Search Results (27)

Subclinical atrial fibrillation (SCAF) episodes are frequently detected in patients with cardiac implantable electronic devices (CIEDs). These asymptomatic arrhythmias are increasingly recognized as potential harbingers of clinical atrial fibrillation and thromboembolic events. However, the management of SCAF—particularly regarding the use of oral anticoagulation (OAC)—remains controversial. This literature review (Medline, Scopus, Goggle scholar, Embase) focuses on using current literature and clinical studies to guide decision-making regarding anticoagulation therapy and other treatment options that can limit complications for patients with SCAF. The decision to initiate anticoagulation in patients with atrial high-rate episodes (AHREs) should be individualized, balancing stroke risk against bleeding potential. Ongoing research and post hoc analyses will further clarify which subgroups may benefit most from therapy, informing future guideline recommendations. Full article

Background and Objectives: An atrial high-rate episode (AHRE) is defined according to the European Society of Cardiology (ESC) guidelines as a heart rate of ≥175 bpm lasting at least 5 min. This study aimed to evaluate whether neuron-specific enolase (NSE) levels, an indicator of neurological impact, could serve as a surrogate biomarker for silent neurological ischemia in patients with atrial high-rate episodes (AHREs). Materials and Methods: Patients with AHRE detected in a pacemaker analysis and a control group without any arrhythmias were included. Patients with AHRE were divided into subgroups according to AHRE duration—Group 1: AHRE < 5 min, Group 2: AHRE ≥ 5 min–<1 h, Group 3: AHRE ≥ 1 h–<24 h, Group 4: AHRE ≥ 24 h. Neuron-specific enolase (NSE) levels were measured using a double-antibody enzyme-linked immunosorbent assay (ELISA) with a sensitivity of 0.05 ng/mL. Imaging techniques were not employed in this study, and NSE was used as an indirect measure of potential neurological impact. Results: There were 160 patients, including 80 (50.0%) in the AHRE group and 80 (50.0%) in the control group. According to AHRE duration, there were 24 (30.0%) patients in Group 1, 33 (41.2%) in Group 2, 19 (23.8%) in Group 3, and 4 (5.0%) in Group 4. Patients with AHRE had statistically significant differences in age, sPAP, transmitral E/A ratio, and NSE levels. The mean NSE levels of all groups were significantly different (p < 0.001). A correlation analysis in patients with AHRE showed a very strong positive correlation between AHRE duration and NSE values as well as correlations with age, virtual CHA₂DS₂-VASc score, and LA diameter. NSE levels were positively correlated with AHRE duration and LA diameter. AHRE duration was an independent predictor of elevated NSE levels. Conclusions: It was shown that AHRE is associated with silent neurological ischemia and that NSE levels can be used to demonstrate these neurological effects. Future studies can contribute to the development of more effective treatment strategies based on these findings by investigating the neurological effects of AHRE in more detail. Full article

Clinical atrial fibrillation (AF) is a well-established major risk factor for stroke and systemic embolism. Pivotal trials have shown that treatment with oral anticoagulation reduces the risk of stroke and systemic embolism in clinical AF with a simultaneous increase in the risk of major bleeding. To help balance the risk of stroke and bleeding in clinical AF, different prediction models including biomarkers and clinical features have been validated. Device-detected AF (DDAF) is also associated with an increased risk of stroke and systemic embolism, but not to the same extent as clinical AF. Two large randomised studies have found significant stroke risk reduction with direct oral anticoagulation in DDAF patients, yet also a significantly increased risk of major bleeding. To date, the question remains how to balance the thromboembolic risk reduction with oral anticoagulation and the increased risk of bleeding in patients with DDAF and to identify the right patients who may benefit from oral anticoagulant treatment. Full article

