Syncope in Athletes: A Prelude to Sudden Cardiac Death?

Athletes are generally healthy but might have certain cardiac disorders which might, during athletic participation or training, result in cardiac symptoms including syncope. Vasovagal syncope is probably the most common cause of syncope in athletes, but syncope in the context of these cardiac disorders might be a warning of sudden death.

Heart rate and death and hospitalization for heart failure in patients with persistent or permanent atrial fibrillation: Insights from the ARISTOTLE trial.

Rate control is fundamental in the treatment of patients with atrial fibrillation (AF). The independent association of heart rate with outcomes and range of heart rate associated with best outcomes remains uncertain. We assessed the relationship between heart rate and clinical outcomes in patients with persistent or permanent AF enrolled in the randomized, double-blind ARISTOTLE trial. In patients with persistent or permanent AF, a faster heart rate is associated with a modest, but statistically significant increase in death and heart failure hospitalizations. TRIAL REGISTRATION: ClinicalTrials.gov (NCT00412984).

Trends in Oral Anticoagulant Use Among 436 864 Patients With Atrial Fibrillation in Community Practice, 2011 to 2020.

Background Among patients with nonvalvular atrial fibrillation (AF) and an elevated stroke risk, guidelines recommend direct oral anticoagulants (DOACs) over warfarin for stroke prevention. Changes in DOAC use over the past decade have not been well described. Methods and Results We evaluated trends in use of DOACs and warfarin from 2011 to 2020 among adults with AF and a CHA2DS2-VASc score ≥2 based on electronic health record data from 88 health systems in the United States contributing to Cerner Real World Data. The use of DOACs and warfarin was described over time, by age, sex, race, and ethnicity, and at the health-system level. We identified 436 864 patients with AF at risk for stroke (median age, 78 years; 52.1% men). From 2011 to 2020, overall anticoagulation rates increased from 56.3% to 64.7%, as DOAC use increased steadily (from 4.7% to 47.9%), while warfarin use declined (from 52.4% to 17.7%). DOAC uptake was similar across age, sex, and race and ethnicity groups but varied by health system. In 2020, the median health-system-level proportion of patients with AF on a DOAC was 49% (interquartile range, 40%-54%). Conclusions Over the past decade, anticoagulation rates for patients with AF have increased modestly as DOACs largely replaced warfarin, though significant gaps remain: One in 3 high-risk patients with AF is not on any anticoagulant. While DOAC adoption was generally consistent across major demographic groups, use between health systems remained highly variable, suggesting that provider and system factors influence DOAC uptake use more than patient-level factors.

Cross stimulation and unusual ventricular activation in a patient with dual chamber pacemaker.

Cross stimulation is defined as stimulation of one cardiac chamber when the stimulation of the other chamber is expected. We present a case of an eighty three year old patient with history of dual chamber pacemaker implantation with recent generator change which showed interesting ECG findings.

Siddha fasting in obese acute decompensated heart failure may improve hospital outcomes through empowerment and natural ketosis.

BACKGROUND: Morbid obesity (BMI > 35 kg/m2 with comorbid conditions) is present in 25 - 35% of acute decompensated heart failure (AHF) patients. Prevalence of HF increases with duration of morbid obesity from 30% at 15 years to over 90% at 30 years. There is a need to develop pragmatic therapies that address the unique physical and mental challenges faced by obese AHF patients. Siddha is 5,000 year old Tamil Medicine using yoga and mind-body methods towards higher consciousness. Hunger gratitude Experience (HUGE) is intuitive Siddha fasting method which may improve in-hospital AHF outcomes independent of weight reduction. CASE SUMMARY: We present 5 cases of morbidly obese patients with cardiorenal syndrome (CRS) that began intermittent fasting either during their AHF hospitalization or in the outpatient setting for refractory symptoms despite hospitalization. Initiation of fasting correlated with reduction of respiratory distress and edema as well as improvements in psychological wellbeing and functional capacity. DISCUSSION: Siddha fasting mediates hemodynamic and anti-inflammatory effects through natural ketosis and psychological benefits through empowerment in AHF. Potential role of fasting in reducing myocardial workload, coronary steal, angina, volume overload, and CRS needs further study in cardiac patients.

