Loperamide-Induced Torsades de Pointes.

Loperamide is a readily available, over-the-counter medication used to treat diarrhea. At therapeutic doses, loperamide exerts its effects mainly on the intestinal opioid receptors with minimal psychoactive effects; however, at supratherapeutic doses, it reaches central opioid receptors. With tighter regulations on opioid prescriptions, loperamide has emerged as a popular drug of abuse among opioid users. At supratherapeutic doses, loperamide can cause severe cardiac toxicity, resulting in wide QRS rhythms, severe bradycardia, prolonged QTc, polymorphic ventricular tachycardia, and cardiac arrest. We present the case of a 27-year-old female with a history of heroin abuse who suffered torsades de pointes resulting in cardiac arrest in the setting of a loperamide overdose.

Polymorphic Ventricular Tachycardia Associated with Coronary Vasospasm in a Patient with Coronavirus Disease 2019 Infection.

A 70-year-old man was admitted to our hospital for restoration of sinus rhythm from atrial fibrillation by direct current counter shocks. On admission, he had a coronavirus disease 2019 (COVID-19) infection and syncope during bed rest. Electrocardiography revealed polymorphic ventricular tachycardia after ST-segment elevation with a normal QT interval. Coronary angiography revealed coronary vasospasm. Coronary vasospasm may be a cause of polymorphic ventricular tachycardia in COVID-19 patients.

The predictive significance of attachment script assessment hyperactivation and deactivation: evidence of associations with romantic relationship functioning.

This study examined the significance of a novel coding system for evaluating hyperactivation, deactivation, and anomalous content in the Attachment Script Assessment for romantic relationship functioning. In a sample of 208 couples (69% White, Mage 28.7 years), we tested whether ASA hyperactivation and deactivation were associated with theoretically relevant correlates, including observed behavior, parasympathetic reactivity, self-reported affective reactivity to conflict, and relationship satisfaction. Exploratory analyses examined associations of secure base script knowledge (SBSK) and anomalous content with these outcomes. ASA hyperactivation and deactivation were associated with behavioral, physiological, and self-reported functioning in theory-consistent ways. Anomalous content was not associated with romantic functioning. SBSK was associated with satisfaction, but this was not robust to covariates. Findings support the predictive validity of the hyperactivation and deactivation dimensions and suggest that these scales complement SBSK, enabling researchers to assess a wider range of behavioral and physiological indicators associated with distinctive forms of attachment insecurity.

Disparities in the implantation of secondary prevention implantable cardioverter defibrillator in the United States.

BACKGROUND: The annual incidence of sudden cardiac death is over 300,000 in the United States (US). Historically, inpatient implantation of secondary prevention implantable cardioverter defibrillator (ICD) has been variable and subject to healthcare disparities. OBJECTIVE: To evaluate contemporary practice trends of inpatient secondary prevention ICD implants within the US on the basis of race, sex, and socioeconomic status (SES). METHODS: The study is a retrospective analysis of the National Inpatient Sample from 2016 to 2020 of adult discharges with a primary diagnosis of ventricular tachycardia (VT), ventricular flutter, and fibrillation (VF). Adjusted ICD implantation rates based on race, sex, and SES and associated temporal trends were calculated using multivariate regression. RESULTS: A total of 193,600 primary VT/VF discharges in the NIS were included in the cohort, of which 57,895 (29.9%) had ICD placement. There was a significant racial and ethnic disparity in ICD placement for Black, Hispanic, Asian, and Native American patients as compared to White patients; adjusted odds ratio (aOR): 0.86 [p < .01], 0.90 [p  =  .03], 0.81[p < .01], 0.45 [p < .01], respectively. Female patients were also less likely to receive an ICD compared to male patients (aOR: 0.75, p < .01). Disparities in ICD placement remained stable over the study period (ptrend ≥ .05 in all races, both sexes and income categories). CONCLUSION: Racial, sex, and SES disparities persisted for secondary prevention ICD implants in the US. An investigation into contributing factors and subsequent approaches are needed to address the modifiable causes of disparities in ICD implantation as these trends have not improved compared to historic data.

