Comparison of Global Longitudinal Strain in Dual-chamber versus Ventricular Pacemaker in Complete Heart Block.

Context: Bradycardia caused by total atrioventricular block (TAVB) is treated by implantation of permanent pacemakers (PPMs) in either dual-chamber (DDD) versus ventricular (VVI) pacing modes. DDD is considered a more physiological pacing mode than VVI as it avoids atrioventricular dyssynchrony. However, previous trials have failed to demonstrate the superiority of DDD in improving quality of life and morbidity. Aims: This study aims to provide postpacemaker function of the left ventricle (LV) measured with global longitudinal strain (GLS), in TAVB patients. Settings and Design: This is a comparative study; samples included in the study are adult TAVB patients undergoing PPM implantation, without significant heart function, and structural abnormality. Echocardiographic parameters are obtained before, after 1 month, and after 3 months post-PPM. Subjects and Methods: A total of 98 TAVB patients undergoes PPM implantation during the study period, 55 patients were excluded, and in the end, only 43 patients fulfill the inclusion criteria. Statistical Analysis Used: Baseline data between DDD and VVI are compared using unpaired t-test. Statistical significance 1 month post-PPM and 3 months post-PPM is analyzed using paired t-test. Results: There were no significant differences between both groups at baseline. However, significant GLS changes are observed 1 month after PPM in the VVI group (P = 0.002), but no significant change was observed in the DDD group even after 3 months (P = 0.055). Conclusions: In our study, we conclude that DDD is superior in maintaining LV function in the short term in TAVB patients after PPM implantation.

TBX3 transfection and nodal signal pathway inhibition promote differentiation of adipose mesenchymal stem cell to cardiac pacemaker-like cells.

BACKGROUND: Mesenchymal stem cells (MSCs) are known as one of the best candidate cells to produce cardiac pacemaker-like cells (CPLCs). Upregulation of TBX3 transcription factor and inhibition of the nodal signal pathway have a significant role in the formation of cardiac pacemaker cells such as sinoatrial and atrioventricular nodes, which initiate the heartbeat and control the rhythm of heart contractions. This study aimed to confirm the effects of transfection of TBX3 transcription factor and inhibition of the nodal signal pathway on differentiating adipose-derived MSCs (AD-MSCs) to CPLCs. AD-MSCs were characterized using flow cytometry and three-lineage differentiation staining. METHODS: The transfection of TBX3 plasmid was carried out using lipofectamine, and inhibition of the nodal signal pathway was done using the small-molecule SB431542. The morphology of the cells was observed using a light microscope. Pacemaker-specific markers, including TBX3, Cx30, HCN4, HCN1, HCN3, and KCNN4, were evaluated using the qRT-PCR method. For protein level, TBX3 and Cx30 were evaluated using ELISA and immunofluorescence staining. The electrophysiology of cells was evaluated using a patch clamp. RESULTS: The TBX3 expression in the TBX3, SM, and TBX + SM groups significantly higher (p < 0.05) compared to the control group and cardiomyocytes. The expression of Cx40 and Cx43 genes were lower in TBX3, SM, TBX + SM groups. In contrast, Cx30 gene showed higher expression in TBX3 group. The expression HCN1, HCN3, and HCN4 genes are higher in TBX3 group. CONCLUSION: The transfection of TBX3 and inhibition of the nodal signal pathway by small-molecule SB431542 enhanced differentiation of AD-MSCs to CPLCs.

Gender Differences of Gly972Arg Polymorphism of the IRS-1 Gene Related to Cardiovascular Disease Risk Factors Among Indonesians.

