bluuebunny/crossref_metadata_2025_split huggingface dataset:
Recurrent syncope, which patient should we follow more closely
Authors: Menezes Fernandes R , Mota T.F , Bispo J.S , Costa H , Azevedo P , Bento D , Marques N , Jesus I 
Published: November 2020

Abstract

Introduction
The importance of education is well recognized in patients presenting with syncope, in order to reduce the recurrence rate.

Purpose
To determine a predictive score of recurrent syncopal episodes after the first medical assessment.

Methods
We conducted a retrospective study enrolling patients followed in our Syncope Consultation from January 2015 to November 2019. Clinical and episodes characteristics, as well as diagnostic studies were analysed. Correlation between variables was performed by the Chi-square and T-Student tests, with a significance level of 95%. Independent predictors of recurrent syncope were identified through a binary logistic regression analysis, considering p=0.05. Then, a discriminatory function was applied using the Wilks lambda test to determine the discriminant score of the analysed groups. SPSS 24.0 was used for statistical analysis.

Results
A total of 694 patients were included, and 420 (60.5%) had recurrent syncope at the first evaluation. After educational approach, 97 (14%) maintained recurrent episodes. In this subgroup, the mean age was 63.7±22.8 years-old and 88.7% already had previous recurrent syncope (vs 56.1%; p&lt;0.001). The prodrome of malaise was common (40.2% vs 26.8%; p=0.008), but 32% of these patients had syncope without prodromes (vs 21.8%; p=0.032). They also had frequently first-degree atrioventricular (AV) block (22.5% vs 6.8%; p&lt;0.001) and 51.7% had a final diagnosis of reflex syncope. No previous medication with calcium channel blockers (CCB) (p&lt;0.001), malaise (p=0.011), not having Q-waves in the electrocardiogram (p=0.022) and the presence of first-degree AV block (p&lt;0.001) were independent predictors of recurrent syncope. A predictive score of recurrence was determined using the formula: 0.108 − 1.556 x (medication with CCB) + 0.989 x (malaise) − 1.031 x (Q-waves) + 2.406 x (first degree AV block). Variables should be replaced by 1 or 0, depending on whether the condition is present or not. A cut-off of 0.283 was obtained with a specificity of 96.1% and a discriminative power of 81.2%.

Conclusion
In our patients presenting with syncope, recurrence rate reduced from 60,5% to 14% just with educational measures. To help identify patients who maintain recurrence, we determined a predictive score using clinical data from the first visit, with a good discriminative power and excellent specificity. It could be used to strengthen education, to direct diagnostic studies and to shorten follow-up visits, but it still needs validation to be used in clinical practice.

Funding Acknowledgement
Type of funding source: None
Onset, severity and recovery of immediate orthostatic hypotension in normals and symptomatic patients: active standing and head-up tilt differ
Authors: Kohno R , Krishnappa D , Abe H , Benditt D.G 
Published: November 2020

Abstract

Background
Orthostatic hypotension (OH) occurring almost immediately (i.e., immediate OH, iOH) after movement to standing position is common, and may cause collapse due to instability or syncope. However, while “classic” OH (cOH) which typically occurs later is well-studied, iOH has received less attention.

Objectives
This study was designed to better understand blood pressure (BP) alterations associated with iOH in normal subjects and in symptomatic patients (pts) and to compare findings with both Active standing and Head-up tilt (HUT).

Methods
We studied 118 patients comprising 4 groups: 1) Normals (n=38), 2) Vasovagal syncope (VVS: n=27), 3) cOH (n=37), and 4) Primary Autonomic Failure (PAF, n=16). We compared timing and magnitude of BP fall and recovery during both drug-free “active standing” (≤10 min) and HUT (70°, ≤20 min). Continuous ECG and beat-to-beat BP were recorded. Statistical significance was tested using paired-t test and ANOVA as appropriate (significance: p≤0.05).

