From Atrial Fibrillation Management to Atrial Myopathy Assessment: The Evolving Concept of Left Atrium Disease in Hypertrophic Cardiomyopathy.

Hypertrophic cardiomyopathy (HCM) is the most prevalent genetically inherited cardiovascular disorder in adults and a significant cause of heart failure and sudden cardiac death. Historically, atrial fibrillation (AF) has been considered as a critical aspect in HCM patients as it is considered to be a marker of disease progression, escalates the frequency of heart failure hospitalisations, increases the risk of thromboembolic events, and worsens quality of life and outcome. Increasing evidence suggests that AF is the result of a subtle long-standing process that starts early in the history of HCM. The process of left atrial dilation accompanied by morphologic and functional remodelling is the quintessential prerequisite for the onset of AF. This review aims to describe the current understanding of AF pathophysiology in HCM, emphasising the role of left atrial myopathy in its development. In addition, we discuss risk factors and management strategies specific to AF in the context of HCM, providing insights into the complexities and challenges of treating this specific patient population.

Harmonization of sensorimotor deficit assessment in a registered multicentre pre-clinical randomized controlled trial using two models of ischemic stroke.

Multicentre preclinical randomized controlled trials (pRCTs) are a valuable tool to improve experimental stroke research, but are challenging and therefore underused. A common challenge regards the standardization of procedures across centres. We here present the harmonization phase for the quantification of sensorimotor deficits by composite neuroscore, which was the primary outcome of two multicentre pRCTs assessing remote ischemic conditioning in rodent models of ischemic stroke. Ischemic stroke was induced by middle cerebral artery occlusion for 30, 45 or 60 min in mice and 50, 75 or 100 min in rats, allowing sufficient variability. Eleven animals per species were video recorded during neurobehavioural tasks and evaluated with neuroscore by eight independent raters, remotely and blindly. We aimed at reaching an intraclass correlation coefficient (ICC) ≥0.60 as satisfactory interrater agreement. After a first remote training we obtained ICC = 0.50 for mice and ICC = 0.49 for rats. Errors were identified in animal handling and test execution. After a second remote training, we reached the target interrater agreement for mice (ICC = 0.64) and rats (ICC = 0.69). In conclusion, a multi-step, online harmonization phase proved to be feasible, easy to implement and highly effective to align each centre's behavioral evaluations before project's interventional phase.

Frailty in cardiology: definition, assessment and clinical implications for general cardiology. A consensus document of the Council for Cardiology Practice (CCP), Association for Acute Cardio Vascular Care (ACVC), Association of Cardiovascular Nursing and Allied Professions (ACNAP), European Association of Preventive Cardiology (EAPC), European Heart Rhythm Association (EHRA), Council on Valvular Heart Diseases (VHD), Council on Hypertension (CHT), Council of Cardio-Oncology (CCO), Working Group (WG) Aorta and Peripheral Vascular Diseases, WG e-Cardiology, WG Thrombosis, of the European Society of Cardiology, European Primary Care Cardiology Society (EPCCS).

Frailty is a health condition leading to many adverse clinical outcomes. The relationship between frailty and advanced age, multimorbidity and disability has a significant impact on healthcare systems. Frailty increases cardiovascular (CV) morbidity and mortality both in patients with or without known CV disease. Though the recognition of this additional risk factor has become increasingly clinically relevant in CV diseases, uncertainty remains about operative definitions, screening, assessment, and management of frailty. Since the burdens of frailty components and domains may vary in the various CV diseases and clinical settings, the relevance of specific frailty-related aspects may be different. Understanding these issues may allow general cardiologists a clearer focus on frailty in CV diseases and thereby make more tailored clinical decisions and therapeutic choices in outpatients. Guidance on identification and management of frailty are sparse and an international consensus document on frailty in general cardiology is lacking. Moreover, new options linked with eHealth are going to better define and manage frailty. This consensus document on definition, assessment, clinical implications, and management of frailty provides an input to integrate strategies pre- and post-acute CV events with a comprehensive view including out of hospital, office-based diagnostic and therapeutic choices, and based on a multidisciplinary team approach (general cardiologists, nurses, and general practitioners).

Atrial fibrillation in older patients and artificial intelligence: a quantitative demonstration of a link with some of the geriatric multidimensional assessment tools-a preliminary report.

