The management of patients with syncope in the emergency department (ED) is challenging because no robust risk tool available has been recommended for clinical use.
To validate the Canadian Syncope ...Risk Score (CSRS) in a new cohort of patients with syncope to determine its ability to predict 30-day serious outcomes not evident during index ED evaluation.
This prospective multicenter cohort study conducted at 9 EDs across Canada included patients 16 years and older who presented to EDs within 24 hours of syncope. Patients were enrolled from March 2014 to April 2018.
Baseline characteristics, CSRS predictors, and 30-day adjudicated serious outcomes, including arrhythmic (arrhythmias, interventions for arrhythmia, or unknown cause of death) and nonarrhythmic (myocardial infarction, structural heart disease, pulmonary embolism, or hemorrhage) serious outcomes, were collected. Calibration and discrimination characteristics for CSRS validation were calculated.
A total of 3819 patients were included (mean SD age 53.9 22.8 years; 2088 54.7% female), of whom 139 (3.6%) experienced 30-day serious outcomes, including 13 patients (0.3%) who died. In the validation cohort, there were no differences between the predicted and observed risk, the calibration slope was 1.0, and the area under the receiver operating characteristic curve was 0.91 (95% CI, 0.88-0.93). The empirical probability of a 30-day serious outcome during validation was 3.64% (95% CI, 3.09%-4.28%) compared with the model-predicted probability of 3.17% (95% CI, 2.66%-3.77%; P = .26). The proportion of patients with 30-day serious outcomes increased from 3 of 1631 (0.3%) in the very-low-risk group to 40 of 78 (51.3%) in the very-high-risk group (Cochran-Armitage trend test P < .001). There was a similar significant increase in the serious outcome subtypes with increasing CSRS risk category. None of the very-low-risk and low-risk patients died or experienced ventricular arrhythmia. At a threshold score of -1 (2145 of 3819 patients), the CSRS sensitivity and specificity were 97.8% (95% CI, 93.8%-99.6%) and 44.3% (95% CI, 42.7%-45.9%), respectively.
The CSRS was successfully validated and its use is recommended to guide ED management of patients when serious causes are not identified during index ED evaluation. Very-low-risk and low-risk patients can generally be discharged, while brief hospitalization can be considered for high-risk patients. We believe CSRS implementation has the potential to improve patient safety and health care efficiency.
Sudden cardiac death risk stratification Deyell, Marc W; Krahn, Andrew D; Goldberger, Jeffrey J
Circulation research,
2015-Jun-05, Letnik:
116, Številka:
12
Journal Article
Recenzirano
Odprti dostop
Arrhythmic sudden cardiac death (SCD) may be caused by ventricular tachycardia/fibrillation or pulseless electric activity/asystole. Effective risk stratification to identify patients at risk of ...arrhythmic SCD is essential for targeting our healthcare and research resources to tackle this important public health issue. Although our understanding of SCD because of pulseless electric activity/asystole is growing, the overwhelming majority of research in risk stratification has focused on SCD-ventricular tachycardia/ventricular fibrillation. This review focuses on existing and novel risk stratification tools for SCD-ventricular tachycardia/ventricular fibrillation. For patients with left ventricular dysfunction or myocardial infarction, advances in imaging, measures of cardiac autonomic function, and measures of repolarization have shown considerable promise in refining risk. Yet the majority of SCD-ventricular tachycardia/ventricular fibrillation occurs in patients without known cardiac disease. Biomarkers and novel imaging techniques may provide further risk stratification in the general population beyond traditional risk stratification for coronary artery disease alone. Despite these advances, significant challenges in risk stratification remain that must be overcome before a meaningful impact on SCD can be realized.