Siddha fasting in morbidly obese heart failure patients achieves significant weight loss and reduces hospitalization.

Two thirds of heart failure (HF) patients are overweight or obese. Current guidelines are unclear about weight reduction goals. We explored impact of Heartful Living (HL,) a cardiologist-led Self-Inquiry (Si) mindfulness program targeting deeper insight and resilience to promote intentional weight loss in morbidly obese HF patients. The primary outcome was >10% intentional weight loss in HF achieved in 6 males and 4 females, BMI 40 (± 8.11)Kg/m2, age of 67.1 (± 10.02) years, who participated in HL and were followed for 10 months to 3 years. Two patients had systolic dysfunction, with a reduced ejection fraction of 25 and 40%. All had diabetes (7) or metabolic syndrome (3). The fasting was unsupervised, at home and intuitive without prespecified parameters. The average weight loss through HUGE fasting was 17.5% of total body weight for all 10 patients, and 25.5% for the 5 patients followed over 2 years. Diabetes, hypertension and renal parameters improved allowing reduction of medications. This prospective case series followed ten morbidly obese patients with HF, and demonstrates intentional weight loss can be achieved with mindfulness. Clinical improvement occurs when HF patients reach over 15% weight loss. Prospective studies are needed to evaluate outcomes in broader HF populations.

Ventricular fibrillation due to coronary spasm after pepper spray.

Pepper spray is used as a crowd control agent and for self-defense. It has been thought to be safe; however, 27 persons have died in police custody after exposure to pepper spray. We report on a 21-year-old man, with no underlying heart disease and a normal ECG and echocardiogram in the past, who was pepper sprayed and developed ventricular fibrillation. An admission ECG showed marked ST segment elevation but subsequent coronary arteriography was normal. We hypothesize that pepper spray triggered coronary spasm, resulting in ventricular fibrillation. This report adds to a body of information that pepper spray is dangerous.

Higher initial weight-based heparin dosing is required with direct oral anticoagulants during catheter ablation for atrial fibrillation.

BACKGROUND: Heparin dosing of patients anticoagulated with direct oral anticoagulants (DOACs) undergoing atrial fibrillation (AF) ablation can be challenging as they require more heparin than those on warfarin therapy. We sought to compare periprocedural activated clotting times (ACTs) of patients on warfarin vs. DOAC and determine an optimal weight-based heparin dosage strategy. METHODS: Patients who underwent AF ablation over 28 months were reviewed for type of anticoagulation, intraprocedural heparin dosing, ACTs, and adverse outcomes. A heparin dosing strategy was then tested in a prospective validation cohort. RESULTS: There were 89 patients in the DOAC group and 43 in the warfarin group. Demographics, comorbidities, and complication rates were similar. Mean ACT and percentage of therapeutic ACTs were lower in the DOAC group, most significantly in those with a weight > 90 kg. In DOAC patients, a higher initial heparin bolus ≥ 150 units/kg yielded a higher percentage of therapeutic intraprocedural ACTs (49% ± 10 vs. 29% ± 7, p = 0.0008). In a prospective validation cohort of 25 patients administered an initial heparin bolus ≥ 150 units/kg, the mean ACT was 295 ± 33 and 49% of the ACTs collected were therapeutic, similar to findings of our high-dose retrospective subgroup. CONCLUSION: Patients on DOACs require more heparin during AF ablation to achieve therapeutic ACT. We suggest an initial heparin dose of at least 150 units/kg in this subset of patients, particularly in those with a weight > 90 kg.

Helicobacter pylori infection selectively increases the risk for carotid atherosclerosis in young males.

