BEAT-IT: A de-novo cardiac screening programme in Maltese adolescents.

AIMS: Sudden cardiac death (SCD) in young individuals is often unexpected, provoking substantial emotional stress for family and friends of the deceased. Cardiac screening may identify individuals who harbour disorders linked to SCD. The feasibility and diagnostic yield of a nationwide cardiac screening programme in adolescents has never been explored. METHODS: All individuals eligible for cardiac screening (students aged 15 years) were systematically invited to enrol. Students were provided with a health questionnaire. ECGs were acquired at school. A physician led consultation was carried out on site. Participants with an abnormal screen were then referred for secondary evaluation to the nation's tertiary centre. Feasibility criteria included a) participation rate >60%, b) adherence to secondary evaluation >80%, and c) cost per individual screened equating to <€100. The diagnostic yield was also evaluated. RESULTS: At the end of enrolment, 2708 students gave consent (mean 15 years, 50.4% male), equating to 67.9% of the eligible cohort. Overall, 109 participants (4.0%) were referred for further evaluation. An abnormal electrocardiogram (ECG) was the most common reason for referral (3.7%). Fifteen individuals (0.6%) were diagnosed with a cardiac condition. Nine (0.3%) had a condition linked to SCD (n = 1 Long-QT syndrome, n = 1 Hypertrophic Cardiomyopathy, n = 5 Wolff-Parkinson White, n = 2 coronary anomalies). The yield was similar in athletes and non-athletes (p = 0.324). The cost per cardiac individual screened equated to €51.15. CONCLUSION: A nationwide systematic cardiac screening programme for adolescent athletes and non-athletes is feasible and cost-efficient, provided that responsible centres have the appropriate infrastructure.

Is There a Role for Vitamin K Antagonist in the Management of Atrial Fibrillation in 2023?

PURPOSE OF REVIEW: To address the following question: Are vitamin K antagonists (VKA) obsolete as stroke prevention therapy for patients with atrial fibrillation (AF) and thromboembolic risk factors? RECENT FINDINGS: A patient-level meta-analysis of the pivotal phase III randomized trials confirmed the favorable treatment effect of direct oral anticoagulants (DOAC) over VKA in multiple key patient subgroups. Among patients with AF and rheumatic heart disease (85% of whom had mitral stenosis), a randomized trial showed that rivaroxaban was not superior to VKA for stroke prevention. Caution should be exercised when prescribing DOAC for AF-related stroke prevention for patients with elevated body mass indices or history of bariatric surgery, patients with bioprosthetic heart valves, and those who require treatment with drugs that interact with cytochrome P450 and P-glycoprotein. Drug costs associated with DOAC remain considerably higher than VKA, by up to 30-fold. Direct oral anticoagulants are preferable over VKA in the large majority of eligible patients with AF and thromboembolic risk factors. The use of DOAC should be avoided for patients with mechanical heart valves or moderate/severe rheumatic mitral stenosis. Vitamin K antagonist is a reasonable option for patients who are under-represented in randomized trials, when there are significant drug-drug interactions or when patients cannot afford DOAC agents due to their higher costs.

Utility of Substrate Mapping Using Extrasystole to Localise Comprehensive Ventricular Tachycardia Circuits: Results From Intra-operative Mapping Studies.

