The influence of atrial high-rate episodes on stroke and cardiovascular death: an update.

Atrial high-rate episodes (AHRE) are atrial tachyarrhythmias detected by continuous rhythm monitoring by pacemakers, defibrillators, or implantable cardiac monitors. Atrial high-rate episodes occur in 10-30% of elderly patients without atrial fibrillation. However, it remains unclear whether the presence of these arrhythmias has therapeutic consequences. The presence of AHRE increases the risk of stroke compared with patients without AHRE. Oral anticoagulation would have the potential to reduce the risk of stroke in patients with AHRE but is also associated with a rate of major bleeding of ∼2%/year. The stroke rate in patients with AHRE appears to be lower than the stroke rate in patients with atrial fibrillation. Wearables like smart-watches will increase the absolute number of patients in whom atrial arrhythmias are detected. It remains unclear whether anticoagulation is effective and, equally important, safe in patients with AHRE. Two randomized clinical trials, NOAH-AFNET6 and ARTESiA, are expected to report soon. They will provide much-needed information on the efficacy and safety of oral anticoagulation in patients with AHRE.

Redefining the Standard for Atrial Fibrillation: A Patient-centric Report.

A roundtable discussion with three European clinical experts in AF and one expert patient diagnosed and treated for AF was conducted in London in October 2019. The panel discussed the implications of AF for patients, current patient pathways, what treatment outcomes were relevant for patients and how the recommendations for the management of AF may change in the future, based on the outcomes of recently published and on-going clinical trials. This article summarises the discussion, and draws upon wider sources to detail best practice and optimal patient treatment pathways.

Supraventricular Arrhythmias in Patients with Adult Congenital Heart Disease.

An increasing number of patients with congenital heart disease survive to adulthood; such prolonged survival is related to a rapid evolution of successful surgical repairs and modern diagnostic techniques. Despite these improvements, corrective atrial incisions performed at surgery still lead to subsequent myocardial scarring harbouring a potential substrate for macro-reentrant atrial tachycardia. Macroreentrant atrial tachycardias are the most common (75 %) type of supraventricular tachycardia (SVT) in patients with adult congenital heart disease (ACHD). Patients with ACHD, atrial tachycardias and impaired ventricular function - important risk factors for sudden cardiac death (SCD) - have a 2-9 % SCD risk per decade. Moreover, ACHD imposes certain considerations when choosing antiarrhythmic drugs from a safety aspect and also when considering catheter ablation procedures related to the inherent cardiac anatomical barriers and required expertise. Expert recommendations for physicians managing these patients are therefore mandatory. This review summarises current evidence-based developments in the field, focusing on advances in and general recommendations for the management of ACHD, including the recently published recommendations on management of SVT by the European Heart Rhythm Association.

Executive Summary: European Heart Rhythm Association Consensus Document on the Management of Supraventricular Arrhythmias: Endorsed by Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulación Cardiaca y Electrofisiologia (SOLAECE).

This paper is an executive summary of the full European Heart Rhythm Association (EHRA) consensus document on the management of supraventricular arrhythmias, published in Europace. It summarises developments in the field and provides recommendations for patient management, with particular emphasis on new advances since the previous European Society of Cardiology guidelines. The EHRA consensus document is available to read in full at http://europace.oxfordjournals.org.

Screening and risk evaluation for sudden cardiac death in ischaemic and non-ischaemic cardiomyopathy: results of the European Heart Rhythm Association survey.

The purpose of this EHRA survey was to examine the current clinical practice of screening and risk evaluation for sudden cardiac death in ischaemic and non-ischaemic cardiomyopathy with a focus on selection of candidates for implantable cardioverter-defibrillator (ICD) therapy, timing of ICD implantation, and use of non-invasive and invasive diagnostic tests across Europe. A systematic screening programme for sudden cardiac death existed in 19 out of 31 centres (61.3%). Implantation of ICDs according to the inclusion criteria of MADIT-II and SCD-HeFT trials was reported in 30 and 29% of centres, respectively, followed by MADIT-CRT (18%), COMPANION (16%), and combined MADIT and MUSTT (7%) indications. In patients with severe renal impairment, ICD implantation for primary prevention of sudden death was always avoided in 8 centres (33.3%), was not used only if creatinine level was >2.5 mg/dL in 10 centres (32.2%), and in patients with permanent dialysis in 8 centres (33.3%). Signal-averaged electrocardiography and heart rate variability were never considered as risk stratification tools in 23 centres (74.2%). Implantation of a loop recorder was performed in patients with borderline indications for ICD therapy in 6 centres (19.4%), for research purposes in 5 (16.1%), and was never performed in 20 (64.5%) centres. In conclusion, the majority of participating European centres have a screening programme for sudden cardiac death and the selection of candidates for ICD therapy was mainly based on the clinical risk stratification and not on non-invasive and invasive diagnostic tests or implantable loop recorder use.

