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Fast and accurate identification of cardiac devices can facilitate device programming and interrogation in various medical settings. We have previously demonstrated the accuracy of the PacemakerID machine learning algorithm for mobile phone cardiac device identification. However, the questions of the reproducibility of this algorithm and whether a single trial sufficiently maximizes accuracy have yet to be answered. Here, we examine 502 chest x-rays performed at a single institution on patients with implantable cardioverter-defibrillators and permanent pacemakers. The PacemakerID mobile phone application was used for five sequential trials on each image and the accuracy of one, three, and five trials were compared. A single trial resulted in a 79% accuracy and 82% positive predictive value with no significant difference (p=0.69) as compared to five trials at identifying device manufacturers. Across all devices, the results of a single trial were not significantly different from those of five trials. Our data demonstrate that a single trial is sufficient to maximize diagnostic accuracy with the PacemakerID mobile phone application, facilitating rapid identification for prompt programming and interrogation of cardiac devices.

Application of artificial intelligence techniques in medicine has rapidly expanded in recent years. Two algorithms for identification of cardiac implantable electronic devices using chest radiography were recently developed: The PacemakerID algorithm, available as a mobile phone application (PIDa) and a web platform (PIDw) and The Pacemaker Identification with Neural Networks (PPMnn), available via web platform. In this study, we assessed the relative accuracy of these algorithms. The machine learning algorithms (PIDa, PIDw, PPMnn) were used to predict device manufacturer using chest X-rays for patients with implanted devices. Each prediction was considered correct if predicted certainty was >75%. For comparative purposes, accuracy of each prediction was compared to the result using the CARDIA-X algorithm. 500 X-rays were included from a convenience sample. Raw accuracy was PIDa 89%, PIDw 73%, PPMnn 71% and CARDIA-X 85%. In conclusion, machine learning algorithms for identification of cardiac devices are accurate at determining device manufacturer, have capacity for improved accuracy with additional training sets and can utilize simple user interfaces. These algorithms have clinical utility in limiting potential infectious exposures and facilitate rapid identification of devices as needed for device reprogramming.

Background Premature ventricular contractions (VPC) have hour-to-hour and day-to-day variation. High VPC burden correlates with cardiomyopathy. Objective To determine the optimal duration for ambulatory electrocardiogram monitoring for accurate assessment of VPC burden. Methods Our group performed a retrospective analysis on patch monitors used for any indication with overall VPC burden ≥5.0% between February 1, 2016, and February 1, 2020. We generated cumulative daily VPC averages for each day of wear and performed linear regression analysis between each cumulative daily average and overall burden. Patients were divided into groups based on low or high VPC frequency, and the analysis was repeated. Split-sample validation was used to internally validate the overall prediction model. Results A total of 116 patches representing 107 patients (mean age: 64.5; female: 48%) were analyzed. Mean overall VPC burden was 13.4% ± 7.5% (range: 5.0%–42.0%). Day 1 R2 was 60%, P Conclusion Mobile telemetry for a period of ∼7 days accurately reflects overall VPC burden. Measurement of VPC burden for only 24–48 hours may not accurately reflect total burden. Monitoring for 2 weeks or longer adds little additional VPC information.

Purpose Hydroxychloroquine, chloroquine, and azithromycin have been used for treatment of COVID-19, but may cause QT prolongation. Minority populations are disproportionately impacted by COVID-19. This study evaluates the risk of QT prolongation and subsequent outcomes after administration of these medications in largely underrepresented minority COVID-19 patients. Methods We conducted an observational study on hospitalized COVID-19 patients in the Montefiore Health System (Bronx, NY). We examined electrocardiograms (ECG) pre/post-medication initiation to evaluate QTc, HR, QRS duration, and presence of other arrhythmias. Results One hundred five patients (mean age 67 years; 44.8% F) were analyzed. The median time from the first dose of any treatment to post-medication ECG was 2 days (IQR: 1–3). QTc in men increased from baseline (440 vs 455 ms, p 500 ms was significantly increased after treatment (16.2% vs. 4.8%, p 500 ms or an increase of 60 ms had a higher frequency of death (47.6% vs. 22.6%, p = 0.02) with an odds ratio of 3.1 (95% CI: 1.1–8.7). Adjusting for race/ethnicity yielded no significant associations. Conclusions Hydroxychloroquine, chloroquine, and/or azithromycin were associated with QTc prolongation but did not result in fatal arrhythmias. Our findings suggest that any harm is unlikely to outweigh potential benefits of treatment. Careful risk-benefit analyses for individual patients should guide the use of these medications. Randomized control trials are necessary to evaluate their efficacies.

Improvements in health indexes over last few decades have been accompanied by escalating health care costs, with spending on health in the near-term projected to be nearly 20% ([1][1]). All major stakeholders agree that this growth in health care spending requires moderation to ensure sustainable

