Research Priorities in the Secondary Prevention of Atrial Fibrillation: A National Heart, Lung, and Blood Institute Virtual Workshop Report.

There has been sustained focus on the secondary prevention of coronary heart disease and heart failure; yet, apart from stroke prevention, the evidence base for the secondary prevention of atrial fibrillation (AF) recurrence, AF progression, and AF-related complications is modest. Although there are multiple observational studies, there are few large, robust, randomized trials providing definitive effective approaches for the secondary prevention of AF. Given the increasing incidence and prevalence of AF nationally and internationally, the AF field needs transformative research and a commitment to evidenced-based secondary prevention strategies. We report on a National Heart, Lung, and Blood Institute virtual workshop directed at identifying knowledge gaps and research opportunities in the secondary prevention of AF. Once AF has been detected, lifestyle changes and novel models of care delivery may contribute to the prevention of AF recurrence, AF progression, and AF-related complications. Although benefits seen in small subgroups, cohort studies, and selected randomized trials are impressive, the widespread effectiveness of AF secondary prevention strategies remains unknown, calling for development of scalable interventions suitable for diverse populations and for identification of subpopulations who may particularly benefit from intensive management. We identified critical research questions for 6 topics relevant to the secondary prevention of AF: (1) weight loss; (2) alcohol intake, smoking cessation, and diet; (3) cardiac rehabilitation; (4) approaches to sleep disorders; (5) integrated, team-based care; and (6) nonanticoagulant pharmacotherapy. Our goal is to stimulate innovative research that will accelerate the generation of the evidence to effectively pursue the secondary prevention of AF.

Sports Cardiology: Core Curriculum for Providing Cardiovascular Care to Competitive Athletes and Highly Active People.

The last few decades have seen substantial growth in the populations of competitive athletes and highly active people (CAHAP). Although vigorous physical exercise is an effective way to reduce the risk of cardiovascular (CV) disease, CAHAP remain susceptible to inherited and acquired CV disease, and may be most at risk for adverse CV outcomes during intense physical activity. Traditionally, multidisciplinary teams comprising athletic trainers, physical therapists, primary care sports medicine physicians, and orthopedic surgeons have provided clinical care for CAHAP. However, there is increasing recognition that a care team including qualified CV specialists optimizes care delivery for CAHAP. In recognition of the increasing demand for CV specialists competent in the care of CAHAP, the American College of Cardiology has recently established a Sports and Exercise Council. An important primary objective of this council is to define the essential skills necessary to practice effective sports cardiology.

Clinical Presentation and Outcomes by Sex in Arrhythmogenic Right Ventricular Cardiomyopathy: Findings from the North American ARVC Registry.

BACKGROUND: Sex differences in clinical presentation and outcomes of hereditary arrhythmias are commonly reported. We aimed to compare clinical presentation and outcomes in men and women with arrhythmogenic right ventricular cardiomyopathy (ARVC) enrolled in the North American ARVC Registry. METHODS: A total of 125 ARVC probands (55 females, mean age 38 ± 12; 70 males, mean age 41 ± 15) diagnosed, as either "affected" or "borderline" were included. Baseline clinical characteristics and time-dependent outcomes including syncope, ventricular tachycardia (VT), fast VT (>240 bpm), ventricular fibrillation (VF), and death were compared between males and females. RESULTS: The percentage of ARVC subjects diagnosed as "affected" (84% vs. 89%; P = 0.424) or "borderline" (16% vs. 11%; P = 0.424) was similar between females and males. Among the baseline characteristics, inverted T-waves in V2 trended to be more common in women (P = 0.09), whereas abnormal signal-averaged ECGs (SAECGs; P < 0.001) and inducible VT/VF (P = 0.026) were more frequent in men. During a mean follow-up of 37 ± 20 months, the probability of ICD-recorded VT/VF or death was not significantly different between men and women (P = 0.456). However, there was a trend toward lower risk of fast VT/VF or death in women compared to men (hazard ratio 0.41, 95% CI 0.151-1.113, P = 0.066). Abnormal SAECG and evidence of intramyocardial fat by cardiac MRI was associated with adverse outcomes in men (P = 0.006 and 0.02 respectively). CONCLUSION: In the North American ARVC Registry, we found similar frequency of "affected" and "borderline" subjects between men and women. Sex-related differences were observed in baseline ECG, SAECG, Holter-recorded ventricular arrhythmias, and VT inducibility. Men showed a trend toward greater risk of fast VT than women.

Prediction and prevention of sudden death in young populations: the role of ECG screening.

Sudden cardiac death (SCD), particularly when it affects a child or a young athlete who is presumed to be healthy, is an emotionally charged event that has a widespread impact. An effective ECG screening strategy for this population is intuitively appealing. The primary objective of ECG screening is to detect occult cardiovascular conditions likely to manifest with SCD. Such an endeavor is only effective if it is highly sensitive with an acceptably low false-positive rate. It also must be accompanied by an intervention that reduces the risk of SCD and improves outcomes. Despite significant advancements, considerable knowledge gaps remain about the etiology of SCD and the frequency with which SCD occurs. Reports of screening programs that have reduced the incidence of SCD have limited generalizability based on program design and the populations studied. Within the USA, considerable gaps in knowledge exist related to the frequency of SCD in youth and to the incremental predictive value of an ECG when added to a standardized history and physical examination. The strategy of ECG screening of young populations needs careful consideration based on principles of effective screening and evidence-based medicine. From a health policy perspective, additional data are needed from robust registries and carefully designed trials before advancing ECG screening in youth.

The future of fellowship training in clinical cardiac electrophysiology: Program directors' perspective 2008.

BACKGROUND: At the Clinical Cardiac Electrophysiology (CCEP) program directors' annual meeting during the 2008 scientific sessions of the Heart Rhythm Society, a consensus emerged for an urgent need to strengthen and rejuvenate fellowship training in clinical cardiac electrophysiology. OBJECTIVE: A writing group of the Heart Rhythm Society Clinical Research and Training Committee was charged with defining these issues. METHODS: A comprehensive questionnaire designed by the writing group was used to conduct an on-line survey of the 101 CCEP program directors in the United States. Data collected included types of programs, current status of programs, duration of fellowship, teaching responsibilities of faculty, responsibilities of fellows, and volume of electrophysiology procedures. Survey responses were collated and analyzed by the writing group. RESULTS: Given the rapid evolution and increased complexity of current electrophysiology procedures, program directors were of the opinion that 1 year of clinical electrophysiology training may no longer be adequate. A need to strengthen both research and didactic training components of fellowship training was also acknowledged. The number of electrophysiology procedures performed by trainees varied greatly between programs, and standardization of didactic training and procedural volume would be welcomed. Recent trends were recognized that indicate the need for a detailed national work-force analysis in CCEP. CONCLUSION: Through this national survey, program directors identified specific areas of need for standardization and strengthening of current fellowship training in CCEP. Based on these, specific measures can be taken to ensure the future of CCEP training.