Aims Current treatment may have changed the risk profiles of survivors of acute myocardial infarction (AMI). We evaluated the utility of Holter-based risk variables in the prediction of sudden ...cardiac death (SCD) among survivors of AMI treated with modern therapy. Methods and results A total of 2130 AMI patients (mean age 59±10 years) were included. The patients were treated with modern therapeutic strategies, for example, 94% were on β-blocking therapy and 70% underwent coronary revascularization. Various risk parameters from Holter monitoring were analysed. During a median follow-up of 1012 days (interquartile range: 750–1416 days), cardiac mortality was 113/2130, including 52 SCDs. All Holter variables predicted the occurrence of SCD (P<0.01), but only reduced post-ectopic turbulence slope (TS) (P<0.001) and non-sustained ventricular tachycardia (P<0.01) remained as marked SCD predictors after adjustment for age, diabetes, and ejection fraction (EF). In a subgroup analysis, none of the Holter variables predicted SCD among those with an EF ≤0.35, but many variables predicted SCD among those with an EF >0.35, particularly TS (hazard ratio 5.9; 95% CI 2.9–11.7, P<0.001). Conclusion Among the post-AMI patients treated according to the current guidelines, the incidence of SCD is low. Various Holter variables still predict the occurrence of SCD, particularly among the patients with preserved left ventricular function.
This study assessed the predictive power of arrhythmia risk markers after an acute myocardial infarction (AMI).
Several risk variables have been suggested to predict the occurrence of sudden cardiac ...death (SCD), but the utility of these variables has not been well established among patients using medical therapy according to contemporary guidelines.
A consecutive series of 700 patients with AMI was studied. The end points were total mortality, SCD, and nonsudden cardiac death (non-SCD). Nonsustained ventricular tachycardia (nsVT), ejection fraction (EF), heart rate variability, baroreflex sensitivity, signal-averaged electrocardiogram (SAECG), QT dispersion, and QRS duration were analyzed (n = 675). Beta-blocking therapy was used by 97% of the patients at discharge and by 95% at one and two years after AMI.
During a mean (±SD) follow-up of 43 ± 15 months, 37 non-SCDs (5.5%) and 22 SCDs (3.2%) occurred. All arrhythmia risk variables differed between the survivors and those with non-SCD (e.g., the standard deviation of N-N intervals was 98 ± 32 vs. 74 ± 21 ms p < 0.001 and the QRS duration was 103 ± 22 vs.89 ± 16 ms p < 0.001). Sudden cardiac death was weakly predicted only by reduced EF (<0.40; p < 0.05), nsVT (p < 0.05), and abnormal SAECG (p < 0.05), but not by autonomic markers or standard ECG variables. The positive predictive accuracy of EF, nsVT, and abnormal SAECG as predictors of SCD was relatively low (8%, 12%, and 13%, respectively).
The common arrhythmia risk variables, particularly the autonomic and standard ECG markers, have limited predictive power in identifying patients at risk of SCD after AMI in the beta-blocking era.
Purpose
Cather ablation is known to influence the autonomic nervous system. This study sought to investigate the association of sinus heart rate pre-/post-ablation and recurrences in patients with ...atrial fibrillation undergoing pulmonary vein isolation (PVI).
Methods
Between January 2012 and December 2017, data of 482 patients undergoing their first PVI were included. Sinus heart rate was recorded before (PRE), directly post-ablation (POST) and 3 months post-ablation (3 M). All patients were screened for atrial tachyarrhythmia recurrences during the one-year follow-up.
Results
In the total study cohort, the mean resting sinus heart rate at PRE mean 57.9 bpm (95% CI 57.1–58.7 bpm) increased by over 10 bpm to POST mean 69.4 bpm (95% CI 68.5–70.3 bpm);
p
< 0.001 followed by a slight decrease at 3 M mean 67.3 bpm (95% CI 66.4–68.2 bpm) but still remaining higher compared to PRE (
p
< 0.001). This pattern was observed in patients with and without recurrences at POST and 3 M (both
p
< 0.001 compared to PRE). However, at 3 M the mean sinus heart rate was significantly lower in patients with compared to patients without recurrences (
p
= 0.031). In this regard, patients with a heart rate change < 11 bpm (PRE to 3 M) or, as an alternative parameter, patients with a heart rate < 60 bpm at 3 M had a significantly higher risk of recurrences compared to the remaining patients (Hazard ratio (HR) 1.82 (95% CI 1.32–2.49),
p
< 0.001 and HR 1.64 (95% CI 1.20–2.25),
p
= 0.002, respectively).