Comparative Rates of Stroke and Rehospitalization of Atrial Fibrillation in Patients with Perioperative Atrial Fibrillation Following Major Emergency Abdominal Surgery and Patients with Non-perioperative Atrial Fibrillation.

BACKGROUND: Major emergency abdominal surgery is associated with postoperative complications and high mortality. Long-term outcomes in patients with perioperative atrial fibrillation (POAF) have recently received increased attention, especially POAF in non-thoracic surgery. PURPOSE: This study aimed to compare long-term AF related hospitalization and stroke in patients with POAF in relation to major emergency abdominal surgery and in patients with non-perioperative AF. METHODS: We crosslinked data from Danish nationwide registries and identified all patients who underwent major emergency abdominal surgery (2000-2018) and were diagnosed with POAF, and patients who developed AF in a non-perioperative setting. Patients with POAF were matched in a 1:5 ratio on age, sex, year of AF diagnosis and oral anticoagulation (OAC) status at the beginning of follow-up with patients with non-perioperative AF. From discharge, we examined adjusted hazard ratios (HR) of stroke using multivariable Cox regression analysis. RESULTS: The study population comprised 1,041 (out of 42,021 who underwent major emergency abdominal surgery) patients with POAF and 5,205 patients with non-perioperative AF. The median age was 78 years [interquartile range: 71-84] for those initiated on OAC therapy and 78 years [interquartile range: 71-85] for those not initiated on OAC therapy. During the first year of follow up, POAF was associated with similar rates of stroke as non-perioperative AF (patients initiated on OAC: HR 0.96 (95% confidence interval (CI) 0.52-1.77) and patients not initiated on OAC: HR 0.69 (95% CI 0.41-1.15). CONCLUSION: POAF in relation to major emergency abdominal surgery was associated with similar rates of stroke as non-perioperative AF. These results suggest that POAF not only carry an acute burden but also a long-term burden in patients undergoing major emergency abdominal surgery.

Exploring the Unknown: Appreciating the Challenges of Non-compaction Cardiomyopathy.

Left ventricular non-compaction cardiomyopathy (LVNC), or non-compaction cardiomyopathy (NCCM), is defined by pronounced left ventricular trabeculations and deep intertrabecular recesses connecting with the ventricular cavity. Patients with NCCM can be asymptomatic or have severe complications, including heart failure, arrhythmias, thromboembolism, and sudden cardiac death. Our case discusses a patient with shortness of breath who was found to have a newly decreased ejection fraction. The workup revealed non-ischemic cardiomyopathy and cardiac MRI showed hyper-trabeculations consistent with NCCM. The patient was started on oral anticoagulation and guideline-directed medical therapy (GDMT) and discharged with an event monitor. NCCM stands as a relatively rare and enigmatic condition, often veiled in ambiguity. The absence of standardized diagnostic and management protocols further complicates its clinical landscape. While echocardiography is the primary diagnostic tool, its tendency for under-diagnosis poses a significant challenge. Conversely, advanced imaging modalities like cardiac MRI may lead to instances of overdiagnosis. Treatment approaches are non-specific, incorporating GDMT, anticoagulation, implantable cardioverter-defibrillator placement, and genetic testing paired with counseling. Prioritizing genetic research is crucial to uncover tailored therapeutic interventions. Establishing consensus guidelines and refining diagnostic accuracy are pivotal steps toward mitigating the risks associated with under and over-diagnosis.

Immune checkpoint inhibitor-induced cardiotoxicity in patients with lung cancer: a systematic review and meta-analysis.

