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Treatment with the wearable cardioverter defibrillator (WCD) may protect against sudden cardiac death (SCD) as a bridging therapy until a cardioverter-defibrillator may be implanted. We analyzed in a multicenter setting a consecutive patient cohort wearing WCD to explore sex differences.We analyzed 708 consecutive patients, 579 (81.8%) from whom were males and 129 (18.2%) females (age, 60.5 ± 14 vs. 61.6 ± 17 years old; p = .44). While the rate of ischemic cardiomyopathy (ICM) as a cause of prescription of WCD was significantly higher in males as compared to females (42.7% vs. 26.4%; p = .001), females received it more frequently due to nonischemic cardiomyopathy (NICM) (55.8% vs. 42.7%); p = .009). The wear time of WCD was equivalent in both groups (21.1 ± 4.3 h/days in males vs. 21.5 ± 4.4 h/days in females; p = .27; and 62.6 ± 44.3 days in males vs. 56.5 ± 39 days in females; p = .15). Mortality was comparable in both groups at 2-year-follow-up (6.8% in males vs. 9.7% in females; p = .55). Appropriate WCD shocks and the incidence of ICD implantations were similar in both groups (2.4% in males vs. 3.9% in females; p = .07) (35.1% in males vs. 31.8% in females; p = .37), respectively. In age tertile analysis, compliance was observed more in 73-91 years old group as compared with 14-51 years old group (87.8% vs. 68.3%; p .001).Compliance for wearing WCD was excellent regardless of sex. Furthermore, mortality and the incidence of ICD implantations were comparable in both sexes. Appropriate WCD shocks were similar in both sexes.

Cardiac resynchronization therapy (CRT) may improve not only impaired left ventricular contractility but can also induce reverse remodeling of native conduction system. Measurement of intrinsic QRS complex width during follow-up is the simplest method to assess reverse electrical remodeling (RER). We aimed to provide a literature review and meta-analysis on incidence and impact of RER and its association with mechanical remodeling. A systematic review and random-effect meta-analysis of studies reporting data on RER was performed. A total of 16 studies were included in this meta-analysis with 930 patients undergoing CRT (mean age 64.0 years, 64.1% males). The weighted mean incidence of RER was 42%. Reverse mechanical remodeling assessed by echocardiography was more frequently observed in patients with RER compared to patients without RER (75.7% vs. 46.6%; odds ratio [OR] 3.7, 95% confidence interval [CI] 2.24-6.09, p lt; 0.01). Mechanical responders had a mean iQRS shortening of 7.7 ms, while mechanical non-responders experienced a mean widening of iQRS by 5.2 ms (p lt; 0.01). Clinical improvement was more frequent in patients with RER vs. patients without RER (82.9% vs. 49.0%; OR 5.26; 95% CI 2.92-9.48; p lt; 0.01). No significant difference in all-cause mortality between patients with and without RER was found. Mean difference between baseline intrinsic QRS and post-implantation paced QRS was significant in patients with later RER (21.2 ms, 95% CI 9.4-32.9, p lt; 0.01), but not in patients without RER (6.6 ms, 95% CI -2.2-15.4, p = 0.14). Gender, initial left bundle block morphology and heart failure etiology were found not to be predictive for RER. Our meta-analysis demonstrates that shortening of iQRS duration is a common finding during follow-up of patients undergoing CRT and is associated with mechanical reverse remodeling and clinical improvement. Clinical Trial Registration: Prospero Database-CRD42021253336.

Background Heightened risk of cardiac arrest following physical exertion has been reported. Among patients with an implantable defibrillator, an appropriate shock for sustained ventricular arrhythmia was preceded by a retrospective self-report of engaging in mild-to-moderate physical activity. Previous studies evaluating the relationship between activity and sudden cardiac arrest lacked an objective measure of physical activity and women were often underrepresented. Objective To determine the relationship between physical activity, recorded by accelerometer in a wearable cardioverter-defibrillator (WCD), and sustained ventricular arrhythmia among female patients. Methods A dataset of female adult patients prescribed a WCD for a diagnosis of myocardial infarction or dilated cardiomyopathy was compiled from a commercial database. Curve estimation, to include linear and nonlinear interpolation, was applied to physical activity as a function of time (days before arrhythmia). Results Among women who received an appropriate WCD shock for sustained ventricular arrhythmia (N = 120), a quadratic relationship between time and activity was present prior to shock. Physical activity increased starting at the beginning of the 30-day period up until day -16 (16 days before the ventricular arrhythmia) when activity begins to decline. Conclusion For patients who received treatment for sustained ventricular arrhythmia, a decline in physical activity was found during the 2 weeks preceding the arrhythmic event. Device monitoring for a sustained decline in physical activity may be useful to identify patients at near-term risk of a cardiac arrest.

