Regional disparities and risk factors of mortality among patients at high risk of sudden cardiac death in emerging countries: a nonrandomized controlled trial.

BACKGROUND: Comprehensive data on patients at high risk of sudden cardiac death (SCD) in emerging countries are lacking. The aim was to deepen our understanding of the SCD phenotype and identify risk factors for death among patients at high risk of SCD in emerging countries. METHODS: Patients who met the class I indication for implantable cardioverter-defibrillator (ICD) implantation according to guideline recommendations in 17 countries and regions underrepresented in previous trials were enrolled. Countries were stratified by the WHO regional classification. Patients were or were not implanted with an ICD at their discretion. The outcomes were all-cause mortality and SCD. RESULTS: We enrolled 4222 patients, and 3889 patients were included in the analysis. The mean follow-up period was 21.6 ± 10.2 months. There were 433 (11.1%) instances of all-cause mortality and 117 (3.0%) cases of SCD. All-cause mortality was highest in primary prevention (PP) patients from Southeast Asia and secondary prevention (SP) patients from the Middle East and Africa. The SCD rates among PP and SP patients were both highest in South Asia. Multivariate Cox regression modelling demonstrated that in addition to the independent predictors identified in previous studies, both geographic region and ICD use were associated with all-cause mortality in patients with high SCD risk. Primary prophylactic ICD implantation was associated with a 36% (HR = 0.64, 95% CI 0.531-0.802, p < 0.0001) lower all-cause mortality risk and an 80% (HR = 0.20, 95% CI = 0.116-0.343, p < 0.0001) lower SCD risk. CONCLUSIONS: There was significant heterogeneity among patients with high SCD risk in emerging countries. The influences of geographic regions on patient characteristics and outcomes were significant. Improvement in increasing ICD utilization and uptake of guideline-directed medical therapy in emerging countries is urgent. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02099721.

Novel scoring system derived from meta-analysis and validated in cohort population for predicting 1-year atrial fibrillation recurrence after cryoballoon catheter ablation: The HeLPS-Cryo score.

BACKGROUND: Atrial fibrillation (AF) recurrence rates in 1 year after cryoballoon ablation catheter (CBCA) are still high. We purposed to identify strong predictors for AF recurrence after the successful CBCA procedure and develop a new scoring system based only on pre-procedural parameters. METHODS: In the derivation phase, a systematic review and meta-analysis identified the strong predictors of AF recurrence after the CBCA. The pooled hazard ratio (HR) was used to create the new scoring system. The second phase validated the new scoring system in the cohort population. RESULTS: A meta-analysis including 29 cohort studies with 16196 participants confirmed that persistent AF, stroke, heart failure, and left atrial diameter (LAD) >40 mm were powerful predictors for AF recurrence after the CBCA procedure. The HeLPS-Cryo (heart failure [1], left atrial dilatation [1], persistent AF [2], and stroke [2]) was developed based on those pre-procedural predictors. It was validated in 140 patients receiving CBCA procedures and revealed excellent predictive performance for 1-year AF recurrence (AUC = 0.8877; 95% CI = 0.8208 to 0.9546). The HeLPS-Cryo score of ≥3 could predict 1-year AF recurrence with sensitivity and specificity of 78.9% and 87.9%, respectively. The positive predictive value was 66.7%, and the negative predictive value was 93.1%. CONCLUSION: The HeLPS-Cryo score can help the physician estimate the probability of 1-year AF recurrence after the successful CBCA procedure. Patients with HeLPS-Cryo score <3 are good candidates for the CBCA procedure.

Impact of amiodarone on plasma concentration of direct oral anticoagulant in patients with atrial fibrillation.

