Symptom burden guiding invasive electrophysiological study in paroxysmal supraventricular tachycardia: The believe SVT registry.

BACKGROUND AND OBJECTIVE: Patients with palpitations clinically suggestive of paroxysmal supraventricular tachycardia (PSVT) are often managed conservatively until ECG-documentation of the tachycardia, leading to high impact on life quality and healthcare resource utilization. We evaluated results of electrophysiological study (EPS), and ablation when appropriate, among these patients, with special focus on gender differences in management. METHODS: BELIEVE SVT is a European multicenter, retrospective registry in tertiary hospitals performing EPS in patients with palpitations, without ECG-documentation of tachycardia or preexcitation, and considered highly suggestive of PSVT by a cardiologist or cardiac electrophysiologist. We analyzed clinical characteristics, results of EPS and ablation, complications, and clinical outcomes during follow-up. RESULTS: Six-hundred eighty patients from 20 centers were included. EPS showed sustained tachycardia in 60.9% of patients, and substrate potentially enabling AVNRT in 14.7%. No major/permanent complications occurred. Minor/transient complications were reported in 0.84% of patients undergoing diagnostic-only EPS and 1.8% when followed by ablation. During a 3.4-year follow-up, 76.2% of patients remained free of palpitations recurrence. Ablation (OR: 0.34, P < .01) and male gender (OR: 0.58, P = .01) predicted no recurrence. Despite a higher female proportion among patients with recurrence, (77.2% vs 63.5% among those asymptomatic during follow-up, P < .01), 73% of women in this study reported no recurrence of palpitations after EPS. CONCLUSIONS: EPS and ablation are safe and effective in preventing recurrence of nondocumented palpitations clinically suggestive of PSVT. Despite a lower efficacy, this strategy is also highly effective among women and warrants no gender differences in management.

Construct Validity of a Questionnaire on Eating and Physical Activity Habits for Adolescents in Mexico City.

The assessment of eating and physical activity habits is an important step in promoting healthy behaviors among the adolescent population and is key in the prevention and management of chronic non-communicable diseases, such as obesity, diabetes, and cardiovascular disease. For this purpose, reliable and valid measuring instruments are essential. In this context, the aim of this article is to present the validation of a self-report questionnaire on eating and physical activity habits among adolescents in Mexico City. In order to validate the questionnaire, a cross-sectional study was conducted with a sample of 2710 adolescents between 11 and 12 years of age, the piloting of the questionnaire was carried out in September 2022 with a focus group, and the programming of the anthropometric measurements was established with the Federal Educational Authority of CDMX, as well as the application of the questionnaire to 33 schools, with these activities being scheduled from 7 November 2022 to 3 February 2023 and having an application duration of 15-25 min for each of the groups to which it was applied; the questionnaire that was applied consists of 31 questions that refer to the frequencies, quantity, or performance of behaviors related to the frequency and type of food, type of physical activity and behaviors related to the act of eating referring to the place where it is carried out (home or away from home) and with whom it is carried out (alone or in company), and about the individual's lifestyle. Subsequently, the reliability of the instrument was evaluated using Cronbach's alpha coefficient, and an exploratory factor analysis was conducted to determine the structure of the questionnaire. The results obtained showed that the questionnaire was adequately reliable (α = 0.778) with an eight-factor structure: four questions on mealtime frequencies, four questions on physical activity and lifestyles, six questions on the consumption of high-calorie foods, four questions on company and food consumption, four questions on the consumption of vegetables and fruits, four questions on the place of food consumption, two questions on the consumption of alcoholic beverages, and three questions on the consumption of sugary drinks, plain water, and milk. In conclusion, the self-report questionnaire on eating and physical activity habits among adolescents in Mexico City is reliable, has adequate internal consistency, and can therefore be used as a useful tool for the evaluation of eating and physical activity habits in this population.