BackgroundThe subcutaneous implantable cardioverter-defibrillator (S-ICD) has been designed to overcome lead-related complications and device endocarditis. Lacking the ability for pacing or resynchronization therapy its usage is limited to selected patients at risk for sudden cardiac death (SCD). ObjectiveThe aim of this single-center study was to assess clinical outcomes of S-ICD and single-chamber transvenous (TV)-ICD in an all-comers population. MethodsThe study cohort comprised a total of 119 ICD patients who underwent either S-ICD (n = 35) or TV-ICD (n = 84) implantation at the University Hospital Frankfurt from 2009 to 2017. By applying an inverse probability-weighting (IPW) analysis based on the propensity score including the Charlson Comorbidity Index (CCI) to adjust for potential extracardiac comorbidities, we aimed for head-to-head comparison on the study composite endpoint: overall survival, hospitalization, and device-associated events (including appropriate and inappropriate shocks or system-related complications). ResultsThe median age of the study population was 66.0 years, 22.7% of the patients were female. The underlying heart disease was ischemic cardiomyopathy (61.4%) with a median LVEF of 30%. Only 52.9% had received an ICD for primary prevention, most of the patients (67.3%) had advanced heart failure (NYHA class II-III) and 16.8% were in atrial fibrillation. CCI was 5 points in TV-ICD patients vs. 4 points for patients with S-ICD (p = 0.209) indicating increased morbidity. The composite endpoint occurred in 38 patients (31.9 %), revealing no significant difference between patients implanted with an S-ICD or TV-ICD (unweighted HR 1.50, 95 % confidence interval (CI) 0.78-2.90; p = 0.229, weighted HR 0.94, 95% CI, 0.61-1.50, p = 0.777). Furthermore, we observed no difference in any single clinical endpoint or device-associated outcome, neither in the unweighted cohort nor following inverse probability-weighting. ConclusionClinical outcomes of the S-ICD and TV-ICD revealed no differences in the composite endpoint including survival, freedom of hospitalization and device-associated events, even after careful adjustment for potential confounders. Moreover, the CCI was evaluated in a S-ICD cohort demonstrating higher survival rates than predicted by the CCI in young, polymorbid (S-)ICD patients.

Introduction Prognosis of survivors from cardiac arrest is generally poor. Acute kidney injury (AKI) is a common finding in these patients. In general, AKI is well characterized as a marker of adverse outcome. In-hospital cardiac arrest (IHCA) represents a special subset of cardiac arrest scenarios with differential predisposing factors and courses after the event, compared to out-of-hospital resuscitations. Data about AKI in survivors after in-hospital cardiac arrest are scarce. Methods In this study, we retrospectively analyzed patients after IHCA for incidence and risk factors of AKI and its prognostic impact on mortality. For inclusion in the analysis, patients had to survive at least 48 h after IHCA. Results A total of 238 IHCA events with successful resuscitation and survival beyond 48 h after the initial event were recorded. Of those, 89.9% were patients of internal medicine, and 10.1% of patients from surgery, neurology or other departments. In 120/238 patients (50.4%), AKI was diagnosed. In 28 patients (23.3%), transient or permanent renal replacement therapy had to be initiated. Male gender, preexisting chronic kidney disease and a non-shockable first ECG rhythm during resuscitation were significantly associated with a higher incidence of AKI in IHCA-survivors. In-hospital mortality in survivors from IHCA without AKI was 29.7%, and 60.8% in patients after IHCA who developed AKI (p

Aims Some retrospective and prospective studies in heart failure patients with indication for cardiac resynchronization therapy (CRT) suggest better clinical outcomes for quadripolar (QP) left ventricular (LV) leads over bipolar (BP) leads. Although, lead failure remains an important safety concern, when using these more complex, novel electrodes. To evaluate safety and efficacy outcomes for QP vs. BP LV leads in patients receiving CRT. Methods and results We performed a comprehensive literature search through 2018 in PubMed, Cochrane Library, and Google Scholar databases to identify studies comparing patients with QP and BP LV CRT leads. A total of 12 studies were selected for analysis comprising 31 403 patients (QP lead: 22 429 patients; BP lead: 8974 patients). Eight studies examined the effects of CRT on survival. In these studies, use of QP electrodes was associated with significantly better survival compared to patients with BP LV leads (OR 0.61, 95% CI 0.50–0.76; P Conclusion Our meta-analysis suggests distinct benefits of QP over BP electrodes in patients undergoing CRT.