BACKGROUND/PURPOSE: Amiodarone increases exposure of direct oral anticoagulants (DOACs). We aimed to analyze the effects of concurrent amiodarone use on DOAC concentrations and clinical outcomes. METHODS: Patients who were ≥20 years of age, had atrial fibrillation, and took DOAC were enrolled to provide trough and peak samples for DOAC concentration measurements using ultra-high-performance liquid chromatography-tandem mass spectrometry. The results were compared with concentrations reported in clinical trials to define above, within, or under the expected range. The outcomes of interest were major bleeding and any gastrointestinal bleeding. Multivariate logistic regression and Cox proportional hazards model were used to determine the impact of amiodarone on above-range concentration and clinical outcomes, respectively. RESULTS: A total of 722 participants (420 men, 58.2%) were enrolled to provide 691 trough samples and 689 peak samples. Among them, 21.3% concurrently used amiodarone. The proportion of patients with above-range trough and peak concentrations was 16.4% and 30.2%, respectively, for amiodarone users, in contrast to 9.4% and 19.8% for amiodarone non-users. The use of amiodarone was associated with above-range trough and peak concentrations (odds ratio [OR] = 2.00 [1.16, 3.47] and 1.82 [1.19, 2.79], respectively). However, amiodarone was not a significant predictor of major bleeding or any gastrointestinal bleeding. CONCLUSION: Concurrent amiodarone use led to increased DOAC concentration but was not associated with a higher risk of major bleeding or any gastrointestinal bleeding. Therapeutic monitoring of DOAC users concurrently taking amiodarone may be recommended for patients with an additional risk of increased DOAC exposure.

On-Table Catheter-Based Neurosalvage Performed by Cardiologists for Embolic Complication during an Endovascular Procedure.

Objectives: To report our experience and clinical results of neurosalvage techniques, performed by interventional cardiologists without moving the patient, to manage cerebral thromboembolic complications. Background: Iatrogenic emboli may be released during an endovascular procedure, causing permanent neurological complications and catastrophic outcomes. Methods: Between July 2013 and December 2017, a total of eight patients suffered from embolic complications during endovascular procedures (two radiofrequency catheter ablation, five coronary angiogram/angioplasty, and one subclavian artery angioplasty). Catheter-based neurosalvage was attempted by experienced interventional cardiologists promptly in the same catheterization room. Results: The embolized locations were the M1 segment of the middle cerebral artery in four patients, the M2/M3 segments in three, and the basilar artery in one. Access to the supra-aortic vessels was achieved. Local intra-arterial thrombolysis was given in five patients (63%) and balloon angioplasty in three (38%). Intra-arterial thrombectomy with a stent retriever was attempted in three patients but failed in one. A combination of different techniques was used in three patients (38%). Final thrombolysis in cerebral infarction grade 3 flow was achieved in seven patients (88%). Favorable clinical outcomes at 1-month follow-up (modified Rankin scale of 0-2) were observed in seven patients (88%), and none of the patients had died at 12 months. Conclusions: Our experience demonstrated that acute embolic complications during an endovascular procedure can be salvaged by interventional cardiologists with acceptable angiographic and clinical results.

Minimal Fluoroscopic Catheter Ablation for Adult Patients with Paroxysmal Supraventricular Tachycardia without the Assistance of Intracardiac Echocardiography.

Background: Radiation exposure during fluoroscopic procedures increases the risk of cancer for both patients and operators. Objectives: The aim of this study was to investigate the safety and efficacy of adopting a three-dimensional electroanatomical mapping (3D EAM) system during ablation for paroxysmal supraventricular tachycardia (PSVT), without the assistance of intracardiac echocardiography (ICE), for both right- and left-chamber cardiac procedures. Methods: We retrospectively enrolled all patients with PSVT from September 2018 to December 2020. The patients were grouped according to the use of the 3D EAM system (3D-guided group, n = 102 vs. conventional group, n = 226). Results: The acute success rates were high in both groups (100% vs. 99.1%). The fluoroscopy time was significantly lower in the 3D-guided group than in the conventional group (2.4 ± 4.4 vs. 19.0 ± 10.8 min); the procedure time was significantly increased in the 3D-guided group (104.5 ± 29.9 vs. 94.0 ± 31.9 min), and this was associated with the post-electrophysiology test diagnosis after adjustment for multiple variables [standardized B coefficient (ß) 0.188]. There was no learning curve for each electrophysiologist in terms of fluoroscopy and procedure times. Conclusions: The 3D EAM system, without the assistance of ICE, was safe and effective in guiding PSVT ablation in both left- and right-chamber ablation.

Highly efficient magnetic ablation and the contrast of various imaging using biocompatible liquid-metal gallium.