The COVID-19 pandemic has led to efforts at rapid investigation and application of drugs which may improve prognosis but for which safety and efficacy are not yet established. This document attempts ...to provide reasonable guidance for the use of antimicrobials which have uncertain benefit but may increase risk of QT interval prolongation and ventricular proarrhythmia, notably, chloroquine, hydroxychloroquine, azithromycin, and lopinavir/ritonavir. During the pandemic, efforts to reduce spread and minimize effects on health care resources mandate minimization of unnecessary medical procedures and testing. We recommend that the risk of drug proarrhythmia be minimized by 1) discontinuing unnecessary medications that may also increase the QT interval, 2) identifying outpatients who are likely to be at low risk and do not need further testing (no history of prolonged QT interval, unexplained syncope, or family history of premature sudden cardiac death, no medications that may prolong the QT interval, and/or a previous known normal corrected QT interval QTc), and 3) performing baseline testing in hospitalized patients or those who may be at higher risk. If baseline electrocardiographic testing reveals a moderately prolonged QTc, optimization of medications and electrolytes may permit therapy. If the QTc is markedly prolonged, drugs that further prolong it should be avoided, or expert consultation may permit administration with mitigating precautions. These recommendations are made while there are no known effective treatments for COVID-19 and should be revisited when further data on efficacy and safety become available.
La pandémie de COVID-19 a donné lieu à des initiatives visant à accélérer l’étude et l’utilisation de médicaments susceptibles d’améliorer le pronostic des patients, mais dont l’innocuité et l’efficacité n’ont pas encore été établies. Les auteurs tentent de formuler des lignes directrices raisonnables quant à l’emploi d’agents antimicrobiens, notamment la chloroquine, l’hydroxychloroquine, l’azithromycine et l’association lopinavir-ritonavir, dont les bienfaits demeurent incertains, mais qui sont susceptibles d’accroître le risque d’allongement de l’intervalle QT et de proarythmie ventriculaire. Durant la pandémie, les efforts visant à limiter la propagation de la maladie et à atténuer au minimum les tensions exercées sur les ressources en soins de santé commandent une restriction des interventions médicales et des tests non nécessaires. Pour que le risque de proarythmie médicamenteuse demeure au plus bas, nous recommandons les mesures suivantes : 1) arrêter l’administration de médicaments non nécessaires aussi susceptibles d’allonger l’intervalle QT; 2) déterminer qui sont les patients ambulatoires présentant un risque faible et n’ayant pas besoin de subir d’autres tests (absence d’antécédents d’allongement de l’intervalle QT ou de syncope inexpliquée, d’antécédents familiaux de mort cardiaque subite prématurée ou de traitement médicamenteux susceptible d’allonger l’intervalle QT, et/ou intervalle QT corrigé QTc normal connu); et 3) réaliser des examens initiaux chez les patients hospitalisés ou chez ceux qui sont exposés à un risque plus élevé. Si les examens électrocardiographiques initiaux révèlent un allongement modéré de l’intervalle QTc, un traitement pourrait être administré sous réserve de l’optimisation de la médication et de l’administration d’électrolytes. Si l’allongement de l’intervalle QTc est marqué, il faut éviter d’administrer des médicaments susceptibles d’allonger davantage cet intervalle, ou encore consulter un spécialiste pour pouvoir traiter le patient en prenant les précautions qui s’imposent. Ces recommandations sont formulées à l’heure où il n’existe encore aucun traitement efficace connu contre la COVID-19; il faudra les revoir lorsque d’autres données relatives à l’efficacité et à l’innocuité des agents en cause seront disponibles.
Over the past decade, there has been an explosion of consumer devices for the purposes of health and fitness tracking. The wearable technology market, composed of devices that monitor physiological ...parameters, such as heart rate and sleep pattern, is anticipated to grow to 929 million connected devices in 2021. These devices encompass wristbands, glasses, in-ear monitors, or electronic shirts, with varying capacity to monitor heart rate, heart rhythm, blood pressure, physical activity, respiratory rate, blood glucose, and sleep patterns. For heart-rate monitoring, most wearable devices use photoplethysmography (PPG) technology, meaning they are inherently less accurate than conventional electrocardiography monitoring techniques (reference standard). However, a growing body of evidence suggests that these technologies can be harnessed to facilitate arrhythmia detection in the appropriate context. Studies evaluating PPG-based wearables in conjunction with machine-learning algorithms have shown promise in detection of such arrhythmias, as atrial fibrillation. Limitations of wearable technologies include their accuracy and accessibility and the clinical implications of wearable-detected arrhythmias. Despite this, wearable technologies represent an important frontier in health evaluation. Future wearables will benefit from improved reliability and accuracy, collect additional health and fitness parameters, support management of chronic disease, and provide real-time connectivity and feedback that may supplant conventional medical monitoring. Wearables have the potential to become truly disruptive in our health care sector, with large segments of the population soon to have readily available health data that the physician must interpret.