Background: The wearable cardioverter defibrillator (WCD) has emerged as a valuable tool used for temporary protection from sudden cardiac death. However, since the WCD uses surface electrodes to detect arrhythmias, it is susceptible to inappropriate detection. Although shock conversion rates for the WCD are reported to be high for detected events, its efficacy in clinical practice tends to be degraded by patient noncompliance. Reasons for this include wearer discomfort and frequent false alarms, which may interrupt sleep and generate anxiety. Up to now, data on the incidence of false alarms emitted by the WCD and their predictors are rare. Objectives: The aim of our study was to assess the relationship between both artifact sensing and episode misclassification burden and wearing compliance in patients with a WCD (ZOLL LifeVest™ 4000 system, ZOLL CMS GmbH, Cologne, Germany). Methods and Results: We conducted a single-center retrospective observational study, analyzing patients with a WCD prescribed at our institution. A total of 134 patients (mean age 51.7 ± 13.8 years, 79.1% male) were included. Arrhythmia recordings were analyzed and categorized as non-sustained ventricular tachycardia, sustained ventricular tachycardia or fibrillation, artifact sensing or misclassified episodes. Indication for WCD prescription was both primary and secondary prophylaxis. A total of 3019 false WCD alarms were documented in 78 patients (average number of false alarms 38.7 ± 169.5 episodes per patient) over a mean WCD wearing time of 71.5 ± 70.9 days (daily WCD wearing time 20.2 ± 5.0 h). In a total of 78 patients (58.2% of the study population), either artifact sensing (76.9%), misclassified episodes (6.4%), or both (16.7%) occurred. Misclassified episodes included sinus tachycardias, atrial flutter, atrial fibrillation, premature ventricular contractions (PVCs), and intermittent bundle branch block. A multiple linear regression identified loop diuretics (regression coefficient [B] −0.11; 95% CI −0.21–(−0.0001); p = 0.049), angiotensin receptor–neprilysin inhibitors (ARNIs) (B −0.11; 95% CI 0.22–(−0.01); p = 0.033), and a higher R-amplitude of the WCD baseline electrocardiogram (ECG) (B −0.17; 95% CI −0.27–(−0.07); p = 0.001) as independent predictors for a lower number of artifact episodes per day. In addition, atrial fibrillation (B 0.05; 95% CI 0.01–0.08; p = 0.010), and calcium antagonists (B 0.07; 95% CI 0.02–0.12; p = 0.012) were independent predictors for increased numbers of misclassified episodes per day, while beta-blockers seemed to reduce them (B −0.06; 95% CI −0.10–(−0.01); p = 0.013). Patients terminated 61.0% of all false alarms manually by pressing the response button on average 1.9 times per false alarm with overall 3.6 manual terminations per affected patient per month. Conclusions: In conclusion, false alarms from the ZOLL LifeVest™ system were frequent, with artifact sensing being the most common cause. Hence, the occurrence of false alarms represents a significant side effect of WCD therapy, and efforts should be made to minimize false alarms. Full article

Background: An atrioventricular defibrillator system with a floating atrial dipole (VDD ICD) can provide atrial sensing by a single lead. Our aim was to compare the arrhythmia detection efficacy of VDD ICDs with conventional single- (VVI) and dual-chamber (DDD) defibrillators. Methods: Data from consecutive patients undergoing ICD implantation were retrospectively analyzed. The primary endpoint was the incidence of device-detected, new-onset atrial arrhythmias, while secondary endpoints were sensing parameters, complication rates, incidence of appropriate/inappropriate ICD therapy, arrhythmic/heart failure-related hospitalizations, and all-cause mortality. Results: A total of 256 patients (mean age 64 ± 12 years, male 75%, primary prophylaxis 28%, mean follow-up 3.7 ± 2.4 years) were included (VVI: 93, VDD: 94, DDD: 69). Atrial arrhythmia episodes were detected more frequently by VDD systems compared to VVI ICDs (aHR 7.087; 95% CI 2.371–21.183; p < 0.001), and at a rate similar to that of DDD ICDs (aHR 1.781; 95% CI 0.737–4.301; p = 0.200). The rate of inappropriate shocks was not different among the three ICD systems. Conclusion: VDD devices revealed an advantage in atrial arrhythmia detection compared to VVI ICDs and were non-inferior to DDD systems. Their main indication may be closer monitoring in high-risk patients with atrial arrhythmias to help therapy optimization and not the improvement of tachycardia discrimination. Full article