BACKGROUND: Cardiovascular disease is driven by traditional risk factors, sex, and genetic differences. The Asian population, specifically Indonesians, has been known at high risk of insulin resistance and endothelial dysfunction. A possible genetic risk factor related to cardiovascular diseases is Gly972Arg polymorphism of insulin receptor substrate 1 (IRS-1) gene, as this impairs endothelial function. To date, whether there is a gender difference in Gly972Arg polymorphism of the IRS-1 gene in Indonesians is unknown. This study aimed to to define whether there is a gender difference in Gly972Arg polymorphism of the IRS-1 gene in Indonesians. METHODS: We studied adults living in two areas (rural and urban) in Indonesia. We collected demographic and clinical data from the study subjects. Gly972Arg polymorphism of the IRS-1 gene (rs1801278) was detected using TaqMan real-time polymerase chain reaction. RESULTS: A total of 378 subjects were recruited. The wild-type allele (CC) was found in 86 (22.8%) subjects, heterozygous mutant allele (CT) in 245 (64.8%), and homozygous mutant allele in 47 (12.4%). The proportion of subjects with T alleles was significantly higher among women than men (54.6% vs. 45.4%, odds ratio: 1.89; p = 0.01). Subjects with T allele more often have hypertension (odds ratio: 1.69, p = 0.058). CONCLUSION: There were a higher proportion of women than men carrying the T allele of Gly972Arg polymorphism among Indonesians. Individuals with the T allele appeared to show a greater prevalence of hypertension. These results may explain a possible mechanism of the high prevalence of metabolic syndrome in Indonesia, especially in women.

Oral Ferrous Sulphate Improves Functional Capacity on Heart Failure Patients with Iron Deficiency Anemia.

Background: Iron deficiency anemia (IDA) in heart failure (HF) is associated with poor functional capacity. Several studies reported the benefit of iron therapy in HF with IDA on improving functional capacity. Therefore, we attempt to investigate the effect of oral iron supplementation on functional capacity in HF patients with IDA. Results: A double blind randomized controlled trial was conducted in National Cardiovascular Center Harapan Kita Hospital Universitas Indonesia. A total of 54 HFREF patients with IDA were enrolled and randomized to either oral Ferrous Sulphate (FS) 200 mg three times a day or placebo with 1:1 ratio for 12 weeks. Primary outcome was functional capacity measured by a six-minute walk test. There were 41 participants completed the study (FS n = 22, placebo n = 19). Ferrous sulphate significantly improved functional capacity changes (46.23 ± 35 m vs -13.7 ± 46 m, p < 0.001, CI -86.8 to -33.2) compared with placebo groups respectively after 12 weeks intervention. Conclusions: Oral FS supplementation for 12 weeks significantly improved functional capacity in HF patients with IDA. Trial registration: clinicaltrials.gov, NCT02998697. Registered 14 December 2016 - Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT02998697.

Rapid Atrial Fibrillation in the Emergency Department.

Atrial fibrillation (AF) is the most common rhythm disorder seen in doctors' offices and emergency departments (EDs). In both settings, an AF holistic pathway including anticoagulation or stroke avoidance, better symptom management, and cardiovascular and comorbidity optimization should be followed. However, other considerations need to be assessed in the ED, such as haemodynamic instability, the onset of AF, the presence of acute heart failure and pre-excitation. Although the Advanced Cardiovascular Life Support guidelines (European Society of Cardiology guidelines, Acute Cardiac Care Association/European Heart Rhythm Association position statements) and several recent AF publications have greatly assisted physicians in treating AF with rapid ventricular response in the ED, further practical clinical guidance is required to improve physicians' skill and knowledge in providing the best treatment for patients. Herein, we combine multiple strategies with supporting evidence-based treatment and experiences encountered in clinical practice into practical stepwise approaches. We hope that the stepwise algorithm may assist residents and physicians in managing AF in the ED.

Simple electrocardiography algorithm for localizing accessory pathway in patients with Wolff-Parkinson-White syndrome.

BACKGROUND: Existing algorithms to predict the location of an accessory pathway (AP) in Wolff-Parkinson-White Syndrome (WPW) have good sensitivity and specificity but complex with various accuracy and inter-observer agreement rates. A simple algorithm with high accuracy and inter-observer agreement rates is needed. METHODS: This was a cross-sectional and retrospective diagnostic study. The data were collected by total population sampling from January 2015 to January 2017. Forty-seven patients were included in the study. Data collected were pre-ablation 12-lead ECGs and ablation reports. These ECGs were evaluated by two independent observers using the simplified algorithm and compared with ablation results. RESULTS: The algorithm had a sensitivity of 45% on the left free wall, 80% on septal, 92% on the right free wall, and the specificity of 96% on the left free wall, 69% on the septal, 85% on the right free wall for AP prediction. The positive predictive value was 90% on the left free wall, 55% on the septal, and 67% on the right free wall APs. The negative predictive value was 70% on the left free wall, 88% on the septal, and 97% on right free wall AP. The positive likelihood ratio was 11.23 on the left free wall, 2.23 on septal and 6.57 on right free wall APs, and the negative likelihood ratio was 0.57 on left free wall APs, 0.28 on septal, and 0.09 on the right free wall APs. Algorithm accuracy varied from 73-87%. Inter-observer agreement calculation was kappa 0.93 for left free wall AP, 0.78 for septal AP, and 0.74 for right free wall AP. CONCLUSION: This simple algorithm has a remarkable accuracy and inter-observer agreement; therefore, it may prove to be helpful even to non-electrophysiologists and has the potential to be integrated into clinical practice.

