Atrial fibrillation (AF) causes important mortality and morbidity on a population-level. So far, we do not have the means to prevent AF or AF-related complications adequately. Therefore, over 70 experts on atrial fibrillation convened for the 2nd AFNET/EHRA consensus conference to suggest directions for research to improve management of AF patients (Appendix 1). The group defined three main areas in need for research in AF: 1. better understanding of the mechanisms of AF; 2. Improving rhythm control monitoring and management; and 3. comprehensive cardiovascular risk management in AF patients. The group put forward the hypothesis that successful therapy of AF and its associated complications will require comprehensive therapy. This applies e.g. to the "old" debate of "rate versus rhythm control", since rhythm control is generally added to underlying (continued) rate control therapy, but also to the emerging debate of "antiarrhythmic drugs versus catheter ablation", of which both may be needed in most patients to maintain sinus rhythm, but also to therapy of conditions that predispose to AF and contribute to cardiovascular complications such as stroke, cognitive decline, heart failure, and acute coronary syndromes. We call for research initiatives aiming at a better understanding of the different causes of AF and its complications, and at development and validation of mechanism-based therapies. The future of AF therapy may require a combination of management of underlying and concomitant conditions, early and comprehensive rhythm control therapy, adequate control of ventricular rate and cardiac function, and continuous therapy to prevent AF-associated complications (e.g. antithrombotic therapy). The reasons for these suggestions are detailed in this paper.
Background Repolarization abnormalities have a central role on the diagnosis of ARVC according to recent HRS consensus document from 2019 stating that T wave inversion in the right precordial leads is a major criteria if it appears in V1-V3 or a minor criteria if it appears in only V1-V2. Purpose The aim of our study was to investigate whether repolarization patterns as recorded by a Body Surface Mapping (BSM) system consisting of a vest with 252 ECG leads, could differentiate ARVC patients and even gene carriers from normal individuals. Our hypothesis is that the method can potentially identify repolarization disturbances earlier or better than conventional 12-lead ECG. Method 12 definite ARVC patients, 20 healthy gene carriers and 8 family members who tested negative for the family mutation (controls) were included. All patients underwent 12-lead ECG, including right precordial leads (V4R) and BSM recordings. Repolarization (T-wave polarity and concordance with QRS complex vector) was analyzed qualitatively in all BSM recordings, the results of which were displayed on a color code map (fig.1). Results The mean age was 49.6, 43.6 and 38.8 years in ARVC patients, healthy gene carriers and controls, respectively. The number of males in the three groups were 8/12, 8/20 and 5/8, respectively. All 8 controls had similar repolarization patterns with negative and concordant T waves on the right back panel, and T waves that successively changed from negative concordant (green) to positive disconcordant (red) and finally positive concordant (blue) on the left front panel (pattern 1). All 12 ARVC patients had different repolarization patterns as compared to the controls. Two of these patients had no apparent repolarization changes on conventional 12 lead ECG. The pattern type 2 repolarization, as defined by same pattern as the controls at the right back panel but different pattern at the front left panel was seen in 3/12 ARVC patients. The remaining 9 ARVC patients had different repolarization patterns both on the front and on the back panel (pattern 3). Among gene carriers, 15 had a normal repolarization pattern (pattern 1) and 5 demonstrated an abnormal repolarization pattern (4 had pattern type 2 and one pattern 3) despite normal surface ECG. Conclusions Using BSM recordings, abnormal repolarization patterns can be detected in all ARVC patients, even in those without repolarization changes on conventional surface ECG. The observation that 25% of gene carriers had divergent repolarization patterns, may indicate an early stage of the disease, and be used as an early diagnostic marker of the disease. Further and larger studies are warranted to confirm these observations. Repolarisation patterns recorded by BSM Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): Selanders Stiftelse
Background The diagnosis of ARVC is complex and challenging requiring multiple investigational tools, most of which include the demonstration of depolarization/conduction abnormalities, described in recent HRS consensus documents 2019. A simple and user friendly diagnostic tool is warranted. Purpose The purpose of our study was therefore to explore whether the analysis of QRS dispersion obtained from 252-leads recorded by a Body Surface Mapping (BSM) system can be used to identify ARVC patients as compared to the traditional ECG criteria including QRS dispersion measured by conventional 12 lead surface ECG. Methods 12 definite ARVC patients (10/12 with known pathogenic mutation) (Group 1) and 8 healthy family members tested negative for the family mutation served as controls (Group 0), were included. All patients underwent 12-lead ECG (50mm/sec), Signal-averaged ECG for late potentials and 252 lead BSM recordings. The QRS duration was measured in each of the 12 ECG leads manually with digital caliper. The QRS duration from the BSM leads were manually analyzed in Matlab by two observers unaware of the diagnosis. For each lead, the mean value of three randomly chosen beats was calculated. The QRS dispersion was calculated as the difference between the minimum and maximum value for both the 12 lead ECG and the BSM recordings. Results The mean age was 49,6 and 38,8 years in ARVC patients and controls, respectively. The number of males in the two groups were 8/12 and 5/8, respectively. Epsilon waves and Terminal Activation Duration (TAD) >55msec were detected in 6/12 and 8/12 ARVC patients, respectively, but in no controls. Late potentials were detected in 11/12 ARVC patients and in 2 controls. The QRS duration and QTc duration was not statistically different in the two Groups. The ECG-QRS dispersion was significantly more pronounced in Group 1 (42 ms ± 15, range 20–70 ms) than in Group 0 (26 ms ± 8, range 16–36 ms) (p=0.013). The BSM-QRS dispersion was significantly longer in Group 1 (68 ms ± 17, range 29–90ms) than in Group 0 (30 ms ± 7, range 22–41ms) (p=0.001). Only one ARVC patient had a BSM-QRS dispersion <50 msec, whereas none of the controls had a QRS dispersion over 50 msec (Fig. 1). Conclusion BSM-QRS dispersion, specifically using the cut off <50 ms, can potentially be a more sensitive and specific method than other ECG related techniques for diagnosing ARVC patients versus non-ARVC patients. Larger patient cohorts and further studies are required to confirm our findings. Figure 1. ECG and BSM-QRS dispersion Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): Selanders Stiftelse
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