Atrial fibrillation (AF) has been associated with higher morbidity and mortality rates, especially in older patients. Subclinical atrial fibrillation (SCAF) is defined as the presence of atrial high-rate episodes (AHREs) > 190 bpm for 10 consecutive beats > 6 min and <24 h, as detected by cardiac implanted electronic devices (CIEDs). The selection of eligible patients for anticoagulation therapy among elderly individuals with AHREs detected through CIEDs remains a contentious issue. The meta-analysis of ARTESiA and NOAH-AFNET 6 clinical trials revealed that taking Edoxaban or Apixaban as oral anticoagulation therapy can reduce the risk of stroke by approximately 32% while increasing the risk of major bleeding by approximately 62%. However, it is still unclear which are, among patients with SCAF, those who can take the highest net clinical benefit from anticoagulant therapy. The present review summarizes the current evidence on this intriguing issue and suggests strategies to try to better stratify the risk of stroke and systemic embolism in patients with AHREs. We propose incorporating some parameters including chronic kidney disease (CKD), obesity, enlarged left atrial volume, the efficacy in blood pressure management, and frailty into the traditional CHA₂DS₂-VASc score. Future trials will be needed to verify the clinical usefulness of the proposed prognostic score mainly in the view of a personalized therapeutic approach in patients with SCAF. Full article

Atrial fibrillation (AF) carries a stroke risk, often necessitating anticoagulation, especially in patients with risk factors. With the advent of implantable and wearable heart monitors, episodes of short bouts of atrial arrhythmias called atrial high-rate episodes (AHREs) or subclinical AF (SCAF) are commonly identified. The necessity of anticoagulation in patients with SCAF is unclear. However, recent randomized controlled trials, the NOAH-AFNET 6 and ARTESIA, have offered insights into this matter. Furthermore, a study-level meta-analysis combining data from both these trials has provided more detailed information. Reviewing the information thus far, we can conclude that DOACs can result in a notable reduction in the risk of ischemic stroke and can potentially decrease the risk of debilitating stroke, albeit with an increased risk of major bleeding. Thus, informed, shared decision-making is essential, weighing the potential benefits of stroke prevention against the risk of major bleeding when considering anticoagulation in this patient population. Full article

Implantable Cardiac Monitor (ICM) devices are demonstrating, as of today, the fastest-growing market for implantable cardiac devices. As such, they are becoming increasingly common in patients for measuring heart electrical activity. ICMs constantly monitor and record a patient’s heart rhythm, and when triggered, send it to a secure server where health care professionals (HCPs) can review it. These devices employ a relatively simplistic rule-based algorithm (due to energy consumption constraints) to make alerts for abnormal heart rhythms. This algorithm is usually parameterized to an over-sensitive mode in order to not miss a case (resulting in a relatively high false-positive rate), and this, combined with the device’s nature of constantly monitoring the heart rhythm and its growing popularity, results in HCPs having to analyze and diagnose an increasingly growing number of data. In order to reduce the load on the latter, automated methods for ECG analysis are nowadays becoming a great tool to assist HCPs in their analysis. While state-of-the-art algorithms are data-driven rather than rule-based, training data for ICMs often consist of specific characteristics that make their analysis unique and particularly challenging. This study presents the challenges and solutions in automatically analyzing ICM data and introduces a method for its classification that outperforms existing methods on such data. It carries this out by combining high-frequency noise detection (which often occurs in ICM data) with a semi-supervised learning pipeline that allows for the re-labeling of training episodes and by using segmentation and dimension-reduction techniques that are robust to morphology variations of the sECG signal (which are typical to ICM data). As a result, it performs better than state-of-the-art techniques on such data with, e.g., an F1 score of 0.51 vs. 0.38 of our baseline state-of-the-art technique in correctly calling atrial fibrillation in ICM data. As such, it could be used in numerous ways, such as aiding HCPs in the analysis of ECGs originating from ICMs by, e.g., suggesting a rhythm type. Full article