BACKGROUND: Although the powerful clinical effects of radiofrequency and microwave ablation have been established, such ablation is associated with several limitations, including a small ablation size, a long ablation time, the few treatment positioning, and biosafety risks. To overcome these limitations, biosafe and efficient magnetic ablation was achieved in this study by using biocompatible liquid gallium as an ablation medium and a contrast medium for imaging. RESULTS: Magnetic fields with a frequency (f) lower than 200 kHz and an amplitude (H) × f value lower than 5.0 × 109 Am-1 s-1 were generated using the proposed method. These fields could generate an ablation size of 3 cm in rat liver lobes under a temperature of approximately 300 °C and a time of 20 s. The results of this study indicate that biomedical gallium can be used as a contrast medium for the positioning of gallium injections and the evaluation of ablated tissue around a target site. Liquid gallium can be used as an ablation medium and imaging contrast medium because of its stable retention in normal tissue for at least 3 days. Besides, the high anticancer potential of gallium ions was inferred from the self-degradation of 100 µL of liquid gallium after around 21 days of immersion in acidic solutions. CONCLUSIONS: The rapid wireless ablation of large or multiple lesions was achieved through the simple multi-injection of liquid gallium. This approach can replace the currently favoured procedure involving the use of multiple ablation probes, which is associated with limited benefits and several side effects. METHODS: Magnetic ablation was confirmed to be highly efficient by the consistent results obtained in the simulation and in vitro tests of gallium and iron oxide as well as the electromagnetic specifics and thermotherapy performance comparison detailed in this study Ultrasound imaging, X-ray imaging, and magnetic resonance imaging were found to be compatible with the proposed magnetic ablation method. Self-degradation analysis was conducted by mixing liquid gallium in acidic solutions with a pH of approximately 5-7 (to imitate a tumour-containing microenvironment). X-ray diffraction was used to identify the gallium oxides produced by degraded gallium ions.

Increases in repolarization heterogeneity predict left ventricular systolic dysfunction and response to cardiac resynchronization therapy in patients with left bundle branch block.

INTRODUCTION: This study aimed to investigate the association between T-wave morphology and impaired left ventricular ejection fraction (LVEF) in patients with complete left bundle branch block (cLBBB), and the predictive value of T-wave morphology for response to cardiac resynchronization therapy (CRT). METHODS AND RESULTS: We enrolled 189 patients with cLBBB on electrocardiogram performed between January 2007 and December 2011 who underwent standard echocardiography. Repolarization parameters, including the QRS-to-T angle (TCRT), T-wave morphology dispersion (TMD), T-wave loop area (PL), and T-wave residuum (TWR), were reconstructed from digital standard 12-lead electrocardiograms by T-wave morphology analysis. CRT response was defined as ≥15% reduction in left ventricular end-systolic volume at 12 months after CRT implantation. The clinical outcome endpoint was a composite of heart failure hospitalization, heart transplantation, or death during follow up (mean, 5.8 years). On logistic regression, a higher heart rate, longer QRS duration, increased TMD, and larger TWR were all independently associated with LVEF < 40%. Among 40 patients who underwent CRT, those with a larger TMD (P = .007), larger PL (P = .025), and more negative TCRT (P = .015) had better response to CRT. A large TMD (P = .018) and large PL (P = .003) were also independent predictors of the clinical outcome endpoint. CONCLUSIONS: Increases in repolarization heterogeneity in patients with cLBBB are associated with impaired LVEF. A large TMD and large PL may be useful as additional predictors of response to CRT, improving patient selection for CRT.

Outcomes associated with amiodarone and lidocaine for the treatment of adult in-hospital cardiac arrest with shock-refractory pulseless ventricular tachyarrhythmia.