Results
Sex and BMI were similar among groups, but PAF pts tended to be older (62±17 yrs) vs Normals (44±16 yrs), VVS (32±12) and OH (45±21 yrs) pts. Time from upright posture to BP nadir was shorter with active standing vs HUT [p&lt;0.005] except in PAF pts [p=NS]. Similarly, magnitude of BP fall (mmHg) tended to be greater with active standing in all groups (Normals −33±21 vs −20±18; VVS −28±16 vs −20±14; OH −37±16 vs −30±23; PAF −38±16 vs −34±28). Finally, except for PAF pts, BP recovery to baseline was shorter with active standing vs HUT (Table).

Conclusion
Active standing and HUT differ in evaluation of symptomatic pts. “Active standing” is associated with lesser time to BP nadir, greater BP fall, and faster BP recovery than with HUT. Additionally, iOH BP nadir typically occurs ≤15–20s after upright posture with rapid recovery necessitating beat-to-beat recordings to assess accurately.

Funding Acknowledgement
Type of funding source: None
Recurrent syncope in patients with a pacemaker and bradyarrhythmia
Authors: Lee C.J.Y , Davidsen J.M , Skals R , Torp-Pedersen C , Soegaard P 
Published: November 2020

Abstract

Objectives
To investigate the risk of recurrent syncope and all-cause mortality after implantation of a pacemaker in patients with bradyarrhythmia.

Background
A pacemaker is generally recommended when syncope is caused by bradyarrhythmias to prevent a new syncope. However, the occurrence and risk of recurrent syncope in patients with bradyarrhythmia after pacemakerimplantation are still unknown.

Methods
Patients with a prior syncope and an implantation of pacemaker were identified. Cumulative incidences of 5-years were estimated for the outcomes stratified into groups according to the type of bradyarrhythmia; and type of pacemaker. The risk of recurrent syncope and all-cause mortality were estimated using adjusted cox proportional hazard regressions.

Results
We identified 8,663 patients with a prior syncope and pacemaker implantation (median age of 78,1 years (SD 69,1–84,8) and 55,1% males). The 5-year cumulative incidence of recurrent syncope was 19,3% (95% confidence intervals (CI) 18,4–20,2). Factors associated with a significant increased risk of recurrent syncope were male sex, age 80 years and above, alcohol related disease, bleeding, chronic obstructive pulmonary disease, chronic kidney disease, stroke, and malignancy. Atrial fibrillation was associated with a significantly decreased risk of recurrent syncope. Patients with an advanced AV conduction abnormality had a lower associated risk of syncope compared to patients with sinus node dysfunction (HR 0,85, 95% CI 0,76–0,94, p=0,003).

Conclusions
One fifth of the cohort had a recurrence syncope after five years. Besides older age and male sex, several comorbidities were found to be associated with a higher risk of recurrence of syncope. Clinicians need to be attentive that a large proportion of patients with bradyarrhythmia suffer from syncope even when treated with a pacemaker.

Funding Acknowledgement
Type of funding source: None
ICD-detected respiratory disturbance index: accuracy for sleep apnea detection and prognostic value
Authors: Boriani G , D'Onofrio A , Pisano E , Pieragnoli P , Locatelli A , Capucci A , Talarico A , Sinagra G , Rapacciuolo A , Piacenti M , Indolfi C , Checchinato C , Ricci R.P 
Published: November 2020

Abstract

Purpose
In patients affected by heart failure an association exists between sleep apnea (SA) measured by polysomnography and adverse outcome. Impedance-based implantable cardioverter defibrillator (ICD) algorithms have been designed to compute the Respiratory Disturbance Index (RDI) to identify severe SA. The purpose of the DASAP-HF study was to evaluate the accuracy of RDI for the prediction of severe SA, and investigate the prognostic value of device-detected RDI values.

