Integration of a Smartphone HF-Dedicated App in the Remote Monitoring of Heart Failure Patients with Cardiac Implantable Electronic Devices: Patient Access, Acceptance, and Adherence to Use.

(200 w) Introduction. Remote monitoring (RM) of cardiac implantable electronic device (CIED) diagnostics helps to identify patients potentially at risk of worsening heart failure (HF). Additionally, knowledge of patient HF-related symptoms is crucial for decision making. Patient smartphone applications may represent an ideal option to remotely collect this information. PURPOSE: To assess real-world HF patient access, acceptance, and adherence to use of an HF-dedicated smartphone application (HF app). METHODS: In this study, 10 Italian hospitals administered a survey on smartphone/app use to HF patients with CIED. The subgroup who accepted it downloaded the HF app. Mean 1-year adherence of the HF app use was evaluated. RESULTS: A total of 495 patients (67 ± 13 years, 79% males, 26% NYHA III-IV) completed the survey, of which 84% had access to smartphones and 85% were willing to use the HF app. In total, 311/495 (63%) downloaded the HF app. Patients who downloaded the HF app were younger and had higher school qualification. Patients who were ≥60 years old had higher mean 1-year adherence (54.1%) than their younger counterparts (42.7%; p < 0.001). Hospitals with RM-dedicated staff had higher mean 1-year patient adherence (64.0% vs. 33.5%; p < 0.001). Adherence to HF app decreased from 63.3% (weeks_1-13) to 42.2% (weeks_40-52, p < 0.001). CONCLUSIONS: High access and acceptance of smartphones/apps by HF patients with CIED allow HF app use for RM of patient signs/symptoms. Younger patients with higher school qualifications are more likely to accept HF app; however, older patients have higher long-term adherence.

Implantable cardioverter defibrillators and devices for cardiac resynchronization therapy: what perspective for patients' apps combined with remote monitoring?

INTRODUCTION: Remote monitoring (RM) of cardiac implantable electronic devices (CIED) allows rapid detection of clinical and electrical events. Recently, several smartphone applications have been developed with the aim of improving patient compliance and better interpreting and integrating data deriving from remote control for the management of heart failure (HF). AREAS COVERED: Studies investigating the role of CIEDs' RM in HF patients to predict and early treat acute decompensation. The importance of new technologies and applications developed to provide crucial information to clinicians, to better manage HF patients. EXPERT OPINION: New medical technologies and smartphone applications for CIEDs' RM were developed to help clinicians in the management of CIED carriers. Indeed, the accessibility of technological devices (e.g. smartphones) and the improvements in medical technology provide the opportunity to optimize HF patients' monitoring by the transmission of device-related data, and with direct involvement of patients themselves. Thanks to these advancements, physicians have the possibility to recognize worsening signs of HF and promptly optimize treatments to potentially avoid hospitalization. The great value of this approach is its potential of reducing scheduled in-office visits or unnecessary medical contacts and optimizing healthcare resources management.

Meta-analysis of Clinical Outcomes of Electrical Cardioversion and Catheter Ablation in Patients with Atrial Fibrillation and Chronic Kidney Disease.

BACKGROUND: Chronic kidney disease (CKD) is associated with adverse outcomes in presence of atrial fibrillation (AF). However, the literature shows limited data on non-pharmacological management of AF in CKD patients. AIM: summarizing the available data on outcomes associated with electrical cardioversion (ECV) and AF catheter ablation (CA) in CKD patients. METHODS: We searched MEDLINE and the Cochrane Central Register of Controlled Trials and performed a metaanalysis. The primary outcome was recurrence of AF. The secondary outcomes were occurrence of thromboembolic events (TEs) and estimated glomerular filtration rate (eGFR) modification. RESULTS: Literature search yielded 26 eligible papers: 22 on CA and 4 concerning ECV. CKD patients presented more AF recurrences 30 days after ECV (OR 2.62, 95%CI 1.28-5.34; p <0.001). Patients with eGFR<60-68 ml/min and on dialysis presented a higher incidence of AF recurrences after CA, median follow up 26.0 and 29.9 months (HR 1.75, 95%CI 1.46-2.09, p <0.001; and HR 1.69, 95%CI 1.22-2.33, p <0.001; respectively). Periprocedural TEs were rare and not associated with CKD or dialysis. However, patients with CKD were at increased risk for delayed TEs after CA (HR 2.61, 95%CI 1.04-6.54; p <0.001). No significant modification of eGFR was associated with ECV or CA in the overall population. CONCLUSION: ECV and CA for sinus rhythm restoration/maintenance in AF patients, albeit theoretically promising, seem to be associated with lower efficacy at medium to long-term in patients with CKD. Further studies are needed to better define the role of ECV and CA in CKD.

Cardiolaminopathies from bench to bedside: challenges in clinical decision-making with focus on arrhythmia-related outcomes.