Public Health Implications of Wasting and Stunting Relationship in Children under Five Years Highly Vulnerable to Undernutrition in Guatemala: The REDAC Study.

(1) Background: Guatemala is the Latin American country with the highest prevalence of childhood stunting. Short height can bias the diagnosis of wasting when using the weight-for-height indicator. The aim of this study was to evaluate the diagnostic concordance of the anthropometric indicators of wasting and the relationship between wasting and stunting in children from highly vulnerable communities in Guatemala. (2) Methods: The sample consisted of 13,031 anthropometric records of children under five years of age (49.5% girls, average age of 27.9 months), including weight, height, and mid-upper arm circumference (MUAC), collected in March-August 2019. The proportions of stunting, underweight, and wasting, assessed by three different indicators, as well as their concurrence through the Composite Index of Anthropometric Failure were calculated. (3) Results: Stunting affected 73% of the sample, and 74.2% showed anthropometric failure. Wasting varied by indicator (weight-for-height: 2.8%; MUAC: 4.4%; MUAC-for-age: 10.6%). Concordance between MUAC and weight-for-height was very low (Kappa: 0.310; sensitivity: 40.9%). MUAC identified more wasted children in the stunted group (53.6% vs. 26.5%), while the opposite occurred in the non-stunted group (34.8% vs. 46.7%). (4) Conclusion: The presence of stunting affected the diagnosis of wasting, and both indicators should be included as diagnostic criteria for screening campaigns and in the treatment of moderate to acute wasting in vulnerable populations affected by multiple forms of undernutrition.

Personalized assessment of the cumulative complication risk of the atrial fibrillation ablation track: The AF-TRACK calculator.

Background: Atrial fibrillation (AF) ablation strategy is associated with a non-negligible risk of complications and often requires repeat procedures (AF ablation track), implying repetitive exposure to procedural risk. Objective: The purpose of this study was to develop and validate a model to estimate individualized cumulative risk of complications in patients undergoing the AF ablation track (Atrial Fibrillation TRAck Complication risK [AF-TRACK] calculator). Methods: The model was derived from a multicenter cohort including 3762 AF ablation procedures in 2943 patients. A first regression model was fitted to predict the propensity for repeat ablation. The AF-TRACK calculator computed the risk of AF ablation track complications, considering the propensity for repeat ablation. Internal (cross-validation) and external (independent cohort) validation were assessed for discrimination capacity (area under the curve [AUC]) and goodness of fit (Hosmer-Lemeshow [HL] test). Results: Complications (N = 111) occurred in 3.7% of patients (2.9% of procedures). Predictors included female sex, heart failure, sleep apnea syndrome, and repeat procedures. The model showed fair discrimination capacity to predict complications (AUC 0.61 [0.55-0.67]) and likelihood of repeat procedure (AUC 0.62 [0.60-0.64]), with good calibration (HL χ2 12.5; P = .13). The model maintained adequate discrimination capacity (AUC 0.67 [0.57-0.77]) and calibration (HL χ2 5.6; P = .23) in the external validation cohort. The validated model was used to create the Web-based AF-TRACK calculator. Conclusion: The proposed risk model provides individualized estimates of the cumulative risk of complications of undergoing the AF ablation track. The AF-TRACK calculator is a validated, easy-to-use, Web-based clinical tool to calibrate the risk-to-benefit ratio of this treatment strategy.

Pharmacological Cardioversion after Pre-Treatment with Antiarrythmic Drugs Prior to Electrical Cardioversion in Persistent Atrial Fibrillation: Impact on Maintenance of Sinus Rhythm.