Background Daylight saving time (DST) imposes a twice-yearly hour shift. The transitions to and from DST are associated with decreases in sleep quality and environmental hazards. Detrimental health effects include increased incidence of acute myocardial infarction (MI) following the springtime transition and increased ischemic stroke following both DST transitions. Conditions effecting sleep are known to provoke atrial fibrillation (AF), however the effect of DST transitions on AF are unknown. Methods Admitted patients aged 18–100 with primary ICD9 code of AF between 2009 and 2016 were included. The number of admissions was compiled and means were compared for the Monday to Thursday period and the entire seven day interval following each DST transition and the entire year for the entire cohort and separated by gender. Significance was determined with Wilcoxon nonparametric tests. Results Admission data for 6089 patients were included, with mean age of 68 years and 53% female. A significant increase was found in mean AF admissions over the Monday to Thursday period (3.09 vs 2.47 admissions/day [adm/d], P = 0.017) and entire week (2.48 vs 2.09 adm/d, P = 0.025) following the DST spring transition compared to the yearly mean. When separated by gender, women exhibited an increase in AF admissions following the DST spring transition (1.78 vs 1.28 adm/d for Monday to Thursday period, P = 0.036 and 1.38 vs 1.11 adm/d for entire week, P = 0.050) while a non-significant increase was seen in men. No significant differences were found following the autumn transition for the entire cohort or when separated by gender. Conclusion An increase in AF hospital admissions was found following the DST springtime transition. When separated by gender, this finding persisted only among women. This finding adds to evidence of negative health effects associated with DST transitions and factors that contribute to AF episodes.

Background Subxyphoid active left ventricular epicardial (LVE) lead implants or VT ablation are attractive but remain a challenge due to concerns of coronary artery damage. We aimed to see if Doppler-guided positioning could permit safe LVE lead placement without coronary angiography. We evaluated the feasibility of a Doppler flow-guided subxyphoid epicardial screw-in lead fixation in a swine model. Methods Acute subxyphoid access to the pericardial space was performed in an anesthetized swine model using a deflectable sheath and a modified needle-derived Doppler flow meter. The audio signal and visual display from the Doppler flow meter were recorded. Coronary angiography was performed to verify the catheter location. A SelectSecure Model 3830 lead (Medtronic) was used to assess pacing in the procedure. Results In both of two swine, the deflectable catheter was inserted into pericardial space via subxyphoid access. The tip of the deflectable catheter with the Doppler was directed to several locations, from quiet (no nearby coronary artery expected) to typical rhythmic pulsatile sound locations which were maximal when superimposed on a coronary artery. Repeated coronary angiograms confirmed the expected findings. A 3830 active lead was fixed into a quiet location for LVE pacing, and confirmed by angiography as distant from a coronary artery. Conclusions Doppler-guided subxyphoid epicardial screw-in lead placement is feasible once the catheter tip is directed and stabilized in a desired LVE location. This obviates the need for repeated (or any) coronary angiography. The Doppler-guided subxyphoid epicardial procedure may also be applicable for epicardial ventricular arrhythmia ablation procedures.

Aging is associated with many ECG changes. ECG abnormalities are known to be more prevalent with age and differ across race and ethnicity, yet there are limited studies categorizing the ECG changes in the older population and the differences seen among racial groups. We sought to determine ECG differences associated with race and ethnicity in this ethnically diverse, elderly population.The ECG parameters of subjects between the ages of 75 and 99 years from a large and diverse inner-city patient population were analyzed. Subjects were grouped into one of four categories: Hispanic, Black, Non-Hispanic White, or Other for analysis. Rhythm, axis, voltage, and conduction parameters were determined according to the 12 SL algorithm and interpretation statements (GE Healthcare, Wauwatosa, Wisconsin) that were confirmed by an overreading cardiologist.38,238 subjects were included. Of all groups, Non-Hispanic Whites exhibited more conduction abnormalities such as bundle branch block compared to the other groups, as well as the highest incidence of atrial fibrillation (AF) (12.6%, p 0.05). Hispanics had the highest proportion of normal sinus rhythm. Blacks exhibited the least amount of AF (6.3%), as well as the highest incidence of LVH (25.5%), RAD (13.5%), and the largest percentage of abnormal ECGs (72.8%).Significant differences among the elderly of different race and ethnicity were noted with most parameters.

Until 2019, guidelines for procedural sedation emphasized a detailed process most applicable for elective procedures scheduled well in advance. These guidelines provided by the American Society of Anesthesiologists were adopted by many specialties and institutions, and they have historically served the medical field well. However, cardiologists and other specialists often encounter urgent situations that demand unscheduled sedation. Physicians have been concerned about performing procedures in a fashion that "departs from the guidelines." In response, the American College of Emergency Physicians (ACEP) has developed a set of guidelines for patients requiring urgent unscheduled sedation. Many of the recommendations made within the novel ACEP guidelines are appropriate for cardiology, but there remain fundamental differences between trauma and other emergencies encountered in the emergency department and urgent cardiac procedures. This paper examines the differences between the American Society of Anesthesiologists and ACEP guidelines and provides some points to consider regarding best practices for cardiologists.

The American College of Emergency Physicians (ACEP) organized a multidisciplinary effort to create a clinical practice guideline specific to unscheduled, time-sensitive procedural sedation, which differs in important ways from scheduled, elective procedural sedation. The purpose of this guideline is to serve as a resource for practitioners who perform unscheduled procedural sedation regardless of location or patient age. This document outlines the underlying background and rationale, and issues relating to staffing, practice, and quality improvement.

Sweet and bitter compounds excite different sensory cells and drive opposing behaviors. However, it remains unclear how sweet and bitter tastes are represented by the neural circuits linking sensation to behavior. To investigate this question in Drosophila, we devised trans-Tango(activity), a strategy for calcium imaging of second-order gustatory projection neurons based on trans-Tango, a genetic transsynaptic tracing technique. We found spatial overlap between the projection neuron populations activated by sweet and bitter tastants. The spatial representation of bitter tastants in the projection neurons was consistent, while that of sweet tastants was heterogeneous. Furthermore, we discovered that bitter tastants evoke responses in the gustatory receptor neurons and projection neurons upon both stimulus onset and offset and that bitter offset and sweet onset excite overlapping second-order projections. These findings demonstrate an unexpected complexity in the representation of sweet and bitter tastants by second-order neurons of the gustatory circuit.