BACKGROUND: The use of immune checkpoint inhibitors (ICIs) for the treatment of lung cancer may precipitate cardiotoxic events. We aimed to perform a meta-analysis to evaluate the cardiotoxicity associated with ICIs in patients with lung cancer. METHODS: A literature search was conducted across four electronic databases (Cochrane CENTRAL, MEDLINE, OVID EMBASE and Google Scholar) from inception through 31st May 2023. Randomized controlled trials (RCTs) assessing the impact of ICIs on cardiac outcomes in lung cancer patients were considered for inclusion. Risk ratios (RR) with 95% confidence intervals (CIs) were pooled and analysis was performed using a random-effects model. The Grading of Recommendations Assessment, Development and Evaluation approach was followed to assess confidence in the estimates of effect (i.e., the quality of evidence). RESULTS: A total of 30 studies including 16,331 patients, were included in the analysis. Pooled results showed that single ICI (RR: 2.15; 95% CI: 1.13-4.12; p = 0.02; I2 = 0%) or a combination of single ICI plus chemotherapy (RR: 1.38 [1.05-1.82]; p = 0.02) significantly increased the risk of cardiac adverse events when compared with chemotherapy alone. No significant difference was noted when a dual ICI (RR: 0.48 [0.13-1.80]; p = 0.27) was compared with single ICI. In addition, there was no significant association between the use of ICIs and incidence of cardiac failure (RR: 1.11 [0.48-2.58]; p = 0.80), or arrhythmia (RR: 1.87; [0.69-5.08]; p = 0.22). CONCLUSION: Compared with chemotherapy alone, use of a single ICI or a combination of single ICI plus chemotherapy significantly increased the risk of cardiotoxicity. However, employing dual immunotherapy did not result in a significant increase in the risk of cardiotoxicity when compared to the use of a single ICI.

Simultaneous Occurrence of Transient Complete Heart Block With Acute Lateral Medullary Infarct.

Lateral Medullary Syndrome (LMS) poses clinical challenges, often resulting from ischemic events in the medulla oblongata. We present a unique case of LMS in a woman in her 60s with a complex medical history. Alongside neurological deficits, she experienced a transient high-grade atrioventricular block (HgAVB), a rare cardiac manifestation linked to LMS. Given the rarity of simultaneous transient HgAVB with acute lateral medullary infarct, only a handful of case reports documenting similar findings are available in the existing literature. More research and case reporting are needed to better our understanding of this area. The patient's condition, marked by a sudden onset of severe headache and left-sided weakness, revealed an acute infarct in the medulla territory. Notably, her HgAVB spontaneously resolved after 72 hours. This case emphasises the crucial need for extended cardiac surveillance in LMS patients due to their susceptibility to life-threatening arrhythmias. The intricate interplay between the brainstem and cardiovascular system highlights autonomic dysregulation as a potential mechanism for cardiac abnormalities. The report advocates for a holistic approach to managing LMS cases, stressing interdisciplinary collaboration for timely diagnosis and intervention, ultimately improving patient outcomes and reducing the risk of fatal arrhythmias.

KardiaMobile 6L versus 12-lead ECG: Effects on clinic utilization time.

INTRODUCTION: We aimed to study whether KardiaMobile 6L 30-second capture technology could shorten ECG collection time compared to standard 12L ECG without compromising data usability. METHODS: A single-center, non-randomized trial was performed on patients presenting for follow-up visits to the electrophysiology (EP) clinic. Providers in the KardiaMobile 6L group were allowed to request a standard 12L if the 6L was deemed insufficient for clinical care. Room utilization times, defined as the time from medical assistant room entry to exit, were compared for each group. RESULTS: There were 100 patients in the study, with 50 in each arm. Average room utilization time for the 12L group and 6L groups were 10.33 ± 2.2 and 7.27 ± 1.93 min, respectively (p < .001). In 8 (16%) visits for the 6L group, an additional 12L was requested. CONCLUSION: For EP follow-up visits, clinic utilization time was significantly reduced with the KardiaMobile 6L compared to the 12L ECG with infrequent need for an additional 12L.

Using induced pluripotent stem cells for drug discovery in arrhythmias.