ECG characteristics of COVID-19 patient with arrhythmias: Referral hospitals data from Indonesia.

Background: Arrhythmia is a significant clinical modifier in COVID-19 patient outcomes. Currently, data on arrhythmia and ECG characteristics in COVID-19 from lower middle-income countries are limited. Methods: COVID-19 was confirmed by polymerase chain reaction testing of a nasopharyngeal sample. All clinical records were systematically evaluated to obtain demographic characteristics and medical comorbidities. The ECG was recorded on admission, in-hospital, and at discharge. Results: Total documented arrhythmia events account for 22% of patients, comprising 6% of new-onset arrhythmia and 16% of existing arrhythmia. Atrial fibrillation is the most common arrhythmia. The ECG changes were a decrease in heart rate (91 ± 22 vs. 83 ± 20, p < .001) and an increase in the QT interval (354.7 ± 53.70 vs. 371.4 ± 59.48 msec, p < .001) from hospital admission to hospital discharge, respectively. The in-hospital HR of 85 bpm or higher increases the risk of death (OR = 2.69, p = .019). Conclusion: The incidence of arrhythmias in COVID-19 patients at COVID-19 referral hospitals in Indonesia is 22%. Atrial fibrillation is the most common arrhythmia in COVID-19 patients. Prolongation of QRS duration from admission to discharge was related to the occurrence of new-onset arrhythmia. The in-hospital HR of 85 bpm or higher increased the risk of death.

Giant lipoma in superior vena cava: A case report and literature review.

INTRODUCTION: Intravascular lipomas are rare occurrences, especially in major vessels. This tumour is composed of adipocytes in a fibrous capsule that has a slow growth rate and usually shows no symptoms. There were only eight reports in the literature regarding intravascular lipoma located in the superior vena cava. CASE PRESENTATION: A 54-year-old man had episodes of supraventricular tachycardia and atrial flutter for over a year. Preoperative radiological findings showed a giant mass that arose from the superior vena cava to the right atrium and a biopsy catheter showed that there were no signs of malignancy. The patient then underwent surgery through median sternotomy and the mass was extirpated on the highest part of the stalk that could be reached. The patient was stable and remained to show no symptoms or evidence of residual mass or stalk in 2 years follow-up. CONCLUSION: The surgical approach in excising lipoma in SVC should be considered wisely with the support of adequate preoperative diagnosis. Since lipoma is a very slow-growing tumour, extensive manipulation that could increase surgical technique difficulty or postoperative morbidity and mortality is not necessary.

2021 Asia Pacific Heart Rhythm Society (APHRS) practice guidance on atrial fibrillation screening.

In this paper, the Asia Pacific Heart Rhythm Society (APHRS) sought to provide practice guidance on AF screening based on recent evidence, with specific considerations relevant to the Asia-Pacific region. A key recommendation is opportunistic screening for people aged ≥65 years (all countries), with systematic screening to be considered for people aged ≥75 years or who have additional risk factors (all countries).

Trainees' perceptions and expectations of formal academic mentoring during the COVID-19 pandemic in Indonesian cardiology residency programs.

