Background Sacubitril/valsartan, the first combined angiotensin receptor-neprilysin inhibitor, has demonstrated a significant benefit compared to angiotensin inhibitor in decreasing ventricular arrhythmias and appropriate implantable cardioverter defibrillator (ICD) shocks in patients with heart failure with reduced ejection fraction (HFrEF). At present, there is no study which evaluates the effect of sacubitril/valsartan on the supraventricular arrhythmic burden in HFrEF patients with an ICD or cardiac resynchronisation therapy-defibrillator (CRT-D) and remote monitoring. Purpose To evaluate the effect of sacubitril/valsartan on the supraventricular arrhythmic burden in HFrEF patients with an ICD or CRTD and remote monitoring. Methods The SAVETHERHYTHM ((SAacubitril Valsartan rEal-world registry evaluating THE arRHYTHMia burden in HFrEF patients with implantable cardioverter defibrillator) is a multicentre, observational, prospective registry enrolling all patients with HFrEF, ICD or CRT-D actively followed through remote monitoring and starting treatment with sacubitril/valsartan. All patients are followed-up for at least one year after sacubitril/valsartan start. The primary endpoint is the mean number of sustained atrial tachycardia or atrial fibrillation (AT/AF) episodes per month. Secondary endpoints include the total burden of AT/AF (defined as the percentage of time in AT/AF per day), the mean number of premature ventricular contractions (PVC) per hour and the percentage of biventricular pacing per day (in patients with CRT-D). All primary and secondary endpoints are collected through remote monitoring. Results At the time of the first ad interim analysis, 60 patients (85.2% male, age 69±10 years) were consecutively enrolled. After treatment with sacubitril/valsartan, patients with at least one episode of AT/AF per month decreased from 32.8% to 21.3% (p=0.015). A significant decrease in number of AT/AF episodes (from 4.3 to 1.2 per year), in AT/AF burden (from 12% to 9%) and in number of PVC (from 83 to 74 per hour) were seen in patients with a previous diagnosis of paroxysmal or persistent AF (n=15; all p<0.05). Patients with permanent AF (n=7) experienced no benefits from sacubitril/valsartan therapy in terms of arrhythmic burden reduction. Patients with no previous history of AF (n=38) showed a decrease in number of AT/AF episodes (from 2.0 to 0.8 per year) and in number of PVC (from 77 to 49 per hour, all p<0.05). No new diagnosis of clinical AF was made after starting treatment with sacubitrl/valsartan, and patients with subclinical AT/AF episodes decreased from 8% to 3%. Conclusions Preliminary data suggest that therapy with sacubitril/valsartan could decrease arrhythmic burden in patients with non-permanent AF and reduce subclinical AT/AF episodes in patients with no history of AF. No positive effect has been noted in patients with permanent AF. Funding Acknowledgement Type of funding source: None
Aims To evaluate the risk of syncopal recurrences after pacemaker implantation in a population of patients with syncope of suspected bradyarrhythmic aetiology. Methods and results Prospective, multicentre, observational registry enrolling 1364 consecutive patients undergoing pacemaker implantation for syncope of bradyarrhythmic aetiology (proven or presumed). Before pacemaker implantation, all patients underwent a cardiac work-up in order to establish the bradyarrhythmic aetiology of syncope. According to the results of the diagnostic work-up, patients were divided into three groups: Group A, patients in whom a syncope-electrocardiogram (ECG) correlation was established (n = 329, 24.1%); Group B, those in whom clinically significant bradyarrhythmias were detected without a documented syncope-ECG correlation (n = 877, 64.3%); and Group C, those in whom bradyarrhythmias were not detected and the bradyarrhythmic origin of syncope remained presumptive (n = 158, 11.6%). During a median follow-up of 50 months, 213 patients (15.6%) reported at least one syncopal recurrence. Patients in Groups B and C showed a significantly higher risk of syncopal recurrences than those in Group A [hazard ratios (HRs): 1.60 and 2.66, respectively, P < 0.05]. Failure to establish a syncope-ECG correlation during diagnostic work-up before pacemaker implantation was an independent predictor of syncopal recurrence on multivariate analysis (HR: 1.90; P = 0.002). Conclusion In selecting patients with syncope of suspected bradyarrhythmic aetiology for pacemaker implantation, establishing a correlation between syncope and bradyarrhythmias maximizes the efficacy of pacing and reduces the risk of syncopal recurrences.