BACKGROUND: Antiarrhythmic drugs (AADs) are frequently initiated in patients with persistent atrial fibrillation (AF) prior to electrical cardioversion (ECV), achieving pharmacological cardioversion (PCV) in some cases. Little is known about the mode of cardioversion and the effect of the type of AAD used in the maintenance of sinus rhythm (SR). METHODS: From three national surveys of patients with persistent AF referred for ECV, we selected those who were pre-treated with AADs (amiodarone or group Ic AADs). We analyzed the effect of the type of cardioversion (pharmacological vs. electrical) and the AAD used in the maintenance of SR at three months. RESULTS: Among the 665 patients selected, 151 had a successful PCV prior to the planned ECV. In the remaining 514 patients, 460 had a successful ECV. A successful PCV was related to a higher rate of SR maintenance than a successful ECV (77.9% vs. 57.5%; p < 0.0001). After a successful PCV, the maintenance of SR was identical in those patients treated with amiodarone and those treated with group Ic AADs (77.4% vs. 77.5%; p = 0.99), whereas after a successful ECV, amiodarone was clearly superior to group Ic AADs (61.3% vs. 43.0%; p = 0.001). Considering patients with successful PCV and ECV together, PCV was an independent factor related to the maintenance of SR. CONCLUSIONS: In patients with persistent AF, successful PCV selects a subgroup with a high probability of maintenance of SR. With regard to drugs, amiodarone was superior to group Ic AADs in patients with ECV, whereas in PCV, no differences were observed.

Prognostic value of implantable defibrillator-computed respiratory disturbance index: The DASAP-HF study.

BACKGROUND: Sleep apnea, as measured by polysomnography, is associated with adverse outcomes in heart failure. The DASAP-HF (Diagnosis and Treatment of Sleep Apnea in Patient With Heart Failure) study previously demonstrated that the respiratory disturbance index (RDI) computed by the ApneaScan algorithm (Boston Scientific) accurately identifies severe sleep apnea in implantable cardioverter-defibrillator (ICD) patients. OBJECTIVE: The purpose of the long-term study phase was to assess the incidence of clinical events after 24 months and investigate the association with RDI values. METHODS: Patients with left ventricular ejection fraction ≤35% implanted with an ICD were enrolled and followed-up for 24 months. The RDI calculated at 1 month after implantation was used to stratify patients (below or above 30 episodes/h). The endpoints were all-cause death and a combination of all-cause death or cardiovascular hospitalization. RESULTS: Of the 265 enrolled patients, 224 had usable RDI values. Severe sleep apnea (RDI ≥30 episodes/h) was diagnosed in 115 patients (51%). These patients were more frequently male (84% vs 72%; P = .030) and had higher creatinine levels. During median follow-up of 25 months, 19 patients (8%) died. Cardiovascular hospitalizations were reported in 19 patients (8%). The risk of all-cause death was higher in patients with RDI ≥30 episodes/h (hazard ratio [HR] 3.33; 95% confidence interval [CI] 1.35-8.21; P = .023), as well as the risk of all-cause death or cardiovascular hospitalization (HR 1.94; 95% CI 1.01-3.76; P = .048). At multivariate analysis, independent predictors of death were RDI ≥30 episodes/h (HR 4.02; 95% CI 1.16-13.97; P = .029) and creatinine levels (HR 2.36; 95% CI 1.26-4.42; P = .008). CONCLUSION: In heart failure patients implanted with an ICD, higher RDI values are associated with death and cardiovascular hospitalizations. Device-detected severe sleep apnea independently predicts death.

Ivabradine for chronic heart rate control in persistent atrial fibrillation. Design of the BRAKE-AF project.