Au cours de la dernière décennie, il y a eu explosion des dispositifs grand public dans le but de suivre la santé et la condition physique. Le marché de la technologie portable, composé d’appareils qui surveillent les paramètres physiologiques tels que la fréquence cardiaque et la structure du sommeil, vont atteindre jusqu’à 929 millions d’appareils connectés en 2021. Ces appareils englobent les bracelets, les lunettes, les moniteurs intra-auriculaires ou les vêtements électroniques dont la capacité à surveiller la fréquence cardiaque, le rythme cardiaque, la pression artérielle, l’activité physique, la fréquence respiratoire, la glycémie et les cycles du sommeil varie. En ce qui concerne la surveillance de la fréquence cardiaque, les appareils les plus portables utilisent la photopléthysmographie (PPG); ils sont donc intrinsèquement moins précis que les techniques d’électrocardiographie traditionnelles (étalon de référence). Toutefois, de plus en plus de données probantes montrent que ces technologies peuvent être utilisées pour faciliter la détection de l’arythmie dans un contexte approprié. Les études visant à évaluer les portables qui utilisent la PPG conjointement avec les algorithmes d’apprentissage automatique se sont révélées prometteuses dans la détection de certaines arythmies comme la fibrillation auriculaire. Malgré cela, les technologies portables constituent une frontière importante dans l’évaluation de la santé. Les futurs portables bénéficieront d’une fiabilité et d’une précision accrue, permettront de collecter d’autres paramètres sur la santé et la condition physique, favoriseront la prise en charge des maladies chroniques et fourniront une connectivité et une rétroaction en temps réel qui pourraient supplanter la surveillance médicale traditionnelle. Les portables risquent de véritablement perturber notre secteur des soins de santé puisque bientôt de larges segments de la population auront des données sur la santé facilement accessibles que le médecin devra interpréter.
Abstract
Brugada syndrome (BrS) was first described as a primary electrical disorder predisposing to the risk of sudden cardiac death and characterized by right precordial lead ST elevation. Early ...description of right ventricular structural abnormalities and of right ventricular outflow tract (RVOT) conduction delay in BrS patients set the stage for the current controversy over the pathophysiology underlying the syndrome: channelopathy or cardiomyopathy; repolarization or depolarization. This review examines the current understanding of the BrS substrate, its genetic and non-genetic basis, theories of pathophysiology, and the clinical implications thereof. We propose that the final common pathway for BrS could be viewed as a disease of ‘reduced RVOT conduction reserve’.
Graphical abstract
Brugada syndrome (BrS) as a disease of impaired right ventricular outflow tract (RVOT) conduction reserve. Normally, intrinsic RVOT conduction reserve may be affected by a patient’s age and gender. In BrS, cellular and tissue abnormalities cause a reduction in RVOT conduction reserve: genetic abnormalities, whether mediated by a pathogenic SCN5A variant, an increased BrS-PRS, and/or additional genetic insults, may have direct effects on Nav1.5, as well as tissue effects causing RVOT inflammation, fibrosis, and gap junction abnormalities. Decreased Nav1.5 current, together with electrical discontinuity caused by RVOT structural changes, converges to disrupt normal depolarization, with or without secondary repolarization effects, leading to impairment of the conduction reserve of the RVOT. In this framework, the marginal conduction reserve can be exposed by acute modulators such as fever, drugs, and altered vagal tone which further impair conduction and expose the Brugada phenotype.
Many patients requiring pacemaker or implantable cardioverter-defibrillator (ICD) surgery are taking warfarin. For patients at high risk for thromboembolic events, guidelines recommend bridging ...therapy with heparin; however, case series suggest that it may be safe to perform surgery without interrupting warfarin treatment. There have been few results from clinical trials to support the safety and efficacy of this approach.
We randomly assigned patients with an annual risk of thromboembolic events of 5% or more to continued warfarin treatment or to bridging therapy with heparin. The primary outcome was clinically significant device-pocket hematoma, which was defined as device-pocket hematoma that necessitated prolonged hospitalization, interruption of anticoagulation therapy, or further surgery (e.g., hematoma evacuation).