BACKGROUND AND AIMS: Atherosclerosis is an important contributing factor to cardiovascular mortality. The role of Helicobacter pylori (H. pylori) infection in atherosclerosis is inconsistent and sometimes controversial. The present study aimed to determine if H. pylori infection is associated with carotid atherosclerosis. METHODS: 17,613 males and females with both carotid ultrasonic examination and 13C-urea breath test for H. pylori infection were screened by a major Chinese university hospital from March 2012 to March 2017 for the study. Baseline demographics, cardiac risk factors, and laboratory studies were obtained. After exclusion for pre-specified conditions, 12,836 individuals were included in the analysis, including 8157 men (63.5%) and 4679 women (36.5%). Analysis was also made for 5-year follow-up data of 1216 subjects (869 males and 347 females) with and without H. pylori infection for development and progression of carotid atherosclerosis. RESULTS: After adjusting for age, sex, body mass index, lipid profile, hypertension, renal function, diabetes mellitus, and smoking, H. pylori infection was found as an independent risk factor for carotid atherosclerosis in males under 50 years, but not in older males or females (odds ratio 1.229, 95% CI 1.054-1.434, p = 0.009). Follow-up data analysis showed that the incidence of carotid atherosclerosis from no atherosclerosis to detectable lesions was significantly higher in young males with persistent H. pylori infection than those without H. pylori infection (p = 0.028) after 3 years. CONCLUSIONS: These data suggest that H. pylori infection might be an important risk factor for carotid atherosclerosis in young Chinese males under 50.

Device monitoring in heart failure management: outcomes based on a systematic review and meta-analysis.

Implantable devices have been developed for continuous monitoring of heart failure. We investigated the effect of fluids and hemodynamic monitoring, using these devices, on heart failure clinical outcomes. Literature search was performed January 2000 through May 2017 of studies comparing device monitored patients with control group. Random-effects meta-analysis was used to pool outcomes across the studies. A total of 5,454 patients were included from 14 studies. There was no difference in heart failure (HF)-related admissions rate [odds ratio (OR) 1.25, 95% CI: 0.92-1.69, P=0.15], all-cause mortality (OR 1.21, 95% CI: 0.91-1.61, P=0.20) or combined admission rate and all-cause mortality (OR 1.21, 95% CI: 0.89-1.64, P=0.22) between the device monitored and the control group. In a subgroup analysis including only pressure sensors devices, there was no difference in all-cause mortality (OR 1.04, 95% CI: 0.62-1.74, P=0.89), however, there was a lower admissions rate (OR 1.63, 95% CI: 1.10-2.41, P=0.02). In a subgroup of only impedance monitoring devices, there was no difference in all-cause mortality or admissions rate. Pressure monitoring was associated with lower HF admissions rate. No improvement in these outcomes was noted with impedance monitoring.

International normalized ratio control and subsequent clinical outcomes in patients with atrial fibrillation using warfarin.

We explored associations between INR measures and clinical outcomes in patients with AF using warfarin, and whether INR history predicted future INR measurements. We included patients in ARISTOTLE who were randomized to and received warfarin. Among patients who had events, we included those with ≥ 3 INR values in the 180 days prior to the event, with the most recent ≤ 60 days prior to the event, who were on warfarin at the time of event (n = 545). Non-event patients were included in the control group if they had ≥ 180 days of warfarin exposure with ≥ 3 INR measurements (n = 7259). The median (25th, 75th) number of INR values per patient was 29 (21, 38) over a median follow-up of 1.8 years. A total of 87% had at least one INR value < 1.5; 49% had at least one value > 4.0. The last INRs before events (median 14 [24, 7] days) were < 3.0 for at least 75% of patients with major bleeding and > 2.0 for half of patients with ischemic stroke. Historic time in therapeutic range (TTR) was weakly associated with future TTR (R2 = 0.212). Historic TTR ≥ 80% had limited predictive ability to discriminate future TTR ≥ 80% (C index 0.61). In patients with AF receiving warfarin, most bleeding events may not have been preventable despite careful INR control. Our findings suggest that INRs collected through routine management are not sufficiently predictive to provide reassurance about future time in therapeutic range or to prevent subsequent outcomes, and might be over-interpreted in clinical practice.

Effect of Catheter Ablation vs Antiarrhythmic Drug Therapy on Mortality, Stroke, Bleeding, and Cardiac Arrest Among Patients With Atrial Fibrillation: The CABANA Randomized Clinical Trial.