Conclusion
Our study confirms the impact of PVI on cardiac autonomic function with a significant sinus heart rate increase post-ablation. Patients with a sinus heart rate change < 11 bpm (PRE to 3 M) are at higher risk for recurrences during one-year post-PVI.
The recently developed fractal analysis of heart rate (HR) variability has been suggested to provide prognostic information about patients with heart failure. This prospective multicenter study was ...designed to assess the prognostic significance of fractal and traditional HR variability parameters in a large, consecutive series of survivors of an acute myocardial infarction (AMI). A consecutive series of 697 patients were recruited to participate 2 to 7 days after an AMI in 3 Nordic university hospitals. The conventional time-domain and spectral parameters and the newer fractal scaling indexes of HR variability were analyzed from 24-hour RR interval recordings. During the mean follow-up of 18.4 ± 6.5 months, 49 patients (7.0%) died. Of all the risk variables, a reduced short-term fractal scaling exponent (α
1 <0.65), measured by detrended fluctuation analysis, was the most powerful predictor of mortality (univariate relative risk 5.05, 95% confidence intervals CI 2.87 to 8.89, p <0.001). A low scaling exponent α
1 predicted death in the patients with and without depressed left ventricular function (p <0.001 and p <0.01, respectively). Several other HR variability parameters also predicted mortality in univariate analyses, but in a multivariate analysis after adjustments for clinical variables and left ventricular ejection fraction, α
1 was the most significant independent HR variability index that predicted subsequent mortality (relative risk 3.90, 95% CI 2.03 to 7.49, p <0.001). Short-term fractal scaling analysis of HR variability is a powerful predictor of mortality among patients surviving an acute myocardial infarction.
The preferential sites for focal atrial tachycardia (FAT) are mainly in the right atrium in both sexes. However, a limited number of studies have indicated that sex differences in the localization of ...FAT. This study investigated possible sex differences in the distribution of FAT in a large cohort of patients referred for ablation.
From 2004 to 2019, 487 patients (298 women) were referred to our institution for ablation of FAT. A standard electrophysiological study was conducted, and isoproterenol or atropine was given when needed. Conventional catheter mapping, electroanatomic contact mapping, and noncontact mapping were used to assess the origin of ectopic atrial tachycardia.
Overall, 451 foci were successfully ablated in 436 patients (90%). Although the foci located along the crista terminalis were more common in women than in men (42% vs. 29%; p=0.023), the opposite were found in the foci located along the tricuspid annulus (5% vs. 11%; p=0.032) and the right atrial appendage (RAA) (1% vs. 3%; p=0.032). Other locations were similarly distributed in men and women. In addition, the presence of persistent FAT was more frequent in men than in women (22% vs. 5%; p<0.001). Finally, the difference in the induction pattern of FAT was also remarkable between sexes.
The distribution of FAT in women and men is different. In addition, persistent FAT seems more often in men than in women. The different distribution, persistency, and induction pattern of FAT should be considered in the successful management of this type of tachycardia.
Radiofrequency (RF) ablation of the cavotricuspid isthmus (CTI) is an effective treatment for atrial flutter (AFL). However, RF may injure cardiac structures such as the atrio-ventricular node or the ...right coronary artery and is usually painful. This prospective, randomized study compares cryoablation (Cryo) with RF ablation regarding efficacy, safety, and perceived pain.
One-hundred and fifty-three patients (78 Cryo; 75 RF) with CTI-dependent AFL--median age 65 years (range 34-82), 140 men (91%)--were randomized to Cryo or RF. Primary endpoint was demonstration of long-term efficacy defined as no symptomatic recurrence of AFL at the 6-month follow-up. Radiofrequency ablation was performed with a 3.5 mm open-irrigated-tip catheter and Cryo with a 9 F, 8 mm tip catheter. Ablation endpoint was bidirectional CTI block. Pain was evaluated with a visual analogue scale (VAS; 0-10). The acute success rate was 92% for Cryo and 95% for RF (P = 0.58). Procedural time was longer in the Cryo group (152 ± 54 min) than the RF group (116 ± 41 min) (P < 0.001). Cryoablation was considerably less painful compared with RF (mean VAS-Cryo 0.7 ± 1.2 vs. VAS-RF 4.6 ± 2.0; P < 0.001). Success rate at 6-month follow-up was 93% (73 of 78) for Cryo and 97% (73 of 75) for RF (P = 0.86). No major adverse events occurred in any group.
Cryoablation of isthmus-dependent AFL is not inferior to RF but with significantly less procedure-related pain.