INTRODUCTION AND OBJECTIVES: Ivabradine is an inhibitor of the If channel, the main determinant of the pacemaker function of the sinus node. The drug has been approved for the treatment of angina and heart failure. There is some evidence of its role as an inhibitor of atrial-ventricular node (AVN) conduction. The aim of the BRAKE-AF project is to assess ivabradine use for rate control in atrial fibrillation (AF). METHODS: A multicenter, randomized, parallel, open-label, noninferiority phase III clinical trial will be conducted to compare ivabradine vs digoxin in 232 patients with uncontrolled permanent AF despite beta-blockers or calcium channel blockers. The primary efficacy endpoint is the reduction in daytime heart rate measured by 24-hour Holter monitoring at 3 months. This clinical trial will be supported by an electrophysiological study of the effect of ivabradine on the action potential of the human AVN. To do this, an experimental model will be used with Chinese hamster ovarium cells transfected with the DNA encoding the expression of the t channels involved in this action potential and recording of the ionic currents with patch clamp techniques. RESULTS: New data will be obtained on the effect of ivabradine on the human AVN and its safety and efficacy in patients with permanent AF. CONCLUSIONS: The results of the BRAKE-AF project might allow inclusion of ivabradine within the limited arsenal of drugs currently available for rate control in AF. CLINICAL TRIAL REGISTRATION: http://www.clinicaltrials.gov. Identifier: NCT03718273.

Quality of life of patients undergoing conventional vs leadless pacemaker implantation: A multicenter observational study.

BACKGROUND: Leadless pacemakers (L-PM) are an emerging effective and safe technology that offer an alternative to conventional pacemakers (C-PM) for right ventricular stimulation. However, there is little information about their potential benefits for quality of life (QoL) in patients with L-PM. We compared QoL between patients with L-PM and C-PM. METHODS: The study population comprised patients undergoing single chamber pacemaker implantation from December 2016 to March 2018. The SF-36 questionnaire was used to evaluate QoL at baseline and at 6 months of followup. We also used a questionnaire consisted of 10 specific questions related to the implant procedure. RESULTS: A total of 106 patients (64 C-PM; 42 L-PM) were included. There were no differences in baseline characteristics between the groups (C-PM vs L-PM), except for age (81.5 vs 77.3 years; P = .012) and diabetes (38% vs 17%; P = .021). Baseline SF-36 scores did not differ between the groups. At 6 months followup, patients in the L-PM group scored significantly higher on physical function (63 vs 42; P < .001), physical role (64 vs 36; P = .004), and mental health (75 vs 65; P = .017), even after adjusting for covariates. Pacemaker-related discomfort and physical restrictions were significantly lower for the L-PM group. CONCLUSION: L-PM is associated with better QoL than C-PM in both physical and mental health. Patients undergoing L-PM implantation reported less procedure-related discomfort, physical restriction, and preoccupation.

Diagnosis-to-ablation time in atrial fibrillation: A modifiable factor relevant to clinical outcome.

INTRODUCTION: Recurrences after atrial fibrillation (AF) ablation are still common. Among the reported clinical and imaging predictors of recurrences, diagnosis-to-ablation time (DAT) has been defined as a predictor of ablation outcome in single-center studies. We aimed to validate DAT in a multicenter real-life cohort. METHODS: This was a multicenter study including consecutive patients undergoing first paroxysmal and persistent AF ablation with radiofrequency or cryoballoon catheters during 2013. Cox proportional hazard regression models were performed to identify predictors of recurrence. RESULTS: In total, 309 patients were included across nine centers (71% men, 57 ± 10 years old, 46% with hypertension, and 66% with CHA2 DS2 -VASc ≤ 1). Most patients had paroxysmal AF (67%) and underwent radiofrequency ablation (68%) with a median DAT of 51 (43) months. Patients with DAT ≤ 1 year (16.6%) were less likely to have repeat procedures (4% vs 18%; P = .017). The adjusted proportional hazards Cox model identified hypertension (P = .005), heart failure (P = .011), nonparoxysmal AF (P = .038), DAT > 1 year (P = .007), and LA diameter (P = .026) as independent predictors for AF recurrence. DAT > 1 year was the only modifiable factor independently associated with recurrence (HR 4.2 [95% CI, 1.5-11.9]) CONCLUSION: Diagnosis-to-ablation time is a modifiable factor independently associated with recurrent arrhythmia and repeat ablation after first AF ablation. An early intervention strategy during the first year from AF diagnosis might improve outcomes.