BACKGROUND: To determine the association between amiodarone or lidocaine and outcomes in adult in-hospital cardiac arrest (IHCA) with shock-refractory ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT). METHODS: A retrospective study in a single medical centre was conducted. Patients experiencing an IHCA between 2006 and 2015 were screened. Shock-refractory ventricular tachyarrhythmias were defined as VF/pVT requiring more than one defibrillation attempt. A multivariate logistic regression analysis was used to study the associations between the independent variables and outcomes. RESULTS: A total of 130 patients were included. Among these, 113 patients (86.9%) were administered amiodarone as the first antiarrhythmic agent (amiodarone first) following VF/pVT, and the other patients were administered lidocaine (lidocaine first). The median time to the first defibrillation and first antiarrhythmic drug administration were 2 and 9 min, respectively. The analysis demonstrated that the amiodarone-first group experienced a higher likelihood of terminating the VF/pVT within three shocks (odds ratio: 11.61, 95% confidence interval: 1.34-100.84; p-value = 0.03), as compared with the lidocaine-first group. However, there were no significant differences between the amiodarone- and lidocaine-first groups in sustained return of spontaneous circulation, survival for 24 h, survival, or favourable neurological outcomes at hospital discharge. CONCLUSION: For patients with IHCA and shock-refractory VF/pVT, the adoption of an amiodarone-first strategy seemed to be associated with the termination of VF/pVT using fewer shocks. Nonetheless, because of the small sample size, additional large-scale studies should be conducted to investigate whether this advantage could be translated into a long-term benefit in survival or neurological outcomes.

Clinical Outcomes of Complete Left Bundle Branch Block According to Strict or Conventional Definition Criteria in Patients with Normal Left Ventricular Function.

BACKGROUND: Complete left bundle branch block (cLBBB) is associated with poor outcomes in patients with heart failure (HF) but appears to have minimal effects on cardiovascular (CV) mortality in relatively healthy adults. New criteria to define strict cLBBB have been proposed. OBJECTIVES: The aim of this study was to stratify the potential risk of cLBBB according to conventional or strict criteria in patients with normal ejection fraction (EF). METHODS: Patients with cLBBB from 2010 to 2013 who underwent baseline echocardiography within 1 year and had a left ventricular ejection fraction (LVEF) > 50% were enrolled. A control group of patients without intraventricular conduction abnormalities matched for age and sex was included. Primary outcomes including CV mortality, HF admission, EF reduction of 40%, and total mortality were compared. RESULTS: A total of 137 patients with cLBBB were included, of whom 118 had strict cLBBB. The mean age was 72 ± 15 years and 56.2% were men. With a median follow-up of 4.3 years, normal LVEF patients with cLBBB but without a history of atrial fibrillation had a significantly higher risk of CV mortality (p < 0.001), EF reduction to 40% (p < 0.001), and admission for HF (p < 0.001). A similar risk of CV events was noted for the patients with conventional and strict cLBBB. CONCLUSIONS: In patients with normal EF and without a history of atrial fibrillation, the presence of cLBBB led to a greater risk of CV mortality, HF admission and EF reduction to < 40%. Strict cLBBB carries a similar risk of CV events to conventional cLBBB.

The prevalence and association of patients with impaired left ventricular ejection fraction and complete left bundle-branch block in Taiwan.

BACKGROUND/PURPOSE: A deleterious effect of complete left bundle-branch block (cLBBB) on left ventricular (LV) function has been established. The underutilization of cardiac resynchronization therapy has been noted in Taiwan and the Asian-Pacific area, but the reasons remain unclear. This study aimed to evaluate the prevalence and association of cLBBB and impaired LV ejection fraction (LVEF) in patients at the National Taiwan University Hospital (NTUH). METHODS: We enrolled 164,049 patients who underwent standard 12-lead electrocardiography (ECG) between January 2010 and December 2013 at NTUH. Echocardiographic examinations within one year of the index ECG were analyzed. Baseline clinical characteristics, electrocardiography and ECG parameters, in patients with cLBBB were compared among those with three different LVEFs (EF <35%, 35%≤ EF<50%, and EF ≥50%). Multivariable logistic regression analysis were conducted to identify independent predictors of impaired LVEF in patient with cLBBB. RESULTS: The prevalence of cLBBB was 0.4% (648 patients), and it increased with age. The estimated prevalence of cLBBB and LVEF <35% was about 0.1%. The effects of age on the distributions of patients with cLBBB by three different EF statuses were significantly disparate. In patients with cLBBB aged >80 years, 64% had a normal EF. However, in those aged between 40 and 60 years, the risk of EF <35% was as high as 45%, and the risk of EF <50% was even higher at 60%. CONCLUSION: Patients in Taiwan had a low prevalence of LVEF<35% and cLBBB. About three-fourth of patients with cLBBB did not experience HF events, and 56% of them had a normal LVEF. The development of an effective triage strategy for these patients is warranted.

