The effect of kidney function on guideline-directed medical therapy implementation and prognosis in heart failure with reduced ejection fraction.

BACKGROUND: Kidney dysfunction (KD) is a main limiting factor of applying guideline-directed medical therapy (GDMT) and reaching the recommended target doses (TD) in heart failure (HF) with reduced ejection fraction (HFrEF). HYPOTHESIS: We aimed to assess the success of optimization, long-term applicability, and adherence of neurohormonal antagonist triple therapy (TT:RASi [ACEi/ARB/ARNI] + ßB + MRA) according to the KD after a HF hospitalization and to investigate its impact on prognosis. METHODS: The data of 247 real-world, consecutive patients were analyzed who were hospitalized in 2019-2021 for HFrEF and then were followed-up for 1 year. The application and the ratio of reached TD of TT at hospital discharge and at 1 year were assessed comparing KD categories (eGFR: ≥90, 60-89, 45-59, 30-44, <30 mL/min/1.73 m2 ). Moreover, 1-year all-cause mortality and rehospitalization rates in KD subgroups were investigated. RESULTS: Majority of the patients received TT at hospital discharge (77%) and at 1 year (73%). More severe KD led to a lower application ratio (p < .05) of TT (92%, 88%, 80%, 73%, 31%) at discharge and at 1 year (81%, 76%, 76%, 68%, 40%). Patients with more severe KD were less likely (p < .05) to receive TD of MRA (81%, 68%, 78%, 61%, 52%) at discharge and a RASi (53%, 49%, 45%, 21%, 27%) at 1 year. One-year all-cause mortality (14%, 15%, 16%, 33%, 48%, p < .001), the ratio of all-cause rehospitalizations (30%, 35%, 40%, 43%, 52%, p = .028), and rehospitalizations for HF (8%, 13%, 18%, 20%, 38%, p = .001) were significantly higher in more severe KD categories. CONCLUSIONS: KD unfavorably affects the application of TT in HFrEF, however poorer mortality and rehospitalization rates among them highlight the role of the conscious implementation and up-titration of GDMT.

The Impact of Specialised Heart Failure Outpatient Care on the Long-Term Application of Guideline-Directed Medical Therapy and on Prognosis in Heart Failure with Reduced Ejection Fraction.

(1) Background: Besides the use of guideline-directed medical therapy (GDMT), multidisciplinary heart failure (HF) outpatient care (HFOC) is of strategic importance in HFrEF. (2) Methods: Data from 257 hospitalised HFrEF patients between 2019 and 2021 were retrospectively analysed. Application and target doses of GDMT were compared between HFOC and non-HFOC patients at discharge and at 1 year. 1-year all-cause mortality (ACM) and rehospitalisation (ACH) rates were compared using the Cox proportional hazard model. The effect of HFOC on GDMT and on prognosis after propensity score matching (PSM) of 168 patients and the independent predictors of 1-year ACM and ACH were also evaluated. (3) Results: At 1 year, the application of RASi, MRA and triple therapy (TT: RASi + ßB + MRA) was higher (p < 0.05) in the HFOC group, as was the proportion of target doses of ARNI, ßB, MRA and TT. After PSM, the composite of 1-year ACM or ACH was more favourable with HFOC (propensity-adjusted HR = 0.625, 95% CI = 0.401-0.974, p = 0.038). Independent predictors of 1-year ACM were age, systolic blood pressure, application of TT and HFOC, while 1-year ACH was influenced by the application of TT. (4) Conclusions: HFOC may positively impact GDMT use and prognosis in HFrEF even within the first year of its initiation.

Useful Electrocardiographic Signs to Support the Prediction of Favorable Response to Cardiac Resynchronization Therapy.