Ambulatory 24–72 h Holter ECG monitoring is recommended for patients with suspected arrhythmias, which are often transitory and might remain unseen in resting standard 12-lead ECG. Holter manufacturers provide software diagnostic tools to assist clinicians in evaluating these large amounts of data. Nevertheless, the identification of short arrhythmia events and differentiation of the arrhythmia type might be a problem in limited Holter ECG leads. This observational clinical study aims to explore a novel and weakly investigated ECG modality integrated into a commercial diagnostic tool ECHOView (medilog DARWIN 2, Schiller AG, Switzerland), while used for the interpretation of long-term Holter-ECG records by a cardiologist. The ECHOView transformation maps the beat waveform amplitude to a color-coded bar. One ECHOView page integrates stacked color bars of about 1740 sequential beats aligned by R-peak in a window (R ± 750 ms). The collected 3-lead Holter ECG recordings from 86 patients had a valid duration of 21 h 20 min (19 h 30 min–22 h 45 min), median (quartile range). The ECG rhythm was reviewed with 3491 (3192–3723) standard-grid ECG pages and a substantially few number of 51 (44–59) ECHOView pages that validated the ECHOView compression ratio of 67 (59–74) times. Comments on the ECG rhythm and ECHOView characteristic patterns are provided for 14 examples representative of the most common rhythm disorders seen in our population, including supraventricular arrhythmias (supraventricular extrasystoles, paroxysmal supraventricular arrhythmia, sinus tachycardia, supraventricular tachycardia, atrial fibrillation, and flutter) and ventricular arrhythmias (ventricular extrasystoles, non-sustained ventricular tachycardia). In summary, the ECHOView color map transforms the ECG modality into a novel diagnostic image of the patient’s rhythm that is comprehensively interpreted by a cardiologist. ECHOView has the potential to facilitate the manual overview of Holter ECG recordings, to visually identify short-term arrhythmia episodes, and to refine the diagnosis, especially in high-rate arrhythmias. Full article

Black esophagus or acute esophageal necrosis is characterized by circumferential black discoloration of the distal esophageal mucosa. It is a rare condition with a multifactorial pathogenesis, and its most common clinical presentation is acute upper gastrointestinal bleeding. It usually affects elderly patients with multiple comorbidities and is associated with a high mortality rate. This is a case report of a 90-year-old man with multiple comorbidities, including diabetes mellitus, atrial fibrillation with complete atrioventricular block, and a history of ischemic stroke, who presented to the emergency department for a syncopal episode followed by coffee ground emesis. Thoraco-abdominal computer tomography showed thickening of the distal esophagus and ruled out major complications such as perforation. The following esophagogastroduodenoscopy showed black circumferential necrosis of the mid and distal esophagus. Multiple irregular ulcers with black necrotic areas were also present in the bulb and second duodenal portion. During the hospitalization, the patient was treated with PPI, NPO nutrition, and broad-spectrum antibiotics with benefits. Two months later, the patient returned to the emergency department due to a new episode of hematemesis with endoscopic evidence of esophageal stricture without necrosis and recurrence of duodenal ulcers. After a few days, the patient died due to worsening of the underlying comorbidities. A black esophagus is associated with duodenal ulcers, which may recur and are possibly due to a common ischemic origin. In this case report, we explore the potential link between black esophagus and duodenal ulcers, discussing the underlying mechanisms and relevant literature supporting this association. Full article