The mushroom body (MB) is a well-characterized associative memory structure within the Drosophila brain. Analyzing MB connectivity using multiple approaches is critical for understanding the functional implications of this structure. Using the genetic anterograde transsynaptic tracing tool, trans-Tango, we identified divergent projections across the brain and convergent downstream targets of the MB output neurons (MBONs). Our analysis revealed at least three separate targets that receive convergent input from MBONs: other MBONs, the fan-shaped body (FSB), and the lateral accessory lobe (LAL). We describe, both anatomically and functionally, a multilayer circuit in which inhibitory and excitatory MBONs converge on the same genetic subset of FSB and LAL neurons. This circuit architecture enables the brain to update and integrate information with previous experience before executing appropriate behavioral responses. Our use of trans-Tango provides a genetically accessible anatomical framework for investigating the functional relevance of components within these complex and interconnected circuits.

Introduction: Atrioventricular node reentry tachycardia (AVNRT) ablation is typically performed with solid tip catheters set to temperature control (TC) mode. Radiofrequency (RF) output, tip temperature (T), and junctional rhythm response (JRR) during RF application have been well defined. JRR in an intermittent burst, sinus-junction-junction, or sinus-junction-sinus pattern is associated with successful modification of the AV nodal slow pathway (SP). Irrigated force-sensing catheters (IFSC) are often utilized for mapping and ablation of the SP. Despite this, parameters for IFSC used in TC mode resulting in JRR have not been well described. Hypothesis: Parameters predicting JRR and successful SP modification with IFSC include power (P), force (F), impedance drop (I), and target temperature (T). Methods: Consecutive patients that underwent electrophysiologic study and successful ablation of typical AVNRT with an IFSC were studied. Lesion parameters including P, T, F, time and I change were analyzed. Lesions producing JRR were considered efficacious. Independent T-Test and ANOVA were used to determine significance between the two groups (efficacious and non-efficacious lesions). Results: 296 lesions in 39 patients (age 52+/-14) were analyzed. All patients had successful SP modification without complication. Average F producing JRR was 8g, average T producing JRR was 41 o C, average I drop producing JRR was 9 Ohms, and average P producing JRR was 28W. Only RF lesion time was a significant predictor of JRR (p=0.009). (Table 1). Conclusions: Successful SP modification with IFSC was accomplished with catheter contact force as low as 2g. Lower average tip T, and lower average P settings compared to parameters typically used with solid tip catheters were observed. Parameters including P, F, T, and I change were not predictive of JRR. Additional studies controlling for catheter location while varying parameters are indicated.

Introduction: Wellens’ sign is a characteristic finding on ECG, often found to be indicative of severe proximal Left anterior descending artery (LAD) stenosis. Our study sought to identify the prevalence of the Wellens’ sign in the ethnically diverse population of the Bronx, NY and elucidate its relationship to the presence of significant CAD. Methods: We retrospectively analyzed an ECG database at Montefiore Medical Center of over 1.7 million ECGs, using six diagnostic codes for anterior ischemia to identify ECGs that resemble the Wellens’ sign. Of the six diagnostic codes, the ECGs of the two highest yielding codes, were identified, then manually reviewed by an electrophysiologist. Patient’s charts and demographics were reviewed and Chi Square test was used to test statistical significance of the data. Results: Of the 1,756,742 ECGs done on 433,218 patients between 2012-2019, 26,624 ECGs were isolated. Subsequently, 2186 of these ECGs were manually reviewed. Wellens’ sign was identified in 448 (0.1%) patients, of which, 229 patients underwent cardiac catheterization, while 219 patients were managed medically. There was no statistical difference seen in the prevalence of Wellens’ Type A and B pattern across various ethnic groups (P = 0.213). Significant LAD stenosis was seen in 80 (35%) patients of whom 22 (10%) had proximal, 40 (17%) had mid, 4 (1%) had distal stenosis, while 14 (6%) patients had diffuse LAD disease. Two-vessel disease was seen in 46 (20%) of the patients, and triple-vessel disease was seen in 23 (10%) of the patients. Most common indication for cardiac catheterization was NSTEMI. Takotsubo cardiomyopathy was diagnosed in 19 (8%) patients who had either no or non-obstructive CAD. Among patients with the Wellens’ sign on the ECG but did not undergo cardiac catheterization, majority had a non-ACS presentation. Conclusions: No statistical difference in the prevalence of Wellens’ sign was seen among the various ethnic groups. In our study population, Wellens’ sign was a rare ECG pattern with a prevalence of 0.1%. When seen in conjunction with a clinical setting suggestive of angina there is a high probability of underlying CAD. Although significant LAD stenosis is the known most common underlying pathology, multivessel CAD may also occur.

SUMMARYSweet and bitter compounds excite different sensory cells and drive opposing behaviors. It is commonly thought that the neural circuits linking taste sensation to behavior conform to a labeled-line architecture, but in Drosophila, evidence for labeled lines beyond first-order neurons is lacking. To address this, we devised trans-Tango(activity), a strategy for calcium imaging of second-order gustatory projection neurons based on trans-Tango, a genetic transsynaptic tracing technique. We found distinct projection neuron populations that respond to sweet and bitter tastants. However, the bitter-responsive population was also activated by water alone. We further discovered that bitter tastants evoke activity upon both stimulus onset and offset. Bitter offset responses are exhibited by both first- and second-order gustatory neurons, but these responses are distributed among multiple types of projection neurons in the second order. These findings suggest a more complex coding scheme for gustatory information than can be explained by a labeled line model.