Cardiac resynchronization therapy (CRT) is a cornerstone therapeutic opportunity for selected patients with heart failure. For optimal patient selection, no other method has been proven to be more effective than the 12-lead ECG, and hence ECG characteristics are extensively researched. The evaluation of particular ECG signs before the implantation may improve selection and, consequently, clinical outcomes. The definition of a true left bundle branch block (LBBB) seems to be the best starting point with which to select patients for CRT. Although there are no universally accepted definitions of LBBB, using the classical LBBB criteria, some ECG parameters are associated with CRT response. In patients with non-true LBBB or non-LBBB, further ECG predictors of response and non-response could be analyzed, such as QRS fractionation, signs of residual left bundle branch conduction, S-waves in V6, intrinsicoid deflection, or non-invasive estimates of Q-LV which are described in newer publications. The most important and recent study results of the topic are summarized and discussed in this current review.

[The effect of kidney function on the optimization of medical therapy and on mortality in heart failure with reduced ejection fraction]. / A vesefunkció hatása a gyógyszeres terápia optimalizálására és a mortalitásra csökkent ejekciós frakciójú szívelégtelenségben.

INTRODUCTION: Renal dysfunction is a main limiting factor of applying and up-titrating guideline-directed medical therapy (GDMT) among patients with heart failure with reduced ejection fraction (HFrEF). OBJECTIVE: Our retrospective monocentric observational study aimed to analyse the application ratio of combined neurohormonal antagonist therapy (RASi: ACEI/ARB/ARNI + ßB + MRA) and 12-month all-cause mortality differences in terms of renal dysfunction among HFrEF patients hospitalized for heart failure. METHOD: We retrospectively analysed the cohort of consecutive HFrEF patients, hospitalized at the Heart Failure Unit of our tertiary cardiological centre in 2019-2021. The application ratio of discharge triple therapy (TT) in five groups established on admission eGFR parameters, representing severity of renal dysfunction (eGFR≥90, eGFR = 60-89, eGFR = 45-59, eGFR = 30-44, eGFR<30 ml/min/1.73 m2) was investigated with chi-square test, while 12-month mortality differences were analysed with Kaplan-Meier method and log-rank test. RESULTS: 257 patients were included. Median eGFR was 57 (39-75) ml/min/1.73 m2, 54% of patients had eGFR<60 ml/min/1.73 m2. The proportion of patients in eGFR≥90, 60-89, 45-59, 30-44, <30 ml/min/1.73 m2 subgroups was 12%, 34%, 18%, 21%, 15%, respectively. 2% of patients were on dialysis. Even though the application rate of TT was notably high (77%) in the total cohort, more severe renal dysfunction led to a significantly lower implementation rate of TT (94%, 86%, 91%, 70%, 34%; p<0.0001): the application rate of RASi (100%, 98%, 96%, 89%, 50%, p<0.0001), ßB (94%, 88%, 96%, 79%, 68%; p = 0.003) and MRA therapy (97%, 99%, 98%, 94%, 82%; p = 0.001) differed significantly. 12-month all-cause mortality was 23% in the whole cohort. Mortality rates were higher in more severe renal dysfunction (3%, 15%, 22%, 31%, 46%; p<0.0001). CONCLUSION: Even though the proportion of patients on TT in the whole cohort was remarkably high, renal dysfunction led to a significantly lower application ratio of TT, associating with worse survival. Our results highlight that despite renal dysfunction the application of HFrEF cornerstone pharmacotherapy is essential. Orv Hetil. 2023; 164(35): 1387-1396.

[Rhythm and rate control in the context of resuscitation and periarrest states]. / Ritmus- és frekvenciakontroll újraélesztés kapcsán és keringésmegingással fenyegeto szívritmuszavarok esetén.

Cardiovascular mortality has declined significantly in recent years, however, sudden cardiac death remains the leading cause of death in a range of different mortality indicators, very often caused by cardiac arrhythmias. The electrophysiological causes of sudden cardiac death include ventricular tachycardia, ventricular fibrillation, asystole and pulseless electrical activity. In addition, other cardiac arrhythmias may also trigger sudden cardiac death, periarrest arrhytmias. The rapid and accurate recognition of the various arrhythmias and their appropriate management are major challenges at both prehospital and hospital care levels. In these conditions, prompt recognition of life-threatening conditions, rapid response and proper treatment are critical. This publication reviews the various device and drug treatment modalities for the management of periarrest arrythmic conditions in the light of the 2021 guidelines of the European Resuscitation Council. This article highlights the epidemiology and aetiology of periarrest arrythmic states, and outlines the state-of-the-art treatment options for various tachy- and bradyarrhythmias, providing guidance in the management of these conditions both in hospital and out-of-hospital settings. Orv Hetil. 2023; 164(13): 504-509.

