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Objectives The study sought to determine the incidence of subclinical atrial fibrillation (AF) in high-risk patients and to compare the effect of continuous versus intermittent monitoring. Background AF often occurs in a subclinical form, which makes it difficult to detect. The authors do not know the incidence of subclinical AF among patients ≥65 years of age with hypertension and diabetes mellitus. This group of patients has increased risk of developing AF and in addition a high thromboembolic risk, if AF is present. Methods A total of 82 outpatients ≥65 years of age (median age 71.3 years [interquartile range [IQR]: 67.4 to 75.1 years]) with hypertension and diabetes mellitus, and no history of AF or any other cardiovascular disease, were consecutively included. All patients received an insertable cardiac monitor (ICM) and were followed for a median of 588 days (IQR: 453 to 712 days). We compared continuous monitoring with 72-h Holter monitoring 1 month after ICM insertion. The primary endpoint was AF ≥2 min for the ICM and AF ≥30 s for the Holter monitoring. Results During follow-up 17 (20.7%) patients were found to have subclinical AF detected by ICM with a median time to first detected episode of 91 days (IQR: 41 to 251 days) from inclusion. Only 2 (2.4%) patients also had AF episodes on the 72-h Holter monitoring. All detected episodes were completely asymptomatic. Conclusions The incidence of subclinical AF in this group of patients was surprisingly high. Continuous monitoring with ICM detected significantly more AF episodes than 72-h Holter monitoring. (Detection of Subclinical Atrial Fibrillation in High Risk Patients Using Implantable Loop Recorder; NCT02041832).

Aortic systolic blood pressure (BP) represents the hemodynamic cardiac and cerebral burden more directly than office systolic BP. Whether invasively measured aortic systolic BP confers additional prognostic value beyond office BP remains debated. In this study, office systolic BP and invasively measured aortic systolic BP were recorded in 21 908 patients (mean age: 63 years; 58% men; 14% with diabetes mellitus) with stable angina pectoris undergoing elective coronary angiography during January 2001 to December 2012. Multivariate Cox models were used to assess the association with incident myocardial infarction, stroke, and death. Discrimination and reclassification were assessed using Harrell’s C and the Continuous Net Reclassification Index. Data were analyzed with and without stratification by diabetes mellitus status. During a median follow-up period of 3.7 years (range: 0.1–10.8 years), 422 strokes, 511 myocardial infarctions, and 1530 deaths occurred. Both office and aortic systolic BP were associated with stroke in patients with diabetes mellitus (hazard ratio per 10 mm Hg, 1.18 [95% confidence interval, 1.07–1.30] and 1.14 [95% confidence interval, 1.05–1.24], respectively) and with myocardial infarction in patients without diabetes mellitus (hazard ratio, 1.07 [95% confidence interval, 1.02–1.12] and 1.05 [95% confidence interval, 1.01–1.10], respectively). In models including both BP measurements, aortic BP lost statistical significance and aortic BP did not confer improvement in either C-statistics or net reclassification analysis. In conclusion, invasively measured aortic systolic BP does not add prognostic information about cardiovascular outcomes and all-cause mortality compared with office BP in patients with stable angina pectoris, either with or without diabetes mellitus.

BACKGROUND: Long QT syndrome (LQTS) is a cardiac ion channelopathy which presents clinically with palpitations, syncope or sudden death. More than 700 LQTS-causing mutations have been identified in 13 genes, all of which encode proteins involved in the execution of the cardiac action potential. The most frequently affected genes, covering > 90% of cases, are KCNQ1, KCNH2 and SCN5A.METHODS: We describe 64 different mutations in 70 unrelated Danish families using a routine five-gene screen, comprising KCNQ1, KCNH2 and SCN5A as well as KCNE1 and KCNE2.RESULTS: Twenty-two mutations were found in KCNQ1, 28 in KCNH2, 9 in SCN5A, 3 in KCNE1 and 2 in KCNE2. Twenty-six of these have only been described in the Danish population and 18 are novel. One double heterozygote (1.4% of families) was found. A founder mutation, p.F29L in KCNH2, was identified in 5 "unrelated" families. Disease association, in 31.2% of cases, was based on the type of mutation identified (nonsense, insertion/deletion, frameshift or splice-site). Functional data was available for 22.7% of the missense mutations. None of the mutations were found in 364 Danish alleles and only three, all functionally characterised, were recorded in the Exome Variation Server, albeit at a frequency of < 1:1000.CONCLUSION: The genetic etiology of LQTS in Denmark is similar to that found in other populations. A large founder family with p.F29L in KCNH2 was identified. In 48.4% of the mutations disease causation was based on mutation type or functional analysis.

Fulminant perimyocarditis is a rare and potentially fatal condition that may mimick myocardial infarction. The long-term prognosis is favourable, once the patient has survived the index admission, and recurrence is extremely rare. This case describes a 35-year-old man, who experienced recurrence twice within six months. Due to the risk of a potentially fatal outcome, patients should be followed closely with clinical controls of infection parameters and echocardiography.

Twiddler's syndrome is a rare cause of pacemaker electrode displacement. The displacement is caused by the patient's manipulation with the pacemaker, so the electrode is retracted. We describe a case of a 79-year-old overweight woman with a known psychiatric anamnesis, who was admitted twice with twiddler's syndrome. Age and overweight are known risk factors for twiddler's syndrome; and in this case the patient's psychiatric habitus was probably an additional risk factor. Before performing a pacemaker implantation it is important to take the patient's risk factors into account, and thus consider submuscular implantation.

Objectives: We assessed the outcome of cascade screening of families with congenital long QT syndrome (LQTS) in Danish heart centers. Methods: Affected family members were identified through systematic family screening. Results: In total, 228 affected relatives were identified from 90 families. A disease-causing mutation useful for presymptomatic genetic testing was found in 82% of probands. Two-thirds of affected relatives fulfilled electrocardiographic criteria for the diagnosis, whereas diagnosis was based on genetic findings in only one-third. The majority of affected relatives were asymptomatic. Symptomatic relatives and probands most often presented with syncope, followed by aborted cardiac arrest and sudden cardiac death. A serious cardiac event (SCE, such as syncope, aborted cardiac arrest or cardiac arrest) was reported by 32% of affected relatives and 87% of probands (p < 0.0001). Fifty-two percent of affected relatives were on β-blockers and 11% had an implantable cardioverter defibrillator (ICD), as compared to 88 and 49% of probands (p < 0.0001). Appropriate ICD therapy was given to 13% of affected relatives and to 27% of probands (p = 0.1). Conclusions: Clinically driven cascade screening of Danish LQTS families identified 2-3 affected relatives per proband. Affected relatives had milder disease courses, but SCEs in a subset strongly support screening. Danish cardiologists have adopted cascade screening of LQTS families according to specific Danish guidelines.

A case of long-lasting nodal arrhythmia and severe hypotension following DC cardioversion for atrial flutter is presented. The patient, treated with the selective serotonin reuptake inhibitor sertraline and with sotalol, thiopental and digoxin, showed no sign of organic disease or drug intoxication. We suggest that drug interaction in combination with the DC shock and an altered sympaticus/parasympaticus balance during anaesthesia provoked the incident.