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Competing Interests: None.

Falls and fear of falling are a major health issue and associated with high injury rates, high medical care costs, and significant negative impact on quality of life. Adults with cardiovascular disease are at high risk of falling. However, the prevalence and specific risks for falls among adults with cardiovascular disease are not well understood, and falls are likely underestimated in clinical practice. Data from surveys of patient-reported and medical record-based analyses identify falls or risks for falling in 40% to 60% of adults with cardiovascular disease. Increased fall risk is associated with medications, structural heart disease, orthostatic hypotension, and arrhythmias, as well as with abnormal gait and balance, physical frailty, sensory impairment, and environmental hazards. These risks are particularly important among the growing population of older adults with cardiovascular disease. All clinicians who care for patients with cardiovascular disease have the opportunity to recognize falls and to mitigate risks for falling. This scientific statement provides consensus on the interdisciplinary evaluation, prevention, and management of falls among adults with cardiac disease and the management of cardiovascular care when patients are at risk of falling. We outline research that is needed to clarify prevalence and factors associated with falls and to identify interventions that will prevent falls among adults with cardiovascular disease.

T-wave oversensing (TWOS) is a relatively common occurrence in pacemakers and defibrillators that can lead to pauses and inappropriate implantable cardioverter-defibrillator shocks. We present a case of TWOS that triggered the Lead Integrity Alert (Medtronic, Minneapolis, MN, USA) without evidence of actual lead failure., (Copyright: © 2020 Innovations in Cardiac Rhythm Management.)

Background: Boston Scientific (Marlborough, MA, USA) implantable cardioverter-defibrillators (ICDs) and cardiac resynchronization therapy defibrillators (CRT-Ds) manufactured between 2008 and 2014 are potentially subject to premature battery depletion through a low-voltage capacitor malfunction occurring as a result of hydrogen buildup within the device. Although some of these devices are currently under advisory, other devices manufactured during this timeframe carry a lower risk of the same malfunction. These same devices are known to have superior longevity in general, and the overall mean lifespan of the devices remains long., Methods: All patients implanted or followed at our two centers who experienced premature battery depletion and had a Boston Scientific ICD or CRT-D potentially at risk for low-voltage capacitor malfunction were studied retrospectively., Results: Nineteen out of 838 patients (2.3%) with devices potentially at risk have had premature battery depletion: 5.7% of those under advisory and 1.1% of those not under advisory. None of our patients had compromised therapy, and all had >27 days of projected battery longevity remaining., Conclusions: Undetected premature battery depletion in this population of ICDs has the potential to expose a patient to an interval of time where the device is unable to provide therapy. However, with enrollment in remote monitoring, regular follow-up, and attention to audible alerts, the risk of therapy loss due to low-voltage state can be effectively mitigated. For these reasons, prophylactic generator replacement is not recommended., (© 2019 Wiley Periodicals, Inc.)

We present three cases within 11 months at a single institution of sustained VT that fell below the programmed detection rate of the patients' implantable cardioverter-defibrillators (ICDs), two of which continued until converting to an agonal VF that did not meet criteria for detection, and a third case that could not be successfully defibrillated after a prolonged period of VT. These episodes may be under-recognized due to the dependence of device diagnostic storage on programming and the post-mortem effort that is often required to review these events. Some patients, likely those with the most advanced heart failure, may not tolerate sustained ventricular tachycardia (VT) and may even die from ventricular arrhythmias without ever having a rhythm that meets detection criteria in a ventricular fibrillation (VF) zone., (© 2015 Wiley Periodicals, Inc.)

Introduction: Cardiac implantable electronic device (CIED) infections are potentially preventable complications associated with high morbidity, mortality, and cost. A recently developed bio-absorbable antibacterial envelope (TYRX™-A) might prevent CIED infections in high-risk subjects. However, data regarding safety and efficacy have not been published., Methods and Results: In a single-center retrospective cohort study, we compared the prevalence of CIED infections among subjects with ≥2 risk factors treated with the TYRX™-A envelope (N = 135), the nonabsorbable TYRX™ envelope (N = 353), and controls who did not receive an envelope (N = 636). Infection was ascertained by individual chart review. The mean (95% confidence interval) number of risk factors was 3.08 (2.84-3.32) for TYRX™-A, 3.20 (3.07-3.34) for TYRX™, and 3.09 (2.99-3.20) for controls, P = 0.3. After a minimum 300 days follow-up, the prevalence of CIED infection was 0 (0%) for TYRX™-A, 1 (0.3%) for TYRX™, and 20 (3.1%) for controls (P = 1 for TYRX™-A vs. TYRX™, P = 0.03 for TYRX™-A vs. controls, and P = 0.002 for TYRX™ vs. controls). In a propensity score-matched cohort of 316 recipients of either envelope and 316 controls, the prevalence of infection was 0 (0%) and 9 (2.8%), respectively, P = 0.004. When limited to 122 TYRX™-A recipients and 122 propensity-matched controls, the prevalence of CIED infections was 0 (0%) and 5 (4.1%), respectively, P = 0.024., Conclusions: Among high-risk subjects, the TYRX™-A bio-absorbable envelope was associated with a very low prevalence of CIED related infections that was comparable to that seen with the nonabsorbable envelope., (© 2015 Wiley Periodicals, Inc.)