Transcatheter edge-to-edge repair (TEER) currently represents a valuable therapeutic option for patients with severe mitral regurgitation (MR) considered at high surgical risk. Besides symptoms and left ventricular (LV) echocardiographic improvements upon TEER, it has been postulated that left atrial (LA) function plays a prognostic role. The aims of our study were to evaluate LA changes after TEER, measured by two-dimensional speckle-tracking echocardiography analysis (2D-STE), their association with atrial fibrillation (AF) occurrence, and relative arrhythmic burden. We considered in a single-center study 109 patients affected by symptomatic severe MR undergoing TEER from February 2015 to April 2022. By 2D-STE, LA reservoir (R_s), conduct (D_s), and contractile (C_s) strains were assessed along with four-chamber emptying fraction (LAEF-4CH) before, 1, 6, and 12 months following TEER. Statistical analysis for comparison among baseline, and follow-ups after TEER was carried out by ANOVA, MANOVA, and linear regression. Successful TEER significantly improved LV dimensions and LA performances, as indicated by all strain components, and LAEF-4CH after 1 year. Strikingly, a significant reduction in arrhythmic burden was observed, since only one case of subclinical AF detected by a previously implanted cardiac electronic device was found in the cohort of sinus rhythm patients (n = 48) undergone TEER; in addition, ventricular rate was reduced in the AF cohort (n = 61) compared to baseline, together with few episodes of nonsustained ventricular tachycardias (5/61, 8.2%) after MR improvement. Overall, TEER was associated with improved cardiac performance, LA function amelioration, and reduced arrhythmic burden. Full article

Background: Unlike atrial fibrillation (AF), atrial flutter (AFl) is thought to be relatively refractory to pharmacological cardioversion (PC), but the evidence is scarce. The aim of this study was to evaluate the clinical characteristics and efficacy of the PC of AFl with amiodarone in comparison to AF. Materials and methods: This retrospective study covered 727 patients with urgent consult for AF/AFl in a high-volume emergency department between 2015 and 2018. AFl was diagnosed in 222 (30.5%; median age: 68 (62; 75) years; 65.3% men). In a nested case-control study, 59 control patients with AF, matched in terms of age and sex with 60 AFl patients, were subject to PC with amiodarone. The primary endpoint was return of sinus rhythm confirmed using a 12-lead ECG. Results: The AFl population had a median CHA2DS2-VASc score of 3 (2; 4) and episode duration of 72 h (16; 120). In the AFl cohort, 36% of patients were initially subject to PC, 33.3% to electrical cardioversion (EC) and 40.5% to catheter ablation. In comparison to the AF group, the AFl patients required a longer hospitalization time, had a higher rate of EC (p < 0.001) and less frequent use of PC (p < 0.001) and, lower left ventricular ejection fraction (p < 0.001) and more pronounced cardiovascular risk factors. The efficacy of PC with amiodarone was significantly lower in AFl than AF group (39% vs. 65%, relative risk (RR) 0.60, p = 0.007). Conclusions: AFl patients shared a greater burden of comorbidities than AF patients, while the efficacy of PC in AFl was low. Patients should be initially managed with primary electrical cardioversion. Full article