Introduction Takotsubo syndrome is a clinical syndrome characterized by typical anamnestic features together with typical ECG and echocardiographic findings. Comparing with the available literature not so many cases of takotsubo syndrome after pacemaker implantation can be found. Furthermore, there are only few articles talking about ECG features in these patient. The case we described allows to observe dynamic ECG alterations in a patient with electro-induced ventriculograms Case Description A 90-year-old male was admitted to the emergency room for important fatigue associated with severe bradycardia (25/min). His cardiovascular history was silent, and his past medical history was characterized by high blood pressure, chronic pulmonary obstructive disease and anemia due to iron deficiency. The ECG showed second degree AVB type 2, with phases of 2:1 AVB and paroxysmal third degree AVB on continuous monitoring. The routine blood tests showed normal T troponin and BNP was 420 pg/mL. The echocardiogram revealed normal biventricular dimensions and systolic function with moderate aortic valve stenosis. The patient underwent urgent permanent DDD pacemaker implantation without previous isoproterenol administration. During the procedure he referred important pain on the site of the wound, and he became confused and agitated. The procedure was complicated by massive pneumothorax that needed quick decompression. On the 2nd day after pacemaker implantation the ECG revealed electro-induced atrium-guided ventriculograms and began to modify with only mild ST-segment elevation in V2 and initial T-wave inversion from V3 to V6 and in I - II - aVF. On the next days, T-waves became deeper and QTc prolonged to 540 ms. These abnormalities were then gradually resolved on the 11th day. Mild transient attenuation of the amplitude of the QRS complexes in V2 – V3 leads on day 1 could be reported. Another echocardiogram was then performed, which showed new apical akinesis with “apical ballooning” aspect and EF of 40%. TnT and BNP values increased. Coronary angiogram was not performed due to patient rejection, so that coronaropathy could not be excluded with certainty. Nevertheless, the patient had only high blood pressure as cardiovascular risk factor and that the probability of the diagnosis of takotsubo cardiomyopathy was assessed of 76,9% by InterTAK diagnostic score, so that we considered Takotsubo syndrome the most likely diagnosis. Therefore, the patient's therapy was then optimized with an increase in the dosage of ACE inhibitors. At one month follow-up the ECG remained stable, and the echocardiogram showed a preserved ejection fraction (EF = 55%), without alterations of the segmental contractility. BNP and TnT values were normal. Therapy was left unmodified. Conclusions Takotsubo syndrome should be consider a rare but possible complication of pacemaker implantation. This is true especially for patients affected by frailty and cognitive impairment. There are no specific ECG criteria for takotsubo syndrome in patients with electro-induced ventriculograms, but anomalies of the repolarization are similar to those in patients with spontaneous ventricular activity. Transient attenuation of the QRS complexes voltages could be seen even just in the precordial leads and it is generally present in the very acute phase.
Subclinical atrial fibrillation (SCAF) is associated with an increased risk of clinical AF, major cardiovascular events and death. Short-term evidence on SCAF in older populations is scarce, especially in the hospital setting. We performed a cross-sectional study on 60 multimorbid older consecutive patients (aged 80+) admitted to an Internal Medicine and Geriatrics Unit for acute medical diseases with no history of AF, in order to investigate prevalence and predictors of SCAF. Portable ECG monitoring was placed on admission and ECG recording lasted for 5 days. Mean age: 85.7±4.9 years. Female prevalence: 58.3%. High burden of comorbidities: 87.9%. All enrolled patients had CHA 2 DS 2 -VASc score ≥3. SCAF was detected in 16 patients (26.7%) and 11 patients (18.4%) had at least a SCAF episode lasting 6 minutes or longer. No clinical, laboratory and echocardiographic parameters predicted SCAF. Patients with ≥2004 supraventricular ectopic beats/24h (SVEBs/24h) had a 6-fold higher prevalence of SCAF than patients with <411 SVEBs/24h (p=0.038). Time to first SCAF episode was within 3 days of ECG recording in all enrolled patients. SCAF is highly prevalent in older adults hospitalized for acute diseases. This finding may affect clinical management and prognosis. Our study could foster larger multicenter studies in similar settings.
Funding Acknowledgements Type of funding sources: None. Background Sacubitril/valsartan (S/V) has demonstrated a significant benefit in decreasing mortality and morbidity in patients with heart failure with reduced ejection fraction (HFrEF) when compared to angiotensin inhibition. Recent studies demonstrated that the benefits of S/V encompass a positive cardiac remodeling, leading to a reduction of ventricular arrhythmias. The effect of S/V on the supraventricular arrhythmic burden is still unknown. Purpose To evaluate the effect of sacubitril/valsartan on the supraventricular arrhythmic burden in HFrEF patients with an implantable cardioverter defibrillator (ICD) or cardiac resynchronisation therapy-defibrillator (CRT-D) and remote monitoring. Methods The SAVE THE RHYTHM is a multicentre, observational, prospective registry is enrolling all patients with HFrEF, ICD or CRT-D actively followed through remote monitoring and starting treatment with sacubitril/valsartan. All patients are followed-up at least one year after sacubitril/valsartan start. The primary endpoint is the number of sustained atrial tachycardia or AF (AT/AF). Secondary endpoints include incidence of AT/AF in the total population, total burden of AT/AF (defined as the percentage of time in AT/AF per day), mean number of premature ventricular contractions (PVC) per hour and percentage of biventricular pacing per day (in patients with CRT-D). All primary and secondary endpoints are collected through remote monitoring. Results At the time of the second ad interim analysis, 188 patients (85.2% male, age 68 ± 10 years) were consecutively enrolled. In patients without permanent AF, treatment with S/V was associated with a reduced incidence of AT/AF episodes, which changed from 32.6% (before treatment start) to 24.3%, 20.5% and 6.9% according to the sacubitril/valsartan dose (24/26 mg, 49/51 mg and 97/103 mg respectively; p= 0.041). A significant decrease in the median annual number of AT/AF episodes was also seen in these patients (16/year before treatment; 12/year at 24/26 mg; 6/year at 49/51 mg and 1/year at 97/103 mg; p = 0.046). No significant differences were reported in terms of PVC or biventricular pacing (all p = NS). Patients with permanent AF experienced no benefits from sacubitril/valsartan therapy in terms of arrhythmic burden reduction. No new diagnosis of clinical AF was made after starting treatment with sacubitrl/valsartan in all patients. Conclusions Preliminary data suggest that therapy with S/V could reduce the episodes of AT/AF in patients with HFrEF and remote monitoring, and the benefit seems related to the maximum tolerated dose of S/V. No positive effect has been noted in patients with permanent AF.
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