Methods
Patients with left ventricular ejection fraction ≤35% implanted with an ICD were enrolled and followed for 24 months. One month after implantation, patients underwent a polysomnographic study (PS) for assessing the apnea-hypopnea index (AHI). The average RDI value was calculated over a 1-week period preceding the sleep study and compared with the assessment of severe SA at PS (AHI ≥30 episodes/h). The endpoint was all-cause death after 24 months.

Results
224 out of 265 enrolled patients had usable RDI values. Patients characteristics: 79% male, 67±10 years, BMI 27±7kg/m2, ejection fraction 29±5%, 54% ischemic cardiomyopathy, 50% CRT-D. The mean AHI value at PS was 21±15 episodes/h. The mean RDI value recorded during the week preceding PS was 30±16 episodes/h. RDI values accurately identified severe SA diagnosed at PS (AUC 0.77; 95% CI 0.70–0.83; P=0.001). Based on the ROC curve analysis, RDI ≥29 episodes/h and AHI ≥17 episodes/h maximized sensitivity and specificity for the prediction of death. Both indexes were independently associated with all-cause death but, after correction for the other independent significant prognostic variables, RDI≥29episodes/h yielded stronger prediction (HR: 12.22, 95% CI:1.64–91.37, p=0.015) as compared to AHI ≥17episodes/h (HR: 4.14, 95% CI:1.17–14.66, p=0.028). Moreover, severe SA diagnosed at PS (AHI ≥30episodes/h) was not associated with death (HR: 1.20, 95% CI:0.3817–3.8266, p=0.761).

Conclusions
In heart failure patients indicated to ICD, severe SA was confirmed to be associated with survival. The ICD-measured RDI accurately identified severe SA detected at PS, and was associated with the risk of death at long-term.

Funding Acknowledgement
Type of funding source: Private company. Main funding source(s): Boston Scientific
Increased 5-year risk of stroke, atrial fibrillation, acute coronary syndrome and heart failure in out-of-hospital cardiac arrest survivors relative to population controls: a nationwide register-based
Authors: Kragholm K , Bundgaard K , Wissenberg M , Folke F , Lippert F , Gislason G , Kober L , Sogaard P , Lip G.Y.H , Torp-Pedersen C 
Published: November 2020

Abstract

Background
Out-of-hospital cardiac arrest (OHCA) survivors are a selected group of patients with younger age and less comorbid conditions relative to non-survivors. Long-term risk of stroke, atrial fibrillation or flutter (AF), acute coronary syndrome (ACS) and heart failure (HF) in OHCA survivors not diagnosed with any of these conditions as part of the cardiac arrest is unknown.

Purpose
To examine 5-year risk of stroke, AF, ACS and HF in 30-day OHCA survivors relative to age- and sex-matched population controls.

Methods
OHCA 30-day survivors and age- and sex-matched population controls not previously diagnosed with stroke, AF, ACS or HF or during the first 30 days after cardiac arrest were included using Danish Cardiac Arrest Registry data from 2001–2015 as well as the Danish Civil Registration System. Characteristics are compared using totals and percentages for categorical data and median and 25–75% percentiles for continuous data. Five-year outcomes are compared using cumulative incidence plots as well as Shared Frailty Cox regression modeling, unadjusted and adjusted for potential confounders including age, sex, hypertension, diabetes, chronic obstructive pulmonary disease (COPD), peripheral arterial disease (PAD), chronic ischemic heart disease (IHD), transient ischemic attack (TIA), thyroid disease, cholesterol-lowering, antiplatelet and anticoagulant agents.

