Shared Decision Making in Cardiac Electrophysiology Procedures and Arrhythmia Management.

Shared decision making (SDM) has been advocated to improve patient care, patient decision acceptance, patient-provider communication, patient motivation, adherence, and patient reported outcomes. Documentation of SDM is endorsed in several society guidelines and is a condition of reimbursement for selected cardiovascular and cardiac arrhythmia procedures. However, many clinicians argue that SDM already occurs with clinical encounter discussions or the process of obtaining informed consent and note the additional imposed workload of using and documenting decision aids without validated tools or evidence that they improve clinical outcomes. In reality, SDM is a process and can be done without decision tools, although the process may be variable. Also, SDM advocates counter that the low-risk process of SDM need not be held to the high bar of demonstrating clinical benefit and that increasing the quality of decision making should be sufficient. Our review leverages a multidisciplinary group of experts in cardiology, cardiac electrophysiology, epidemiology, and SDM, as well as a patient advocate. Our goal is to examine and assess SDM methodology, tools, and available evidence on outcomes in patients with heart rhythm disorders to help determine the value of SDM, assess its possible impact on electrophysiological procedures and cardiac arrhythmia management, better inform regulatory requirements, and identify gaps in knowledge and future needs.

Guidance for Rebooting Electrophysiology Through the COVID-19 Pandemic From the Heart Rhythm Society and the American Heart Association Electrocardiography and Arrhythmias Committee of the Council on Clinical Cardiology: Endorsed by the American College of Cardiology.

Coronavirus disease 2019 (COVID-19) has presented substantial challenges to patient care and impacted health care delivery, including cardiac electrophysiology practice throughout the globe. Based upon the undetermined course and regional variability of the pandemic, there is uncertainty as to how and when to resume and deliver electrophysiology services for arrhythmia patients. This joint document from representatives of the Heart Rhythm Society, American Heart Association, and American College of Cardiology seeks to provide guidance for clinicians and institutions reestablishing safe electrophysiological care. To achieve this aim, we address regional and local COVID-19 disease status, the role of viral screening and serologic testing, return-to-work considerations for exposed or infected health care workers, risk stratification and management strategies based on COVID-19 disease burden, institutional preparedness for resumption of elective procedures, patient preparation and communication, prioritization of procedures, and development of outpatient and periprocedural care pathways.

Guidance for cardiac electrophysiology during the COVID-19 pandemic from the Heart Rhythm Society COVID-19 Task Force; Electrophysiology Section of the American College of Cardiology; and the Electrocardiography and Arrhythmias Committee of the Council on Clinical Cardiology, American Heart Association.

Coronavirus disease 2019 (COVID-19) is a global pandemic that is wreaking havoc on the health and economy of much of human civilization. Electrophysiologists have been impacted personally and professionally by this global catastrophe. In this joint article from representatives of the Heart Rhythm Society, the American College of Cardiology, and the American Heart Association, we identify the potential risks of exposure to patients, allied healthcare staff, industry representatives, and hospital administrators. We also describe the impact of COVID-19 on cardiac arrhythmias and methods of triage based on acuity and patient comorbidities. We provide guidance for managing invasive and noninvasive electrophysiology procedures, clinic visits, and cardiac device interrogations. In addition, we discuss resource conservation and the role of telemedicine in remote patient care along with management strategies for affected patients.

Electrophysiology studies in patients undergoing ICD implantation: findings from the NCDR®.

BACKGROUND: Electrophysiology studies (EPS) have historically played a role in sudden death risk stratification. More recent studies point to the left ventricular ejection fraction (EF) as a guide to implantable cardioverter defibrillators (ICD) implantation. The extent of EPS use in patients undergoing ICD implantation in the current era remains unknown. METHODS: Patients undergoing de novo ICD implantation in the ICD Registry between September 2006 and March 2009 who also underwent EPS within 30 days before implant were compared to the remaining cohort to identify clinical characteristics that correlated with EPS performance. Multivariate models were generated using hierarchical logistic regression analysis. RESULTS: EPS were performed in 33,786 of 275,273 patients. Those undergoing EPS were more likely to have had a history of syncope, family history of sudden death, lack of congestive heart failure, narrower QRS intervals, and higher EF. Overall, 63.9% of EPS were performed in patients receiving primary prevention ICDs. Ventricular tachyarrhythmias were induced in 46.1% of primary prevention and 54.2% of secondary prevention ICD recipients. Monomorphic ventricular tachycardia was the most common type of arrhythmia induced in both groups. Complication rates were not higher in those undergoing EPS. CONCLUSIONS: EPS were performed predominantly in patients with borderline or less well-defined risk factors for sudden death. Ventricular arrhythmias induced from EPS were not uncommon and may help identify individuals at higher risk for future ICD therapies. Efforts to better define the role of EPS in patients undergoing ICD implantation should be considered.

Blunted vagal reactivity predicts stress-precipitated tobacco smoking.