An "inappropriately appropriate" shock in a subcutaneous implantable cardioverter-defibrillator: The importance of the SMART pass algorithm.

We report on a case of a 78-years-old patient with a subcutaneous implantable cardioverter defibrillator (S-ICD) and an episode of a sustained ventricular tachycardia (VT) at a rate slower than the programmed shock zone. Because of T-wave oversensing the device interpreted it as fast VT that triggered the delivery of an "inappropriately appropriate shock" that terminated it. The patient had again more VT episodes but after programming the SMART pass algorithm (previously programmed "OFF") the device showed no longer frequent T-wave oversensing and no additional inappropriate shocks occurred.

Left atrial geometry and outcome of atrial fibrillation ablation: results from the multicentre LAGO-AF study.

Aims: Left atrial (LA) remodelling is a key determinant of atrial fibrillation (AF) ablation outcome. Optimal methods to assess this process are scarce. LA sphericity is a shape-based parameter shown to be independently associated to procedural success. In a multicentre study, we aimed to test the feasibility of assessing LA sphericity and evaluate its capability to predict procedural outcomes. Methods and results: This study included consecutive patients undergoing first AF ablation during 2013. A 3D model of the LA chamber, excluding pulmonary veins and LA appendage, was used to quantify LA volume (LAV) and LA sphericity (≥82.1% was considered spherical LA). In total, 243 patients were included across 9 centres (71% men, aged 56 ± 10 years, 44% with hypertension and 76% CHA2DS2-VASc ≤ 1). Most patients had paroxysmal AF (66%) and underwent radiofrequency ablation (60%). Mean LA diameter (LAD), LAV, and LA sphericity were 42 ± 6 mm, 100 ± 33 mL, and 82.6 ± 3.5%, respectively. Adjusted Cox models identified paroxysmal AF [hazard ratio (HR 0.54, P = 0.032)] and LA sphericity (HR 1.87, P = 0.035) as independent predictors for AF recurrence. A combined clinical-imaging score [Left Atrial Geometry and Outcome (LAGO)] including five items (AF phenotype, structural heart disease, CHA2DS2-VASc ≤ 1, LAD, and LA sphericity) classified patients at low (≤2 points) and high risk (≥3 points) of procedural failure (35% vs. 82% recurrence at 3-year follow-up, respectively; HR 3.10, P < 0.001). Conclusion: In this multicentre, real-life cohort, LA sphericity and AF phenotype were the strongest predictors of AF ablation outcome after adjustment for covariates. The LAGO score was easy to implement, identified high risk of procedural failure, and could help select optimal candidates. Clinical Trial Registration Information: NCT02373982 (http://clinicaltrials.gov/ct2/show/NCT02373982).

Delta of the local ventriculo-atrial intervals at the septal location to differentiate tachycardia using septal accessory pathways from atypical atrioventricular nodal re-entry.

Aims: Tachycardia mediated by septal accessory pathways (AP) and atypical atrioventricular nodal re-entry (AVNRT) require careful electrophysiologic evaluation for differential diagnosis. We aim to describe the differential behaviour of local ventriculo-atrial (VA) intervals which predicts the tachycardia mechanism. Methods and results: The local VA intervals at the para-Hisian septum were measured under three different situations: (i) tachycardia; (ii) sustained entrainment from the right ventricular apex (RVA); and (iii) continuous pacing from the RVA during sinus rhythm. Differences were computed as follows: Δ-VAentr = VA during entrainment - VA during tachycardia; and Δ-VApac = VA while pacing during sinus rhythm - VA during tachycardia. In contrast to AVNRT, we hypothesized that an invariable retrograde conduction through the septal AP will keep the result of the subtractions close to 0 ms in cases of ortodromic atrioventricular re-entrant tachycardia (AVRT). We analysed 55 atypical AVNRT (45% posterior type) and 82 AVRT (10 anteroseptal, 18 para-Hisian, 12 mid-septal, and 42 posteroseptal). Δ-VAentr was longer for AVNRT (98.5 ± 40.3 ms) compared with septal AP (-5.7 ± 19.3 ms; P < 0.001). A value of 50 ms showed 98.7% sensitivity and 92% specificity (AUC 0.99; 95% CI 0.98-1). According to physiological criteria, a negative Δ-VAentr remains unobserved in the case of AVNRT (positive predictive value 100% for septal AP). Δ-VApac was also longer for AVNRT (66.5 ± 14.6 ms) compared with septal AP (-9.7 ± 3.3 ms; P < 0.001). A value of 50 ms showed 100% sensitivity and 74% specificity (AUC 0.86; 95% CI 0.76-0.93). Conclusions: Delta of the local VA intervals enables distinction between atypical AVNRT and AVRT mediated by septal AP.