Background: Recent economic trends influenced by healthcare reform, an aging population, changes in physician reimbursement, and increasing competition will have a significant impact on the electrophysiology workforce. Therefore, there is an important need to obtain information about the EP workforce to assess training of arrhythmic healthcare providers in order the meet the requisite societal need. This report summarizes the data collected by the HRS Workforce Study Task Force in relation to physician workforce issues., Objective: The HRS Workforce Study Task Force was charged with conducting a comprehensive study to assess changes in the field of electrophysiology since the last workforce study conducted in 2001 and to identify the population and distribution of professionals who treat patients with heart rhythm disorders., Methods: A series of comprehensive questionnaires were designed by the HRS Workforce Study Task Force to conduct online surveys with physicians, basic science researchers, and allied professionals. Data collected in the physician survey included: personal demographics and professional profile characteristics such as primary work setting and areas of affiliation; workload characteristics such as hours worked, time spent by activity, workload relative to capacity, competition for patients, volume by specific procedure, sources of referrals, income levels, personal mobility, and anticipated future changes in the respondent's practice. Survey responses were collated and analyzed by the Workforce Study Task Force., Results: Work capacity is expected to increase to offset some of the economic drivers; however, recruitment of new EPs could be challenging and uncertain. Specifically, geographic mobility (>50 miles) appears to be minimal at present overall and unlikely to significantly change for the majority of physicians once they have established themselves in a given community following the completion of their training. Practice time is predominantly spent performing device implantations, device follow-ups and ablations. These activities are being tasked upon younger physicians, thereby suggesting a need for trained allied professionals to assume a greater role in device management. The perception of competition varied by respondent age and geographic location but, in general, was felt to be at least moderate by most respondents. Furthermore, there are concerns that increasing competition may dilute operator experience and potentially lower high quality outcomes if increasing competition leads to lower procedural volumes., Conclusion: Based on findings from this study, the task force identified specific workforce (supply) trends and the key drivers of current and future challenges. Although specific areas will require further analysis, overall, the current EP workforce is stable, with the exception of geographic dispersion. However, the workforce must adapt to the key economic drivers (demand) and address future recruitment challenges., (Copyright 2010 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Objectives: This study was performed to determine the incidence of symptomatic, sustained atrial fibrillation in a group of patients with paroxysmal supraventricular tachycardia. The effects of the mechanism of paroxysmal supraventricular tachycardia (atrioventricular [AV] node reentry vs. AV reentry through an accessory pathway) and heart rate during the tachycardia on the occurrence of atrial fibrillation were also assessed., Background: There is a substantial incidence of atrial fibrillation in patients with paroxysmal supraventricular tachycardia, but the precise incidence and the factors that determine it are unknown., Methods: One hundred sixty-nine patients with paroxysmal supraventricular tachycardia were followed up by regular clinic visits and transtelephonic electrocardiographic monitoring during symptomatic episodes of arrhythmia. The Kaplan-Meier product-limit method was used to estimate the proportion of patients remaining free of atrial fibrillation during the observation period. The Cox proportional hazards model was used to assess the effect of mechanism and heart rate during paroxysmal supraventricular tachycardia on the atrial fibrillation-free period., Results: Thirty-two (19%) of the 169 patients had an episode of atrial fibrillation during a mean follow-up period of 31 months. The cumulative percent of patients experiencing an episode of atrial fibrillation was 6% within 1 month, 9% within 4 months and 12% within 1 year. The mechanism of paroxysmal supraventricular tachycardia was not associated with the time to occurrence of atrial fibrillation; the hazard ratio corresponding to classification in the AV node reentry group was 0.8 (p > 0.6). The heart rate during paroxysmal supraventricular tachycardia was not associated with the time to occurrence of atrial fibrillation; the hazard ratio associated with an increase in heart rate of 50 beats/min during the tachycardia was 1.15 (p > 0.5)., Conclusions: This study suggests that atrial fibrillation will develop in approximately 12% of patients with paroxysmal supraventricular tachycardia during a 1-year follow-up period. The occurrence of atrial fibrillation is not related to the mechanism or heart rate of the paroxysmal supraventricular tachycardia.

