Comprehensive multicomponent cardiac rehabilitation in cardiac implantable electronic devices recipients: a consensus document from the European Association of Preventive Cardiology (EAPC; Secondary prevention and rehabilitation section) and European Heart Rhythm Association (EHRA).

Cardiac rehabilitation (CR) is a multidisciplinary intervention including patient assessment and medical actions to promote stabilization, management of cardiovascular risk factors, vocational support, psychosocial management, physical activity counselling, and prescription of exercise training. Millions of people with cardiac implantable electronic devices live in Europe and their numbers are progressively increasing, therefore, large subsets of patients admitted in CR facilities have a cardiac implantable electronic device. Patients who are cardiac implantable electronic devices recipients are considered eligible for a CR programme. This is not only related to the underlying heart disease but also to specific issues, such as psychological adaptation to living with an implanted device and, in implantable cardioverter-defibrillator patients, the risk of arrhythmia, syncope, and sudden cardiac death. Therefore, these patients should receive special attention, as their needs may differ from other patients participating in CR. As evidence from studies of CR in patients with cardiac implantable electronic devices is sparse, detailed clinical practice guidelines are lacking. Here, we aim to provide practical recommendations for CR in cardiac implantable electronic devices recipients in order to increase CR implementation, efficacy, and safety in this subset of patients.

European Heart Rhythm Association (EHRA) position paper on arrhythmia management and device therapies in endocrine disorders, endorsed by Asia Pacific Heart Rhythm Society (APHRS) and Latin American Heart Rhythm Society (LAHRS).

Endocrine disorders are associated with various tachyarrhythmias, including atrial fibrillation (AF), ventricular tachycardia (VT), ventricular fibrillation (VF), and bradyarrhythmias. Along with underlying arrhythmia substrate, electrolyte disturbances, glucose, and hormone levels, accompanying endocrine disorders contribute to development of arrhythmia. Arrhythmias may be life-threatening, facilitate cardiogenic shock development and increase mortality. The knowledge on the incidence of tachy- and bradyarrhythmias, clinical and prognostic significance as well as their management is limited; it is represented in observational studies and mostly in case reports on management of challenging cases. It should be also emphasized, that the topic is not covered in detail in current guidelines. Therefore, cardiologists and multidisciplinary teams participating in care of such patients do need the evidence-based, or in case of limited evidence expert-opinion based recommendations, how to treat arrhythmias using contemporary approaches, prevent their complications and recurrence in patients with endocrine disorders. In recognizing this close relationship between endocrine disorders and arrhythmias, the European Heart Rhythm Association (EHRA) convened a Task Force, with representation from Asia-Pacific Heart Rhythm Society (APHRS) and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLAECE), with the remit of comprehensively reviewing the available evidence and publishing a joint consensus document on endocrine disorders and cardiac arrhythmias, and providing up-to-date consensus recommendations for use in clinical practice.

The impact of modular cardiac rehabilitation on quality of life and exercise tolerance in patients with myocardial infarction and COVID-19 infection.

Introduction: Acute myocardial infarction (AMI) remains one of the leading causes of death worldwide during cardiovascular diseases. An important step in the secondary prevention of recurrent myocardial infarction is cardiac rehabilitation (CR). However, with the onset of the global COVID-19 pandemic, the CR programs in many clinics were limited due to the quarantine measures. Knowledge about the effects of CR on quality of life and exercise tolerance in AMI patients with COVID is scarce. Aim: To evaluate the use of a modular CR program on quality of life and exercise tolerance among post-AMI patients with COVID-19 recovery, and in those with no history of COVID-19 infection. Material and methods: This study included 118 patients with or recovering from acute myocardial infarction. They were divided into 2 groups: the first group included 86 patients, who had slight "ground-glass opacity" changes on the computed tomography (CT) scans, and the second group comprised 32 patients, who had no history of coronavirus infection or no change on CT scan of the lungs during the pandemic. The CR program was modified due to the pandemic era. Results: Physical tolerance increased in both groups after CR 3.6 months as compared to before the CR program (duration of training in seconds (p < 0.05), a 6-minute walk test (p < 0.05), the maximal oxygen consumption (VO2max) (p < 0.05), and the metabolic equivalent of task (MET) (p < 0.05)). Similarly, quality of life measures improved in both groups. Treatment satisfaction was higher in the first group at the beginning and the end of CR. Conclusions: The modular CR program improves exercise capacity and quality of life with AMI and COVID-19 similar to that of patients without AMI. Patients after COVID-19 should undergo rehabilitation.

Comprehensive multicomponent cardiac rehabilitation in cardiac implantable electronic devices recipients: a consensus document from the European Association of Preventive Cardiology (EAPC; Secondary prevention and rehabilitation section) and European Heart Rhythm Association (EHRA).