Importance: Catheter ablation is effective in restoring sinus rhythm in atrial fibrillation (AF), but its effects on long-term mortality and stroke risk are uncertain. Objective: To determine whether catheter ablation is more effective than conventional medical therapy for improving outcomes in AF. Design, Setting, and Participants: The Catheter Ablation vs Antiarrhythmic Drug Therapy for Atrial Fibrillation trial is an investigator-initiated, open-label, multicenter, randomized trial involving 126 centers in 10 countries. A total of 2204 symptomatic patients with AF aged 65 years and older or younger than 65 years with 1 or more risk factors for stroke were enrolled from November 2009 to April 2016, with follow-up through December 31, 2017. Interventions: The catheter ablation group (n = 1108) underwent pulmonary vein isolation, with additional ablative procedures at the discretion of site investigators. The drug therapy group (n = 1096) received standard rhythm and/or rate control drugs guided by contemporaneous guidelines. Main Outcomes and Measures: The primary end point was a composite of death, disabling stroke, serious bleeding, or cardiac arrest. Among 13 prespecified secondary end points, 3 are included in this report: all-cause mortality; total mortality or cardiovascular hospitalization; and AF recurrence. Results: Of the 2204 patients randomized (median age, 68 years; 37.2% female; 42.9% had paroxysmal AF and 57.1% had persistent AF), 89.3% completed the trial. Of the patients assigned to catheter ablation, 1006 (90.8%) underwent the procedure. Of the patients assigned to drug therapy, 301 (27.5%) ultimately received catheter ablation. In the intention-to-treat analysis, over a median follow-up of 48.5 months, the primary end point occurred in 8.0% (n = 89) of patients in the ablation group vs 9.2% (n = 101) of patients in the drug therapy group (hazard ratio [HR], 0.86 [95% CI, 0.65-1.15]; P = .30). Among the secondary end points, outcomes in the ablation group vs the drug therapy group, respectively, were 5.2% vs 6.1% for all-cause mortality (HR, 0.85 [95% CI, 0.60-1.21]; P = .38), 51.7% vs 58.1% for death or cardiovascular hospitalization (HR, 0.83 [95% CI, 0.74-0.93]; P = .001), and 49.9% vs 69.5% for AF recurrence (HR, 0.52 [95% CI, 0.45-0.60]; P < .001). Conclusions and Relevance: Among patients with AF, the strategy of catheter ablation, compared with medical therapy, did not significantly reduce the primary composite end point of death, disabling stroke, serious bleeding, or cardiac arrest. However, the estimated treatment effect of catheter ablation was affected by lower-than-expected event rates and treatment crossovers, which should be considered in interpreting the results of the trial. Trial Registration: ClinicalTrials.gov Identifier: NCT00911508.

Ticagrelor as an Alternative for Clopidogrel-Associated Acute Arthritis.

A 65-year-old Caucasian man was hospitalized for a non-ST-elevation myocardial infarction. On discharge, the patient was started on multiple new medications, including clopidogrel and atorvastatin. Twenty-six days after discharge, he presented to the Emergency Department (ED) with polyarthralgias. He was instructed to stop atorvastatin and to follow up with rheumatology and cardiology clinic. At cardiology clinic follow-up 43 days after ED discharge, clopidogrel was discontinued and patient was switched to ticagrelor. On follow-up one month later, his symptoms had completely resolved. During the next 4 months, patient had routine follow-up due to participation in Cardiopulmonary Rehab and he had no cardiac events or recurrence of joint symptoms. Our patient had no history of arthritis. Because he initially presented with 2 medication classes associated with arthritis, each was withdrawn separately. The temporal association of patient's symptomatic improvement strongly suggests that the arthritis was caused by clopidogrel. Our patient was able to tolerate ticagrelor with complete resolution of his arthritis and no cardiac events. Clopidogrel-induced arthritis is a rare adverse drug event. For patients with a recent drug-eluting stent, alternative antiplatelet therapy with ticagrelor may provide positive cardiac outcomes without similar adverse effects.

Digoxin and Mortality in Patients With Atrial Fibrillation.