Implantable cardioverter-defibrillator-computed respiratory disturbance index accurately identifies severe sleep apnea: The DASAP-HF study.

BACKGROUND: Sleep apnea (SA) is a relevant issue in the management of patients with heart failure for risk stratification and for implementing treatment strategies. OBJECTIVE: The purpose of this study was to evaluate in patients with implantable cardioverter-defibrillators (ICDs) the performance of the respiratory disturbance index (RDI) computed by the ApneaScan algorithm (Boston Scientific Inc., Natick, MA) as a discriminator of severe SA. METHODS: ICD-indicated patients with left ventricular ejection fraction ≤35% were enrolled. One month after implantation, patients underwent a polysomnographic study. We evaluated the accuracy of the RDI for the prediction of severe SA (apnea-hypopnea index [AHI] ≥30 episodes/h) and the agreement between RDI and AHI during the sleep study night. RESULTS: Two hundred sixty-five patients were enrolled to obtain the required sample of 173 patients with AHI and RDI data for analysis. The mean AHI was 21 ± 15 episodes/h and severe SA was diagnosed in 38 patients (22%), while the mean RDI was 33 ± 13 episodes/h. On the basis of the receiver operating characteristic curve analysis of RDI values, the area under the curve was 0.77 (95% confidence interval [CI] 0.70-0.83; P < .001). At an RDI value of 31 episodes/h, severe SA was detected with 87% (95% CI 72%-96%) sensitivity and 56% (95% CI 48%-66%) specificity. RDI closely correlated with AHI recorded during the same night (r = 0.74; 95% CI 0.57-0.84; P < .001), and the Bland-Altman agreement analysis revealed a bias of 11 episodes/h, with limits of agreement being -10 to 32 episodes/h. CONCLUSION: The RDI accurately identified severe SA and demonstrated good agreement with AHI. Therefore, it may serve as an efficient tool for screening patients at risk of SA.

Training Primary Health Professionals in Breast Cancer Prevention: Evidence and Experience from Mexico.

To analyze the key successful factors of a national educational strategy for early breast cancer detection developed in Mexico for primary health care personnel from 2008 to 2014, an educational strategy to train physicians, nurses, health promoters, and medical students from local ministries of health with a competency-based approach was developed and implemented using diverse educational modalities, face-to-face, blended, and a massive open online course (MOOC). Formative and summative evaluations were used during the implementation of the course. A total of 19,563 health professionals were trained from 2008 to 2014. The graduation rate, an average of all educational modalities, was 91 %, much higher than those previously reported in the literature. The factors that might have influenced this success were (1) the training strategy, which was designed according to the characteristics and specific needs of the target groups; (2) the political will and commitment of the country's health authorities; (3) the technological and educational models used; and (4) the punctual follow-up of participants. This study shows that carefully designed educational interventions can improve service professionals' competencies and that regardless of the modality, face-to-face, blended learning, or MOOC, high graduation rates can be achieved. Further evaluation is required to demonstrate that the competencies remained in all target groups after 6 months of the intervention and that the women served by the trained personnel were provided accurate information and timely diagnoses of breast cancer.