Improving the utilization of implantable cardioverter defibrillators for sudden cardiac arrest prevention (Improve SCA) in developing countries: Clinical characteristics and reasons for implantation refusal.

BACKGROUND: Despite available evidence that implantable cardioverter defibrillators (ICDs) reduce all-cause mortality among patients at risk for sudden cardiac death, utilization of ICDs is low especially in developing countries. OBJECTIVE: To summarize reasons for ICD or cardiac resynchronization therapy defibrillator implant refusal by patients at risk for sudden cardiac arrest (Improve SCA) in developing countries. METHODS: Primary prevention (PP) and secondary prevention (SP) patients from countries where ICD use is low were enrolled. PP patients with additional risk factors (syncope, ejection fraction < 25%, nonsustained ventricular tachycardia [NSVT], or frequent premature ventricular complexes) were further categorized as "1.5 PP patients." Candidates who declined implantation were asked for reasons for refusal. Baseline factors that may have influenced the implant decision were examined using logistic regression. RESULTS: Among 3892 patients, the implant refusal rate was 46.5% among PP patients (n = 2700), and 10.3% among SP patients (n = 1192). The most common refusal reason was inability to pay for the device (53.8%), followed by not believing in the benefits of the ICD (19.4%). Among PP ICD candidates, those with no syncope, no NSVT, no premature ventricular contractions, shorter QRS duration, no atrial arrhythmias, and no left bundle branch block were more likely to refuse implant. Among SP candidates, a history of cardiovascular surgery and no sinus node dysfunction were significant predictors of ICD refusal. Additionally, countries had significant differences in patient refusal rates among PP and SP groups. CONCLUSION: Implant refusal among PP patients is high in many countries. Increased reimbursement and better awareness of the benefits of an ICD could increase their utilization.

Proarrhythmic risk and determinants of cardiac autonomic dysfunction in collagen-induced arthritis rats.

BACKGROUNDS: Patients with rheumatoid arthritis (RA) have increased risk of sudden cardiac death (SCD), which is two-fold higher than general population. The driving cause of SCD was considered due to lift-threatening arrhythmia where systemic inflammation acts as the pathophysiological basis linking RA to autonomicdysfunction. METHODS: To assess the sympathetic over-activity of "inflammatory reflex", we measured heart rate variability (HRV) in a rat collagen-induced arthritis (CIA) model, whose arthritis is induced in Lewis rats by intradermal injection of emulsion of type II collagen. Single-lead electrocardiogram (ECG) was recorded for 30 min every two days. Time and frequency-domain parameters, detrended fluctuation analysis (DFA), deceleration (DC) and acceleration capacity (AC) were analyzed. RESULTS: Compared with 9 control rats, many of HRV parameters of 9 CIA rats revealed significant different. At the beginning of arthritis, LF/HF was significant higher than controls (1st week: 2.41 ± 0.7 vs. 1.76 ± 0.6, p < 0.05; 2nd week: 2.24 ± 0.5 vs. 1.58 ± 0.5, p < 0.05) indicating intensive inflammatory reflex at the initial phase of inflammation but no significant difference was observed in the following recover phase. The similar trend of DFA parameters was noted. However, the DC appeared progressive lower despite of no significant increase of the LF/HF compared with controls since 4th week. CONCLUSIONS: We observed sympathetic over-activation of inflammatory reflex during early stage of arthritis in CIA rats. The ongoing decline of DC indicated advanced cardiac autonomic dysfunction regardless of remission of acute arthritis.

2016 Guidelines of the Taiwan Heart Rhythm Society and the Taiwan Society of Cardiology for the management of atrial fibrillation.