BACKGROUND: Substrate mapping-based identification of all ventricular tachycardia (VT) circuits (diastolic activation), including partial and complete diastolic circuits in clinical and nonclinical VT, could be beneficial in guiding VT ablation to prevent VT recurrence. The utility of extrasystole induced late potentials has not been compared with late potentials in sinus rhythm (SR) and right ventricular pacing (RVp). METHODS: Intraoperative simultaneous panoramic endocardial mapping of 21 VTs in 16 ischemic heart disease patients was performed with the use of a 112-bipole endocardial balloon. The decrement of near-field electrogram later than surface QRS during extrasystole (eLP) was studied. RESULTS: Patients had a mean age of 52 ± 9 years and were predominantly (75%) male. The mean sensitivity of eLP (0.75 [95% confidence interval [CI] 0.72-0.78]) to detect VT circuits was better than SR (0.33 [0.30-0.36]; P < 0.001) and RVp (0.36 [0.33-0.39]; P < 0.001) without significant differences in specificity, eLP (0.77 [0.74-0.81], SR (0.82 [0.80-0.84]; P = 0.23), and RVp (0.81 [0.78-0.83]; P = 0.11). Both negative (NPV) and positivie (PPV) predictive values were significantly better for eLP mapping. The mean NPV was 0.77 (95% CI 0.74-0.81), 0.57 (0.55-0.59), and 0.58 (0.55-0.61) for eLP, SR, and RVp, respectively (P < 0.0001). PPV was 0.75 (95% CI 0.72-0.78), 0.63 (0.59-0.67), and 0.63 (0.59-0.67) for eLP, SR, and RVp, respectively (P < 0.001). Overall diagnostic performance (area under the receiver operating characteristic curve) was significantly better for eLP (0.85 [95% CI 0.80-0.90] compared with SR (0.63 [0.56-0.72]; P < 0.001) or RVp (0.61 [0.52-0.74]; P < 0.001). CONCLUSIONS: Evoked late potential mapping is a better tool to detect comprehensive diastolic circuits activated during VT, compared with eLP mapping in sinus rhythm or RV pacing.

The juvenile ECG pattern in adolescent athletes and non-athletes in a national cardiac screening program (BEAT-IT).

BACKGROUND: Anterior T wave inversion (TWI) is frequent in healthy adolescent individuals (juvenile ECG pattern), normalising after puberty. Its clinical implications are uncertain. AIM: This study assessed a) national prevalence of anterior TWI, b) ST segment morphology, c) proportion of individuals with a juvenile ECG pattern whose ECG normalises and d) factors predicting TWI persistence >16 years. METHODS: Adolescents (mean 15y) in Malta were systematically invited to enrol in a cardiac screening program. Subjects completed a health questionnaire and an ECG at their school. Participants with TWI were labelled as TWI in V1-V2 or extended TWI (V1-V3/4). The latter were followed at 1 year with a repeat ECG. Those with persistent extended anterior TWI were offered evaluation and surveillance. RESULTS: The prevalence of isolated anterior TWI was 5.0%, commoner in females (6.3%) independent of athletic ability. Extended TWI was commoner in female athletes (4.2%, non-athletes 2.1%). Females often had shallow TWI without overt ST segment abnormalities. Deep TWI and ST segment changes were more frequent in males. Only 0.2% of cases persisted ≥16 years of age. ST segment characteristics were not able to predict T wave normalisation. No events took place during follow up (40 ± 9 months). CONCLUSION: Anterior TWI is a frequent phenomenon in adolescents, especially in females. Female athletes are also more likely to have extended anterior TWI. Only 0.2% of cases have persistent anterior TWI at 16 years of age. Chest wall anatomy may explain this phenomenon in females. It is uncommon in males, hence why surveillance is more prudent.

Cobalt Cardiomyopathy Secondary to Hip Arthroplasty: An Increasingly Prevalent Problem.

A forty-year-old man experienced worsening heart failure four years following bilateral complicated total hip replacement. His condition was extensively worked up but no underlying pathology was immediately evident. Given the cobalt-chromium alloy component present in the hip arthroplasties, the raised cobalt blood levels, and a fitting clinical picture coupled with radiological findings, the patient underwent right hip revision. Evidence of biotribocorrosion was present on direct visualisation intraoperatively. The patient subsequently experienced symptomatic improvement (NYHA class III to class I) and echocardiography showed recovery of ejection fraction. Cobalt exists as a bivalent and trivalent molecule in circulation and produces a cytotoxicity profile similar to nanoparticles, causing neurological, thyroid, and cardiological pathology. Blood levels are not entirely useful as there is no identifiable conversion factor for levels in whole blood, serum, and erythrocytes which seem to act independently of each other. Interestingly cobalt cardiomyopathy is frequently compounded by other possible causes of cardiomyopathy such as alcohol and a link has been postulated. Definitive treatment is revision of the arthroplasty as other treatments are unproven.