This prospective study tested whether the natriuretic peptides predict cardiac death among patients using beta-blocking therapy after an acute myocardial infarction (AMI).
Natriuretic peptides have ...provided prognostic information after AMI, but their predictive value has not been well established in the era of beta-blocker use.
A series of 521 patients (mean age 61 ± 10 years) with AMI was included in the study. The end points were total mortality and non-sudden and sudden cardiac death (SCD). Plasma concentrations of atrial natriuretic peptide (ANP), N-terminal atrial natriuretic propeptide (N-ANP), brain natriuretic peptide (BNP), and ejection fraction (EF) were analyzed before hospital discharge. The cardiac medication was optimized (e.g., adherence to beta-blocking therapy was 97% at discharge and 95% at one year after AMI).
During a mean follow-up of 43 ± 13 months, total mortality was 11.5% (60/521), cardiac mortality was 6.3% (33/521), and 3.1% (16/521) experienced SCD. On univariate analysis, high levels of all measured peptides and low EF predicted the occurrence of non-SCD (p < 0.001 for all). Peptides and EF also predicted the occurrence of SCD (p < 0.05), with elevated BNP (>23.0 pmol/l) being the most powerful predictor (hazard ratio HR 4.4, 95% confidence interval CI 1.4 to 13.8; p = 0.01). After adjusting for clinical variables, only elevated BNP (HR 3.9, 95% CI 1.2 to 12.3, p = 0.02) and low EF (<40%) (p = 0.03) remained as significant predictors of SCD.
Natriuretic peptides retain their prognostic value in the beta-blocking era among survivors of AMI. Elevated BNP provides information on the risk of subsequent SCD, independent of clinical variables and left ventricular EF.
Abstract Background Altered atrial conduction is linked to susceptibility to atrial fibrillation (AF). Whether signal propagation to left atrium (LA) during sinus rhythm differs between patients with ...paroxysmal lone AF and healthy subjects is not known. Methods In 107 patients with lone paroxysmal AF (age 45 ± 12 years) and 94 controls 99-channel magnetocardiography (MCG) was recorded over anterior chest. The duration of the atrial wave (Pd) and the MCG maps over time intervals corresponding to early and later LA activations were determined. Based on magnetic field orientations in LA maps, MCG atrial waves were classified into 3 types which are related to distinct interatrial conduction routes: Type 1 to Bachmann bundle, Type 2 to margin of fossa ovalis or multisite, and Type 3 to coronary sinus ostial connections. Results Pd was longer in AF patients than in controls (112 ± 13 vs. 104 ± 13; p < 0.001), which was most obvious in Type 1 wave (109 ± 12 vs. 102 ± 11 ms, p = 0.003). The distribution of the atrial wave types differed between AF patients and controls: Type 1 occurred in 67% and Type 2 in 20% of controls whereas Type 1 occurred in 54% and Type 2 in 42% of AF patients, p < 0.01 for difference. Conclusions Susceptibility to paroxysmal lone AF is associated with propagation of atrial signal to LA via margin of fossa ovalis or multiple pathways. When conduction occurs via Bachmann bundle, it is related with prolonged atrial activation. Thus altered and alternative conduction pathways may contribute to pathogenesis of lone AF.
The epidemiologic pattern of sudden cardiac death (SCD) may have changed in the modern treatment era of patients after an acute myocardial infarction (AMI). We evaluated the effect of optimized ...medical and revascularization therapy on the incidence of SCD after an AMI. A total of 2,130 consecutive patients (mean age 59 ± 10 years) with an AMI from 2 European centers (Germany and Finland) was included in the study. In this population, 1,004 patients (47%) were treated with an optimized medical and revascularization strategy (defined as treatment with revascularization, β blockers, aspirin, statins, and angiotensin-converting enzyme inhibitors). Nonoptimized treatment, defined as a lack of any optimized treatment, was received by 1,126 patients (53%). During the mean follow-up of 2.9 ± 1.3 years, the incidence of SCD was very low among patients who received optimized treatment (1.2%, annual incidence 0.4%) compared with those who did not (3.6%, annual incidence 1.4%, p <0.01). The treatment strategy that had the greatest effect on differences in the SCD rate was revascularization therapy, with the hazard ratio of SCD being 2.1 (95% confidence interval 1.2 to 3.7, p <0.01) for SCD among nonrevascularized patients. Nonoptimized treatment was more often received by older patients, women, diabetic patients, and those with depressed left ventricular function. In conclusion, the incidence of SCD is low in the modern treatment era of patients after an AMI. Coronary revascularization seems to have a great effect on altered the epidemiologic pattern of SCD.
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