Atrial fibrillation (AF) is the most common sustained arrhythmia. Both the incidence and prevalence of AF are increasing, and the burden of AF is becoming huge. Many innovative advances have emerged in the past decade for the diagnosis and management of AF, including a new scoring system for the prediction of stroke and bleeding events, the introduction of non-vitamin K antagonist oral anticoagulants and their special benefits in Asians, new rhythm- and rate-control concepts, optimal endpoints of rate control, upstream therapy, life-style modification to prevent AF recurrence, and new ablation techniques. The Taiwan Heart Rhythm Society and the Taiwan Society of Cardiology aimed to update the information and have appointed a jointed writing committee for new AF guidelines. The writing committee members comprehensively reviewed and summarized the literature, and completed the 2016 Guidelines of the Taiwan Heart Rhythm Society and the Taiwan Society of Cardiology for the Management of Atrial Fibrillation. This guideline presents the details of the updated recommendations, along with their background and rationale, focusing on data unique for Asians. The guidelines are not mandatory, and members of the writing committee fully realize that treatment of AF should be individualized. The physician's decision remains most important in AF management.

Improve the prevention of sudden cardiac arrest in emerging countries: the Improve SCA clinical study design.

AIMS: This study aims to demonstrate that primary prevention (PP) patients with one or more additional risk factors are at a similar risk of life-threatening ventricular arrhythmias when compared with secondary prevention (SP) patients, and would receive similar benefit from an implantable cardioverter defibrillator (ICD), or cardiac resynchronization therapy-defibrillator (CRT-D) implant. The study evaluates the benefits of therapy for high-risk patients in countries where defibrillation therapy for PP of SCA is underutilized. METHODS: Enrolment will consist of 4800 ICD-eligible patients from Asia, Latin America, Eastern Europe, the Middle East, and Africa. Upon enrolment, patients will be categorized as SP or PP. Primary prevention patients will be assessed for additional risk factors: syncope/pre-syncope, non-sustained ventricular tachycardia, frequent premature ventricular contractions, and low left ventricular ejection fraction. Those PP patients with one or more risk factors will be categorized as '1.5' patients. Implant of an ICD/CRT-D will be left to the patient and/or physician's discretion. The primary endpoint will compare the appropriate ICD therapy rate between SP and 1.5 patients. The secondary endpoint compares mortality between 1.5 implanted and non-implanted patients. CONCLUSION: The Improve SCA study will investigate a subset of PP patients, believed to be at similar risk of life-threatening ventricular arrhythmias as SP patients. Results may help clinicians identify and refer the highest risk PP patients for ICDs, help local societies expand guidelines to include PP of SCA utilizing ICDs, and provide additional geographical-relevant evidence to allow patients to make an informed decision whether to receive an ICD. TRIAL REGISTRATION: NCT02099721.

Unique clinical characteristics and SCN5A mutations in patients with Brugada syndrome in Taiwan.

BACKGROUND/PURPOSE: Brugada syndrome (BrS) is a hereditable sudden cardiac death (SCD). Mutations in the SCN5A gene (the most common BrS-causing gene) are responsible for 20-25% of this disease in Caucasian populations. However, the prevalence of SCN5A mutations in patients with BrS in the Chinese Han population in Taiwan remains unknown. Therefore, in this study, we investigated the prevalence of the SCN5A mutation in the largest BrS cohort in Taiwan. METHODS: We consecutively enrolled 47 unrelated patients with BrS from medical centers and hospitals in Taiwan between 2000 and 2010. Mutations within all the 27 translated exons, and exon-intron boundaries of the SCN5A-encoded cardiac sodium channel were screened in all patients with BrS using direct sequencing. A total of 500 unrelated healthy volunteers with a normal electrocardiogram were genotyped as a control group. RESULTS: SCN5A genetic variants were identified in 14 of the 47 patients with BrS and four of the 14 patients with BrS had missense mutations (1651 G>A, 1776 C>G, 3578 G>A). The prevalence rate of SCN5A mutations was approximately 8% (4/47), which was significantly lower than that reported in Caucasian populations (20-25%; p = 0.0007). The average age of these 14 BrS patients with SCN5A variants at diagnosis (12 men and 2 women) was 40 ± 13 years. Four patients experienced SCD, and six presented with seizure or syncope. Only three patients (3/14, 21.4%) had a family history of SCD. CONCLUSION: The prevalence of SCN5A mutations in the Chinese Han population in Taiwan may be lower than that reported in the Caucasian populations. In addition, most patients with BrS did not have a family history of SCD.