Atrial fibrillation (AF) associates with disability and frailty. Aim of this study was to evaluate in older AF patients, using artificial intelligence (AI), the relations between geriatric tools and daily standing and resting periods. We enrolled thirty-one > 65 years patients undergoing electrical cardioversion of AF (age: 79 ± 6 years; women: 41.9%; CHA2DS2-VASc: 3.7 ± 1.2; MMSE: 27.7 ± 2.7; GDS: 3.0 ± 2.8). The data of the first day following the procedure were analyzed using machine-learning techniques in a specifically designed cloud platform. Standing, activity, time (582 ± 139 min) was directly associated with MMSE and inversely with GDS. Sleep length was 472 ± 230 min. Light sleep, the longer resting phase, was inversely related to GDS. The Chest Effort Index, a measure of obstructive sleep apnea, grew with GDS. In conclusion, AI devices can be routinely used in improving older subjects' evaluation. A correlation exists between standing time, MMSE, and depressive symptoms. GDS associates to length and quality of sleep.

The CHA2DS2-VASc score and Geriatric Multidimensional Assessment tools in elderly patients with persistent atrial fibrillation undergoing electrical cardioversion. A link with arrhythmia relapse?

INTRODUCTION: The CHA2DS2-VASc score is widely used for stroke risk stratification in patients with atrial fibrillation (AF). Our endpoints were to evaluate in an old population undergoing electrical cardioversion (ECV) of persistent AF if the CHA2DS2-VASc was associated with some of the Geriatric Multidimensional Assessment tools and with the presence of sinus rhythm at the follow-up. METHODS: We enrolled all the consecutive patients admitted in a day-hospital setting aged ≥60 years. The Mini-Mental State Examination (MMSE; neurocognitive function), the 15-item Geriatric Depression Scale (GDS; depressive symptoms) and the Short Physical Performance Battery (SPPB; physical functioning) were administered before ECV. RESULTS: Between 2017 and 2019, 134 patients were enrolled (mean age: 77±9 years, range: 60-96; men: 63.4%; EF: 60±12%). Hypertension was the most frequent comorbid condition (82.1%). The CHA2DS2-VASc score was 3.8±1.6. Abnormal values of MMSE, GDS and SPPB were observed in 7.9, 19.8 and 22.3% of cases, respectively. There were significant correlations between the CHA2DS2-VASc score and the MMSE (p=0.008), the GDS (p<0.001) and the SPPB (p<0.001). Depressive symptoms increased CHA2DS2-VASc correlation with SPPB of about 20%. CHA2DS2-VASc score was higher in patients with arrhythmia relapse (p=0.048; mean length of follow-up: 195 days). This association persisted even after adjustment for amiodarone therapy. CONCLUSIONS: The CHA2DS2-VASc score significantly correlated with neuro-cognitive performance, depressive symptoms and physical functioning. It was also associated with AF relapse. Accordingly, in the elderly, the CHA2DS2-VASc could help quantify thrombo-embolic risk, give an indication of frailty status and help to choose between a rate- and a rhythm-control strategy.

Patients' knowledge and attitudes regarding living with implantable electronic devices: results of a multicentre, multinational patient survey conducted by the European Heart Rhythm Association.

The purpose of this patient survey was to analyse the knowledge, experiences, and attitudes regarding cardiac implantable electronic devices (CIED) in patients with pacemakers, implantable cardioverter-defibrillators (ICDs), or cardiac resynchronization devices. Of the 1644 patients with CIEDs from seven European countries, 88% were over 50 years of age. Most patients (90%) knew what device they were implanted with and felt sufficiently informed about the indications for therapy. As many as 42% of patients needed additional information on the battery replacement and limitations in physical activity. The self-reported incidence of complications was 9%, and among these, a quarter of the respondents felt insufficiently informed about the possibility of complications and their management. The majority of patients (83%) were followed by face-to-face visits, which was the most commonly preferred follow-up strategy by the patients. Nearly 75% of the patients reported improved quality of life after device implantation, but about 40% had worries about their device. Less than 20% had discussed with their physician or thought about device handling in the end-of-life circumstances or end-stage disease. Notably, almost 20% of the ICD patients did not wish to answer the question regarding what they wanted to be done with their ICD in case of end-stage disease, indicating the challenges in approaching these issues.

The effects of gender on electrical therapies for the heart: procedural considerations, results and complications: A report from the XII Congress of the Italian Association on Arrhythmology and Cardiostimulation (AIAC).

Use of cardiac implantable devices and catheter ablation is steadily increasing in Western countries following the positive results of clinical trials. Despite the advances in scientific knowledge, tools development, and techniques improvement we still have some grey area in the field of electrical therapies for the heart. In particular, several reports highlighted differences both in medical behaviour and procedural outcomes between female and male candidates. Women are referred later for catheter ablation of supraventricular arrhythmias, especially atrial fibrillation, leading to suboptimal results. On the opposite females present greater response to cardiac resynchronization, while the benefit of implantable defibrillator in primary prevention seems to be less pronounced. Differences on aetiology, clinical profile, and development of myocardial scarring are the more plausible causes. This review will discuss all these aspects together with gender-related differences in terms of acute/late complications. We will also provide useful hints on plausible mechanisms and practical procedural aspects.