Cardiac resynchronization therapy (CRT) resulting in maximal QRS narrowing may be associated with improved outcomes. Various atrioventricular (AV) delay settings, including the new SyncAV™ algorithm (St. Jude Medical/Abbott, St. Paul, MN, USA), aimed at maximal QRS narrowing were tested in an 81-year old CRT recipient. Maximal QRS narrowing from 160 to 100 ms was achieved with a manually programmed value of SyncAV™ −30 ms. At 2 months, the patient proved to be a CRT super-responder. SyncAV™ algorithm is a new way for effective QRS narrowing with potentially improved outcomes.

OBJECTIVES The number of cardiac implantable electronic devices is growing worldwide because they play a relevant role in improving the survival rate in patients with specific heart diseases. Cardiac implantable electronic devices complications including infection, dysfunction or venous stenosis increase the need for the least traumatic way to explant leads. Our goal was to report the successes and procedural complication rates of transvenous lead extraction (TLE) in a consecutive series of patients. METHODS From 2010 to 2016, 108 patients underwent TLE of 227 leads due to endocarditis (n = 21; 19%), pocket infection (n = 58; 54%) or lead dysfunction (n = 29; 27%). In 98% (n = 106) of the patients, laser-assisted lead extraction was performed. In 2% (n = 2) of the patients, the application of a solitary locking stylet was sufficient. The patient mean age was 68 ± 14 years; 25% of the patients had previous cardiac surgery. TLE was performed a mean of 9 ± 6 years after the implantation of the existing device. RESULTS Complete procedural success (removal of all lead material from the vascular space) was achieved in 98.7% (n = 224), and clinical success (achievement of all clinical goals associated with the indication for lead removal and absence of major complications) was achieved in 98% (n = 106). In 2 patients the procedure failed due to a vascular tear requiring a thoracotomy. In 1 patient, complete lead extraction was not possible due to heavy calcification (coronary-sinus lead). The 30-day mortality rate was 3.7% (n = 4); the patients died of multiorgan failure (n = 1), cardiac failure (n = 1) and septicaemia (n = 2). The procedure-related major complication rate was 2% (n = 2). CONCLUSIONS Laser-assisted TLE seems to be a safe and effective procedure with an acceptable complication rate.

Aims Preventing hospitalization by detecting early evidence of heart failure (HF) decompensation in an outpatient setting can improve patient's quality of life and reduce costs of care. The purpose of this study was to assess the value of cardiac acoustic biomarkers (CABs), a combination of cardiohaemic vibrations synchronized with ECG signals, and heart rate (HR) for detecting HF decompensation during first 3 months after hospital discharge for HF. Methods and results Patients with an ejection fraction ≤35% (HFrEF) and hospitalized for decompensated HF were enrolled in a prospective observational study. All subjects wore a wearable cardioverter‐defibrillator (ZOLL LifeVest®, Pittsburgh, PA, USA) that is capable of recording CABs and HR. The primary endpoint of the study was the first HF event, defined as HF readmission or HF emergency room visit. From June 2017 through August 2019, 671 patients with HFrEF were enrolled. Eighty‐one patients (12.1%) had a total of 112 HF events. The algorithm detected HF events with a median of 32 days (interquartile range = 11‐45) in advance of the first HF event. The algorithm had a sensitivity of 69%, specificity of 60%, positive predictive value of 19%, and a negative predictive value of 94%. Of note, the baseline (first 7 days post‐enrolment) algorithm using CABs and HR was superior to New York Heart Association classification in detecting patients more likely to have HF decompensation (sensitivity and specificity of 61% and 68% vs. 46% and 55%, respectively). Conclusions This prospective international registry showed that an algorithm incorporating CABs and HR data detected HF events 30 days in advance of the event in patients with HFrEF during first 3 months after hospital discharge. Therefore, integrating CAB technology into clinical practice may prevent HF rehospitalizations.