QTc Heterogeneity in Rest Magnetocardiography is Sensitive to Detect Coronary Artery Disease: In Comparison with Stress Myocardial Perfusion Imaging.

BACKGROUND: Stress nuclear myocardial perfusion imaging (MPI) is an established method for diagnosis and prognosis of coronary artery disease (CAD). However, radiation exposure limits its clinical application. Magnetocardiography (MCG) has been proposed as a non-contact, rapid and non-radiation technique with high reproducibility. The aim of the study was to evaluate the diagnostic efficacy of rest MCG in CAD comparing to stress MPI. METHODS: We prospectively enrolled 55 patients with suspected CAD (64 ± 10 years) who were scheduled for coronary angiography (CA). MCG, stress (201)Tl MPI and CA were performed within 3 months. The spatial distribution maps of QTc interval (21 × 21 in resolution) were derived from a 64-channel MCG system (KRISS, Korea). T-wave propagation mapping, repolarization heterogeneity index with QTc dispersion and smoothness index of QTc (SI-QTc) were analyzed, and the diagnostic criteria for CAD were developed based on the receiver operating characteristic (ROC) curve analysis. RESULTS: Patients with significant CAD (≥ 70% luminal stenosis, n = 36) had higher QTc dispersion and SI-QTc than controls (both p < 0.05). The diagnostic sensitivity and specificity were 0.8330, 0.6842 for QTc dispersion ≥ 79 ms; 0.7778, 0.6842 for SI-QTc ≥ 9.1 ms; and 0.8611, 0.6842 for combination. There was no difference of area under ROC curve by using criteria of QTc dispersion ≥ 79 ms, SI-QTc ≥ 9.1 ms or combination (0.7588, 0.7310, 0.7727, p = NS), and non-inferior to stress MPI (p = NS). CONCLUSIONS: The QTc heterogeneity parameters of rest MCG yield a good sensitivity and acceptable specificity for detection of CAD, and may provide an alternative to stress MPI without stress and radiation. KEY WORDS: Coronary artery disease (CAD); Magnetocardiography (MCG); Myocardial perfusion imaging (MPI); Repolarization.

Outcomes with T-wave discordance of left bundle branch block and preserved or mildly reduced ejection fraction.

AIMS: Left bundle branch block (LBBB) is associated with an increased risk of adverse outcomes for patients with heart failure. The prognosis of LBBB in patients with a preserved ejection fraction (EF) remains controversial. This study investigated the predictive value of T-wave discordance for the prognosis of patients with LBBB and preserved or mildly reduced EF. METHODS AND RESULTS: We enrolled 707 patients with complete LBBB and left ventricular (LV) EF ≥ 40% observed using electrocardiograms (ECGs) and echocardiograms between January 2010 and December 2018. Their serial ECGs were reviewed during the follow-up period. The T-wave pattern was classified as discordant LBBB (dLBBB) or concordant LBBB (cLBBB) according to the 12-lead ECG T-wave morphology. The primary outcome was the composite of cardiovascular death or hospitalization for heart failure during a median follow-up period of 3.1 years. A multivariable Cox regression analysis was used to evaluate the independent predictors of the primary outcome. Patients with dLBBB had more comorbidities, a higher heart rate, a longer QRS and QTc duration, a larger LV end-systolic volume and left atrial dimension, a lower LVEF, and a higher mitral E/A ratio and E/e', compared with those with cLBBB. Older age [hazard ratio (HR) = 1.023, 95% confidence interval (CI) = 1.001-1.046, P = 0.023], history of heart failure (HR = 2.440, 95% CI = 1.524-3.905, P = 0.001), chronic kidney disease (HR = 1.917, 95% CI = 1.182-3.110, P = 0.008), larger LV end-systolic volume (HR = 1.046, 95% CI = 1.017-1.075, P = 0.002), lower LVEF (HR = 0.916, 95% CI = 0.885-0.948, P = 0.001), and presence of dLBBB (HR = 1.63, 95% CI = 1.011-2.628, P = 0.032) were independent predictors of the primary outcome in patients with LBBB and LVEF ≥ 40%. The discordant or concordant T-wave morphology of LBBB could transform from one subtype to the other in up to 23% of the study population during the follow-up period, and individuals with persistent or transformed dLBBB faced an increased risk of cardiovascular death or non-fatal heart failure hospitalization. CONCLUSIONS: In patients with LBBB and EF ≥ 40%, dLBBB serves as an independent predictor of a higher risk of cardiovascular death or non-fatal heart failure hospitalization.