Implantation of subcutaneous implantable cardioverter defibrillators in Europe: results of the European Heart Rhythm Association survey.

AIMS: The purpose of this European Heart Rhythm Association (EHRA) survey is to provide an overview of the current use of subcutaneous cardioverter defibrillators (S-ICDs) across a broad range of European centres. METHODS AND RESULTS: A questionnaire was sent via the internet to centres participating in the EHRA electrophysiology research network. Questions included standards of care and policies used for patient management, indications, and techniques of implantation of the S-ICDs. In total, 52 centres replied to the questionnaire. More than one-fourth of the responding centres does not implant the S-ICD (n = 14, 27%). The majority reported to have implanted <10 (50%) or 10-29 (23%) S-ICDs during the last 12 months. Lack of reimbursement (25%), non-availability (19%), and cost of the device (25%) seem to limit the use of the S-ICD. The most commonly reported indications for S-ICD implantation are a difficult vascular access (82%), a history of previous complicated transvenous ICD (8O%), young age (69%), or an anticipated higher risk of infection (63%). Inappropriate therapies were the most frequently reported major problems (38%), but the majority of respondents (51%) never encountered any issue after an S-ICD implantation. Most of the respondents (83%) anticipate significant increase of S-ICD use within the next 2 years. CONCLUSION: This survey provides a contemporary insight into S-ICD implantation and management in the European electrophysiology centres, showing different approaches, depending on local policies. Cost issues or lack of reimbursement strongly influence the dissemination of the device. However, most respondents retain that S-ICD use will significantly increase in a very short time.

[Use of devices in elderly patients with chronic heart failure]. / I dispositivi negli anziani con scompenso cardiaco cronico.

Chronic heart failure (CHF) is a frequent and clinically relevant condition in elderly patients. Despite the improvements in medical therapy, CHF mortality is persistently high. The introduction into clinical practice of pacemakers for cardiac resynchronization therapy (CRT) and of implantable cardioverter-defibrillators (ICD) has significantly increased survival in CHF patients. In spite of clinical and epidemiological data, evidence of the effectiveness of these devices in the elderly is scant, and the few existing data derive from observational studies. Regarding CRT, in 1787 patients, the InSync/InSync ICD study showed no age-related differences in the prevalence of responders to therapy (about 60%) and in procedural complication rates (11%). Regarding ICD, in the 6311 patients enrolled in the Italian Clinical Service Project, 22.6% of the excess mortality observed in older subjects was due to comorbid conditions. Specific controlled clinical trials are needed to address the impact of CRT and ICD on health-related quality of life, disability and cognitive profile. The findings obtained will be useful to clarify clinical, ethical and cost-effectiveness issues in order to develop specific age-oriented guideline recommendations.

Improved exercise tolerance and quality of life with cardiac rehabilitation of older patients after myocardial infarction: results of a randomized, controlled trial.

BACKGROUND: Whether cardiac rehabilitation (CR) is effective in patients older than 75 years, who have been excluded from most trials, remains unclear. We enrolled patients 46 to 86 years old in a randomized trial and assessed the effects of 2 months of post-myocardial infarction (MI) CR on total work capacity (TWC, in kilograms per meter) and health-related quality of life (HRQL). METHODS AND RESULTS: Of 773 screened patients, 270 without cardiac failure, dementia, disability, or contraindications to exercise were randomized to outpatient, hospital-based CR (Hosp-CR), home-based CR (Home-CR), or no CR within 3 predefined age groups (middle-aged, 45 to 65 years; old, 66 to 75 years; and very old, >75 years) of 90 patients each. TWC and HRQL were determined with cycle ergometry and Sickness Impact Profile at baseline, after CR, and 6 and 12 months later. Within each age group, TWC improved with Hosp-CR and Home-CR and was unchanged with no CR. The improvement was similar in middle-aged and old persons but smaller, although still significant, in very old patients. TWC reverted toward baseline by 12 months with Hosp-CR but not with Home-CR. HRQL improved in middle-aged and old CR and control patients but only with CR in very old patients. Complications were similar across treatment and age groups. Costs were lower for Home-CR than for Hosp-CR. CONCLUSIONS: Post-MI Hosp-CR and Home-CR are similarly effective in the short term and improve TWC and HRQL in each age group. However, with lower costs and more prolonged positive effects, Home-CR may be the treatment of choice in low-risk older patients.