Background Data on the arrhythmic burden of women at risk for sudden cardiac death are limited, especially in patients using the wearable cardioverter-defibrillator (WCD). Objective We aimed to characterize WCD compliance, atrial and ventricular arrhythmic burden, and WCD outcomes by sex in patients enrolled in the Prospective Registry of Patients Using the Wearable Cardioverter Defibrillator (WEARIT-II U.S. Registry). Methods In the WEARIT-II Registry, we stratified 2000 patients by sex into women (n = 598) and men (n = 1402). WCD wear time, ventricular and atrial arrhythmic events during WCD use, and implantable cardioverter-defibrillator (ICD) implantation rates at the end of WCD use were evaluated. Results The mean WCD wear time was similar in women and men (94 days vs 90 days; P = .145), with longer daily use in women (21.4 h/d vs 20.7 h/d; P = .001). Burden of ventricular tachycardia or ventricular fibrillation was higher in women, with 30 events per 100 patient-years compared with 18 events per 100 patient-years in men (P = .017), with similar findings for treated and non-treated ventricular tachycardia/ventricular fibrillation. Recurrent atrial arrhythmias/sustained ventricular tachycardia was also more frequent in women than in men (167 events per 100 patient-years vs 73 events per 100 patient-years; P = .042). However, ICD implantation rate at the end of WCD use was similar in both women and men (41% vs 39%; P = .448). Conclusion In the WEARIT-II Registry, we have shown a higher burden of ventricular and atrial arrhythmic events in women than in men. ICD implantation rates at the end of WCD use were similar. Our findings warrant monitoring women at risk for sudden cardiac death who have a high burden of atrial and ventricular arrhythmias while using the WCD.

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Aims Cephalic vein cutdown (CVC) and subclavian puncture (SP) are widely used techniques for lead insertion of cardiac implantable electronic devices (CIEDs). Whether one technique is superior to the other, is still being debated. The purpose of this study was to compare CVC vs. SP for lead implantation in CIEDs with respect to the incidence of pneumothorax, lead failure, and bleeding. Methods and results We performed a systematic search of the pertinent literature on lead implantation in CIEDs via PubMed and Cochrane databases published over the last 25 years. Standard meta-analytic methods were applied to compare incidences of outcomes of interest. Sensitivity analysis was conducted to determine the impact of each study on the overall effect size. Risk of publication bias was assessed. A total of 20 studies were included in the analysis. These studies comprised more than 30 000 patients with more than 50 000 leads implanted via CVC or SP. The incidence of pneumothorax was lower with the CVC technique (n = 29/15 065, 0.19% vs. n = 205/15 824, 1.30%) [odds ratio (OR) 0.21, 95% confidence interval (CI) 0.10-0.42, P

Cardiac sarcoidosis is a rare immunologic disease causing heart involvement in 5% of patients. Cardiac sarcoidosis may manifest clinically as a cardiomyopathy with impaired left ventricular (LV) function or as tachyarrhythmias or bradyarrhythmias. On autopsy, cardiac granulomas can be found in approximately 25% of patients. The most common location for granulomas and scars is the LV free wall, followed by the intraventricular septum, often with involvement of the conduction system. ...

Data on preferred ICD lead type and optimal RV lead position in patients undergoing CRT-D implantation are limited. To compare dual- versus single-coil ICD leads and non-apical versus apical RV lead position and their impact on clinical parameters and survival in CRT-D recipients. A total of 563 consecutive patients with advanced heart failure and indication for CRT-D implantation were enrolled in two European tertiary centers. Endpoints were improvement in NYHA functional class, changes in echo- and electrocardiographic parameters, and all-cause and cardiovascular mortality. In this retrospective analysis, a total of 313 (56%) dual- and 250 (44%) single-coil ICD leads were used. RV leads were placed non-apically in 262 (47%) and apically in 296 (53%) patients, respectively. Over a mean follow-up of 41 ± 34 months, all-cause mortality and cardiovascular mortality were similar for patients with dual- versus single-coil ICD lead (adjusted HR 0.81, 95% CI 0.58–1.12 and aHR 1.22, 95% CI 0.73–2.04) and non-apical versus apical RV lead position (aHR 0.98, 95% CI 0.71–1.36 and aHR 0.76, 95% CI 0.44–1.31). Non-apical RV lead position was associated with greater reduction in QRS duration after CRT implantation (− 14.4 ± 32.1 vs. − 4.3 ± 34.3 ms, p