PURPOSE: During medical residency programs, physicians develop their professional identities as specialists and encounter high expectations in terms of achieving competencies. The responsibilities of medical trainees include caring for patients, balancing work with personal life, and weathering stress, depression, and burnout. Formal academic mentoring programs strive to ease these burdens. The coronavirus disease 2019 (COVID-19) pandemic has altered the trainee­academic mentor relationship, and solutions are needed to address these challenges. The present study aimed to evaluate the formal academic mentoring process through trainees' perceptions and expectations of formal mentoring programs during COVID-19 in Indonesian cardiology residency programs. METHODS: This cross-sectional study used a self-administered online questionnaire to capture trainees' perceptions and expectations regarding academic mentoring programs in 3 cardiology residency programs in Indonesia from October to November 2020. The questionnaire was developed before data collection. Perceptions of the existing mentoring programs were compared with expectations. RESULTS: Responses were gathered from 169 out of 174 residents (response rate, 97.3%). Most trainees reported having direct contact with COVID-19 patients (88.82%). They stated that changes had taken place in the mode and frequency of communication with their academic advisors during the pandemic. Significant differences were found between trainees' perceptions of the existing mentoring programs and their expectations for academic mentoring programs (P<0.001). CONCLUSION: Despite the challenges of interacting with their academic mentors, trainees still perceived academic mentors as a vital resource. Study programs need to consider trainees' expectations when designing academic mentoring programs.

Indonesian registry on atrial fibrillation (OneAF).

BACKGROUND: Data on the optimal therapeutic international normalized ratio (INR) for non-valvular and valvular atrial fibrillation (AF) in Indonesia is currently unavailable. Therefore, we designed the Indonesian Registry on Atrial Fibrillation (OneAF) registry in order to seek a safe and beneficial range of INR in Indonesian patients with non-valvular and valvular AF. METHODS/DESIGN: The OneAF registry is a nationwide collaboration of the Indonesian Heart Rhythm Society (InaHRS) enrolling all hospitals with cardiac electrophysiologists in Indonesia. It is a prospective, multicentre, nationwide, observational study aiming to recruit non-valvular and valvular AF patients in Indonesia. The registry was started in January 2020 with a planned 2 years of recruitment. There are 2 respondents for this registry: non-cohort and cohort respondents. Non-cohort registry respondents are AF patients at hospitals who fulfill inclusion and exclusion criteria but did not consent for a 24 month follow up. Whereas patients who consented for a 24 month follow up were included as cohort registry respondents. Key data collected includes basic sociodemographic information, symptoms and signs, medical history, results of physical examination and laboratory test, details of diagnostics and treatment measures and events. RESULTS: Currently, a total of 1568 respondents have been enrolled in the non-cohort registry, including 1065 respondents with non-valvular AF (67.8%) and 503 respondents with valvular AF (32.2%). We believe that the OneAF registry will provide insight into the regional variability of anticoagulant treatment for AF, the implementation of rhythm/rate control approaches, and the clinical outcomes concerning cardiocerebrovascular events. TRIAL REGISTRATION: Registered at clinicaltrials.gov (NCT04222868).

Incidence and impact of cardiac arrhythmias in coronavirus disease 2019 (COVID-19): A systematic review and meta-analysis.

BACKGROUND: Studies have shown that cardiac arrhythmias may occur in up to 44% of patients with severe coronavirus disease 2019 (COVID-19) and has been associated with an increased risk of death. This systematic review and meta-analysis aimed to evaluate the incidence of cardiac arrhythmias in patients with COVID-19 and their implications on patient prognosis. METHODS: We performed a systematic literature search from PubMed, SCOPUS, Europe PMC, Cochrane Central Databases, and Google Scholar + Preprint Servers. The primary endpoint of the study was poor outcomes including mortality, severe COVID-19, and the need for ICU care. RESULTS: A total of 4 studies including 784 patients were analyzed. The incidence of arrhythmia in patients with COVID-19 was 19% (9-28%; I2: 91.45). Arrhythmia occurred in 48% (38-57%; I2: 48.08) of patients with poor outcome and 6% (1-12%; I2: 85.33%) of patients without poor outcome. Patients with COVID-19 experiencing arrhythmia had an increased risk of poor outcome (RR 7.96 [3.77, 16.81], p < 0.001; I2: 71.1%). The funnel-plot analysis showed an asymmetrical funnel plot with most of the studies on the right side of the effect estimate. The regression-based Egger's test showed indication of small-study effects (p = 0.001). CONCLUSION: Cardiac arrhythmias were significantly associated with an increased risk of poor outcome in COVID-19. Arrhythmias were observed in 19% of patients with COVID-19 and in 48% of patients with COVID-19 and poor outcomes.