The data and safety monitoring board recommended termination of the trial after the second prespecified interim analysis. Clinically significant device-pocket hematoma occurred in 12 of 343 patients (3.5%) in the continued-warfarin group, as compared with 54 of 338 (16.0%) in the heparin-bridging group (relative risk, 0.19; 95% confidence interval, 0.10 to 0.36; P<0.001). Major surgical and thromboembolic complications were rare and did not differ significantly between the study groups. They included one episode of cardiac tamponade and one myocardial infarction in the heparin-bridging group and one stroke and one transient ischemic attack in the continued-warfarin group.
As compared with bridging therapy with heparin, a strategy of continued warfarin treatment at the time of pacemaker or ICD surgery markedly reduced the incidence of clinically significant device-pocket hematoma. (Funded by the Canadian Institutes of Health Research and the Ministry of Health and Long-Term Care of Ontario; BRUISE CONTROL ClinicalTrials.gov number, NCT00800137.).
Abstract
Aims
The term idiopathic ventricular fibrillation (IVF) describes survivors of unexplained cardiac arrest (UCA) without a specific diagnosis after clinical and genetic testing. Previous ...reports have described a subset of IVF individuals with ventricular arrhythmia initiated by short-coupled trigger premature ventricular contractions (PVCs) for which the term short-coupled ventricular fibrillation (SCVF) has been proposed. The aim of this article is to establish the phenotype and frequency of SCVF in a large cohort of UCA survivors.
Methods and results
We performed a multicentre study including consecutive UCA survivors from the CASPER registry. Short-coupled ventricular fibrillation was defined as otherwise unexplained ventricular fibrillation initiated by a trigger PVC with a coupling interval of <350 ms. Among 364 UCA survivors, 24/364 (6.6%) met diagnostic criteria for SCVF. The diagnosis of SCVF was obtained in 19/24 (79%) individuals by documented ventricular fibrillation during follow-up. Ventricular arrhythmia was initiated by a mean PVC coupling interval of 274 ± 32 ms. Electrical storm occurred in 21% of SCVF probands but not in any UCA proband (P < 0.001). The median time to recurrent ventricular arrhythmia in SCVF was 31 months. Recurrent ventricular fibrillation resulted in quinidine administration in 12/24 SCVF (50%) with excellent arrhythmia control.
Conclusion
Short-coupled ventricular fibrillation is a distinct primary arrhythmia syndrome accounting for at least 6.6% of UCA. As documentation of ventricular fibrillation onset is necessary for the diagnosis, most cases are diagnosed at the time of recurrent arrhythmia, thus the true prevalence of SCVF remains still unknown. Quinidine is effective in SCVF and should be considered as first-line treatment for patients with recurrent episodes.
Graphical Abstract
Short-coupled ventricular fibrillation (SCVF) is a distinct primary electrical disorder accounting for at least 6.6% of otherwise idiopathic VF. Quinidine is highly effective for SCVF.
Arrhythmogenic cardiomyopathy (ACM) is an arrhythmogenic disorder of the myocardium not secondary to ischemic, hypertensive, or valvular heart disease. ACM incorporates a broad spectrum of genetic, ...systemic, infectious, and inflammatory disorders. This designation includes, but is not limited to, arrhythmogenic right/left ventricular cardiomyopathy, cardiac amyloidosis, sarcoidosis, Chagas disease, and left ventricular noncompaction. The ACM phenotype overlaps with other cardiomyopathies, particularly dilated cardiomyopathy with arrhythmia presentation that may be associated with ventricular dilatation and/or impaired systolic function. This expert consensus statement provides the clinician with guidance on evaluation and management of ACM and includes clinically relevant information on genetics and disease mechanisms. PICO questions were utilized to evaluate contemporary evidence and provide clinical guidance related to exercise in arrhythmogenic right ventricular cardiomyopathy. Recommendations were developed and approved by an expert writing group, after a systematic literature search with evidence tables, and discussion of their own clinical experience, to present the current knowledge in the field. Each recommendation is presented using the Class of Recommendation and Level of Evidence system formulated by the American College of Cardiology and the American Heart Association and is accompanied by references and explanatory text to provide essential context. The ongoing recognition of the genetic basis of ACM provides the opportunity to examine the diverse triggers and potential common pathway for the development of disease and arrhythmia.
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