BACKGROUND Targeted temperature management (TTM) represents an effective therapy to improve neurologic outcome in patients who survive an out-of-hospital cardiac arrest (OHCA). First publications about this therapy reported a higher incidence of infections in patients who underwent TTM induced by external cooling devices. Whether intravascular cooling devices are also associated with an increased infection rate has not been investigated so far. METHODS In a single center retrospective study, the incidence of early onset pneumonia (EOP) in OHCA patients with or without intravascular TTM at 33 °C target temperature for 24 h who survived at least 24 h after admission was analyzed. RESULTS A total of 68 OHCA survivors (mean age 65 ± 15 years) were included in this analysis. The most common causes of OHCA were myocardial infarction (35 %), primary ventricular fibrillation (24 %), asystole (15 %), and pulmonary embolism (7 %). Of those, 32 patients (48 %) received TTM. The overall incidence of EOP was 38 %. Incidence of EOP did not differ significantly between groups, was more frequent in the group without TTM (42 % vs. 34 %, p = 0.57) and had no impact on mortality (hazard ratio = 1.02; 95 % confidence interval 0.25-4.16; p = 0.97). CONCLUSION Intravascular TTM at 33 °C with a cooling catheter is not associated with more infective complications in OHCA patients. This finding underscores the safety of TTM.

The wearable cardioverter defibrillator (WCD) is used for temporary protection of patients deemed to be at high risk for sudden death. There is limited experience regarding the clinical development of patients with tachymyopathy. We aimed to evaluate the clinical development of tachymyopathy patients protected with a WCD in a single-center non-randomized patient cohort. We fitted 130 consecutive patients deemed to be at high risk for ventricular tachyarrhythmias with the WCD. Of these, 20 patients (15%) presenting with newly diagnosed heart failure in the setting of rapidly conducted atrial fibrillation/flutter were suspected to suffer from tachymyopathy. The control group consisted of the remaining 110 patients with other indications for WCD therapy. LVEF increased by more than 10% in 13/20 (65%) tachymyopathy patients compared to 40/110 (36%) patients in the control population (p = 0.01). Similarly, BNP levels decreased in 15/20 (75%) tachymyopathy patients compared to 41/110 (37%) in the control group (p = 0.05). ICD implantation rates were lower in the tachymyopathy group (3/20) compared to the control population (40/110; p = 0.04). On further follow-up (mean 12 ± 8 months), patients with suspected tachymyopathy had no sustained ventricular arrhythmias. Compared to 5/110 patients in the control group, no tachymyopathy patient died. Most of the patients with suspected tachymyopathy have a favorable clinical outcome. The WCD is useful for temporary protection while LV function recovers.

Meta-Analysis of Pacemaker Lead PerforationIntroduction Two leadless pacemaker (PM) systems were recently developed to avoid pocket- and lead-related complications. As leadless PMs are implanted with a large delivery catheter, cardiac perforation remains a major safety concern. We aimed to provide a literature review on incidence of cardiac perforation with conventional and with leadless PM systems. Methods and Results A systematic review over the last 25 years for studies reporting data on PM lead perforation was performed. Findings were synthesized descriptively. Where control groups were available, data were meta-analyzed to identify important clinical risk factors. A total of 28 studies comprising 60,744 patients undergoing conventional PM implantation were analyzed. The incidence of lead perforation ranged from 0% to 6.37% (mean 0.82%, weighted mean 0.31%, median of 0.40%). There was no significant difference in perforation risk between atrial and ventricular electrodes (POR 0.72, 95% confidence interval [CI], 0.28–1.87, P = 0.50) and between MRI conditional and conventional leads (POR 5.93, 95% CI, 0.72–48.76, P = 0.10). The use of active fixation leads (POR 4.25, 95% CI, 1.00–17.95, P = 0.05) and utilization of DDD versus VVI PM systems (POR 3.50, 95% CI, 1.48–8.28, P < 0.01) were associated with higher rates of perforation. In the 2 leadless PM studies, the incidence of cardiac perforation was 1.52% for each. Conclusion PM lead perforation rates vary in individual studies with an overall low incidence. Leadless PMs seem to be associated with a slightly higher perforation risk, most likely reflecting a learning curve effect of this novel technology.