Results
Of 4362 30-day survivors, 1063 were stroke-, AF-, ACS- and HF-naïve and 1051 were matched to population controls using age, sex and time of OHCA event as matching variables. The figure depicts the risk of stroke beyond day 30 to 5 years of follow-up was 4.7% versus 1.7% for OHCA survivors vs. controls. Risks of AF, ACS and HF were 7.0% vs. 2.1%, 4.7% versus 1.2% and 12.2% vs. 1.0%, respectively. OHCA 30-day survivors were significantly more likely to have PAD relative to controls, 4.9% vs. 1.1%. Differences in IHD (22.0% vs. 1.7%), hypertension (28.1% vs. 14.6%), diabetes (9.5% vs. 4.1%), lipid-lowering agents (27.6% vs. 9.5%), COPD (11.3% vs. 2.2%) were also significant. When adjusting for these comorbidities as well as for thyroid diseases, chronic kidney disease, cancer, antiplatelet and anticoagulant therapy, differences remained highly significant: HR stroke 3.33 [95% CI 2.21–5.02], HR AF 3.26 [2.28–4.66], HR ACS 3.36 [2.14–5.27] and HR HF 11.50 [8.02–16.48].

Conclusion
We demonstrate an increased five-year risk of stroke, atrial fibrillation or flutter, acute coronary syndrome and heart failure in out-of-hospital cardiac arrest survivors without prior existence of any of these conditions. These results indicate that OHCA survivors continue to remain high-risk patients for cardiovascular events and prevention intervention is warranted.

Funding Acknowledgement
Type of funding source: None
Efficacy of epicardial and endocardial ablation in the prevention of ventricular tachycardia in arrythmogenic right ventricular cardiomyopathy- a meta analysis
Authors: Sattar Y , Ullah W , Mamtani S , Alraies C 
Published: November 2020

Abstract

Introduction
Ventricular tachycardia is a major complication associated with increased risk of sudden cardiac death in arrhythmogenic ventricular cardiomyopathy. Recurrence of VT status post catheter endocardial ablation with conventional mapping is a evolving discussion in management of VT prevention in ARVC. With the evolution of new mapping techniques to locate ectopic foci of VT, a combination of endo- and epicardial catheter ablation have proven to be efficacious in the prevention of frequency of VT recurrence and its duration.

Methods
Using PubMed, Ovid (MEDLINE) and Cochrane database we searched using the MeSH terms including: “arrhythmogenic right ventricular cardiomyopathy”, “arrhythmogenic right ventricular dysplasia”, “monomorphic ventricular tachycardia”, “polymorphic ventricular Tachycardia”, “endocardial catheter ablation”, “epicardial catheter ablation”. The primary outcomes were to assess VT frequency and duration status post endocardial or epicardial or a combination of both types of ablation. The secondary outcome includes sudden cardiac arrest or sudden cardiac death after procedure. ANOVA with post HOC analysis was performed using SPSS v.26 (IBM Corp, NY, USA)

Results
A total of 33 studies included 1437 patients with a mean male=67%. The data analysis showed a mean VT prevention for endocardial ablation was 65%, epicardial 78%, and for combined epi-endocardial was 89% (figure-1). The mean procedural mortality rate was 2%. In order to test the hypothesis that combined epi-endocardial ablation was more successful in the prevention of VT recurrence, we performed a one-way analysis of variance (ANOVA). The analysis was statistically significant F(2,14)=5.879, 95% CI, p=0.014. Post Hoc test (Tukey HSD test) with multiple comparisons indicated that patients who underwent combined epi-endocardial ablation experienced a statistically significant difference in VT prevention of 89% (95% CI p=0.01) compared to only endocardial ablation, mean VT prevention of 65% (95% CI, p=0.189) or only epicardial, mean VT prevention of 78% (95% CI, p=0.353).

Conclusion
With new mapping techniques, use of endocardial, and epicardial ablation is linked to decrease VT frequency, duration, ICD shocks, and sudden cardiac death in patients with ARVC in cohorts with prior failure of antiarrhythmics.
Total VT Prevention across target sites

Funding Acknowledgement
Type of funding source: None
Activation pattern during his pacing: how close are we to normal physiology?
Authors: Yasin O , Vaidya V , Tri J , Van Zyl M , Ladejobi A , Xiao P , Han J , Scheuermann C , Bush J , Taubel R , Pedersen J , Yngsdal L , Asirvatham S , Cha Y 
Published: November 2020

Abstract

Background
His bundle pacing aims to mimic the activation pattern of normal conduction to maintain ventricular synchrony. However, selective His capture can be challenging, and the activation sequence during His pacing may not replicate normal conduction.