The Optimization of Guideline-Directed Medical Therapy during Hospitalization among Patients with Heart Failure with Reduced Ejection Fraction in Daily Clinical Practice.

INTRODUCTION: Hospitalization due to heart failure (HF) progression is associated with poor prognosis. This highlights the role of the implementation of guideline-directed medical therapy (GDMT) in improving the morbidity and mortality of patients with heart failure with reduced ejection fraction (HFrEF). There are limited data about the intrahospital applicability of GDMT in real-world circumstances. We aimed to assess retrospectively the use of cornerstone GDMT including RASi (ACEI/ARB/ARNI), ßB, MRA, and SGLT2i treatment in a consecutive real-world HFrEF patient population admitted with signs and symptoms of HF to the HF Unit of a Hungarian tertiary cardiac center between 2019 and 2021. The independent predictors of therapy optimization and the applicability of new HFrEF medication (ARNI, SGLT2i, vericiguat) were also investigated. METHODS: Statistical comparison of admission and discharge medication was accomplished with Fisher's exact test. The independent predictors of the introduction of triple therapy (RASi + ßB + MRA) were analyzed using univariate and multivariate logistic regression. The proportion of patients eligible for vericiguat based on the inclusion and exclusion criteria of the VICTORIA trial was also investigated, as well as the number of patients suitable for ARNI and SGLT2i, taking into account the contraindications of application contained in the ESC 2021 HF Guidelines. RESULTS: 238 patients were included. During hospitalization, the use of RASi (69% vs. 89%) (ACEI/ARBs [58% vs. 70%], ARNI [10% vs. 19%]), ßBs (69% vs. 85%), and MRAs (61% vs. 95%) increased significantly (p < 0.05) compared to at admission, and the use of SGLT2i (3% vs. 11%) also rose (p = 0.0005). The application ratio of triple (RASi + ßB + MRA; 43% vs. 77%) and quadruple (RASi + ßB + MRA + SGLT2i; 2% vs. 11%) therapy increased as well (p < 0.0001). The independent predictors of discharge application of triple therapy revealed through multivariate logistic regression analysis were age, duration of hospitalization, eGFR, NTproBNP, and presence of diabetes mellitus. Sixty-eight percent of the cohort would have been suitable for vericiguat, 83% for ARNI, and 84% for SGLT2i. CONCLUSION: High rates of application of disease-modifying drugs are achievable among hospitalized HFrEF patients in severe clinical condition; thus, awareness of the need for their initiation must be raised.

Association between electrical and mechanical remodeling after cardiac resynchronization therapy: systematic review and meta-analysis of observational studies.

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 < 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 < 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 < 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 < 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.

The application of landiolol in the cardiovascular and intensive care / A landiolol alkalmazási lehetoségei a kardiológiai és intenzív terápiás ellátásban.