BACKGROUND: Digoxin is widely used in patients with atrial fibrillation (AF). OBJECTIVES: The goal of this paper was to explore whether digoxin use was independently associated with increased mortality in patients with AF and if the association was modified by heart failure and/or serum digoxin concentration. METHODS: The association between digoxin use and mortality was assessed in 17,897 patients by using a propensity score-adjusted analysis and in new digoxin users during the trial versus propensity score-matched control participants. The authors investigated the independent association between serum digoxin concentration and mortality after multivariable adjustment. RESULTS: At baseline, 5,824 (32.5%) patients were receiving digoxin. Baseline digoxin use was not associated with an increased risk of death (adjusted hazard ratio [HR]: 1.09; 95% confidence interval [CI]: 0.96 to 1.23; p = 0.19). However, patients with a serum digoxin concentration ≥1.2 ng/ml had a 56% increased hazard of mortality (adjusted HR: 1.56; 95% CI: 1.20 to 2.04) compared with those not on digoxin. When analyzed as a continuous variable, serum digoxin concentration was associated with a 19% higher adjusted hazard of death for each 0.5-ng/ml increase (p = 0.0010); these results were similar for patients with and without heart failure. Compared with propensity score-matched control participants, the risk of death (adjusted HR: 1.78; 95% CI: 1.37 to 2.31) and sudden death (adjusted HR: 2.14; 95% CI: 1.11 to 4.12) was significantly higher in new digoxin users. CONCLUSIONS: In patients with AF taking digoxin, the risk of death was independently related to serum digoxin concentration and was highest in patients with concentrations ≥1.2 ng/ml. Initiating digoxin was independently associated with higher mortality in patients with AF, regardless of heart failure.

Smartphone-based Arrhythmia Detection: Should we encourage patients to use the ECG in their pocket?

The detection of atrial fibrillation (AF) is important for stroke prevention in patients with AF. This paper aimed to investigate the current landscape of smartphone-based arrhythmia detection and monitoring. The current technology can be divided into smartphone-based photoplethysmography (PPG) and smartphone-based single-lead electrocardiograms (ECGs). Our literature review concluded there are currently no validated PPG applications for the detection of arrhythmias available to the general population. However, an initial validation study indicates that the current development in Cardiio Rhythm PPG application, when made available, could provide an accurate and reliable means to detect AF in patients at risk of developing AF. The smartphone-based single-lead ECG devices are more promising. Multiple studies have shown the AliveCor smartphone ECG to be a reliable and accurate means of detecting atrial fibrillation. A drawback is that this device strictly provides data and is not capable of making a diagnosis of atrial fibrillation. The recorded ECG needs to be sent to a physician or medical professional for further review. In conclusion, these devices show promise in arrhythmia assessment, managing patients with AF, and diagnosing AF early in high risk patients. Caution should be used when assessing data provided by these devices, as validation in a real-world setting is still underway.

Anti-thrombotic therapy for atrial fibrillation in patients with chronic kidney disease: Current views.

Chronic kidney disease (CKD) occurs in approximately one-third of patients with non-valvular atrial fibrillation (AF). The presence of CKD, particularly advanced CKD, confers increased risk of both thromboembolism and major bleeding in this group of patients who are already at risk for ischemic stroke and systemic embolism and at risk of bleeding due to anticoagulation. Studies assessing the effect of warfarin on risk of ischemic stroke, systemic embolism, and major bleeding have produced disparate results, particularly in patients with advanced CKD including those treated with hemodialysis. The direct oral anticoagulants (DOAC's) have been studied in patients with stage III (moderate) CKD and appear to be as effective or more effective (dabigatran 150 mg twice daily) than warfarin in preventing ischemic stroke or embolism in this group. Two of the DOAC's, apixaban and edoxaban, confer lower risk of major bleeding than warfarin with appropriate dose adjustments. Substantial gaps exist in our knowledge of anti-thrombotic therapy in patients with AF and CKD, primarily due to exclusion of patients with advanced CKD from randomized controlled trials comparing DOAC's with warfarin.

Effect of Apixaban on All-Cause Death in Patients with Atrial Fibrillation: a Meta-Analysis Based on Imputed Placebo Effect.