Purpose
Compare the right ventricular (RV) and left ventricular (LV) activation pattern in sinus rhythm and His bundle pacing.

Methods
Baseline LV and RV map was created in sinus rhythm using Rhythmia mapping system (Boston Scientific Corporation) in canine animal model. Medtronic 3830 lead was placed near the bundle of His under fluoroscopic, intracardiac echocardiogram, and electroanatomic guidance. Conduction system capture was confirmed by observing a QRS duration &lt;120ms and an isoelectric segment between pacing artifact and QRS on surface ECG. Repeat LV and RV activation map was obtained during His pacing. Average QRS, HV and pacing to V intervals were calculated with standard deviation.

Results
Mapping was performed successfully in four animals. At baseline, the average QRS duration was 44±2.6ms and HV interval was 32±4.2ms. Earliest site of myocardial activation was in the mid-septal LV region. The earliest RV myocardial activation was also at the septum closer to the apex, but later than the LV (Figure1A). With His pacing, the average QRS duration was 70±17.0ms and the average stim to V interval was 31±8.7ms. During His pacing, the earliest site of activation was in the RV septum, with an activation pattern from base to apex in both the RV and LV.

Conclusion
Unlike normal physiology, the activation pattern during conduction system pacing is from base to apex with earliest site in the RV.

Funding Acknowledgement
Type of funding source: Public hospital(s). Main funding source(s): Mayo Clinic
External validation of a heart failure risk prediction model in a remote monitoring cohort submitted to cardiac resynchronization therapy
Authors: Cardoso I , Coutinho M , Portugal G , Valentim A , Delgado A.S , Grazina A , Viegas J.M , Cunha P.S , Valente B , Oliveira M , Pereira R 
Published: November 2020

Abstract

Background
Patients (P) submitted to cardiac ressynchronization therapy (CRT) are at high risk of heart failure (HF) events during follow-up. Continuous analysis of various physiological parameters, as reported by remote monitoring (RM), can contribute to point out incident HF admissions. Tailored evaluation, including multi-parameter modelling, may further increase the accuracy of such algorithms.

Purpose
Independent external validation of a commercially available algorithm (“Heart Failure Risk Status” HFRS, Medtronic, MN USA) in a cohort submitted to CRT implantation in a tertiary center.

Methods
Consecutive P submitted to CRT implantation between January 2013 and September 2019 who had regular RM transmissions were included. The HFRS algorithm includes OptiVol (Medtronic Plc., MN, USA), patient activity, night heart rate (NHR), heart rate variability (HRV), percentage of CRT pacing, atrial tachycardia/atrial fibrillation (AT/AF) burden, ventricular rate during AT/AF (VRAF), and detected arrhythmia episodes/therapy delivered. P were classified as low, medium or high risk. Hospital admissions were systematically assessed by use of a national database (“Plataforma de Dados de Saúde”). Accuracy of the HFRS algorithm was evaluated by random effects logistic regression for the outcome of unplanned hospital admission for HF in the 30 days following each transmission episode.

Results
1108 transmissions of 35 CRT P, corresponding to 94 patient-years were assessed. Mean follow-up was 2.7 yrs. At implant, age was 67.6±9.8 yrs, left ventricular ejection fraction 28±7.8%, BNP 156.6±292.8 and NYHA class &gt;II in 46% of the P. Hospital admissions for HF were observed within 30 days in 9 transmissions. Stepwise increase in HFRS was significantly associated with higher risk of HF admission (odds ratio 12.7, CI 3.2–51.5). HFRS had good discrimination for HF events with receiving-operator curve AUC 0.812.

Conclusions
HFRS was significantly associated with incident HF admissions in a high-risk cohort. Prospective use of this algorithm may help guide HF therapy in CRT recipients.