The Mushroom Body (MB) is a well-characterized associative memory structure within theDrosophilabrain. Although previous studies have analyzed MB connectivity and provided a map of inputs and outputs, a detailed map of the downstream targets is missing. Using the genetic anterograde transsynaptic tracing tool,trans-Tango, we identified divergent projections across the brain and convergent downstream targets of the MB output neurons (MBONs). Our analysis revealed at least three separate targets that receive convergent input from MBONs: other MBONs, the fan shaped body (FSB), and the lateral accessory lobe (LAL). We describe, both anatomically and functionally, a multilayer circuit in which inhibitory and excitatory MBONs converge on the same genetic subset of FSB and LAL neurons. This circuit architecture provides an opportunity for the brain to update information and integrate it with previous experience before executing appropriate behavioral responses.Highlights-The postsynaptic connections of the output neurons of the mushroom body, a structure that integrates environmental cues with associated valence, are mapped usingtrans-Tango.-Mushroom body circuits are highly interconnected with several points of convergence among mushroom body output neurons (MBONs).-The postsynaptic partners of MBONs have divergent projections across the brain and convergent projections to select target neuropils outside the mushroom body important for multimodal integration.-Functional connectivity suggests the presence of multisynaptic pathways that have several layers of integration prior to initiation of an output response.

The mushroom body (MB) is a well-characterized associative memory structure within the Drosophila brain. Analyzing MB connectivity using multiple approaches is critical for understanding the functional implications of this structure. Using the genetic anterograde transsynaptic tracing tool, trans-Tango, we identified divergent projections across the brain and convergent downstream targets of the MB output neurons (MBONs). Our analysis revealed at least three separate targets that receive convergent input from MBONs: other MBONs, the fan-shaped body (FSB), and the lateral accessory lobe (LAL). We describe, both anatomically and functionally, a multilayer circuit in which inhibitory and excitatory MBONs converge on the same genetic subset of FSB and LAL neurons. This circuit architecture enables the brain to update and integrate information with previous experience before executing appropriate behavioral responses. Our use of trans-Tango provides a genetically accessible anatomical framework for investigating the functional relevance of components within these complex and interconnected circuits.

Wellens' sign is considered to be an ominous sign indicative of underlying significant proximal left anterior descending artery stenosis. We sought to identify the prevalence of the Wellens' pattern in a large ethnically diverse urban population and assess its association with the presence and extent of coronary artery disease.We utilized the MUSE ECG database of Montefiore Medical Center, an academic tertiary health care system, to identify ECGs from 2012 to 2019 exhibiting a Wellens' pattern. From a dataset of 1.76 million tracings, six screening diagnosis codes were selected to approximate the Wellens' pattern. These codes were used to generate a cohort of ECGs for manual review by a board certified cardiologist to determine if a Wellens' pattern was present.Of 1,756,742 ECGs performed on 433,218 patients from 2012 to 2019; after initial screening 2186 ECGs were identified for manual review. Of these, 448 (0.1%) patients were confirmed to have a Wellens' pattern. 229 patients underwent cardiac catheterization, while 219 patients were managed medically. No statistical difference was seen in the occurrence of Wellens' Type A and B pattern across the ethnic groups after multivariate analysis. Women were more likely to have Type B Wellens' compared to men (OR 2.40 (1.58, 3.62) P 0.0001). 80 (35%) patients had single vessel LAD disease of which 22 (10%) had proximal, 40 (17%) had mid, 4 (1%) had distal stenosis, while diffuse LAD disease was seen in 14 (6%) patients. Two vessel disease was seen in 46 (20%) patients with a Wellens' pattern, and triple vessel disease was seen in 23 (10%) patients. Of note, 71 (31%) patients had either normal or nonobstructive coronary disease despite exhibiting a Wellens' pattern ECG.Wellens' sign is a rare electrocardiographic pattern which when seen in a patient with an appropriate clinical presentation, suggests but is not definitive for the presence of significant coronary disease, often but not exclusively in an LAD distribution. We found no statistical difference in the occurrence of Wellens' sign among different racial/ethnic groups. Patients with a Wellens' pattern may have critical lesions at a variety of LAD sites as well as in multiple vessels. As such, the interventionalist needs to be prepared for these uncertainties at the time of cardiac catheterization.

Background Contribution of modifiable risk factors for the risk of new onset atrial fibrillation (AF) in minority populations is poorly understood. Our objective was to compare the population attributable risk (PAR) of various risk factors for incident AF between Hispanic, African American and non-Hispanic Whites. Methods An ECG/EMR database was interrogated for individuals free of AF for development of subsequent AF from 2000 to 2013. Cox regression analysis controlled for age > 65, male gender, body mass index > 40 kg/m2, systolic blood pressure > 140 mm Hg, diabetes mellitus, heart failure, socioeconomic status less than the first percentile in New York State, and race/ethnicity. PAR was calculated as (prevalence of X) ∗ (HR − 1)/HR, where HR is the hazard ratio, and X is the risk factor. Results 47,722 persons free of AF (43% Hispanic, 37% Black and 20% White) were followed for subsequent incident AF. Hypertension in African Americans and Hispanics had a 7.93% and 7.66% greater PAR compared with non-Hispanics Whites. Similar findings existed for the presence of heart failure, with a higher PAR in non-Whites compared to Whites. Conclusion In conclusion, modifiable risk factors play an important role in the risk of incident AF. Higher PAR estimates in African Americans and Hispanics were observed for elevated systolic blood pressure and heart failure. Identification of these modifiable risk factors for atrial fibrillation in non-White minorities may assist in targeting better prevention therapies and planning from a public health perspective. No funding sources were used for this study.