Cardiac rehabilitation (CR) is a multidisciplinary intervention including patient assessment and medical actions to promote stabilization, management of cardiovascular risk factors, vocational support, psychosocial management, physical activity counselling, and prescription of exercise training. Millions of people with cardiac implantable electronic devices live in Europe and their numbers are progressively increasing, therefore, large subsets of patients admitted in CR facilities have a cardiac implantable electronic device. Patients who are cardiac implantable electronic devices recipients are considered eligible for a CR programme. This is not only related to the underlying heart disease but also to specific issues, such as psychological adaptation to living with an implanted device and, in implantable cardioverter-defibrillator patients, the risk of arrhythmia, syncope, and sudden cardiac death. Therefore, these patients should receive special attention, as their needs may differ from other patients participating in CR. As evidence from studies of CR in patients with cardiac implantable electronic devices is sparse, detailed clinical practice guidelines are lacking. Here, we aim to provide practical recommendations for CR in cardiac implantable electronic devices recipients in order to increase CR implementation, efficacy, and safety in this subset of patients.

Atrial fibrillation in acute heart failure: A position statement from the Acute Cardiovascular Care Association and European Heart Rhythm Association of the European Society of Cardiology.

Atrial fibrillation and acute heart failure frequently co-exist and can exacerbate each other. Their combination leads to increased morbidity and mortality. However, the prevalence and significance, as well as the treatment, of atrial fibrillation in acute heart failure are not well studied. Management of atrial fibrillation in acute heart failure requires a multidisciplinary team approach. Treatment of underlying disease(s), identification and treatment of potentially correctable causes and precipitating factors and anticoagulation are crucial. In this article, current evidence on atrial fibrillation in the setting of acute heart failure is summarised. The recommendations on management of atrial fibrillation in the prehospital stage, the treatment of reversible causes, when and how to use rate or rhythm control, maintenance of sinus rhythm, catheter ablation and pacing, anticoagulation, as well as measures on prevention of atrial fibrillation are provided.

Premature ventricular complexes: diagnostic and therapeutic considerations in clinical practice : A state-of-the-art review by the American College of Cardiology Electrophysiology Council.

Premature ventricular complexes (PVCs) are common arrhythmias in the clinical setting. PVCs in the structurally normal heart are usually benign, but in the presence of structural heart disease (SHD), they may indicate increased risk of sudden death. High PVC burden may induce cardiomyopathy and left ventricular (LV) dysfunction or worsen underlying cardiomyopathy. Sometimes PVCs may be a marker of underlying pathophysiologic process such as myocarditis. Identification of PVC burden is important, since cardiomyopathy and LV dysfunction can reverse after catheter ablation or pharmacological suppression. This state-of-the-art review discusses pathophysiology, clinical manifestations, how to differentiate benign and malignant PVCs, PVCs in the structurally normal heart, underlying SHD, diagnostic procedures (physical examination, electrocardiogram, ambulatory monitoring, exercise testing, echocardiography, cardiac magnetic resonance imaging, coronary angiography, electrophysiology study), and treatment (lifestyle modification, electrolyte imbalance, medical, and catheter ablation).

Heart rate variability as a predictor of sudden cardiac death.

Different noninvasive approaches have been developed for risk stratification of patients with myocardial infarction and heart failure with aim to select patients at high risk of sudden cardiac death who might mostly benefit from preventive therapy. Reduced heart rate variability (HRV) was a strong predictor of mortality in myocardial infarction and heart failure in early studies. However, in the era of modern treatment strategies the prognostic significance of HRV indices has been challenged. We thought to review the role of conventional, nonlinear and novel spectral indices of HRV in prediction of sudden cardiac death in patients with myocardial infraction and heart failure.

Effects of gender and altitude on short-term heart rate variability in children.

OBJECTIVE: We aimed to study short-term heart rate variability (HRV) in 113 apparently healthy children permanent residents of moderate altitudes, the effects of gender and altitude. METHODS: Children were assigned into 3 groups according with altitude of residence: Group 1--1650 m/a/s/l (n=38), Group 2--1740 m/a/s/l (n=36) and Group 3--2030 m/a/s/l (n=39). All children underwent short-term electrocardiographic recordings with spectral analysis of HRV at rest and during standing. Statistical analysis was performed using multivariate ANOVA analysis. RESULTS: Heart rate variability analysis showed significant increase in SDNN, high frequency and total powers in parallel with increase of the altitude of residence (p<0.0001, p<0.03 and p<0.01, respectively). The magnitude of the HRV response to posture did not differ between groups except index of sympathetic modulation, LFNU, which rose to a significantly lesser degree (F=3.45, p<0.03) in Group 3, as compared with Group 1 and 2. Girls had lower HRV as compared with boys. CONCLUSION: Thus, in apparently healthy children, residents of moderate altitudes, increase in altitude levels is accompanied by higher overall variability and parasympathetic modulation of the sinus node and lower sympathetic response to posture. Heart rate variability in children, residents of moderate altitudes is also dependent of gender, resembling similar relationship in inhabitants of sea level.