PURPOSE: Vitamin K antagonists (VKAs) are the standard of care for stroke prevention in patients with atrial fibrillation (AF); therefore, there is not equipoise when comparing newer oral anticoagulants with placebo in this setting. METHODS: To explore the effect of apixaban on mortality in patients with AF, we performed a meta-analysis of apixaban versus placebo using a putative placebo analysis based on randomized controlled clinical trials that compared warfarin, aspirin, and no antithrombotic control. We used data from two prospective randomized controlled trials for our comparison of apixaban versus warfarin (Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation) and apixaban versus aspirin (Apixaban Versus Acetylsalicylic Acid to Prevent Stroke in Atrial Fibrillation Patients Who Have Failed or Are Unsuitable for Vitamin K Antagonist Treatment). Using meta-analysis approaches, we indirectly compared apixaban with an imputed placebo with respect to the risk of death in patients with AF. We used results from meta-analyses of randomized trials as our reference for the comparison between warfarin and placebo/no treatment, and aspirin and placebo/no treatment. RESULTS: In these meta-analyses, a lower rate of death was seen both with warfarin (odds ratio [OR] 0.74, 95% confidence interval [CI] 0.57-0.97) and aspirin (OR 0.86, 95% CI 0.69-1.07) versus placebo/no treatment. Using data from ARISTOTLE and AVERROES, apixaban reduced the risk of death by 34% (95% CI 12-50%; p = 0.004) and 33% (95% CI 6-52%; p = 0.02), respectively, when compared with an imputed placebo. The pooled reduction in all-cause death with apixaban compared with an imputed placebo was 34% (95% CI 18-47%; p = 0.0002). CONCLUSIONS: In patients with AF, indirect comparisons suggest that apixaban reduces all-cause death by approximately one third compared with an imputed placebo.

The Role of Cardiovascular Implantable Electronic Devices in the Detection and Treatment of Subclinical Atrial Fibrillation: A Review.

Importance: Subclinical atrial fibrillation (AF) is associated with an increased risk for stroke. Observations: Subclinical AF is asymptomatic, short in duration, and usually detected with long-term, continuous monitoring. Most prior studies have explored its consequences using cardiovascular implantable electronic devices (CIEDs). Although current prevalence estimates are derived from study populations with prior CIEDs, 3 trials will assess the time to a first AF diagnosis among patients receiving a CIED for purposes of AF detection. Stroke risk estimates are currently limited to patients with a prior CIED and vary widely, ranging from a hazard ratio of 0.87 (95% CI, 0.58-1.31) to 9.40 (95% CI, 1.80-47.00). Stroke risk pathogenesis may include factors that are proximately causal, upstream risk activators, and risk markers. The treatment of subclinical AF may be a useful stroke prevention strategy; however, no direct evidence of benefit from oral anticoagulation exists in this population. Two ongoing trials will assess the risk and benefit of non-vitamin K oral anticoagulants among patients at high risk for stroke with a previously placed implantable CIED, but without a prior diagnosis of clinical AF. If clinical benefit is proven, then the cost-effectiveness of screening for and the treatment of subclinical AF will require additional study. Conclusions and Relevance: At present, no evidence suggests that implanting a CIED to detect AF or initiating oral anticoagulation therapy among those in whom AF is detected is beneficial. Ongoing and future studies will identify people at high risk for developing subclinical AF and will evaluate the efficacy, safety, and economic value of oral anticoagulation therapy in this population.

Management of bleeding in patients receiving non-vitamin K antagonists.

Anticoagulation with non-vitamin K antagonists (Non vitamin K oral anticoagulant (NOACs)) including dabigatran, rivaroxaban, apixaban and edoxaban is at least as effective as warfarin, has fewer drug and food interactions and does not require monthly monitoring. Although major bleeding with NOACs is infrequent, there remains concern about the ability to effectively treat episodes of major bleeding. New agents have been developed that are capable of providing rapid reversal of the anticoagulation effect of NOACs. Idarucizumab normalises the dilute thrombin time and the ecarin clotting time, both of which are elevated with dabigatran. Andexanet alfa reduces increased anti-factor Xa activity seen with the use of rivaroxaban and apixaban. A universal reversal agent is in development. These agents, unlike agents to reverse the anticoagulation effect of vitamin K antagonists, appear to reverse the specific NOAC anticoagulant. The development of reversal agents is a major advancement in managing bleeding in the era of NOACs. Future studies will be required to determine the impact on important clinical outcomes.