Sudden cardiac death (SCD) is reported to account for two-thirds of deaths due to cardiovascular causes in the United States, taking half a million lives every year ([1][1]). In cohort studies on SCD, women accounted for only 25% of the patient populations and less often had coronary artery disease

Background The prospective WEARIT-II-EUROPE registry aimed to assess the value of the wearable cardioverter-defibrillator (WCD) prior to potential ICD implantation in patients with heart failure and reduced ejection fraction considered at risk of sudden arrhythmic death. Methods and results 781 patients (77% men; mean age 59.3 ± 13.4 years) with heart failure and reduced left ventricular ejection fraction (LVEF) were consecutively enrolled. All patients received a WCD. Follow-up time for all patients was 12 months. Mean baseline LVEF was 26.9%. Mean WCD wearing time was 75 ± 47.7 days, mean daily WCD use 20.3 ± 4.6 h. WCD shocks terminated 13 VT/VF events in ten patients (1.3%). Two patients died during WCD prescription of non-arrhythmic cause. Mean LVEF increased from 26.9 to 36.3% at the end of WCD prescription (p Conclusions Mortality after WCD prescription was mainly driven by heart failure and non-cardiovascular death. In patients with HFrEF and a potential risk of sudden arrhythmic death, WCD protected observation of LVEF progression and appraisal of competing risks of potential non-arrhythmic death may enable improved selection for beneficial ICD implantation. Graphic abstract

Background Resuming activity following a new diagnosis of dilated cardiomyopathy (DCM) or myocardial infarction (MI) is important for improvements in morbidity and mortality. Activity is also associated with an improved ejection fraction (EF) and lower risk of reinfarction. Patient management could benefit from having normative values and expected gains in activity early following diagnosis of DCM or MI. Purpose Assess the change in activity among women for the first 30 days after hospital discharge following a new DCM diagnosis or MI. Methods Female adult patients prescribed a wearable cardioverter defibrillator (WCD) for a diagnosis of DCM (n=3550) or MI (n=1422) with low EF were included. Step count was measured by WCD accelerometer. Change in activity over time was analyzed, including weekly percentage gains. Results Women with DCM were significantly younger (64, SD = 13) than women post-MI (67, SD = 12). Median daily step count across the entire 30-day period was 4093 (IQR: 2123–6609). Women with DCM demonstrated a higher step count compared to women post-MI, 4405 (IQR: 2348–6986) and 3352 (IQR: 1644–5709), respectively, even after correcting for the difference in age between the groups. The greatest increases in activity for all occurred from week 1 to week 2. Women with DCM or post-MI had a 15.4% and 19.1% increase, respectively. Incremental increases in activity continued throughout the month. Conclusion Physical activity among women with newly diagnosed DCM or MI and a low EF increased within the first 30 days. The most significant increase occurred from week 1 to week 2. This data can be used as a benchmark to develop and assess prescriptive activity programs for women.

Background Previous studies highlighted the importance of adequate heart rate control in heart failure patients, and suggested under-treatment with beta-blockers especially in women. However, data on women achieving effective heart rate control during beta-blocker therapy optimization are lacking. Methods The wearable cardioverter defibrillator (WCD) allows continuous monitoring of heart rate (HR) trends during WCD use. In the current study, we assessed resting HR trends (nighttime: midnight-7am) in women, both at the beginning of WCD use and at the end of WCD use to assess the adequacy of beta-blockade following a typical 3 months of therapy optimization with beta-blockers. An adequate heart rate control was defined as having a nighttime HR Results There were a total of 21,453 women with at least 30 days of WCD use (>140 hours WCD use on the first and last week). The mean age was 67 years (IQR 58–75). The mean nighttime heart rate was 72 bpm (IQR 65–81) at the beginning of WCD use, that decreased to 68 bpm (IQR 61–76) at the end of WCD use with therapy optimization. Women had an insufficient heart rate control with resting heart rate ≥70 bpm in 59% at the beginning of WCD use that decreased to 44% at the end of WCD use, but still remained surprisingly high. Interestingly, there were 21% of the women starting with HR ≥70 bpm at the beginning of use (BOU) who achieved adequate heart rate control by the end of use (EOU). Interestingly, 6% of women with adequate heart rate control at the start of therapy optimization ended up having higher heart rates >70 bpm at the end of the therapy optimization time period (Figure). Figure 1 Conclusions A significant proportion of women with heart failure and low ejection fraction do not reach an adequate heart rate control during the time of beta blocker initiation/titration. The wearble cardioverter defibrillator is a monitoring device that has been demonstrated in this study to appropriately identify patients with inadequate heart rate control at the end of the therapy optimization period. The WCD could be utilized to improve management of beta-blocker therapy in women and improve the achievement of adequate heart rate control in women.