Atrial high-rate episodes (AHREs) are atrial tachyarrhythmias that are exclusively detected by cardiac implantable electronic devices (CIEDs) with an atrial lead. The objective of this study was to investigate the incidence and predictive factors for AHREs, and to evaluate the ability of inflammation biomarkers to predict the occurrence of AHREs. 102 patients undergoing CIED procedure who received a dual chamber pacemaker were included. CIED interrogation was performed 1 year after the implantation procedure. Patients were divided into groups according to the occurrence of AHREs, which was the primary endpoint of the study. The mean age of the patients was of 73 ± 8.6 years and 48% were male. The incidence of AHREs was 67% at 1 year follow-up. Patients with AHREs were older, had higher left atrial indexed volume (LAVi), higher baseline galectin-3 levels (1007.5 ± 447.3 vs. 790 ± 411.7 pg/mL) and received betablockers more often, along with amiodarone and anticoagulants. Interestingly, the CHADSVASC score did not differ significantly between the two groups. A cut-off value of galectin > 990 pg/mL predicted AHREs with moderate accuracy (AUC of 0.63, 95% CI 0.52 to 0.73, p = 0.04), and this association was confirmed in the univariate regression analysis (OR 1.0012, 95% CI 1.0001 to 1.0023, p = 0.0328). However, based on the multivariate regression analysis, galectin lost its prognostic significance under the effect of LAVi, which remained the only independent predictor of AHREs (OR 1.0883, 95% CI 1.0351 to 1.1441, p = 0.0009). AHREs are common in CIEDs patients. Galectin-3 may bring additional data in the prediction of AHREs. Full article

Background: Arrhythmias are a well known complication in patients with single ventricle physiology (SVP). However, there is still a lack of data regarding arrhythmias in older patients. The aim of this study was to analyze arrhythmia type and frequency, treatment and recurrence rates in patients with SVP over the age of 40 years. Methods: Data was obtained retrospectively from clinical records. All patients > 40 years with SVP with arrhythmias between 2005 and 2018 were included in the study. Treatment was classified as medical, interventional (electrophysiological studies (EPS) in combination with catheter ablation) or direct current cardioversion (DCCV). Results: Altogether, 29 patients (11 female; mean 47.5 ± 4.6 years) with 85 arrhythmia episodes were identified. The median follow-up time was 6.3 years. Cavo-tricuspid (CTI) and non-CTI related intra-atrial reentrant tachycardia (IART) and atrial fibrillation (AF) were most common (48.2% and 37.6%, respectively). In total, 18 EPS/ablations were performed in 9 patients and 52 DCCVs in 20 patients. Acute success was 98% for DCCV and 72.2% for EPS/ablation. Recurrence rate was high (70% for DCCV and 55% for EPS). AT recurrences occurred after a median of 8 and 2.5 months, respectively. On multivariate analyses, age was the only risk factor for arrhythmia recurrence (HR 0.58, 95% C.I. 0.43–0.78, p < 0.0001). Pacemaker implantation was necessary in seven patients (AV block n = 4, sinus node dysfunction n = 3) and one patient received an ICD for secondary prophylaxis. Sudden death occurred in three patients. Conclusions: The most common arrhythmias in patients with SVP > 40 years are IART and AF. Arrhythmia recurrence following EPS or DCCV is frequent. Older age is an independent risk factor for arrhythmia recurrence. Full article

Atrial fibrillation (AF) is the most frequent chronic arrhythmia worldwide, and it is associated with significant morbidity and mortality, making it a considerable burden both to patients and the healthcare system. Nowadays, an early attempt to restore sinus rhythm in acute symptomatic AF through electrical or pharmacological cardioversion is the most common approach in the Emergency Department (ED). However, considering the high percentage of spontaneous cardioversion of paroxysmal AF reported by many studies, this approach may not be the ideal choice for all patients. In this manuscript we performed a review of the most relevant studies found in literature with the aim of identifying the main determinants of spontaneous cardioversion, focusing on those easy to detect in the ED. We have found that the most relevant predictors of spontaneous cardioversion are the absence of Heart Failure (HF), a small atrial size, recent-onset AF, rapid Atrial Fibrillatory Rate and the relationship between a previous AF episode and Heart Rate/Blood Pressure. A number of those are utilized, along with other easily determined parameters, in the recently developed “ReSinus” score which predicts the likelihood of AF spontaneous cardioversion. Such identification may help the physician decide whether immediate cardioversion is necessary, or whether to adopt a “watch-and-wait” strategy in the presence of spontaneous cardioversion determinants. Full article