Impact of cerebral small vessel disease burden and drug level at admission on direct oral anticoagulant associated intracerebral hemorrhage.

INTRODUCTION: Direct oral anticoagulant (DOAC)-associated intracerebral hemorrhage (ICH) is a catastrophic complication. The aim of this study was to investigate the association between computed tomography (CT)-based cerebrovascular small vessel disease (SVD) burden and DOAC-ICH as well as the DOAC concentration upon hospital admission and ICH outcome. PATIENTS AND METHODS: The study included two cohorts: (1) DOAC-ICH: patients who suffered from DOAC-ICH and underwent drug level measurements upon admission; (2) DOAC-non-ICH: stable DOAC users who underwent head CT without ICH during treatment. We categorized the DOAC levels of the DOAC-ICH patients as low (<50 ng/mL), medium (50-300 ng/mL), and high (>300 ng/mL). The CT-based SVD burden (including white matter lesions [WML], lacunes, and cerebral atrophy) was evaluated, and SVD scores (range, 0-3) were used to evaluate SVD severity. RESULTS: A total of 43 DOAC-ICH patients and 177 DOAC-non-ICH patients were enrolled. DOAC-ICH patients were more likely to have WML, lacunes, or cerebral atrophy compared to DOAC-non-ICH patients. After adjustment, the SVD burden was associated with DOAC-ICH, with a higher risk of more severe SVD (SVD score of 2; odds ratio [OR], 10.3 [3.17, 33.3]; score of 3; OR, 16.8 [4.50, 62.6]). The proportions of patients with high, medium, and low drug levels in the DOAC-ICH group were 16.3%, 55.8%, and 27.9%, respectively. Additionally, the high-level group displayed a larger hematoma size and had worse functional outcomes at 3 months than the other two groups. DISCUSSION AND CONCLUSION: The severity of SVD burden was associated with DOAC-ICH. Furthermore, high DOAC levels in ICH were associated with unfavorable clinical outcomes. To address the potential selection bias from these two cohorts, a prospective study to investigate the co-contribution of drug levels and SVD to DOAC-ICH is essential.

Sex-based differences in obstructive sleep apnea and atrial fibrillation: Implication of atrial fibrillation burden.

Background: Obstructive sleep apnea (OSA) is a risk factor for atrial fibrillation (AF); however, it is unclear whether AF increases the risk of OSA. Furthermore, sex differences among patients with both AF and OSA remain unclear. We aimed to determine the association between an increased AF burden and OSA and investigate the differences in clinical characteristics between women and men with AF and OSA. Methods: This was a descriptive, cross-sectional analysis from a prospective cohort study. Patients with non-valvular AF were recruited from the cardiac electrophysiology clinic of a tertiary center; they underwent a home sleep apnea test and 14-day ambulatory electrocardiography. Moderate-to-severe OSA was defined as an apnea-hypopnea index of ≥15. Results: Of 320 patients with AF, 53.4% had moderate-to-severe OSA, and the mean body mass index (BMI) was 25.6 kg/m2. Less women (38.2%) had moderate-to-severe OSA than men (59.3%) (p < 0.001). In the multivariate analysis, age, being a man, and BMI were significantly associated with moderate-to-severe OSA. AF burden was associated with moderate-to-severe OSA only in men (odds ratio: 1.008; 95% confidence interval: 1.001-1.014). Women and men with OSA had similar BMI (p = 0.526) and OSA severity (p = 0.754), but women were older than men (70.1 ± 1.3 vs. 63.1 ± 0.9 years, p < 0.001). Women with moderate-to-severe OSA had a lower AF burden than men did (27.6 ± 7.1 vs. 49.5 ± 3.9%, p = 0.009). Conclusions: AF burden is a sex-specific risk factor for OSA and is limited to men. In contrast, women with both AF and OSA have a lower AF burden than men, despite being older and having similar OSA severity and body habitus. Thus, AF may develop later in women with OSA than in men.