PURPOSE Survey the usage and application protocol of antimicrobial agent pocket irrigation for cardiovascular implantable electronic device (CIED) infection prophylaxis. BACKGROUND Local antibiotic usage for CIED infection prophylaxis, in particular pocket irrigation, is a well-known strategy but with little data on its clinical effectiveness. METHODS An anonymous voluntary online survey was sent to a total of 2,092 arrhythmia-oriented cardiologists in 51 countries (1,490 from the United States). RESULTS There were 487 responses (response rate 23.3%: U.S. 28.2%, outside of the U.S. 11.1%). Eighty-seven percent of respondents use intraoperative antimicrobial agent pocket irrigation and/or an antimicrobial eluting pouch to reduce CIED infection. Fifty-four percent of respondents believe that it is effective to use an antimicrobial agent pocket irrigation to reduce CIED infection; 33% of respondents are uncertain; a few consider this strategy ineffective (13%) or offered no opinion. Significant differences exist in the practice patterns and beliefs between the U.S. and non-U.S. countries (P

Traditional right ventricular (RV) pacing for the management of bradyarrhythmias has been pursued successfully for decades, although there remains debate regarding optimal pacing site with respect to both hemodynamic and clinical outcomes. The deleterious effects of long-term RV apical pacing have been well recognized. This has generated interest in approaches providing more physiological stimulation, namely, His bundle pacing (HBP). This paper reviews the anatomy of the His bundle, early clinical observations, and current approaches to permanent HBP. By stimulating the His-Purkinje network, HBP engages electrical activation of both ventricles and may avoid marked dyssynchrony. Recent studies have also demonstrated the potential of HBP in patients with underlying left bundle branch block and cardiomyopathy. HBP holds promise as an attractive mode to achieve physiological pacing. Widespread adaptation of this technique is dependent on enhancements in technology, as well as further validation of efficacy in large randomized clinical trials.

Left atrial appendage (LAA) closure has evolved as an effective strategy for stroke prevention in patients with atrial fibrillation who are considered suitable for oral anticoagulation. There is strong evidence based on randomized clinical trials with 1 percutaneous device, as well as a large registry experience with several devices, regarding the safety and efficacy of this strategy. In addition, there is encouraging data regarding the effect of epicardial LAA closure on decreasing arrhythmia burden and improvements in systemic homeostasis by neurohormonal modulation. However, there are several unresolved issues regarding optimal patient selection, device selection, management of periprocedural complications including device-related thrombus, residual leaks, and pericarditis. In this review, we summarize the rationale, evidence, optimal patient selection, and common challenges encountered with mechanical LAA exclusion.

No previous studies have examined the interaction between body mass index (BMI) and race/ethnicity with the risk of atrial fibrillation (AF). We retrospectively followed 48,323 persons free of AF (43% Hispanic, 37% black, and 20% white; median age 60 years) for subsequent incident AF (ascertained from electrocardiograms). BMI categories included very severely underweight (BMI 40 kg/m2). Cox regression analysis controlled for baseline covariates: heart failure, gender, age, treatment for hypertension, diabetes, PR length, systolic blood pressure, left ventricular hypertrophy, socioeconomic status, use of β blockers, calcium channel blockers, and digoxin. Over a follow-up of 13 years, 4,744 AF cases occurred. BMI in units of 10 was associated with the development of AF (adjusted hazard ratio 1.088, 95% confidence interval 1.048 to 1.130, p

Medical devices have been targets of hacking for over a decade, and this cybersecurity issue has affected many types of medical devices. Lately, the potential for hacking of cardiac devices (pacemakers and defibrillators) claimed the attention of the media, patients, and health care providers. This is a burgeoning problem that our newly electronically connected world faces. In this paper from the Electrophysiology Section Council, we briefly discuss various aspects of this relatively new threat in light of recent incidents involving the potential for hacking of cardiac devices. We explore the possible risks for the patients and the effect of device reconfiguration in an attempt to thwart cybersecurity threats. We provide an outline of what can be done to improve cybersecurity from the standpoint of the manufacturer, government, professional societies, physician, and patient.

Lower socioeconomic status (SES) is associated with a higher risk of cardiovascular disease. However, the association between SES and mortality in patients with atrial fibrillation (AF) is not clear. We examined whether SES predicts all-cause mortality in patients hospitalized with AF. This is a retrospective study of patients aged >18 years, admitted with a primary diagnosis of AF to Montefiore Medical Center between 2000 and 2010. Multivariable logistic regression models were used to determine predictors of survival adjusted for age, gender, heart failure, diabetes mellitus, chronic kidney disease, previous myocardial infraction, chronic obstructive pulmonary disease, hypertension, peripheral vascular disease, and SES. SES was determined using the New York City Department of Health Standardized Score (a log composite score of household income, value of housing units, net rental income, household occupations, and educational level). The cohort was divided into quartiles based on SES score, with Q4 the highest and Q1 the lowest SES score. There were 4,503 patients identified with a mean follow up of 4.5 years in the following SES quartiles: Q1 (n = 1,132), Q2 (n = 1,119), Q3 (n = 1,126), and Q4 (n = 1,126). The unadjusted mortality varied across quartiles (Q1 to Q4), 54%, 58%, 56%, and 59%, respectively (p = 0.004). After controlling for other variables in the multivariable analysis, patients with the lowest SES (Q1) had a significantly higher mortality than patients in the quartile with the highest (Q4) SES (odds ratio 1.3, CI 1.1 to 1.5). In conclusion, patients admitted to the hospital with AF have varying mortality based on their SES. After controlling for co-morbidities, patients with AF and lower SES scores had higher mortality. Further research studies are warranted to study this risk of increased mortality in AF population.