Funding Acknowledgement
Type of funding source: None
Pacemaker lead-induced progression of primary vs. secondary tricuspid regurgitation
Authors: Riesenhuber M , Spannbauer A , Pezawas T , Schukro C , Gwechenberger M , Stix G , Anvari A , Wrba T , Khazen C , Andreas M , Laufer G , Hengstenberg C , Gyongyosi M 
Published: November 2020

Abstract

Background
Currently no data are available whether the implantation of right ventricular (RV) pacemaker (PM) lead worsens preexisting primary or secondary (functional due to RV dilatation, RVD) tricuspid regurgitation (TR).

Purpose
The aim of the present retrospective analysis was to assess TR after PM implantation with a RV lead.

Methods
Patients with PM implantation (n=990) were enrolled if they had routine echocardiography including assessment of TR before first implantation and immediately after. RVD and severity of TR were characterized visually. Based on RVD in baseline echocardiography, patients were divided into 2 groups: with primary TR (without preexisting RVD, n=743) or secondary TR (with preexisting RVD, n=243).

Results
Lead-induced worsening of TR was present in both groups (Table 1). Progression from mild/moderate to severe TR was observed in 6.7% of patients with primary TR, compared to 25.6% of patients with secondary TR (P=0.001). Using an ordinal regression model, the probability to progress to severe TR with primary TR was 14.8% (95% CI 11.0%-19.7%), compared to 41.6% (95% CI 40.3%-42.8%) with secondary TR (P&lt;0.001).

Conclusion
Preexisting secondary TR was associated with higher rates of lead-induced progression to severe TR compared to primary TR. Leadless pacing or tricuspid valve clipping post-PM implantation could be an option for patients with preexisting secondary TR and indication for a PM.
Table 1. Patient characteristics.

Funding Acknowledgement
Type of funding source: Public grant(s) – EU funding. Main funding source(s): This study was supported by the European Union's Horizon 2020 Future and Emerging Technologies Programme [Grant number 732170].
Comparison of efficacy of different endovascular lead extraction techniques
Authors: Bracke F , Verberkmoes N , Rademakers N , Van 't Veer M , Van Gelder B.M 
Published: November 2020

Abstract

Background
Reports on lead extraction often concern a single technique, rendering direct comparison between techniques difficult.

Purpose
We compared efficacy and complications of consecutively used endovascular extraction techniques in a single centre.

Methods
Single centre observational study of consecutive lead extractions from 1997 to 2019. The preferential technique used over time was at first a laser sheath (LS), subsequently a femoral approach (FA) if feasible, and finally rotational mechanical sheaths (RMT). The FA remained the preferential initial technique for atrial and coronary sinus leads during the latter period. Extraction results are reported per lead for the initial technique before any alternative approach was initiated.

Results
A total of 1725 leads (including 222 ICD) leads were extracted in 775 patients. Primary endovascular extraction was attempted in 1703 leads (median implant time 6.0 yrs. [IQR 2.7–10.2]) with the remainder being surgically removed. Traction sufficed to remove 588 leads (median implant time 2.4 yrs. [IQR 1.2 - 4.7]). The table shows the radiological and procedural success of the initially used technique per lead. Including use as backup technique there were 7.4%, 0.5% and 1.2% major complications with respectively LS, FA, and RMT. Including backup approaches, clinical success (lead completely removed or only lead fragment &lt;4cm left behind without mayor complication) for endovascular extraction of the 1703 leads was 94.8%.

Conclusion
The laser sheath has an inferior procedural outcome compared to rotational mechanical sheaths or a femoral approach which is largely the results of a higher complication rate. The femoral approach and mechanical rotational sheaths are seemingly equally effective, but the femoral approach is not suitable for many ICD leads and technically more demanding for ventricular leads. In current practice, the combination of a femoral approach and rotational mechanical sheaths yields optimal results.

Funding Acknowledgement
Type of funding source: None