The Prevalence of Low Left Atrial Appendage Emptying Velocity and Thrombus in Patients Undergoing Catheter Ablation for Atrial Fibrillation on Uninterrupted Peri-procedural Warfarin Therapy.

Introduction: The 2012 HRS/EHRA/ECAS guidelines encourage pre-procedural transesophageal echocardiography (TEE) prior to ablation for atrial fibrillation (AF), but acknowledge a lack of consensus in patients maintained on therapeutic warfarin before, during and after the procedure. This is partly because the incidence of left atrial appendage (LAA) thrombus is so low, that it is hard to draw clear conclusion regarding the characteristics of patients who develop thrombus. We hypothesize that the presence of low LAA emptying velocities, which predisposes to thrombus, and/or thrombus itself can be predicted in patients undergoing ablation, based upon clinical characteristics and transthoracic echocardiography (TTE). Methods: In this multicentre study, we undertook TTE and transesophageal echocardiograms (TEE) in 586 patients (age 59.9±0.4 years old, 64.5% male) undergoing catheter ablation for AF who were anticoagulated on warfarin (target international normalized ratio 2-3.5) for ≥3 consecutive weeks prior to procedure and maintained on warfarin for the procedure. Results: Low peak LAA emptying velocities (<40cm/s) were identified in 111 (24.7%) patients and LAA thrombus was identified in 3 patients (0.5%) despite having therapeutic INRs. The 3 patients with thrombus had LAA emptying velocities of 23, 29 and 31 cm/s. None of the remaining patients had a peri-procedural stroke. Patients with peak LAA emptying velocities <40cm/s or thrombus on TEE had significantly (p<0.05) higher CHA2DS2-VASc scores (1.7± 0.1 v's 1.4±0.1), and were more likely to have impaired LVSF (odds ratio [95% CI]: 2.66 [1.52-4.66]), a LA diameter >4.6cm on TTE (2.40 [2.13-5.41]), or persistent AF (2.60 [1.63-4.14]) compared to those with a higher LAA velocity without thrombus. Conclusion: In patients on uninterrupted warfarin therapy, a CHA2DS2-VASc score ≥1 or LA diameter >4.6cm on TTE identifies 91.5% of those at risk of developing thrombus with LAA emptying velocity of <40 cm/s and 100% of those with thrombus in our cohort.

Increased energy intake entirely accounts for increase in body weight in women but not in men in the UK between 1986 and 2000.

There is debate over the casual factors for the rise in body weight in the UK. The present study investigates whether increases between 1986 and 2000 for men and women were a result of increases in mean total energy intake, decreases in mean physical activity levels or both. Estimates of mean total energy intake in 1986 and 2000 were derived from food availability data adjusted for wastage. Estimates of mean body weight for adults aged 19-64 years were derived from nationally representative dietary surveys conducted in 1986-7 and 2000-1. Predicted body weight in 1986 and 2000 was calculated using an equation relating body weight to total energy intake and sex. Differences in predicted mean body weight and actual mean body weight between the two time points were compared. Monte Carlo simulation methods were used to assess the stability of the estimates. The predicted increase in mean body weight due to changes in total energy intake between 1986 and 2000 was 4·7 (95 % credible interval 4·2, 5·3) kg for men and 6·4 (95 % credible interval 5·9, 7·1) kg for women. Actual mean body weight increased by 7·7 kg for men and 5·4 kg for women between the two time points. We conclude that increases in mean total energy intake are sufficient to explain the increase in mean body weight for women between 1986 and 2000, but for men, the increase in mean body weight is likely to be due to a combination of increased total energy intake and reduced physical activity levels.