Background The Wearable Cardioverter Defibrillator (WCD) is an effective therapy for treating ventricular arrhythmias (VT/VF) in at-risk patients, while providing continuous heart rate (HR) monitoring. Because women are under-represented in defibrillator trials, we chose to specifically focus on HR control in women prior to VT/VF events. Purpose To evaluate HR profiles preceding sustained VT/VF in women fitted with a WCD. Methods Data from women fitted with WCD (≥30 days use) from 2015 to 2018 were obtained from the manufacturer's database. HR is expressed as a weekly resting nighttime median (midnight to 7 am). Men (random sample) with the same inclusion criteria served as a control. Results A total of 21,440 women, age 67±15 years, were included for analysis. Over a median WCD use of 90 days (59–116 days), 118 women (0.6%) and 133 men (0.8%) received shocks for VT/VF (p=0.01). Resting HR one-week preceding VT/VF was above the target of 70bpm in 55% of shocked women (65 of 118) versus 44% of non-shocked women (9,272 of 21,322, p=0.01) (figure). HR one week before WCD shock was similar in women and men (71 bpm vs. 72 bpm; p=0.60). Younger women (≤50 years) had higher HR prior to shock than older women (HR 80 bpm vs. 70 bpm p=0.003). Among shocked patients, 24-hour-survival was 89% in women and 88% in men. During three-month follow-up, the same percentage of men and women died after receiving adequate WCD shock therapy (18%). Heart rate profiles Conclusions Women with adequate heart rate control experienced significantly less spontaneous VT/VF than those with higher heart rates. The WCD can be utilized as a diagnostic tool to monitor HR in at-risk women in addition to treating sustained VT/VF.

The use of quadripolar (QP) left ventricular leads for cardiac resynchronization therapy (CRT) is intended to improve outcomes compared with conventional bipolar leads (BP). Hence, the number of implanted quadripolar CRT systems is increasing despite limited long-term data. The aim of this study is to evaluate clinical response and long-term outcomes of CRT recipients who were implanted with quadripolar versus bipolar left ventricular leads. Data from consecutive patients receiving a CRT defibrillator in one German and one Hungarian tertiary referral center were retrospectively collected. Long-term survival and response to CRT were analyzed. A total of 536 patients with structural heart disease and a mean left ventricular ejection fraction (LVEF) of 25% received a CRT defibrillator (CRT-D) system for primary (79%) or secondary (21%) prevention of sudden death. Comorbidities did not differ significantly between patients receiving a QP (n = 123) or a BP lead (n = 413). Procedure (101 vs. 120 min) and fluoroscopy times (14 vs. 20 min) were shorter in patients implanted with QP compared with BP (both p

Aims The effects of digitalis on mortality in patients with structural heart disease are controversially discussed. We aimed to assess the effects of digitalis administration in implantable cardioverter defibrillator (ICD) recipients. Methods and results This retrospective analysis comprises 1020 consecutive patients who received an ICD at our institution and who were followed for up to 10 years (median 37 months). A total of 438 patients were receiving digitalis at the time of ICD implantation and 582 did not. Patients on digitalis were more often in atrial fibrillation and had more often a prolonged QRS duration of ≥120 ms, a severely impaired left ventricular ejection fraction, and higher New York Heart Association (NYHA) classification heart failure. Crude Kaplan–Meier analysis demonstrated significantly higher mortality in patients on digitalis (HR = 2.47; 95% CI 1.87–3.25; P = 0.001). After adjustment for patient characteristics found statistically significant in adjusted Cox regression analysis (age, gender, NYHA classification, and QRS duration of ≥120 ms), a HR of 1.65 remained (95% CI 1.14–2.39; P = 0.01). Patients on digitalis died more often from cardiac arrhythmic and cardiac non-arrhythmic causes than patients not on digitalis ( P = 0.04). There was no difference in mortality between patients receiving digitoxin and those receiving digoxin (HR = 1.55; 95% CI 0.74–3.25; P = 0.25). Conclusion In this large ICD patient population, digitalis use at baseline was independently associated with increased mortality even after careful adjustment for possible confounders. Digitalis should be used with great caution in this population.