Efficacy and safety of renal denervation in addition to pulmonary vein isolation for atrial fibrillation and hypertension-Systematic review and meta-analysis of randomized controlled trials.

INTRODUCTION: This systematic review and meta-analysis aimed to assess the latest evidence on the use of renal denervation (RDN) + pulmonary vein isolation (PVI) compared to PVI alone for treating atrial fibrillation (AF) with hypertension. METHODS: A systematic literature search from several electronic databases was performed up until January 2020. The primary outcome was AF recurrence defined as AF/atrial flutter (AFL)/atrial tachycardia (AT) ≥30 seconds at 12-month follow-up and the secondary outcome was procedure-related complications. RESULTS: There were 568 subjects from five studies. AF recurrence was 90/280 (32.1%) in the RDN + PVI group and 142/274 (51.8%) in the PVI group. RDN + PVI was associated with a lower incidence of AF recurrence (RR 0.62 [0.51, 076], P < .001; I 2: 0%). Pooled analysis of HR showed that RDN + PVI was associated with reduced AF recurrence (HR 0.51 [0.38, 0.70], P < .001; I 2: 0%). Complications were 7/241 (2.9%) in the RDN + PVI group and 8/237 (3.4%) in the PVI group. The rate of complications between the groups was similar (RR 0.87 [0.33, 2.29], P = .77; I 2: 0%). In the subgroup analysis of paroxysmal AF, RDN + PVI was shown to reduce AF recurrence (RR 0.64 [0.49, 0.82], P < .001; I 2: 0% and HR 0.56 [0.38, 0.82], P = .003; I 2: 0%) compared to PVI alone. RDN + PVI has a moderate certainty of evidence in the reducing AF recurrence with an absolute reduction of 197 fewer per 1000 (from 254 fewer to 124 fewer). CONCLUSION: RDN in addition to PVI, is associated with reduced 12-month AF recurrence and similar procedure-related complications compared to PVI alone.

Elevated N-terminal pro-brain natriuretic peptide is associated with increased mortality in patients with COVID-19: systematic review and meta-analysis.

OBJECTIVES: This systematic review and meta-analysis aimed to assess the association between N-terminal pro-brain natriuretic peptide (NT-proBNP) and mortality in patients with COVID-19. METHODS: Systematic literature search from several electronic databases were performed. The outcome was mortality (non-survivor) in patients with COVID-19 pneumonia. NT-proBNP data were in continuous variable (pg/mL), dichotomous data (elevated/non-elevated) and effect estimate adjusted to cardiac injury/elevated biomarkers of cardiac injury. RESULTS: A total of 967 patients from six studies were included in this analysis. NT-proBNP was higher in non-survivor group (standardised mean difference 0.75 (0.44, 1.07), p<0.001; I2: 61%). Elevated NT-proBNP was associated with increased mortality (RR 3.63 (92.21, 5.95), p<0.001; I2: 60%). Sensitivity analysis by removing a study reduces heterogeneity (risk ratio 3.47 (2.36, 5.11), p<0.001; I2: 49%). Pooled adjusted HR (adjusted to cardiac injury/elevated biomarkers of cardiac injury) showed that elevated NT-proBNP was independently associated with mortality (HR 1.37 (1.19, 1.57), p<0.001; I2: 0%, p=0.77). Pooled analysis of multiple cut-off point resulted in a sensitivity of 76% (46%-92%) and specificity of 88% (71%-96%). Summary receiver operating characteristic curve analysis demonstrates an area under curve of 0.90 (0.87-0.93). Elevated NT-proBNP has a likelihood ratio (LR) +6.4 and LR -0.3. CONCLUSION: Elevated NT-proBNP level was associated with increased mortality in COVID-19 pneumonia.

Hypertension is associated with increased mortality and severity of disease in COVID-19 pneumonia: A systematic review, meta-analysis and meta-regression.