Patients receiving minimally symptomatic shocks from their implantable cardioverter defibrillators were studied prospectively using transtelephonic ECG loop monitoring. The time course to the first subsequent shock was evaluated. Twenty-nine consecutive patients who received a shock preceded by mild palpitations or no symptoms were given a transtelephonic ECG loop monitor and instructed to activate the monitor if a subsequent shock occurred. Kaplan-Meier analysis was used to quantitate the time to first shock during the study period. The point estimate +/- standard error of patients receiving a shock during the study period was 31% +/- 9% at 30 days, 41% +/- 9% at 60 days, and 60% +/- 9% at 120 days. The ECG was successfully transmitted in 7 of 13 patients who had shocks in the 60-day monitoring period, and demonstrated inappropriate shocks in 6 of 7. Determination of the cause of shock led to a change in subsequent management in all 7 patients. We conclude that the incidence of inappropriate shocks may be higher than estimated previously in patients with minimal symptoms prior to the shock. There are thousands of patients with implantable cardioverter defibrillators that have no storage function for treated tachycardias; transtelephonic ECG loop monitoring can determine the cause of implantable cardioverter defibrillator discharge in these patients, and the diagnosis is invaluable in their management.

Background: Paroxysmal atrial fibrillation and paroxysmal supraventricular tachycardia are recognized clinically when patients seek treatment for symptoms due to recurrent arrhythmias; atrial fibrillation also increases the risk of stroke. The frequency with which asymptomatic arrhythmias occur in patients with these arrhythmias is unknown., Methods and Results: Twenty-two patients with paroxysmal atrial fibrillation (n = 8) or paroxysmal supraventricular tachycardia (n = 14) were studied for 29 days with two different ambulatory ECG-monitoring techniques to measure the relative frequency of asymptomatic and symptomatic arrhythmias. All class I antiarrhythmic drugs, calcium channel blockers, beta-blockers, and digitalis were withheld. Sustained asymptomatic arrhythmia events (defined as lasting at least 30 seconds) were documented using continuous ambulatory ECG monitoring once weekly for a total of 5 of the 29 study days; symptomatic arrhythmia events were documented using transtelephonic ECG monitoring for all 29 days of the study. In the group of patients with paroxysmal atrial fibrillation, asymptomatic arrhythmia events occurred significantly more frequently than symptomatic arrhythmia events; the mean rates, expressed as events/100 d/patient (95% confidence interval), were 62.5 (40.4, 87.3) and 5.2 (2.7, 9.0) (P < .01); the ratio of the mean rates was 12.1 (5.8, 26.4). In contrast, in the group of patients with paroxysmal supraventricular tachycardia, asymptomatic arrhythmia events were significantly less frequent than symptomatic arrhythmia events; the mean rates were 0.0 (0.0, 5.3) and 7.4 (5.0, 10.6) (P = .02). The ratio of the mean rates was 0.0 (0.0, 0.8)., Conclusions: In a group of patients with paroxysmal atrial fibrillation, sustained asymptomatic atrial fibrillation occurs far more frequently than symptomatic atrial fibrillation. However, it is not known whether asymptomatic atrial fibrillation is a potential risk factor for stroke even when patients are not having symptomatic arrhythmias.

Background: Ambulatory outpatients (n = 150) with a history of paroxysmal supraventricular arrhythmia were studied to establish the characteristics of the first recurrence of symptomatic tachycardia (time to first recurrence, heart rate during tachycardia, and observed rhythm that was regular versus irregular) when no antiarrhythmic drug was being taken. Baseline variables were examined to assess their impact on time to first recurrence: index arrhythmia (paroxysmal atrial fibrillation [n = 37] versus paroxysmal supraventricular tachycardia [n = 113]), age (mean +/- SD, 43.3 +/- 16.1 years), female sex (n = 71), or presence of other heart or lung disease (n = 53)., Methods and Results: Transtelephonic monitoring of the ECG was used to document the rhythm during recurrences of symptomatic tachycardia. Time to first recurrence of symptomatic tachycardia and heart rate during tachycardia were measured, the observed rhythm was classified as irregular (consistent with paroxysmal atrial fibrillation) or regular (consistent with paroxysmal supraventricular tachycardia), and the hour of recurrence was recorded. Advancing age was significantly associated with a decreasing time to first recurrence (p < 0.001); the estimated increase in the hazard function was 25% with each 10 years of advancing age. After the effect of age was adjusted for, neither the classification of arrhythmia (p > 0.2), presence of other heart or lung disease (p > 0.8), nor sex (p > 0.9) was significantly associated with time to first recurrence. Among patients with paroxysmal supraventricular tachycardia, 6.5% had atrial fibrillation recorded at the next symptomatic arrhythmia; among patients with paroxysmal atrial fibrillation, 11.8% had a regular tachycardia recorded at the next symptomatic arrhythmia. There was a circadian pattern to the hour of occurrence of paroxysmal supraventricular tachycardia but not paroxysmal atrial fibrillation., Conclusions: Age is more important than other clinical variables, including the ECG classification of a paroxysmal supraventricular arrhythmia in predicting the occurrence of symptomatic arrhythmias. Arrhythmias documented by ECG during symptoms are often different from the arrhythmia documented at the time of referral, which may confound interpretation of antiarrhythmic drug effects.

