Rationale and design of the VAST-AF trial: A randomized controlled, blinded, clinical trial to evaluate transcutaneous vagal nerve stimulation for the prevention of persistent atrial fibrillation recurrence.

BACKGROUND: Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia and is linked to significant symptoms and an elevated risk of heart failure, thromboembolism and disabling stroke. Not only do patients suffer from AF and the concomitant complications, but it is a great economic burden for healthcare systems all over the world. Despite remarkable progress in the field of AF, the basic mechanisms of AF development remain unresolved. Data suggests that the (cardiac) autonomous nervous system (ANS) plays a significant role in AF. Recent studies have shown that stimulating the ANS could have a beneficial effect on paroxysmal and postoperative AF. Consequently, this therapy could provide another viable target for treating persistent AF, as well. METHODS: The VAST-AF trial is a prospective, double-blinded, randomized, and sham-controlled clinical trial. One hundred and twenty patients diagnosed with persistent AF and cardioversion in sinus rhythm (SR) will be randomly assigned to either transcutaneous vagal nerve stimulation (tVNS) or sham treatment in a 1:1 ratio. The primary objective of this study is to examine whether a daily tVNS reduces the recurrence rate of AF. Secondary endpoints include quality of life, time to first AF recurrence and ECG parameters of the ANS. Follow-up is scheduled at 30 days, 3 and 6 months. After 3 months, stimulation is withdrawn, and patients evaluated regarding a still detectable effect of tVNS. CONCLUSION: The VAST-AF trial represents the first randomized and sham-controlled study to investigate the potential benefits of transcutaneous vagal nerve stimulation on the recurrence of atrial fibrillation. Patients with persistent atrial fibrillation and successful electrical cardioversion will be assessed. A decrease in the rate of recurrence and consecutive hospitalizations could decidedly enhance the quality of life of patients and decrease healthcare expenses. Nevertheless, it does not compete with treatments such as catheter ablation, but rather serves as an additional tool in the armamentarium of the electrophysiologist.

A New Inherited Syndrome Causing Sudden Cardiac Death with Distinct ST-Segment Depression and Ankyrin-2-Mutation.

Introduction: Sudden cardiac death (SCD) is a serious threat. In individuals under the age of 35 years sudden arrhythmic death is the most frequent cause. In younger persons, genetically determined cardiac diseases (eg, cardiomyopathies and ion-channel diseases) account for an important proportion of these cases. Methods: We investigated the case of a 23-year-old male with SCD, specific ECG changes and left ventricular hypertrophy. Family history was significant for SCD in the paternal line. A precise analysis was performed by an international multidisciplinary expert panel including autopsy of the index patient's heart, molecular autopsy, whole-exome sequencing, analysis of the pedigree and examination of available family members. Results: Three cases of SCD were reported in paternal relatives. The index patient exhibited specific ECG changes (ST-depression), which were also found in five paternal relatives and the brother of the index patient. Post-mortem analysis of the heart yielded mild idiopathic concentric hypertrophy without myocardial disarray. The genetic analysis of the index patient showed two nucleotide variations in two different genes (ANK2: c.11791G>A, MYO18B: c.3761G>A), which were also expressed in five relatives. Two family members had showed all indicators of the inherited syndrome including distinct ECG changes and genetic changes. Conclusion: We describe a distinct inheritable syndrome causing SCD, characterized by specific ECG changes and mutations of ANK2 and MYO18. As far as we know this is the first description of this syndrome.

Reduced rate of admissions for acute coronary syndromes during the COVID-19 pandemic: an observational analysis from a tertiary hospital in Germany.

BACKGROUND: Several observational studies have suggested a worrying reduction in hospitalisations for acute coronary syndromes in the emergency cardiology department in the last few months all over the world. The aim of the present study is to assess the impact of the current COVID-19 health crisis on admission for acute coronary syndrome (ACS) in the cardiology department of a tertiary general hospital in Germany with a COVID-19 ward. METHODS AND RESULTS: The authors retrieved clinical data evaluating consecutive patients with ACS admitted to their emergency cardiology department. Data from January to June 2020, as well as for a 5-week period corresponding to this year's COVID-19 outbreak in south-west Germany (23rd March-26th April), were analysed and compared to data from equivalent weeks in the previous 2 years. A trend of reduction in admissions for ACS was observed from the beginning of the outbreak in the region at the end of March 2020. This trend continued and even intensified after a fall in COVID-19 cases in the area; the number of ACS patients in April 2020 was 25% and in June 29% lower than in January 2020 (p-value for linear trend <0.001). An even more consistent reduction was observed as compared with the equivalent weeks in the previous 2 years (38% and 30% lower than in 2019 and 2018, respectively; p = 0.009). CONCLUSIONS: The COVID-19 health and social crisis has caused a worrying trend of reduced cardiological admissions for ACS, without evidence of a decrease in its incidence. Understanding and counteracting the causes appears to be crucial to avoiding major long-term consequences for healthcare systems worldwide.