OBJECTIVE: To investigate the association between hypertension and outcome in patients with Coronavirus Disease 2019 (COVID-19) pneumonia. METHODS: We performed a systematic literature search from several databases on studies that assess hypertension and outcome in COVID-19. Composite of poor outcome, comprising of mortality, severe COVID-19, acute respiratory distress syndrome (ARDS), need for intensive care unit (ICU) care and disease progression were the outcomes of interest. RESULTS: A total of 6560 patients were pooled from 30 studies. Hypertension was associated with increased composite poor outcome (risk ratio (RR) 2.11 (95% confidence interval (CI) 1.85, 2.40), p < 0.001; I2, 44%) and its sub-group, including mortality (RR 2.21 (1.74, 2.81), p < 0.001; I2, 66%), severe COVID-19 (RR 2.04 (1.69, 2.47), p < 0.001; I2 31%), ARDS (RR 1.64 (1.11, 2.43), p = 0.01; I2,0%, p = 0.35), ICU care (RR 2.11 (1.34, 3.33), p = 0.001; I2 18%, p = 0.30), and disease progression (RR 3.01 (1.51, 5.99), p = 0.002; I2 0%, p = 0.55). Meta-regression analysis showed that gender (p = 0.013) was a covariate that affects the association. The association was stronger in studies with a percentage of males < 55% compared to ⩾ 55% (RR 2.32 v. RR 1.79). CONCLUSION: Hypertension was associated with increased composite poor outcome, including mortality, severe COVID-19, ARDS, need for ICU care and disease progression in patients with COVID-19.

Serum Galectin-3 level and recurrence of atrial fibrillation post-ablation - Systematic review and meta-analysis.

BACKGROUND: Serum galectin-3, a circulating biomarker of fibrosis, has been associated with atrial remodelling. Recent studies investigating serum galectin-3 and AF recurrence post-ablation have shown mixed results. We aimed to analyze the latest evidence on the association between serum galectin-3 and AF recurrence after catheter ablation. METHODS: We performed a comprehensive search on topics that assesses serum galectin-3 and AF recurrence post-ablation up until August 2019. RESULTS: There were 597 patients from seven studies. The mean difference of serum galectin-3 was similar in both AF recurrence and non AF recurrence group (mean difference 0.78 ng/mL [-0.56, 2.13]; p = 0.25; I2: 69%. Upon removal of a study in sensitivity analysis, the serum galectin-3 became higher in AF recurrence group (mean difference 1.41 ng/mL [0.47, 2.34], p = 0.003; I2: 17%). Serum galectin-3 was associated with a higher risk for AF recurrence (HR 1.25 [1.01, 1.55]; p = 0.04; I2: 76%). Upon removal of a study in sensitivity analysis, HR became 1.45 [1.07, 1.96], p = 0.02; I2: 47%. Meta-analysis of adjusted HR demonstrated that high serum galectin-3 independently predicts AF recurrence (HR 1.15 [1.02, 1.29], p < 0.02; I2: 57%, p = 0.10) CONCLUSION: Serum galectin-3 is associated with an increased risk of AF recurrence post-ablation. Further studies are required, especially emphasis on the cut-off point should be given, before integrating it in routine risk stratification for AF ablation.

Evidence-Based Case Report: The Use of D-Dimer Assay to Exclude Left Atrial Thrombus in Patient with Atrial Fibrillation >48 Hours.

INTRODUCTION: Patients with atrial fibrillation (AF) for >48 hours who are a candidate for cardioversion should have transesophageal echocardiography (TEE) performed to exclude left atrial thrombus (LAT) that may cause systemic thromboembolism upon conversion to sinus rhythm. However, TEE facilities were limited, especially in developing countries. CASE ILLUSTRATION: A 50 years-old man presented with exertional dyspnea and palpitation for 72 hours prior to admission. Electrocardiography showed AF with a ventricular rate of 140x/minute. Cardioversion was decided to be the best approach. This patient has an AF >48 hours of onset, hence, LAT should be excluded by the use of TEE. Unfortunately, there was no TEE facility nearby. DISCUSSION: Upon comprehensive search on the use of D-Dimer assay to exclude the LAT in AF patients, we found seven studies showed increased D-dimer level in those with left atrial thrombus. In 4 studies, AUC was > 0.70, sensitivity and specificity varied from 75.9% to 89% and 73.1% to 95% respectively. However, there is no single cut-off point, due to the heterogeneity of cut-off points. CONCLUSION: D-dimer assay combined with other variables of atrial thrombus exclusion score is valuable in excluding LAT. Previously, weeks of anticoagulation is more advisable before attempting cardioversion in the absence of nearby TEE facilities. With current evidence, a low D-dimer and ATE score of 0 is safe for cardioversion.