INTRODUCTION: Arrhythmias are disturbances in the normal rhythm of the heart and account for significant cardiovascular morbidity and mortality worldwide. Historically, preclinical research has been anchored in animal models, though physiological differences between these models and humans have limited their clinical translation. The discovery of human induced pluripotent stem cells (iPSC) and subsequent differentiation into cardiomyocyte has led to the development of new in vitro models of arrhythmias with the hope of a new pathway for both exploration of pathogenic variants and novel therapeutic discovery. AREAS COVERED: The authors describe the latest two-dimensional in vitro models of arrhythmias, several examples of the use of these models in drug development, and the role of gene editing when modeling diseases. They conclude by discussing the use of three-dimensional models in the study of arrythmias and the integration of computational technologies and machine learning with experimental technologies. EXPERT OPINION: Human iPSC-derived cardiomyocytes models have significant potential to augment disease modeling, drug discovery, and toxicity studies in preclinical development. While there is initial success with modeling arrhythmias, the field is still in its nascency and requires advances in maturation, cellular diversity, and readouts to emulate arrhythmias more accurately.

Cryoablation Utilizing the KODEX-EPD Mapping System Versus Conventional Cryoballoon Ablation in the Management of Patients With Atrial Fibrillation: A Literature Review and Meta-Analysis.

Atrial fibrillation (AF) is the most commonly encountered cardiac arrhythmia globally. AF is associated with different consequences, such as peripheral vascular embolism, stroke, dementia, heart failure, and death. Catheter ablation (CA) has become a reliable therapeutic option for symptomatic AF. Utilizing mapping systems in conducting cryoablation is supposed to improve pulmonary vein isolation (PVI) durability and overall treatment success rate. We performed a review of relevant articles. We formulated a search strategy as follows: (atrial fibrillation AND ("cryoballoon ablation" OR cryoablation) AND (KODEX-EPD AND KODEX OR mapping). Data were collected from Web of Science, PubMed, Cochrane Library, and SCOPUS databases. We assessed the efficacy, procedural characteristics, and safety of cryoablation using the KODEX-EPD mapping system versus conventional cryoablation. We demonstrated the superiority of cryoablation guided by the KODEX-EPD system as it was associated with a significantly lower recurrence rate after the procedure (RR = 0.61, P = 0.03). Furthermore, it allowed a significant reduction in the volume of contrast medium used during the procedure (MD = -20.46, P = 0.04) when compared to the conventional cryoablation. We found no significant difference between both procedures in terms of successful cryoballoon-based PVI (P = 1.00), procedural duration (P = 0.95), procedural complications (P = 0.607), fluoroscopic time (P = 0.36), and fluoroscopic dose (P = 0.16). The use of the novel KODEX-EPD mapping system in the cryoablation procedure was associated with a significant reduction of the volume of contrast medium use and the recurrence rate compared with the conventional cryoablation while preserving similar efficacy, safety profile, and procedure time.

Relationships between adrenal insufficiency and cardiovascular outcomes in patients with atrial fibrillation, atrial flutter and paroxysmal supraventricular tachycardia.

BACKGROUND: Patients with Adrenal Insufficiency (AI) face elevated cardiovascular risks, but little remains known about arrhythmia outcomes in this context. METHOD: Analyzing the 2016-2019 Nationwide Inpatient Sample, we identified cases of Atrial Fibrillation, Atrial Flutter, and paroxysmal supraventricular tachycardia (PSVT) with a secondary diagnosis of AI. Mortality was the primary outcome while vasopressors and/or mechanical ventilation use, length of stay (LOS), and total hospitalization charges (THC) constituted secondary outcomes. Multivariate linear and logistic regression models were used to adjust for confounders. RESULTS: Among patients with Atrial Fibrillation, Atrial Flutter, and PSVT (N=1,556,769), 0.2% had AI. AI was associated with higher mortality (adjusted OR [aOR] 2.29, p=0.001), vasopressor and/or mechanical ventilation use (aOR 2.54, p<0.001), THC ($62,347 vs. $41,627, p<0.001) and longer LOS (4.4 vs. 3.2 days, p<0.001) compared to no AI. CONCLUSION: AI was associated with higher adverse outcomes in cases of Atrial Fibrillation, Atrial Flutter, and PSVT.

Treating Atrial Fibrillation is No Maze: A Reminder to Heart Teams for Concomitant Surgical Ablation for Atrial Fibrillation With Cardiac Surgery.

