Clinical significance and prognostic value of right bundle branch block in permanent pacemaker patients.

AIMS: In patients undergoing pacemaker implantation with no prior history of heart failure (HF), the presence of left bundle branch block (LBBB) has been identified as an independent predictor of HF-related death or hospitalization, while the prognostic significance of right bundle branch block (RBBB) remains uncertain. We aimed to assess the long-term risk of all-cause mortality in patients with a standard indication for permanent pacing and normal or moderately depressed left ventricular function when RBBB is detected at the time of implantation. METHODS: We retrospectively enrolled 1348 consecutive patients who had undergone single- or dual-chamber pacemaker implantation at the study center, from January 1990 to December 2022. Patients with a left ventricular ejection fraction ≤35% or a prior diagnosis of HF were excluded. RESULTS: The baseline 12-lead electrocardiogram revealed an RBBB in 241 (18%) and an LBBB in 98 (7%) patients. During a median follow-up of 65 [25th-75th percentile: 32-117] months, 704 (52%) patients died. The combined endpoint of cardiovascular death or HF hospitalization was reached by 173 (13%) patients. On multivariate analysis, RBBB was confirmed as an independent predictor of death [hazard ratio, 1.33; 95% confidence interval (CI), 1.09-1.63; P  = 0.005]. However, when considering the combined endpoint of cardiovascular death and HF hospitalization, this endpoint was independently associated with LBBB (hazard ratio, 2.13; 95% CI, 1.38-3.29; P  < 0.001), but not with RBBB. CONCLUSION: In patients with standard pacemaker indications and normal or moderately depressed left ventricular function, the presence of basal RBBB was an independent predictor of mortality. However, it was not associated with the combined endpoint of cardiovascular death and HF hospitalization.

Non-high-density lipoprotein cholesterol versus low-density lipoprotein cholesterol in clinical practice: ANMCO position paper.

Bloodstream cholesterol is a central contributor to atherosclerotic cardiovascular diseases. For several decades, low-density lipoprotein cholesterol (LDL-C) has been the main biomarker for the prediction of cardiovascular events and therapeutic target of lipid-lowering treatments. More recently, several findings have supported the greater reliability of non-high-density lipoprotein cholesterol (non-HDL-C) as a predictive factor and possible therapeutic target in refining antiatherogenic treatments, especially among patients with lower LDL-C and higher triglyceride values. This article discusses the limits of current standard methods for assessing LDL-C levels and emphasizes the persistent residual cardiovascular risk in patients treated with lipid-lowering agents on the basis of recommended LDL-C targets. It highlights that patients with controlled LDL-C and non-targeted non-HDL-C have a higher cardiovascular risk. The article focuses on the role of non-HDL-C as a better predictor of atherosclerotic disease as compared with LDL-C and as a therapeutic target. Finally, this article includes an executive summary aimed at refining preventive approaches in atherosclerotic cardiovascular disease.

Continuous monitoring of sleep-disordered breathing with pacemakers: Indexes for risk stratification of atrial fibrillation and risk of stroke.

BACKGROUND: Sleep apnea (SA) is a risk factor for atrial fibrillation (AF). Advanced pacemakers are now able to calculate indexes of SA severity. HYPOTHESIS: We investigated the changes in pacemaker-measured indexes of SA, we assessed their predictive value for AF occurrence and the associated risk of stroke and death at long-term. METHODS: We enrolled 439 recipients of a pacemaker endowed with an algorithm for the calculation of a Respiratory Disturbance Index (RDI). The RDI variability was measured over the first 12 months after implantation, as well as its potential association with the occurrence of AF, defined as device-detected cumulative AF burden ≥6 hoursours in a day. RESULTS: The individual RDI mean was 30 ± 18 episodes/h, and the RDI maximum was 59 ± 21 episodes/h. RDI ≥30 episodes/h was detected in 351 (80%) patients during at least one night. The proportion of nights with RDI ≥30 episodes/h was 14% (2%-36%). AF ≥6 hours was detected in 129 (29%) patients during the first 12 months. The risk of AF was higher in patients with RDI maximum ≥63 episodes/h (HR:1.74; 95%CI: 1.22-2.48; P = .001) and with RDI mean ≥ 46 episodes/h (HR:1.63; 95%CI: 1.03-2.57; P = .014). The risk of all-cause death or stroke was higher in patients with AF burden ≥6 hours (HR:1.75; 95%CI: 1.06-2.86; P = .016). Moreover, among patients with no previous history of AF the risk was higher in those with RDI maximum ≥63 episodes/h (HR:1.96; 95%CI: 1.06-3.63; P = .031). CONCLUSIONS: Pacemaker-detected SA showed a considerable variability during follow-up. We confirmed the association between RDI and higher risk of AF, and we observed an association between higher RDI maximum and all-cause death or stroke among patients with no previous history of AF.

Cardiac Rehabilitation and Endothelial Function.

Endothelial dysfunction is an early abnormality in the process of atherosclerosis and cardiovascular disease and has been associated with worse clinical outcome. Cardiac rehabilitation (CR) has been reported to be helpful to reduce cardiovascular events in various types of cardiac disease, but the mechanisms of its beneficial effects remain only partially known. In this article, we review the studies that assessed the effect of CR on endothelial function in patients with various cardiac conditions. Available data show that CR significantly improves impaired endothelial function in these patients, which may contribute to the beneficial effects of CR on clinical outcome.

Effects of exercise training in heart failure with preserved ejection fraction: an updated systematic literature review.