Lamin A/C gene mutations can be associated with cardiac diseases, usually referred to as 'cardiolaminopathies' characterized by arrhythmic disorders and/or left ventricular or biventricular dysfunction up to an overt picture of heart failure. The phenotypic cardiac manifestations of laminopathies are frequently mixed in complex clinical patterns and specifically may include bradyarrhythmias (sinus node disease or atrioventricular blocks), atrial arrhythmias (atrial fibrillation, atrial flutter, atrial standstill), ventricular tachyarrhythmias and heart failure of variable degrees of severity. Family history, physical examination, laboratory findings (specifically serum creatine phosphokinase values) and ECG findings are often important 'red flags' in diagnosing a 'cardiolaminopathy'. Sudden arrhythmic death, thromboembolic events or stroke and severe heart failure requiring heart transplantation are the most dramatic complications of the evolution of cardiolaminopathies and appropriate risk stratification is clinically needed combined with clinical follow-up. Treatment with cardiac electrical implantable devices is indicated in case of bradyarrhythmias (implant of a device with pacemaker functions), risk of life-threatening ventricular tachyarrhythmias (implant of an ICD) or in case of heart failure with wide QRS interval (implant of a device for cardiac resynchronization). New technologies introduced in the last 5 years can help physicians to reduce device-related complications, thanks to the extension of device longevity and availability of leadless pacemakers or defibrillators, to be implanted in appropriately selected patients. An improved knowledge of the complex pathophysiological pathways involved in cardiolaminopathies and in the determinants of their progression to more severe forms will help to improve clinical management and to better target pharmacological and non-pharmacological treatments.

Gender Differences in Post-Traumatic Stress.

Acute stress can trigger cardiovascular events and disease. The earthquake is an "ideal" natural experiment for acute and chronic stress, with impact mainly on the cardiovascular system. On May 20th and 29th, 2012, two earthquakes of magnitude 5.9° to 6.4° on the Richter scale, hit the province of Modena and Reggio Emilia, an area of the north-center of Italy never considered at seismic risk. The purpose of our study was to assess whether there were gender-specific differences in stress-induced incidence of cardiovascular events and age of patients who arrived at the Emergency Departments (ED) of the three main teaching hospitals of the University of Modena and Reggio Emilia. Global access of patients, divided in relation to age, gender, and diagnosis was compared with that one detected in the same departments and in the same interval of time in 2010. The data collected were relative to consecutive cases derived by retrospective chart and acute cardiovascular events were classified according to ICD-9 (International Classification of Diseases, ninth revision). A total of 1,401 accesses were recorded in the year of earthquake versus 530 in 2010 (p ≤ 0.05), with no statistically significant differences in number of cases and mean age in relation to gender, despite the number of women exceeded that of men in 2012 (730 vs. 671); the opposite occurred, in 2010 (328 vs. 202). The gender analysis of 2012 showed a prevalence of acute coronary syndromes (ACSs 177 vs. 73, p ≤ 0.03) in men, whereas women presented more strokes and transient ischemic attacks (TIAs) (90 vs. 94, p ≤ 0.05), atrial fibrillation (120 vs. 49, p ≤ 0.05), deep venous thrombosis and pulmonary embolism (DVT/PE; 64 vs. 9, p ≤ 0.05), panic attacks (124 vs. 26, p ≤ 0.03), aspecific chest pain (122 vs. 18, p ≤ 0.05), TakoTsubo cardiomyopathy (10 vs. 0, p ≤ 0.05), and DVT/PE (61 vs. 3, p ≤ 0.03). The gender analysis of 2010 showed no difference in number of accesses and age, with higher incidence of ACS in men (130 vs. 34, p ≤ 0.05) and aspecific chest pain in women (42 vs. 5, p ≤ 0.05). The analysis between 2012 and the standard period (2010) showed women recurring to ED in larger number with more panic attacks (124 vs. 3, p ≤ 0.01), more atrial fibrillation (120 vs. 40, p ≤ 0.01) and, as a possible consequence, more TIAs and strokes (190 vs. 25, p ≤ 0.005), more TakoTsubo (10 vs. 0, p ≤ 0.05), DVT/PE (61 vs. 3, p ≤ 0.05), and aspecific chest pain (122 vs. 5, p ≤ 0.01). The difference between men's accesses to ED was less striking, but in 2012 men reported more panic attacks (26 vs. none, p ≤ 0.05), more atrial fibrillations, TIAs, and strokes (49 vs. 13, p ≤ 0.05 and 94 vs. 18, p ≤ 0.03). In conclusion, clinical (stress induced) events recorded during and immediately after the 2012 earthquakes were quite different between women and men, although the pathophysiological mechanism was probably the same, consisting acute sympathetic nervous activation, with elevation of blood pressure and heart rate, endothelial dysfunction, platelet and hemostatic activation, increased blood viscosity, and hypercoagulation. Women, in our observation, appeared to be more sensitive and responsive to acute stress, although men also appeared to suffer from stress effects when compared with a standard period, which, nevertheless, reflects in our population the most common epidemiology of gender difference in ED accesses for cardiovascular events.