Association between PR Interval, First-degree atrioventricular block and major arrhythmic events in patients with Brugada syndrome - Systematic review and meta-analysis.

BACKGROUND: Risk stratification in patients with asymptomatic Brugada Syndrome is challenging, and despite recent advances, there is no clear evidence. The first-degree atrioventricular block was hypothesized to be a predictor of arrhythmic events. Measurement of the PR interval and diagnosing atrioventricular block from surface ECG is easy, noninvasive, and cost-effective. We aimed to assess the latest evidence on PR interval or first-degree atrioventricular block and major arrhythmic events related to Brugada Syndrome. METHODS: We performed a comprehensive search in PubMed for "atrioventricular block" OR "PR interval" and "Brugada syndrome." We included studies that have a component of PR interval and/or first-degree atrioventricular block and major arrhythmic events related to Brugada Syndrome including syncope/VT/VF/appropriate ICD shocks/ICD implantation. RESULTS: We included 1526 subjects from 7 studies. Pooled mean difference of PR interval in 4 studies showed a significant difference [MD 10.77 ms (2.97-18.57) P = 0.007, moderate-high heterogeneity I2 = 53% P = 0.08]. On sensitivity analysis by removing a study, it became MD 6.50 ms [1.97-11.03], P = 0.005, heterogeneity I2 = 0% P = 0.52. Indicating that PR interval was prolonged by small margin. Pooled analysis of the association between a first-degree atrioventricular block and major arrhythmic events was significant [OR 3.33 (2.02-5.50) P < 0.001, low heterogeneity I2 = 0% P = 0.57]. CONCLUSION: First-degree AV block is associated with more frequent major arrhythmic events in Brugada syndrome patients. PR interval seemed to be prolonged but is yet to be determined whether the PR interval association is still significant if it did not cross the first-degree AVB threshold.

Electrocardiographic early repolarization is associated with future ventricular arrhythmia after acute myocardial infarction-Systematic Review and Meta-Analysis.

BACKGROUND: Early repolarization (ER) has been linked to ventricular arrhythmia (VA) and sudden cardiac death in patients without structural heart disease. We aimed to assess the latest evidence on whether ER is associated with future VA after acute myocardial infarction (AMI). METHODS: We performed a comprehensive search on the topic that assesses ER and VA/adverse cardiovascular events in AMI. We included studies with sufficient details on ER and VA, we also performed a meta-analysis on their morphology. RESULTS: A total of 3350 subjects from 9 studies were included. Five hundred and twenty-one (15.55%) had ER and 2829 (84.45%) did not. On meta-analysis, ER (+) in AMI was associated with VA with a pooled odds ratio (OR) of 3.58 (2.70-4.73), P < 0.001; heterogeneity I 2 34%. Subgroup analysis of patients with ST-segment elevation myocardial infarction (STEMI) showed an OR of 2.79 [1.98-3.93], P < 0.001; heterogeneity I 2 0%. Inferior location of ER (+) was associated with VA OR 3.98 [1.86-8.53], P = 0.008; I 2 67%. Notching had a 5.41 [3.52-8.32], P < 0.001; low heterogeneity I 2 0% of having VA. Pooled OR for J-point elevation was 4.72 [2.63-8.46], P < 0.001; I 2 25%. Horizontal ST-segment was associated with VA with an OR of 4.30 [1.89-975], P < 0.001; I 2 59%. Lateral location and slurred morphology were not associated with VA. Upon sensitivity analysis for inferior location and horizontal ST-segment, removal of a study reduces heterogeneity significantly. CONCLUSION: Early repolarization especially those with the inferior location, notching morphology, an elevated J-point and horizontal ST-segment had a higher likelihood of VA in AMI including STEMI patients.