common by natural agents than by iatrogenic agents, but no difference in the survival-to-discharge rate is evident. [ABSTRACT FROM AUTHOR]

Importance: There is limited evidence that the use of severity of illness scores in pediatric patients can facilitate timely admission to the intensive care unit or improve patient outcomes.Objective: To determine the effect of the Bedside Paediatric Early Warning System (BedsidePEWS) on all-cause hospital mortality and late admission to the intensive care unit (ICU), cardiac arrest, and ICU resource use.Design, Setting, and Participants: A multicenter cluster randomized trial of 21 hospitals located in 7 countries (Belgium, Canada, England, Ireland, Italy, New Zealand, and the Netherlands) that provided inpatient pediatric care for infants (gestational age ≥37 weeks) to teenagers (aged ≤18 years). Participating hospitals had continuous physician staffing and subspecialized pediatric services. Patient enrollment began on February 28, 2011, and ended on June 21, 2015. Follow-up ended on July 19, 2015.Interventions: The BedsidePEWS intervention (10 hospitals) was compared with usual care (no severity of illness score; 11 hospitals).Main Outcomes and Measures: The primary outcome was all-cause hospital mortality. The secondary outcome was a significant clinical deterioration event, which was defined as a composite outcome reflecting late ICU admission. Regression analyses accounted for hospital-level clustering and baseline rates.Results: Among 144 539 patient discharges at 21 randomized hospitals, there were 559 443 patient-days and 144 539 patients (100%) completed the trial. All-cause hospital mortality was 1.93 per 1000 patient discharges at hospitals with BedsidePEWS and 1.56 per 1000 patient discharges at hospitals with usual care (adjusted between-group rate difference, 0.01 [95% CI, -0.80 to 0.81 per 1000 patient discharges]; adjusted odds ratio, 1.01 [95% CI, 0.61 to 1.69]; P = .96). Significant clinical deterioration events occurred during 0.50 per 1000 patient-days at hospitals with BedsidePEWS vs 0.84 per 1000 patient-days at hospitals with usual care (adjusted between-group rate difference, -0.34 [95% CI, -0.73 to 0.05 per 1000 patient-days]; adjusted rate ratio, 0.77 [95% CI, 0.61 to 0.97]; P = .03).Conclusions and Relevance: Implementation of the Bedside Paediatric Early Warning System compared with usual care did not significantly decrease all-cause mortality among hospitalized pediatric patients. These findings do not support the use of this system to reduce mortality.Trial Registration: clinicaltrials.gov Identifier: NCT01260831. [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]

Smart garments, which can capture electrocardiogram signals at any time or location, can alert others to the risk of heart attacks and prevent sudden cardiac death when people are sleeping, walking, or running. Novel wearable electrodes for smart garments based on conductive chitosan fabrics were fabricated by electroless plating of silver nanoparticles onto the surfaces of the fibers. The electrical resistance, which is related to the silver content of the composite fabrics, can be as low as 0.0332 ± 0.0041 W/sq due to the strong reactivity between amine groups and silver ions. After washing these fabrics eight times, the electrical resistance remained below 1 Ω/sq. The conductive chitosan fabrics were applied to smart garments as wearable electrodes to capture electrocardiogram signals of the human body in static state, jogging state, and running state, which showed good data acquisition ability and sensitivity. [ABSTRACT FROM AUTHOR]