Symptomatic paroxysmal supraventricular tachycardia is a troubling arrhythmia for many patients. To test the efficacy of oral diltiazem to reduce symptomatic recurrences of paroxysmal supraventricular tachycardia, we enrolled 17 patients in a double-blind, placebo-controlled crossover study. Sixteen of 17 patients completed a dose-ranging phase and were entered into the randomized phase. Although the time to first recurrence of tachycardia was slightly longer when patients took diltiazem, the difference was not significant (p = 0.15). The hazard ratio of the time to first recurrence on placebo compared with oral diltiazem was 2.7 (95% confidence interval, 0.8 to 9.1). Of the patients who had a recurrence of tachycardia in both treatment periods, the median reduction in heart rate in patients receiving diltiazem was 20 beats/min. (p less than 0.01; 95% confidence interval, 6 to 42).

To determine whether there are differences in responses to thrombolytic therapy in certain populations, the data for the Thrombolysis and Angioplasty in Myocardial Infarction (phase 1) study were analyzed for black and white patients. Baseline variables including risk factors and extent of coronary artery disease were similar in the 352 white and 24 black patients. The time from onset of chest pain to recombinant tissue-type plasminogen activator (rt-PA) therapy and rt-PA dosing regimens were the same in the two groups. The patency rate of the infarct-related artery at 90 minutes was 91% for blacks and was 72% for whites (p = 0.051). Blacks displayed significantly lower nadir fibrinogen levels (0.57 +/- 0.62 versus 1.3 +/- 0.76 g/l, p less than 0.0001), greater delta fibrinogen (baseline-nadir) (2.7 +/- 1.1 versus 1.7 +/- 1.1 g/l, p less than 0.0001), and increased peak levels of fibrin(ogen) degradation products (837 +/- 865 versus 245 +/- 475 micrograms/ml, p less than 0.0001). rt-PA antigen levels tended to be higher in blacks than in whites (2.8 +/- 2.2 versus 2.2 +/- 3.2 micrograms/ml [p = 0.10] at the peak and 1.6 +/- 1.3 versus 0.99 +/- 1.4 micrograms/ml [p = 0.06] at the end of the maintenance infusion). Major clinical outcomes including survival until time of hospital discharge (92% black versus 93% white, p = 0.68) were not significantly different. However, despite undergoing fewer angioplasty procedures (25% versus 46.3%, p = 0.047), blacks received more transfusions (58.8% versus 19.5% were administered greater than or equal to 2 units packed erythrocytes, p = 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

In contrast to the published data on Human Immunodeficiency Virus (HIV) infection in parenteral drug abusers, there is a paucity of data on prison inmates and virtually none on psychiatric inpatients. Because our facility serves each of these patients groups, we designed an anonymous seroprevalance study. We tested 1,496 unduplicated sera using sequential enzyme-linked immunosorbent assay (ELISA) and Western blot tests. The overall prevalence of Western blot positive serum was 0.53%. The prevalence rates for the different services of our hospital, Corrections, Detoxification Program, and general Department of Mental Health inpatients, were 4.62%, 0.99%, and 0.25% respectively. While these data demonstrate the increased prevalence of HIV infection among prison inmates, they fail to show a greater prevalence among South Carolina psychiatric inpatients than among general hospital patients.

Several reports have suggested an association between chronic allopurinol ingestion and cortical and subcapsular cataract formation. To examine this possibility we identified 51 allopurinol users and compared their lenses with those of 76 patients who did not use allopurinol. The existence of lens opacities and the level of visual acuity were assessed by review of medical records or by prospective ophthalmic examinations; in both phases of the study the examiners were blinded as to the patient's use or non-use of allopurinol. Three different outcomes were considered: formation of any cataract, formation of a posterior subcapsular cataract, and formation of a cataract contributing to a corrected visual acuity of 20/30 or worse. The risk ratio for the formation of any cataract was 1.3 (95% confidence interval: 0.8, 2.0), the risk ratio for the formation of a posterior subcapsular cataract was 0.9 (0.3, 2.0), and the risk ratio for the formation of a cataract contributing to a loss of visual acuity was 1.3 (0.6, 2.9). None of these risk ratios was changed appreciably after controlling for age, sex, hypertension, or diabetes. Thus, after a mean of 6.9 years of allopurinol use, we found no evidence to confirm that allopurinol users were at higher risk of acquiring cataracts.