Atrial fibrillation (AF) is the most prevalent arrhythmia and is often found during times of other cardiac pathologies that require surgical management including coronary revascularization and valve surgery. Surgical ablation of AF, most frequently performed through the Cox-Maze IV procedure, is highly effective in restoring sinus rhythm. Despite robust society guideline recommendations for concomitant surgical ablation (CSA) for AF, the practice has yet to be widely adopted. In this review, we discuss the current indications for CSA, its efficacy in maintaining freedom from atrial tachyarrhythmias, stroke, and adverse long-term outcomes, the safety profile of SA when performed alongside cardiac surgical cases, and challenges with its implementation across the most common concomitant cardiac operations. In conclusion, we present a reminder to multidisciplinary heart teams to consider CSA when indicated for their patients.

Life-saving fall detection by a smartwatch in a case of ventricular fibrillation.

New smart devices that have the potential to support the health and well-being of their owners have become available. In particular, smart watches are able to identify a fall by the person who is wearing the watch and report it to pre-defined contacts and the local emergency control center. Falls in older people are common and only rarely caused by malignant cardiac arrhythmia. The case of an elderly male whose smart watch automatically reported his fall due to ventricular fibrillation to the local emergency control center is described. Through the intervention of the wearer's device, the activated dispatcher called the patient's wife, who found her husband lying unresponsive on the floor. Emergency medical services responded immediately and were able to successfully resuscitate the patient. A hospital discharge without any long-term complications was achieved.

Prognostic Impact of Sinus Rhythm in Atrial Fibrillation Patients: Separating Rhythm Outcomes From Randomized Strategy Findings From the CABANA Trial.

BACKGROUND: Clinically detected atrial fibrillation (AF) is associated with a significant increase in mortality and other adverse cardiovascular events. Since the advent of effective methods for AF rhythm control, investigators have attempted to determine how much these adverse prognostic AF effects could be mitigated by the restoration of sinus rhythm (SR) and whether the method used mattered. METHODS: The CABANA trial (Catheter Ablation versus Antiarrhythmic Drug Therapy for Atrial Fibrillation) randomized 2204 AF patients to ablation versus drug therapy, of which 1240 patients were monitored in follow-up using the CABANA ECG rhythm monitoring system. To assess the prognostic benefits of SR, we performed a prespecified analysis using Cox survival modeling with heart rhythm as a time-dependent variable and randomized treatment group as a stratification factor. RESULTS: In the 1240 patient study cohort, 883 (71.2%) had documented AF at some point during their postblanking follow-up. Among the 883 patients, 671 (76.0%) experienced AF within the first year of postblanking follow-up, and 212 (24.0%) experienced their first AF after ≥1 year of postblanking follow-up. The primary CABANA end point (death, disabling stroke, serious bleeding, or cardiac arrest) occurred in 95 (10.8%) of the 883 patients with documented AF and in 29 (8.1%) of the 357 patients with no AF recorded during follow-up. In multivariable time-dependent analysis, the presence of SR (compared with non-SR) was associated with a significantly reduced risk of the primary end point (adjusted hazard ratio, 0.57 [95% CI, 0.38-0.85]; P=0.006; independent of treatment strategy [ablation versus drugs]). Corresponding results for all-cause mortality were adjusted hazard ratio of 0.59 [95% CI, 0.35-1.01]; P=0.053). CONCLUSIONS: In patients in the CABANA trial with detailed long-term rhythm follow-up, increased time in SR was associated with a clinically consequential decrease in mortality and other adverse prognostic events. The predictive value of SR was independent of the therapeutic approach responsible for reducing the burden of detectable AF. REGISTRATION: URL: https://clinicaltrials.gov; Unique Identifier: NCT00911508.

The diagnostic efficiency of artificial intelligence based 2 hours Holter monitoring in premature ventricular and supraventricular contractions detection.