Összefoglaló. A landiolol intravénásan alkalmazandó, kifejezetten cardioselectiv, gyors hatású és rövid felezési ideju béta-1-receptor-blokkoló, mely elsosorban negatív chronotrop és inotrop hatással bír, vérnyomáscsökkento hatása elhanyagolható. Foleg hemodinamikailag instabil állapotú, supraventricularis ritmuszavarban szenvedo betegek kamrafrekvenciájának csökkentésére használható. Nagy esetszámú, randomizált vizsgálatok igazolták hatékonyságát szívmutétek után jelentkezo pitvarfibrilláció megelozésében, valamint súlyos akut szívelégtelenségben és szívmutétek posztoperatív szakában jelentkezo pitvari tachyarrhythmiák kezelésében. Ezek mellett kisebb vizsgálatok alapján a használata biztonságosnak tunik akut myocardialis infarctusban, hatékony szeptikus állapotú, pitvarfibrillációban szenvedo betegek kamrafrekvencia- és ritmuskontrolljára, valamint nem cardialis mutétek esetén a pitvarfibrilláció prevenciójára és kezelésére. Sikerrel alkalmazható elektromos vihar esetén is, és jól használható angiográfiás coronaria-CT-vizsgálat elott az optimális szívfrekvencia elérésére. A gyógyszer 2016 óta Európában, 2018 óta Magyarországon is elérheto. Orv Hetil. 2022; 163(2): 53-62. Summary. Landiolol is an intravenous, selective beta-1-receptor blocking agent with rapid onset of action and ultra-short half-life that has a predominant negative chronotropic and only mild negative inotropic effect without significant reduction of blood pressure. Landiolol is indicated to control the ventricular heart rate predominantly in patients with hemodynamic instability due to supraventricular tachyarrhythmia. Large randomized controlled trials have proven the efficacy of landiolol in the prevention of atrial fibrillation and atrial tachyarrhythmias in severe acute heart failure or post-cardiac surgery. Based on lower case-number studies, the administration of landiolol has been proven to be efficient and safe in rhythm and rate control in atrial fibrillation complicating acute myocardial infarction, sepsis, and in the prevention of atrial fibrillation in non-cardiac surgery. Landiolol may be used in electrical storm, and even during coronary CT-angiography to achieve an optimal heart rate for imaging. The drug is available in Europe since 2016 and in Hungary since 2018. Orv Hetil. 2022; 163(2): 53-62.

An Interaction Effect Analysis of Thermodilution-Guided Hemodynamic Optimization, Patient Condition, and Mortality after Successful Cardiopulmonary Resuscitation.

Proper hemodynamic management is necessary among post-cardiac arrest patients to improve survival. We aimed to investigate the effects of PiCCO™-guided (pulse index contour cardiac output) hemodynamic management on mortality in post-resuscitation therapy. In this longitudinal analysis of 63 comatose patients after successful cardiopulmonary resuscitation cooled to 32-34 °C, 33 patients received PiCCO™, and 30 were not monitored with PiCCO™. Primary and secondary outcomes were 30 day and 1 year mortality. Kaplan-Meier curves and log-rank tests were used to assess differences in mortality among the groups. Interaction effects to disentangle the relationship between patient's condition, PiCCO™ application, and mortality were assessed by means of Chi-square tests and logistic regression models. A 30 day mortality was significantly higher among PiCCO™ patients, while 1 year mortality was marginally higher. More severe patient condition per se was not the cause of higher mortality rate in the PiCCO™ group. Patients in better health conditions (without ST-elevation myocardial infarction, without cardiogenic shock, without intra-aortic balloon pump device, or without stroke in prior history) had worse outcomes with PiCCO™-guided therapy. Catecholamine administration worsened both 30 day and 1 year mortality among all patients. Our analysis showed that there was a complex interaction relationship between PiCCO™-guided therapy, patients' condition, and 30 day mortality for most conditions.

Proportion of Patients Eligible for Cardiac Contractility Modulation: Real-Life Data from a Single-Center Heart Failure Clinic.

INTRODUCTION: Based on recently published randomized controlled trials, cardiac contractility modulation (CCM) seems to be an effective device-based therapeutic option in symptomatic chronic heart failure (HF) (CHF). The aim of the current study was to estimate what proportion of patients with CHF and left ventricular ejection fraction (LVEF) <50% could be eligible for CCM based on the inclusion criteria of the FIX-HF-5C trial. METHODS: Consecutive patients referred and followed up at our HF clinic due to HF with reduced or mid-range LVEF were retrospectively assessed. After a treatment optimization period of 3-6 months, the inclusion criteria of the FIX-HF-5C trial (New York Heart Association (NYHA) class III/IV, 25% ≤ LVEF ≤45%, QRS <130 ms, and sinus rhythm) were applied to determine the number of patients eligible for CCM. RESULTS: Of the 640 patients who were involved, the proportion of highly symptomatic patients in NYHA class III/IV decreased from 77.0% (n = 493) at baseline to 18.6% (n = 119) after the treatment optimization period (p < 0.001). Mean LVEF increased significantly from 29.0 ± 7.9% to 36.3 ± 9.9% (p < 0.001), while the proportion of patients with 25% ≤ LVEF ≤45% increased from 69.7% (n = 446) to 73.3% (n = 469) (p < 0.001). QRS duration was below 130 ms in 63.1% of patients, while 30.0% of patients had persistent or permanent atrial fibrillation. We found that the eligibility criteria for CCM therapy based on the FIX-HF-5C study were fulfilled for 23.0% (n = 147) of patients at baseline and 5.2% (n = 33) after treatment optimization. CONCLUSION: This single-center cohort study showed that 5% of patients with CHF and impaired LVEF immediately after treatment optimization fulfilled the inclusion criteria of the FIX-HF-5C study and would be candidates for CCM.