Background Electrocardiography (ECG) is poorly sensitive, but highly specific for the diagnosis of left ventricular hypertrophy. However, previous studies documenting this were small and lacked patient diversity. Furthermore, little is known about the impact of patient characteristics on the sensitivity and specificity of ECG for left ventricular hypertrophy. To address this issue, the present study was conducted to ascertain the sensitivity and specificity of ECG for left ventricular hypertrophy in a large, diverse patient population. Methods We performed a retrospective cohort study using ECG and echocardiography (ECHO) data from a large metropolitan health system. All patients had one ECG and ECHO on file, obtained within 1 week of each other. Sensitivity and specificity of ECG for left ventricular hypertrophy were determined by comparing results from the MUSE® 12-SL (GE Healthcare, Chicago, IL) computer-generated algorithm for ECG to ECHO left ventricular mass index. Subgroup analyses of individual patient characteristics were performed with corresponding chi-squared analyses to determine significance. Results A total of 13,960 subjects were included in the study. The typical subject was 60 years of age or older, female, overweight, and hypertensive, and demonstrated low socioeconomic status. The sensitivity and specificity of ECG for left ventricular hypertrophy in the overall cohort were 30.7% and 84.4%, respectively, with multiple patient characteristics influencing these results. Conclusions This is the first study to confirm the sensitivity and specificity of ECG for left ventricular hypertrophy in a large, diverse patient population with significant minority representation. Furthermore, although these statistical measures are influenced by patient characteristics, such differences are likely not clinically significant.

Premature ventricular complexes (PVCs) are common arrhythmias in the clinical setting. PVCs in the structurally normal heart are usually benign, but in the presence of structural heart disease (SHD), they may indicate increased risk of sudden death. High PVC burden may induce cardiomyopathy and left ventricular (LV) dysfunction or worsen underlying cardiomyopathy. Sometimes PVCs may be a marker of underlying pathophysiologic process such as myocarditis. Identification of PVC burden is important, since cardiomyopathy and LV dysfunction can reverse after catheter ablation or pharmacological suppression. This state-of-the-art review discusses pathophysiology, clinical manifestations, how to differentiate benign and malignant PVCs, PVCs in the structurally normal heart, underlying SHD, diagnostic procedures (physical examination, electrocardiogram, ambulatory monitoring, exercise testing, echocardiography, cardiac magnetic resonance imaging, coronary angiography, electrophysiology study), and treatment (lifestyle modification, electrolyte imbalance, medical, and catheter ablation).

Background The weekend effect is a phenomenon in which worse outcomes have been found to occur over the weekend. This has been investigated in the context of stroke, ST-elevation myocardial infarction, and pulmonary embolism among others. Atrial fibrillation (AF) is the most common sustained arrhythmia, and admissions for AF have been increasing. However, few studies exist investigating the existence of a weekend effect regarding AF. Previous studies have been limited by a pragmatic but unrealistic definition of the weekend starting at midnight on Friday and ending midnight on Sunday. In addition, the studies that exist have conflicting data regarding outcomes of mortality and length of stay (LOS). Methods Over a 5-year period, 3233 patients with a primary diagnosis of AF were admitted to an academic center. A retrospective analysis was performed to determine rates of cardioversion, 30-day readmission, 30-day mortality, LOS, and time to cardioversion among patients admitted over the weekend compared with those admitted during the work week. Weekend was defined as the 48-hour period, including Saturday and Sunday. Results Baseline demographics and common risk factors were found to be equivalent in weekend admissions compared with weekday admissions. These characteristics were found to be equivalent in those who underwent cardioversion and those who did not. There was no statistically significant difference between groups in odds of cardioversion, 30-day readmission, or 30-day mortality. Difference in mean LOS and mean time to cardioversion was not statistically significant between groups. Conclusion In conclusion, a weekend effect was not identified regarding AF in an academic hospital.

Until 2019, guidelines for procedural sedation emphasized a detailed process most applicable for elective procedures scheduled well in advance. These guidelines provided by the American Society of Anesthesiologists were adopted by many specialties and institutions, and they have historically served the medical field well. However, cardiologists and other specialists often encounter urgent situations that demand unscheduled sedation. Physicians have been concerned about performing procedures in a fashion that "departs from the guidelines." In response, the American College of Emergency Physicians (ACEP) has developed a set of guidelines for patients requiring urgent unscheduled sedation. Many of the recommendations made within the novel ACEP guidelines are appropriate for cardiology, but there remain fundamental differences between trauma and other emergencies encountered in the emergency department and urgent cardiac procedures. This paper examines the differences between the American Society of Anesthesiologists and ACEP guidelines and provides some points to consider regarding best practices for cardiologists.