The reliability of cardiogenic impedance and correlation with echocardiographic and plethysmographic parameters for predicting CRT time intervals post implantation.

AIMS: Encouraging data have been reported on the use of cardiogenic impedance (CI) in cardiac resynchronization therapy (CRT) optimization. The purposes of this study were to: evaluate the stability of certain CI vectors 24 h postimplantation, study the correlation between these CI signals and selected echocardiographic parameters, and examine the possibility of non-invasive calibration of the patient-specific impedance-based prediction model. METHODS AND RESULTS: Thirteen patients received a CRT-defibrillator device with monitor capability of the dynamic impedance between several electrodes. At implantation, a patient-specific impedance-based prediction model was created for identification of optimal atrioventricular and interventricular (VV) delays and calibrated on invasive measurements of left ventricular contractility (LV dP/dtmax). Simultaneously, non-invasive measurements of LV dP/dtmax and stroke volume (SV) were obtained using a finger plethysmograph. Patients were re-evaluated with echocardiography and new CI measurements the day after implantation. The hemodynamic benefit achieved by optimal VV setting according to the patient-specific impedance-based prediction model at follow-up was not as large as the one obtained at implantation. In a multivariate partial least square regression analysis, a correlation was found between aortic velocity time integral (VTI) and a generic linear combination of CI features (P < 0,005). No correlation was found between the patient-specific impedance-based prediction models and the non-invasive measurements of LV dP/dtmax and SV. CONCLUSION: Cardiogenic impedance signals can be used to optimize CRT settings but seem less feasible as an ambulatory tool since calibration is required. The positive correlation between aortic VTI and CI measurements seems promising, although a larger cohort is required to create an echocardiography-based patient-specific model.

Current practice in out-of-hospital cardiac arrest management: a European heart rhythm association EP network survey.

AIMS: The purpose of this EP wire is to examine clinical practice in the field of out-of-hospital cardiac arrest (OHCA) management, with special focus on in-hospital diagnostic and therapeutic strategies. METHODS AND RESULTS: Fifty-three European centres, all members of the EHRA-EP Research network, completed the questions of the survey. A dedicated strategy for OHCA management is active in 85% of the centres. Shockable tachyarrhythmias such as initial OHCA rhythm are reported in >70% of the patients in 64% of the centres. In-hospital therapeutic hypothermia was applied in >50% of the patients in 53% of the centres and in <50% in 47% of the centres. In the year 2011 90% of the centres performed >10 primary percutaneous coronary angioplasties (PCI) in OHCA patients. The survival rate, when the initial documented rhythm was shockable, was >30% in 42% of the centres, and conversely, was significantly lower when asystole or pulseless electrical activity was the initial rhythm. A favourable neurological recovery was reported in >50% of the patients in 13 (26%) centres and in 21-50% of the patients in 21 (44%). CONCLUSIONS: This EP wire survey demonstrates a favourable implementation in OHCA of an invasive management strategy, including coronary angiography/PCI and implantable cardioverter defibrillator therapy, while therapeutic hypothermia appears to be underused.

A prospective randomised comparison of large-tip cryoablation and 8-mm-tip radiofrequency catheter ablation of atrial flutter.

PURPOSE: Although radiofrequency (RF) energy is routinely used for tricuspid isthmus (TI) ablation, it is often associated with discomfort. The paucity of studies comparing the feasibility and efficacy of cryo- versus RF energy for TI-ablation urged us to conduct a prospective, randomised trial. METHODS: Forty patients with atrial flutter (AFl) were randomised to RF- or cryoenergy for TI-ablation. Perceived pain was scored from 1 to 10 on a Visual Analogue Scale. RESULTS: Significantly lower pain scores were recorded for cryoablation versus RF ablation (0.96 +/- 0.73 versus 4.2 +/- 2.4, p = 0.00004). Cryoablation was associated with significantly longer procedure duration and ablation time (137 +/- 35 versus 111 +/- 29 min, p = 0.016 and 81 +/- 40 versus 48 +/- 30 min, p = 0.007) and lower acute success rate (56% versus 100%, p = 0.001) than RF ablation. The recurrence of AFl was 20% (cryo) versus 15% (RF; p = 0.45) after a mean of 15.1 months follow-up. CONCLUSION: Cryoablation results in significantly less pain and discomfort compared to RF ablation of AFl, which is offset by the significantly lower acute success rate.