Pilot analysis of the usefulness of mortality risk score systems at resuscitated patients / Halálozásikockázat-becslo pontrendszerek alkalmazhatóságának elozetes vizsgálata újraélesztett betegek körében.

Összefoglaló. Bevezetés: A cardiovascularis halálokok közül világszerte nagy jelentoségu a hirtelen szívhalál. Annak ellenére, hogy a cardiopulmonalis resuscitatio és a postresuscitatiós intenzív osztályos kezelés is komoly metodikai és technikai fejlodésen ment keresztül az elmúlt idoszakban, kevés az olyan validált pontrendszer, amely jól becsülné a beteg intenzív osztályra kerülésekor a mortalitási rizikót. Célkituzés: A sikeres újraélesztést követo intenzív osztályos kezelés kezdetekor felmért, a cardiogen shock rizikóstratifikációjára alkalmazott CardShock Risk Score (CSRS) és az általunk hozzáadott, specifikus súlyozófaktorokkal (iniciális ritmus, inotropigény) módosított CardShock Risk Score (mCSRS) összevetése a mortalitás elorejelzésében post-cardiac arrest szindrómás betegeknél. Módszerek: Retrospektív vizsgálatunk során 172, kórházon kívül sikeresen újraélesztett és klinikánkon ellátott consecutiv betegbol a CSRS- és mCSRS-pontrendszerek segítségével végül 123 beteg adatait elemeztük. A CSRS- és mCSRS-változók és a korai/késoi mortalitás közötti összefüggést Cox-regressziós analízissel vizsgáltuk. A pontszámok alapján 3 csoportba (1-3, 4-6, 7+) soroltuk a betegeket. Az összevont csoportok túlélését log-rank teszttel hasonlítottuk össze. Eredmények: A betegpopuláció átlagéletkora 63,6 év volt (69% férfi), és a hirtelen szívhalál hátterében 80%-ban akut coronaria szindróma állt. A korai/késoi mortalitást leginkább a felvétel utáni neurológiai állapot, a szérumlaktátszint, a vesefunkció, az iniciális ritmus és a beteg katecholaminigénye határozta meg. A mCSRS alkalmazását követoen mind az "1-3" és a "4-6" (p≤0,001), mind a "4-6" és a "7+" (p = 0,006) csoportok között szignifikáns különbséget találtunk a túlélésben. Következtetés: A felvételkori pontok alapján a mCSRS pontosabban definiálja és differenciálja egymástól az általunk beválasztott két extra súlyozófaktorral az enyhe, a közepes és a magas mortalitási rizikóval bíró betegpopulációkat, mint a CSRS. Orv Hetil. 2021; 162(2): 52-60. INTRODUCTION: Sudden cardiac death is one of the most significant cardiovascular causes of death worldwide. Although there have been immense methodological and technical advances in the field of cardiopulmonary resuscitation and following intensive care in the last decade, currently there are only a few validated risk-stratification scoring systems for the quick and reliable estimation of the mortality risk of these patients at the time of admission to the intensive care unit. OBJECTIVE: Our aim was to correlate the mortality prediction risk points calculated by CardShock Risk Score (CSRS) and modified (m) CSRS based on the admission data of the post-cardiac arrest syndrome (PCAS) patients. METHODS: The medical records of 172 out-of-hospital resuscitated cardiac arrest patients, who were admitted at the Heart and Vascular Centre of Semmelweis University, were screened retrospectively. Out of the 172 selected patients, 123 were eligible for inclusion to calculate CSRS and mCSRS. Based on CSRS score, we generated three different groups of patients, with scores 1 to 3, 4 to 6, and 7+, respectively. Mortality data of the groups were compared by log-rank test. RESULTS: Mean age of the patients was 63.6 years (69% male), the cause of sudden cardiac death was acut coronary syndrome in 80% of the cases. The early and late mortality was predicted by neurological status, serum lactate level, renal function, initial rhythm, and the need of catecholamines. Using mCSRS, a significant survival difference was proven in between the groups "1-3" vs "4-6" (p≤0.001), "4-6" vs "7+" (p = 0.006). CONCLUSION: Compared to the CSRS, the mCSRS expanded with the 2 additional weighting points differentiates more specifically the low-moderate and high survival groups in the PCAS patient population treated in our institute. Orv Hetil. 2021; 162(2): 52-60.