BACKGROUND Early repolarization (ER) pattern on ECG is associated with an increased mortality in Caucasians. This study analyzed the association between ER pattern and all-cause mortality in a population of multiple ethnicities. METHODS A total of 20 000 individuals were randomly selected and their ECGs were analyzed for ER pattern using the 2015 consensus: end-QRS notching or slurring with a J-point (Jp) ≥0.1 mV in contiguous inferior or lateral leads. Exclusion criteria were age

Electrophysiology (EP) is an increasingly complicated field. Recognition of the complexity and scope of EP training has resulted in a consensus that it requires more than 12 months to become competent in the vast array of required decision-making and procedural skills. We aim to provide an update on

Eric S. Williams, MD, MACC, Chair Jonathan L. Halperin, MD, FACC, Co-Chair James A. Arrighi, MD, FACC Eric H. Awtry, MD, FACC Eric R. Bates, MD, FACC John E. Brush, Jr, MD, FACC Salvatore Costa, MD, FACC Lori Daniels, MD, MAS, FACC Akshay Desai, MD, FACC[‡][1] Douglas E. Drachman, MD

Three-dimensional electroanatomic mapping (EAM) systems reduce radiation exposure when radio frequency catheter ablation (RFCA) procedures are performed by well-trained senior operators. Given the steep learning curve associated with complex RFCA, trainees and their mentors must rely on multiple imaging modalities to maximize safety and success, which might increase procedure and fluoroscopy times. The objective of the present study is to determine if 3-D EAM (CARTO and ESI-NavX) improves procedural outcomes (fluoroscopy time, radio frequency time, procedure duration, complication, and success rates) during CA procedures as compared to fluoroscopically guided conventional mapping alone in an academic teaching hospital. We analyzed a total of 1070 consecutive RFCA procedures over an 8-year period for fluoroscopic time stratified by ablation target and mapping system. Multivariate logistic regression and adjusted odds ratios were calculated for each variable. No statistically significant differences in acute success rates were noted between conventional and 3-D mapping cases [CARTO (p = 0.68) or ESI-NavX (p = 0.20)]. Moreover, complication rates were also not significantly different between CARTO (p = 0.23) and ESI-NavX (p = 0.53) when compared to conventional mapping. Procedure, radio frequency, and fluoroscopy times were significantly longer with CARTO and ESI-NavX versus conventional mapping [fluoroscopy time: CARTO, 28.3 min; ESI, 28.5 min; and conventional, 24.3 min; p

Background— Nonvalvular atrial fibrillation is the most common arrhythmia. Patients with nonvalvular atrial fibrillation are at increased risk of stroke; therefore, we evaluated the efficacy and safety of different approaches to prevent this major complication. Methods and Results— We conducted electronic database searches of phase III randomized controlled trials. The groups were novel oral anticoagulants, Watchman left atrial appendage occlusion device (DEVICE), and warfarin. Efficacy outcomes were stroke or systemic embolism, and all-cause mortality. Safety outcome was major bleeding and procedure-related complications. A subgroup analysis of the elderly population was done. We used random-effects model to compare pooled outcomes and tested for heterogeneity. Odds ratios (ORs) and 95% confidence intervals (CIs) were computed for each outcome. Seven randomized controlled trials (n=73 978) were included. There was a significant difference favoring novel oral anticoagulants for systemic embolism (OR, 0.84; 95% CI, 0.72–0.97; P =0.01), all-cause mortality (OR, 0.89; 95% CI, 0.84–0.94; P P =0.026) compared with warfarin. No difference was seen between DEVICE and warfarin for efficacy end points; however, DEVICE had more complications (OR, 1.85; 95% CI, 1.14–3.01; P =0.012). In the elderly (6 randomized controlled trials, n=30 699), systemic embolism was favored with novel oral anticoagulants over warfarin (OR, 0.77; 95% CI, 0.68–0.87; P ≤0.001). No evidence of significant publication bias was found. Conclusions— Novel oral anticoagulants is superior to warfarin for stroke prevention in nonvalvular atrial fibrillation. This benefit was also observed in the elderly population. DEVICE is a reasonable noninferior alternative to warfarin for stroke prevention, but cautious use is essential given safety concerns.

Background Early repolarization (ER), once thought to be a benign finding on electrocardiograph (ECG), has recently been associated with an increased risk of sudden cardiac death. As there are limited data in the Hispanic population, we investigated possible associations between automated ECG ER readings and overall mortality, using the classic definition involving J-point elevation with ST segment elevation. Methods An ECG and electronic medical record (EMR) database from a regional medical center was interrogated. Inclusion criteria included Hispanic ethnicity and age over 18 from 2000 to 2011. A Cox model assessed the outcome of death. Varying morphological characteristics of ER were analyzed for high-risk features. Results There were n = 33,944 Hispanics of who n = 532 (1.6%) had ER with a mean follow-up period of 5.29 years. After adjustment for demographic, clinical, lifestyle, and laboratory variables, ER was not significantly related to all-cause mortality (hazard ratio [HR]: 1.18, 95% confidence interval [CI]: 0.90–1.54, P = 0.23). However, mortality risk of ER varied by gender and age (P interaction = 0.007). The risk of ER for mortality was highest for females (HR: 2.01, CI: 1.39–3.10, P = 0.001), with the highest overall risk for women over the age of 75 (HR: 2.09, CI: 1.12–3.92, P = 0.021) compared to women under age 75 (HR: 1.72, CI: 0.95–3.11, P = 0.075). Conclusions ER is not associated with an increased risk of death in the overall Hispanic population. However, our analysis suggests a higher risk of overall mortality in the elderly Hispanic female population with ER.