RATIONALE: Long-term smoking can lead to changes in autonomic function, including decreased vagal tone and altered stress responses. One index of the inability to adapt to stress may be blunted vagal reactivity. Stress is a primary mechanism involved in relapse to smoking, but mechanisms leading to stress-precipitated relapse are not well understood. OBJECTIVES: Using an experimental paradigm of stress-precipitated smoking behavior, we examined whether autonomic reactivity mediates the relationship between stress and smoking. High-frequency heart rate variability (HF-HRV), a putative measure of vagal tone, and the ratio of low-to-high frequency HRV (LF/HF), a measure of sympathovagal balance, were assessed. METHODS: Using a within-subjects design, 32 nicotine-dependent, 15-h abstinent smokers (a subgroup from McKee et al. (J Psychopharmacol 25(4):490-502, 2011)) were exposed to individualized script-driven imagery of stressful and relaxing scenarios and assessed on the ability to resist smoking and subsequent ad-lib smoking. HRV was monitored throughout each laboratory session (maximum 60 min following imagery). RESULTS: As expected, stress and ad-lib smoking additively decreased HF-HRV and increased LF/HF. Blunted stress-induced HF-HRV responses reflecting decreased vagal reactivity were associated with less time to initiate smoking and increased craving relief and reinforcement from smoking. These relationships were specific to HF-HRV following stress as neither baseline HF-HRV, HF-HRV following relaxing imagery, or LF/HF predicted smoking behavior. CONCLUSIONS: The current findings are the first to experimentally demonstrate that stress-precipitated decreased vagal reactivity predicts the ability to resist smoking. Findings suggest that strategies that normalize vagal reactivity in early abstinent smokers may lead to improved smoking cessation outcomes.

Noninvasive detection of risk for emotion-provoked myocardial ischemia.

OBJECTIVES: To test an easily administered, noninvasive technology to identify vulnerability to mental stress ischemia. BACKGROUND: Myocardial ischemia provoked by emotional stress (MSI) in patients with stable coronary artery disease (CAD) predicts major adverse cardiac events. A clinically useful tool to risk stratify patients on this factor is not available. METHODS: Patients with documented CAD (n = 68) underwent single photon emission CT myocardial perfusion imaging concurrent with pulse wave amplitude assessment by peripheral arterial tonometry (PAT) during a mental stress protocol of sequential rest and anger stress periods. Heart rate and blood pressure were assessed, and blood was drawn for catecholamine assay, during rest and stress. MSI was defined by the presence of a new perfusion defect during anger stress (n = 26) and the ratio of stress to rest PAT response was calculated. RESULTS: Patients with MSI had a significantly lower PAT ratio than those without MSI (0.76 +/- 0.04 versus 0.91 +/- 0.05, p = .03). An ROC curve for optimum sensitivity/specificity of PAT ratio as an index of MSI produced a sensitivity of 0.62 and a specificity of 0.63. Among patients taking angiotensin converting enzyme (ACE) inhibitors, the sensitivity and specificity of the test increased to 0.86 and 0.73, respectively; 90% of patients without MSI were correctly identified. CONCLUSIONS: PAT in concert with ACE inhibition may provide a useful approach to assess risk for MSI. Future studies should help determine how best to utilize this approach for risk assessment in the clinical setting.

Gender differences in ventricular arrhythmia recurrence in patients with coronary artery disease and implantable cardioverter-defibrillators.

OBJECTIVES: We sought to determine whether men and women with coronary artery disease (CAD) and implantable cardioverter-defibrillators (ICDs) differ in frequency of arrhythmia recurrence and whether gender differences are independent of clinical, electrocardiographic, and electrophysiologic characteristics. BACKGROUND: Epidemiologic studies show that women have a lower rate of sudden cardiac death (SCD) than men, even among patients with CAD. Whether this is due to differing susceptibilities to ischemia or to arrhythmia is unknown. METHODS: The clinical records and ICD data disks of 340 men and 59 women with CAD who received an ICD between June 1990 and June 2000 were reviewed. Ventricular tachycardia (VT) or ventricular fibrillation (VF) recurrences were compared between genders and relationship with other factors was analyzed. RESULTS: Sustained VT/VF occurred in 52% of men and 34% of women (p < 0.01). Men experienced more total VT/VF events (p < 0.01), more shock-treated VT/VF events (p < 0.03), more electrical storms (p < 0.001), and had VT/VF on more days in follow-up (p < 0.01). Gender differences were independent of measured clinical, electrocardiographic, and electrophysiologic factors. In stratified analyses, the gender differences in VT/VF recurrence were greatest in patients presenting with sustained monomorphic VT and those with inducible VT at electrophysiology study. CONCLUSIONS: Women were less likely to experience VT/VF, and had fewer VT/VF episodes, than men. These findings were strongest in patients with evidence of a stable anatomic VT circuit: those with clinical or electrophysiologically induced VT. This study suggests that differing susceptibility to arrhythmia triggering may underlie the known differences in SCD rates between men and women.