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Background Previous studies highlighted the importance of adequate heart rate control in heart failure patients, and suggested under-treatment with beta-blockers especially in women. However, data on women achieving effective heart rate control during beta-blocker therapy optimization are lacking. Methods The wearable cardioverter defibrillator (WCD) allows continuous monitoring of heart rate (HR) trends during WCD use. In the current study, we assessed resting HR trends (nighttime: midnight-7am) in women, both at the beginning of WCD use and at the end of WCD use to assess the adequacy of beta-blockade following a typical 3 months of therapy optimization with beta-blockers. An adequate heart rate control was defined as having a nighttime HR Results There were a total of 21,453 women with at least 30 days of WCD use (>140 hours WCD use on the first and last week). The mean age was 67 years (IQR 58-75). The mean nighttime heart rate was 72 bpm (IQR 65-81) at the beginning of WCD use that decreased to 68 bpm (IQR 61-76) at the end of WCD use with therapy optimization. Women had an insufficient heart rate control with resting heart rate ≥ 70 bpm in 59% at the beginning of WCD use that decreased to 44% at the end of WCD use, but still remained surprisingly high. Interestingly, there were 21% of the women starting with HR ≥ 70 bpm at the beginning of use (BOU) who achieved adequate heart rate control by the end of use (EOU). Interestingly, 6% of women with adequate heart rate control at the start of therapy optimization ended up having higher heart rates >70 bpm at the end of the therapy optimization time period (Figure). Conclusions A significant proportion of women with heart failure and low ejection fraction do not reach an adequate heart rate control during the time of beta blocker initiation/titration. The wearble cardioverter defibrillator is a monitoring device that has been demonstrated in this study to appropriately identify patients with inadequate heart rate control at the end of the therapy optimization period. The WCD could be utilized to improve management of beta-blocker therapy in women and improve the achievement of adequate heart rate control in women.

Bei Patienten mit Vorhofflimmern wird die Mortalitat und Morbiditat in erster Linie durch thromboembolische Komplikationen erhoht. Das Risiko fur ischamische Schlaganfalle ist bei Vorhofflimmern 4- bis 5-fach hoher als bei sinusrhythmischen Patienten. Fur die Schlaganfallpravention wird Aspirin nicht mehr empfohlen und die Antikoagulation mit Vitamin-K-Antagonisten weist in der Therapie zahlreiche Limitierungen auf. Die direkten oralen Antikoagulanzien sind sehr viel einfacher anzuwenden und haben weitere Vorteile wie eine kurze Halbwertszeit oder fehlende bzw. einzelne Wechselwirkungen mit Nahrungsmitteln bzw. anderen Medikamenten. Vor allem ist ein regelmasiges Monitoring der blutverdunnenden Wirkung nicht notig.

There are conflicting data regarding the effect of digoxin use on mortality in patients with atrial fibrillation (AF) or with congestive heart failure (CHF). The aim of this meta-analysis was to provide detailed analysis of the currently available study reports. We performed a MEDLINE and a COCHRANE search (1993-2014) of the English literature dealing with the effects of digoxin on all-cause-mortality in subjects with AF or CHF. Only full-sized articles published in peer-reviewed journals were considered for this meta-analysis. A total of 19 reports were identified. Nine reports dealt with AF patients, seven with patients suffering from CHF, and three with both clinical conditions. Based on the analysis of adjusted mortality results of all 19 studies comprising 326 426 patients, digoxin use was associated with an increased relative risk of all-cause mortality [Hazard ratio (HR) 1.21, 95% confidence interval (CI), 1.07 to 1.38, P < 0.01]. Compared with subjects not receiving glycosides, digoxin was associated with a 29% increased mortality risk (HR 1.29; 95% CI, 1.21 to 1.39) in the subgroup of publications comprising 235 047 AF patients. Among 91.379 heart failure patients, digoxin-associated mortality risk increased by 14% (HR 1.14, 95% CI, 1.06 to 1.22). The present systematic review and meta-analysis of all available data sources suggest that digoxin use is associated with an increased mortality risk, particularly among patients suffering from AF.

Sudden cardiac death (SCD) remains a major public health burden despite enormous advances in post-resuscitation care, management of structural heart diseases, and antiarrhythmic treatment modalities. Primary and secondary prevention of sudden cardiac death require understanding of the underlying substrate causing ventricular arrhythmias and its modification by pharmacological (i.e. heart failure therapy) or interventional (catheter ablation) methods. Antiarrhythmic drug therapy has experienced ups and downs during the last 30years balancing high antiarrhythmic potential, toxic side effects and pro-arrhythmic potency. Therefore, the implantable cardioverter-defibrillator (ICD) remains irreplaceable in primary and secondary prevention of SCD. Hybrid therapy combing antiarrhythmic drugs (predominantly amiodarone) with ICD therapy represents an often-used treatment option. This short review provides an overview of current pharmacological therapy aiming to prevent SCD.