Physical activity is associated with a lower risk of adverse cardiovascular outcomes, including heart failure (HF). Exercise training is a class IA level recommendation in patients with stable HF, but its impact is less clear in heart failure with preserved ejection fraction (HFpEF). The aim of this study was to analyze the effects of the exercise training on cardiovascular outcomes in patients with HFpEF. A systematic literature search was conducted on the main electronic databases, proceedings of major meetings, and reference lists of the identified studies, using specific terms for only English language studies published between 2000 and 2018. We followed the PRISMA to perform our review. Quality of studies was also assessed. The systematic review identified 9 studies on 348 patients, of moderate (n = 2) to good (n = 7) quality. The training consisted of a combination of supervised in-hospital and home-based outpatient programs, including aerobic exercise, endurance and resistance training, walking, and treadmill and bicycle ergometer. Most of the protocols ranged 12-16 weeks, with a frequency of 2-3 sessions weekly, lasting 20-60 min per session. There were significant improvements in peak oxygen uptake, 6-min walking test distance, and ventilatory threshold, whereas quality of life and echocardiographic parameters improved only in some studies. Endothelial function/arterial stiffness remained unchanged. No adverse events were reported. Appropriate exercise programs are able to get a favorable cardiovascular outcome in patients with HFpEF. This could also benefit in terms of quality of life, even if more controversial. Further researches are necessary.

Fixed and Low-Dose Combinations of Blood Pressure-Lowering Agents: For the Many or the Few?

Despite the widespread availability of several effective classes of drugs, systemic arterial hypertension remains poorly controlled in the majority of patients worldwide. In this article, we discuss the different modalities and effects of combination therapy and possible future research questions. Treatment with a single antihypertensive agent can effectively reduce blood pressure in only a limited number of patients, while most require therapy with two or more agents to achieve target levels. As initial therapy, American and European guidelines suggest a combination of two antihypertensive drugs and the use of a third antihypertensive drug when hypertension is still uncontrolled. Initial combination therapy is recommended in high-risk patients for an immediate blood pressure response, improved tolerability and possibly increased patient adherence. In addition to the potential benefits of combining different drug classes with synergistic pharmacological and physiological actions, this approach is useful for increasing the patient compliance with treatment, in particular if provided at fixed doses in a single pill. The minimisation of side effects is critical for the long-term treatment of a largely asymptomatic condition such as systemic hypertension. Low-dose combinations of different drugs from classes with complementary actions may provide the best ratio of lower side effects and improved tolerability with a significant blood pressure reduction, particularly in high-risk patients. This approach could be aided by a multidisciplinary lifestyle intervention on risk factors.

Occurrence of atrial fibrillation in pacemaker patients and its association with sleep apnea and heart rate variability.

AIMS: Sleep apnea (SA) is a risk factor for atrial fibrillation (AF) occurrence. Sympathovagal imbalance is a mechanism that predisposes to the development of AF and that occurs in SA. Some pacemakers can detect SA events and continuously measure a time domain measure of heart rate variability (HRV), i.e. the standard deviation of 5-min median atrial-atrial sensed intervals (SDANN). We evaluated the association between the occurrence of AF and device-detected SA and SDANN in patients who received pacemakers. METHODS: We enrolled 150 consecutive patients undergoing implantation of a dual-chamber pacemaker, capable of SA and SDANN estimation. The SA was defined as severe if the Respiratory Disturbance Index was ≥30 episodes/h for at least one night during the first week after implantation. RESULTS: Sixteen patients in permanent AF were excluded from our analysis. During follow-up, AF (cumulative device-detected AF duration > 6 h/day) occurred in 24(18%) patients out of the remaining 134 patients. Severe SA was detected in 84 patients. SDANN values were available in 74 patients and the median value was 76 ms [25°-75°percentile:58-77]. The risk of AF was higher in patients with severe SA (log-rank test; p = .033). The presence of either or both conditions (severe SA and SDANN < 76 ms) was associated with shorter time to AF event (p = .042) and was an independent predictor of AF (hazard ratio: 2.37; 95%CI:1.08 to 5.21; p = .033). CONCLUSION: In pacemaker patients, device-diagnosed severe SA and reduced SDANN are associated with a higher risk of AF.

Antithrombotic Therapy After Percutaneous Coronary Intervention in Atrial Fibrillation: The Triple Trouble.

One of the most common conundrums in all cardiovascular medicine pertains to the care of patients with atrial fibrillation after percutaneous coronary intervention, because of both dual antiplatelet therapy and oral anticoagulant therapy would seem to be necessary to reduce risks of stent thrombosis and thromboembolism, respectively, but also with an inevitable trade-off of more bleeding. Patients who require triple therapy are at high risk of both ischaemia and bleeding; therefore, defining a personalised secondary prevention strategy aimed at achieving the best net clinical benefit is essential. The good news is that we have entered an era of increased perceived and tangible safety that applies to both non-vitamin K-antagonist oral anticoagulants and newer drug-eluting stents. Even if the consistency across the major trials and the significantly lower risk of bleeding with dual therapy make it hard to argue that triple therapy should be used routinely, the aggregate evidence suggests that the net clinical benefit of dual therapy should give cardiologists confidence to drop aspirin when they are using a contemporary percutaneous coronary intervention strategy with drug-eluting stents. Waiting for more randomised trials and meta-analyses, for the time being, in patients not in clinical trials, full-dose oral triple therapy with dual antiplatelet agents and full-dose anticoagulation should be avoided as a routine practice, and the choice of the proper, that is, safer, oral anticoagulant, namely a non-vitamin K-antagonist oral anticoagulant, may be regarded by now as an additional bleeding avoiding strategy in patients with atrial fibrillation undergoing percutaneous coronary intervention.