Sudden cardiac death (SCD) is a devastating and all too common result of both acquired and genetic heart diseases. The profound sadness endured by families is compounded by the risk many of these deaths confer upon surviving relatives. For those with known cardiac disease, disease‐specific therapy and risk stratification are key to reducing sudden death. For families of a SCD victim, uncovering a definitive cause of death can help relieve the agonising uncertainty and is a vital first step in screening surviving relatives and instituting therapy to reduce SCD risk. Increasing knowledge about the molecular mechanisms and genetic drivers of malignant arrhythmias in the diverse clinical entities that can cause SCD is vital if we are to optimise risk stratification and personalise patient care. Advances in diagnostic tools, disease‐specific therapy and defibrillator technology are improving outcomes for patients and their families but there is still much progress to be made.

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PMI as defined by the current Universal Definition using hsTnT is an independent predictor of adverse clinical outcome at 12 months in patients undergoing PCI. Accordingly, PMI remains a clinically relevant factor in current practice and should be considered a key outcome measure in clinical trials and a potential target for therapy.

Background Current genetic testing guidelines recommend against broad, multi-phenotype genetic testing in survivors of sudden cardiac arrest (SCA) where no cause is identified on clinical screening. Recent reports describe malignant arrhythmic events preceding detectable structural changes in patients with pathogenic variants in cardiomyopathy genes, who go on to demonstrate structural changes in follow up. Purpose We sought to investigate the utility of a broad genetic testing approach, sequencing genes implicated in both arrhythmia syndromes and cardiomyopathy, in SCA survivors where no cause was identified after thorough clinical evaluation. Methods We retrospectively reviewed the clinical and genetic profiles of SCA survivors referred to a specialised genetic heart disease multidisciplinary team in Australia. Multi-phenotype genetic testing included analysis of 174 cardiac genes associated with arrhythmia or cardiomyopathy. Results The cohort was comprised of 86 SCA survivors. A clinical diagnosis was made in 46 (53%) patients while 40 (47%) cases were considered idiopathic, with no cause of arrest identified despite thorough clinical investigation. Thirty-two survivors of idiopathic SCA (80%) underwent broad, multi-phenotype genetic testing through genome (n=1), exome (n=26) or extended panel (n=5) analysis. The majority of the cohort were male (62.5%, n=25) and ≤35 years of age at time of arrest (60%, n=24). Events in this group most commonly occurred at rest or sleep (65.8%, n=25) and 5 patients had a family history of sudden death (12.5%). Seven disease causing variants were identified with a testing yield of 21.9%. There was no difference in demographic or clinical factors between those with and without a disease-causing variant. Six (85.7%) of these clinically actionable variants were identified in genes associated with cardiomyopathy (PKP2, MYBPC3, DES, DSP and ACTN2) that would not have been analysed on a standard commercial cardiac arrhythmia panel. Cardiac magnetic resonance (CMR) imaging was performed prior to genetic testing in 4 of the 6 cases found to have disease-causing variants in cardiomyopathy genes (2 patients did not have CMR performed due to the presence of cardiac devices), with 2 (50%) showing sub-diagnostic changes while 2 (50%) revealed a structurally normal heart. Conclusion A broad approach to genetic testing in idiopathic SCA can improve care for patients and their families by identifying clinically actionable variants that would be missed by phenotype specific gene panels and thus significantly increase the rate of diagnosis. “Concealed cardiomyopathy” represents a clinical challenge in how to manage patients and their relatives who carry a pathogenic cardiomyopathy variant, have no overt signs of structural disease, yet have an important risk of sudden cardiac arrest. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Cardiac Society of Australia and New Zealand; National Health and Medical Research Council (Australia)

Background: The prevalence and clinical course of atrial fibrillation (AF) in hypertrophic cardiomyopathy (HCM) is well described, though less so for other inherited cardiomyopathies (familial dilated cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, left ventricular noncompaction); and inherited arrhythmia syndromes (long QT syndrome, Brugada syndrome or catecholaminergic polymorphic ventricular tachycardia [CPVT]). We examined the frequency, clinical characteristics and AF-related management and outcomes amongst this patient population. Methods: We retrospectively studied consecutive probands with inherited cardiomyopathy (n = 962) and inherited arrhythmia syndromes (n = 195) evaluated between 2002 and 2018.Results: AF was observed in 5% to 31% of patients, with the highest frequency in HCM. Age of AF onset was 45.8 ± 21.9 years in the inherited arrhythmia syndromes compared with 53.3 ± 15.3 years in the inherited cardiomyopathies, with four CPVT patients developing AF at a median age of 20 years. Overall, 11% of patients with AF had a transient ischemic attack or stroke of which a total of 80% were anticoagulated; with 48% of events occurring at a CHA 2 DS 2 -VASc < 2. Amongst sarcomere-positive HCM, AF was independently associated with age (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.02-1.08; P = .0014), left atrial area (OR, 1.11; 95% CI, 1.05-1.17; P = .0005) and MYH7 variants (OR, 2.55; 95% CI, 1.16-5.61; P = .020).Conclusion: Up to one-third of inherited heart disease patients will develop AF. While common general population risk factors are key in patients with HCM, the genotype is independently associated with AF. Amongst inherited arrhythmia syndromes, AF is less common, though often occurs below the age of 50 years. K E Y W O R D Satrial fibrillation, inherited arrhythmia syndrome, inherited cardiomyopathy, sarcomere genes

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