Background PR interval prolongation on electrocardiogram (ECG) increases the risk of atrial fibrillation (AF). Non-Hispanic Whites are at higher risk of AF compared to African Americans and Hispanics. However, it remains unknown if prolongation of the PR interval for the development of AF varies by race/ethnicity. Therefore, we determined whether race affects the PR interval length's ability to predict AF and if the commonly used criterion of 200 ms in AF prediction models can continue to be used for non-White cohorts. Methods This is a retrospective epidemiological study of consecutive inpatient and outpatients. An ECG database was initially interrogated. Patients were included if their initial ECG demonstrated sinus rhythm and had two or more electrocardiograms and declared a race and/or ethnicity as non-Hispanic White, African American or Hispanic. Development of AF was stratified by race/ethnicity along varying PR intervals. Cox models controlled for age, gender, race/ethnicity, systolic blood pressure, BMI, QRS, QTc, heart rate, murmur, treatment for hypertension, heart failure and use of AV nodal blocking agents to assess PR interval's predictive ability for development of AF. Results 50,870 patients met inclusion criteria of which 5,199 developed AF over 3.72 mean years of follow-up. When the PR interval was separated by quantile, prolongation of the PR interval to predict AF first became significant in Hispanic and African Americans at the 92.5th quantile of 196–201 ms (HR: 1.42, 95% CI: 1.09–1.86, p=0.01; HR: 1.32, 95% CI: 1.07–1.64, p=0.01, respectively) then in non-Hispanic Whites at the 95th quantile at 203–212 ms (HR: 1.24, 95% CI: 1.24–1.53, p=0.04). For those with a PR interval above 200 ms, African Americans had a lower risk than non-Hispanic Whites to develop AF (HR: 0.80, 95% CI: 0.64–0.95, p=0.012), however, no significant difference was demonstrated in Hispanics. Conclusions This is the first study to validate a PR interval value of 200 ms as a criterion in African Americans and Hispanics for the development of AF. However, a value of 200 ms may be less sensitive as a predictive measure for the development of AF in African Americans compared to non-Hispanic Whites.

A 64-year-old woman with Jervell and Lange-Nielsen syndrome and ventricular fibrillation being treated with nadolol was evaluated for shortness of breath. A dual-chamber implantable cardioverter-defibrillator (device model CD2207-36Q; ventricular lead model 7122Q/58; and atrial lead model 1688TC/52

Background Direct oral anticoagulants (DOACs) and amiodarone are widely used in the treatment of nonvalvular atrial fibrillation. The DOACs are P-glycoprotein (P-gp) and cytochrome p-450 (CYP3A4) substrates. Direct oral anticoagulant levels may be increased by the concomitant use of potent dual P-gp/CYP3A4 inhibitors, such as amiodarone, which can potentially translate into adverse clinical outcomes. We aimed to assess the efficacy and safety of drug–drug interaction by the concomitant use of DOACs and amiodarone. Methods We performed a systematic review of MEDLINE, the Cochrane Central Register of Clinical Trials, and Embase, limiting our search to randomized controlled trials of patients with atrial fibrillation that have compared DOACs versus warfarin for prophylaxis of stroke or systemic embolism, to analyze the impact on stroke or systemic embolism, major bleeding, and intracranial bleeding risk in patients with concomitant use of amiodarone. Risk ratio (RR) 95% confidence intervals were measured using the Mantel-Haenszel method. The fixed effects model was used owing to heterogeneity ( I 2 ) Results Four trials with a total of 71,683 patients were analyzed, from which 5% of patients (n = 3212) were concomitantly taking DOAC and amiodarone. We found no statistically significant difference for any of the clinical outcomes (stroke or systemic embolism [RR 0.85; 95% CI, 0.67-1.06], major bleeding [RR 0.91; 95% CI, 0.77-1.07], or intracranial bleeding [RR 1.10; 95% CI, 0.68-1.78]) among patients taking DOAC and amiodarone versus DOAC without amiodarone. Conclusion On the basis of the results of this meta-analysis, co-administration of DOACs and amiodarone, a dual P-gp/CYP3A4 inhibitor, does not seem to affect efficacy or safety outcomes in patients with atrial fibrillation.

Background: Antitachycardia pacing (ATP) in implantable cardioverter-defibrillators (ICD) decreases patient shock burden but has recognized limitations. A new automated ATP (AATP) based on electrophysiological first principles was designed. The study objective was to assess the feasibility and safety of AATP in ambulatory ICD patients. Methods and Results: Enrolled patients had dual chamber or cardiac resynchronization therapy ICDs, history of ≥1 ICD-treated ventricular tachycardias (VT)/ventricular fibrillation episode, or a recorded, sustained monomorphic VT. Detection was set to ventricular fibrillation number of intervals to detect=24/32, VT number of intervals to detect≥16, and a fast VT zone of 240 to 320 ms. AATP prescribed the components and delivery of successive ATP sequences in real time, using the same settings for all patients. ICD datalogs were uploaded every ≈3 months, at unscheduled visits, exit, and death. Episodes and adverse events were adjudicated by separate committees. Results were adjusted (generalized estimating equations) for multiple episodes. AATP was downloaded into the ICDs of 144 patients (121 men), aged 67.4±11.9 years, left ventricular ejection fraction 33.1±13.6% (n=137), and treated 1626 episodes in 49 patients during 14.5±5.1 months of follow-up. Datalogs permitted adjudication of 702 episodes, including 669 sustained monomorphic VT, 20 polymorphic VT, 10 supraventricular tachycardia, and 3 malsensing episodes. AATP terminated 39 of 69 (59% adjusted) sustained monomorphic VT in the fast VT zone, 509 of 590 (85% adjusted) in the VT zone, and 6 of 10 in the ventricular fibrillation zone. No supraventricular tachycardias converted to VT or ventricular fibrillation. No anomalous AATP behavior was observed. Conclusions: The new AATP algorithm safely generated ATP sequences and controlled therapy progression in all zones without need for individualized programing.