Risk of arrhythmias and cardiac complications after electrical injury / Arrhythmiarizikó és cardialis szövodmények áramütéses balesetet követoen.

Összefoglaló. Az áramütés súlyos esetben hirtelen halállal vagy több szervrendszer kiterjedt károsodásával járhat. A magasfeszültségu áramütés (>1000 V) általában súlyosabb égési sérülésekkel és magasabb kórházi mortalitással jár, mint az alacsonyfeszültségu, de a sérülések súlyosságát a feszültségen kívül a test ellenállása, az áramexpozíció ideje, az áram fajtája, erossége és útja is befolyásolja. A kritikus állapotú vagy súlyos égési sérüléseket szenvedett betegek sürgosségi ellátása komplex és multidiszciplináris szemléletet igényel. A súlyos szövodményekkel járó áramütéses balesetek ugyanakkor a fejlett országokban ritkák: az áramütés következtében sürgosségi osztályon jelentkezo betegek dönto többsége panaszmentesen vagy minor panaszokkal kerül felvételre. A ritmuszavarok az áramütéses balesetek messze leggyakoribb cardialis szövodményei, és rendszerint közvetlenül az áramütés után jelentkeznek. Az elektromos áram kamrafibrillációt vagy asystoliát is kiválthat, mely a baleset helyszínén ellátás nélkül halálhoz vezethet. Bár sok helyen elterjedt gyakorlat az áramütést szenvedett betegek rutinszeru monitorozása, a klinikailag releváns arrhythmiák összességében ritkák, és a felvételi EKG alapján diagnosztizálhatók, ezért EKG-monitorozás csak meghatározott rizikófaktorok esetén szükséges. Jelen munkánk célja összefoglalni az áramütést szenvedett betegek optimális sürgosségi ellátásával kapcsolatos legfontosabb szempontokat, különös tekintettel az áramütéses balesetet követoen fellépo cardialis szövodményekre és arrhythmiákra, valamint az EKG-monitorozás indikációira. Orv Hetil. 2020; 161(47): 1979-1988. Summary. Electrical accidents (EA) may cause sudden death or severe injuries of multiple organs. High voltage injuries (>1000 V) are associated with more severe burn injuries and higher in-hospital mortality than low voltage injuries, however, the severity of complications depends on several other factors like resistance of the body, duration of current exposition, intensity, type and pathway of current. Critically ill patients with severe burns and/or other injuries require a multidisciplinary intensive treatment. However, such complications are rare in the developed countries: most patients present in the emergency department with no or minor symptoms and do not require hospital admission. Arrhythmias are the most frequent cardiac complications after EA. Electrical current may cause ventricular fibrillation or asystolia which can lead to death on the scene. In patients presenting in the emergency department, clinically relevant arrhythmias are rare and can be diagnosed by a 12-lead ECG, therefore a systematic monitoring may not be indicated. Aim of our work is to review the most frequent complications after an electrical accident with special focus on cardiac complications and arrhythmias. The other aim of the manuscript is to summarize the most important aspects of emergency treatment and indication for ECG monitoring after electrical accident. Orv Hetil. 2020; 161(47): 1979-1988.