Regional distribution and extent of perfusion abnormalities, and the lung to heart uptake ratios during exercise thallium-201 SPECT imaging in patients with cardiac syndrome X.

BACKGROUND: Cardiac syndrome X is defined as angina-like chest pain with transient ischemic ST-segment changes during exercise and angiographically normal epicardial coronary arteries. Studies with myocardial perfusion imaging in this syndrome have indicated that some patients, but not all, have an abnormality on perfusion scan. However, the impact of these perfusion abnormalities on pulmonary thallium uptake is not clear in this group of patients. OBJECTIVE: To evaluate the regional distribution and extent of perfusion abnormalities, and the lung to heart (L:H) uptake ratios using exercise thallium-201 single-photon emission computed tomography (TI-201 SPECT) in patients with cardiac syndrome X. METHODS: The study group consisted of 31 selected cardiac syndrome X patients with regional perfusion abnormalities during exercise TI-201 SPECT imaging. A control group included 26 healthy subjects with normal coronary angiograms, exercise testing and exercise TI-201 SPECT imaging. Exercise TI-201 SPECT results were analyzed with further estimation of the L:H ratios, number and localization of regional perfusion defects, and their mean extent scores expressed in pixels and in per cent of the left ventricular wall. Twenty-two patients with known coronary artery disease were also included in the analysis of the L:H ratios. RESULTS: Multiple perfusion defects were detected in 13 (42%) patients and perfusion defects of single localization were detected 18 (58%) patients. All patients had reversible perfusion abnormalities: 21 (67.7%) had anterior, 14 (45.2%) had inferior and 12 (38.7%) had lateral localization of perfusion defects. The analysis of the extent of the perfusion defects revealed that the mean scores of the extent of the single regional defects were 38.61+/-43.8 pixels and those of multiregional defects were 106.1+/-55.2 pixels, which corresponded to 6.05+/-1.8% and 16.6+/-5.4% of the left ventricular wall defects, respectively. Patients with cardiac syndrome X had a significantly higher L:H ratio during exercise than the healthy subjects (0.46+/-0.02 versus 0.34+/-0.03, P<0.01). In addition, L:H ratios were found to be higher in patients with multiple perfusion defects (0.50+/-0.02) than in patients who had only anterior (0.45+/-0.08) or inferior (0.43+/-0.02) perfusion defects (P<0.05 for both). There were no statistically significant differences in the rest L:H ratios between the study and control groups. Also, no significant differences were observed in exercise L:H ratios between the cardiac syndrome X patients and the patients with coronary artery disease (0.46+/-0.02 versus 0.49+/-0.03, P>0.05). CONCLUSIONS: The results suggest that multiple perfusion defects in multiple vascular regions are relatively common in cardiac syndrome X patients, with the majority of these patients having at least one abnormal perfusion bed. Patients with this syndrome who have perfusion abnormalities also had significantly higher L:H ratios during exercise than did the control patients. Increased exercise L:H ratios were more prominent in patients with multiple perfusion defects.

Prognostic implications of arrhythmias during primary percutaneous coronary interventions for ST-elevation myocardial infraction.

The authors reviewed current knowledge on occurrence, clinical and prognostic significance, and management of sustained ventricular arrhythmias, atrial fibrillation and bradyarrhythmias in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary interventions (PCI). Cardiac arrhythmias worsen clinical course and prognosis in patients with ST-elevation myocardial infarction undergoing primary PCI. Sustained ventricular arrhythmias developing during or early after PCI and associated with mechanical restoration of coronary flow and reperfusion do not affect mortality, whereas those related to incomplete revascularization and ongoing ischemia are associated with poor prognosis. New-onset atrial fibrillation increases mortality and stroke rates in patients undergoing primary PCI. Among bradyarrhythmias, high-degree atrioventricular block is associated with short- and long-term mortality. Prompt and complete revascularization is the cornerstone of arrhythmia management. Arrhythmias related to reperfusion do not usually require specific treatment, whereas those because of ongoing ischemia, incomplete revascularization and presence of substrate require adequate management including nonpharmacological and pharmacological therapies.

'Real-world' observational studies in arrhythmia research: data sources, methodology, and interpretation. A position document from European Heart Rhythm Association (EHRA), endorsed by Heart Rhythm Society (HRS), Asia-Pacific HRS (APHRS), and Latin America HRS (LAHRS)

The field of observational studies or "real world studies" is in rapid development with many new techniques introduced and increased understanding of traditional methods. For this reason, the current paper provides an overview of current methods with focus on new techniques. Some highlights can be emphasized: We provide an overview of sources of data for observational studies. There is an overview of sources of bias and confounding. Next There is an overview of causal inference techniques that are increasingly used. The most commonly used techniques for statistical modelling are reviewed with focus on the important distinction of risk versus prediction. The final section provides examples of common problems with reporting observational data.