BACKGROUND: Electrocardiography (ECG) and 24 hours Holter monitoring (24 h-Holter) provided valuable information for premature ventricular and supraventricular contractions (PVC and PSVC). Currently, artificial intelligence (AI) based 2 hours single-lead Holter (2 h-Holter) monitoring may provide an improved strategy for PSVC/PVC diagnosis. HYPOTHESIS: AI combined with single-lead Holter monitoring improves PSVC/PVC detection. METHODS: In total, 170 patients were enrolled between August 2022 and 2023. All patients wore both devices simultaneously; then, we compared diagnostic efficiency, including the sensitivity/specificity/positive predictive-value (PPV) and negative predictive-value (NPV) in detecting PSVC/PVC by 24 h-Holter and 2 h-Holter. RESULTS: The PPV and NPV in patients underwent 2 h-Holter were 76.00%/87.50% and 96.35%/98.55, respectively, and the sensitivity and specificity were 79.17%/91.30%, and 95.65%/97.84% in PSVC/PVC detection compared with 24 h-Holter. The areas under the ROC curves (AUCs) for PSVC and PVC were 0.885 and 0.741, respectively (p < .0001). CONCLUSIONS: The potential advantages of the 2 h-Holter were shortened wearing period, improved convenience, and excellent consistency of diagnosis.

Arrhythmogenic Left Ventricular Cardiomyopathy: From Diagnosis to Risk Management.

PURPOSE OF REVIEW: Left ventricular arrhythmogenic cardiomyopathy (ALVC) is a rare and poorly characterized cardiomyopathy that has recently been reclassified in the group of non-dilated left ventricular cardiomyopathies. This review aims to summarize the background, diagnosis, and sudden cardiac death risk in patients presenting this cardiomyopathy. RECENT FINDINGS: Although there is currently a lack of data on this condition, arrhythmogenic left ventricular dysplasia can be considered a specific disease of the left ventricle (LV). We have collected the latest evidence about the management and the risks associated with this cardiomyopathy. SUMMARY: Left ventricular arrhythmogenic cardiomyopathy is still poorly characterized. ALVC is characterized by fibrofatty replacement in the left ventricular myocardium, with variable phenotypic expression. Diagnosis is based on a multiparametric approach, including cardiac magnetic resonance (CMR) and genetic testing, and is important for sudden cardiac death (SCD) risk stratification and management. Recent guidelines have improved the management of left ventricular arrhythmogenic cardiomyopathy. Further studies are necessary to improve knowledge of this cardiomyopathy.

Patient With Gender Dysphoria Diagnosed With Multiple Sclerosis Following Takotsubo Cardiomyopathy and Ventricular Arrhythmia: A Case Report and Systematic Literature Review.

A 34-year-old transgender woman presented with ventricular tachycardia and was diagnosed with takotsubo cardiomyopathy. Further evaluation revealed an underlying diagnosis of multiple sclerosis (MS) with brainstem lesions that may have triggered takotsubo cardiomyopathy. In this report, we also systematically reviewed published cases of takotsubo cardiomyopathy and MS and found that basal type takotsubo cardiomyopathy was the most common, and most patients presented with brainstem involvement of MS. An awareness of these associations by physicians, along with multidisciplinary collaboration, may facilitate the early diagnosis and improve the prognosis of these patients.

Coronary microvascular dysfunction, arrythmias, and sudden cardiac death: A literature review.

The coronary vascular system has a unique structure and function that is adaptive to myocardial demand. It is composed of a continuous network of vessels receding in size from epicardial arteries to the microvascular circulation. Failure to meet myocardial demand results in ischemia, angina, and adverse myocardial outcomes. It is evident that 50 % of patients with angina have a non-obstructive coronary disease and 66 % of these patients have coronary microvascular dysfunction (CMD). The impact of CMD on the atria and ventricles is exhibited through its association with atrial fibrillation and distortion of ventricular repolarization. Ultimately, this influence increases the risk of mortality, morbidity, and sudden cardiac arrest. CMD serves as an independent risk for atrial fibrillation, increases ventricular electrical inhomogeneity, and contributes to the progression of cardiac disease. The underlying pathogenesis may be attributed to oxidative stress evident through reactive oxygen species, impaired vasoactive function, and structural disorders such as fibrotic changes. Myocardial ischemia, brought about by a demand-supply mismatch in CMD, may create a milieu for ventricular arrythmia and sudden cardiac arrest through distortion of ventricular repolarization parameters such as QT dispersion and corrected QT dispersion.