Anterior wall ST-elevation myocardial infarction in biventricular paced rhythm.

There is a lack of evidence on electrocardiographic criteria for ST-elevation myocardial infarction (STEMI) in patients with biventricular paced rhythm. In all previous case reports of STEMI in biventricular paced rhythm, concordant ST-elevations and/or discordant ST-elevations >5 mm were present. This report describes the case of a patient with anterior STEMI and discordant ST-elevations of less than 5 mm during biventricular stimulation with epicardial left ventricular lead and highlights the importance of comparing the electrocardiogram to previous recordings when STEMI is suspected.

Risk of cardiac arrhythmias after electrical accident: a single-center study of 480 patients.

OBJECTIVE: Patients with electrical injury are considered to be at high risk of cardiac arrhythmias. Due to the small number of studies, there is no widely accepted guideline regarding the risk assessment and management of arrhythmic complications after electrical accident (EA). Our retrospective observational study was designed to determine the prevalence of ECG abnormalities and cardiac arrhythmias after EA, to evaluate the predictive value of cardiac biomarkers for this condition and to assess in-hospital and 30-day mortality. METHODS: Consecutive patients presenting after EA at the emergency department of our institution between 2011 and 2016 were involved in the current analysis. ECG abnormalities and arrhythmias were analyzed at admission and during ECG monitoring. Levels of cardiac troponin I, CK and CK-MB were also collected. In-hospital and 30-day mortality data were obtained from hospital records and from the national insurance database. RESULTS: Of the 480 patients included, 184 (38.3%) had suffered a workplace accident. The majority of patients (96.2%) had incurred a low-voltage injury (< 1000 V). One hundred and four (21.7%) patients had a transthoracic electrical injury while 13 (2.7%) patients reported loss of consciousness. The most frequent ECG disorders at admission were sinus bradycardia (< 60 bpm, n = 50, 10.4%) and sinus tachycardia (> 100 bpm, n = 21, 4.4%). Other detected arrhythmias were as follows: newly diagnosed atrial fibrillation (n = 1); frequent multifocal atrial premature complexes (n = 1); sinus arrest with atrial escape rhythm (n = 2); ventricular fibrillation terminated out of hospital (n = 1); ventricular bigeminy (n = 1); and repetitive nonsustained ventricular tachycardia (n = 1). ECG monitoring was performed in 182 (37.9%) patients for 12.7 ± 7.1 h at the ED. Except for one case with regular supraventricular tachycardia terminated via vagal maneuver and one other case with paroxysmal atrial fibrillation, no clinically relevant arrhythmias were detected during the ECG monitoring. Cardiac troponin I was measured in 354 (73.8%) cases at 4.6 ± 4.3 h after the EA and was significantly elevated only in one resuscitated patient. CK elevation was frequent, but CK-MB was under 5% in all patients. Both in-hospital and 30-day mortality were 0%. CONCLUSIONS: Most of cardiac arrhythmias in patients presenting after EA can be diagnosed by an ECG on admission, thus routine ECG monitoring appears to be unnecessary. In our patient cohort cardiac troponin I and CK-MB were not useful in risk assessment after EA. Late-onset malignant arrhythmias were not observed.

[The role of therapeutic hypothermia in post-resuscitation care - review of the literature and personal experience]. / A terápiás hypothermia szerepe a postresuscitatiós ellátásban - irodalmi áttekintés és saját tapasztalatok.

In the last fifteen years mild therapeutic hypothermia became an accepted and widespread therapeutic method in the treatment of successfully resuscitated patients due to sudden cardiac death. Based on the available evidence therapeutic hypothermia is part of the resuscitation guidelines, however, many aspects of its therapeutic use are based on empirical facts. In particular, the subjects of intense debate are the ideal target temperature and the benefit of hypothermia in patients found with non-shockable rhythm. Hypothermia affects almost all organ systems and, therefore, early detection and treatment of side effects are essential. The aim of the authors is to summarize the clinical role and pathophysiologic effects of therapeutic hypothermia in the treatment of resuscitated patients based on current evidence and their practical experience.