An alternating QRS: How does it go even though it's pretty slow?

We present the case of a 42 year old patient with a history of childhood lymphoma treated with chemotherapy and radiation who underwent combined aortic and mitral valve replacements and who postoperatively developed an interesting ECG which showed complete heart block and an alternating left bundle branch and narrow complex QRS pattern at a heart rate of 69 beats per minute (bpm). We discuss potential mechanisms for this interesting pattern.

Risk and predictors of mortality after implantable cardioverter-defibrillator implantation in patients with sarcoid cardiomyopathy.

BACKGROUND: Implantable cardioverter-defibrillators (ICDs) are recommended for patients with cardiac sarcoidosis (CS) with an indication for pacing, prior ventricular arrhythmias, cardiac arrest, or left ventricular ejection fraction <35%, but data on outcomes are limited. METHODS: Using data from the National Cardiovascular Data Registry ICD Registry between April 1, 2010 and December 31, 2015, we evaluated a propensity matched cohort of CS patients implanted with ICDs versus non-ischemic cardiomyopathies (NICM). We compared mortality using Kaplan-Meier survival curves and Cox proportional hazards models. RESULTS: We identified 1,638 patients with CS and 8,190 propensity matched patients with NICM. The rate of death at 1 and 2 years was similar in patients with CS and patients with NICM (5.2% vs 5.4%, P = 0.75 and 9.0% vs 9.3%, P = 0.72, respectively). After adjusting for other covariates, patients with CS had similar mortality at 2 years after ICD implantations compared with NICM patients (RR 1.03, 95% CI 0.87-1.23). Among patients with CS, multivariable logistic regression identified 6 factors significantly associated with increased 2-year mortality: presence of heart failure (HR 1.92, 95% CI 1.44-3.22), New York Heart Association (NYHA) Class III heart failure (HR 1.68, 95% CI 1.16-2.45), NYHA Class IV heart failure (HR 3.08, 95% CI 1.49-6.39), atrial fibrillation/flutter (HR 1.66, 95% CI 1.17-2.35), chronic lung disease (HR 1.64, 95% CI 1.17-2.29), creatinine >2.0 mg/dL (HR 4.07, 95% CI 2.63-6.30), and paced rhythm (HR 2.66, 95% CI 1.07-6.59). CONCLUSION: Mortality following ICD implantation was similar in CS patients compared with propensity matched NICM patients. Presence of heart failure, NYHA class, atrial fibrillation/flutter, chronic lung disease, renal dysfunction, and paced rhythm at time of implantation were all predictors of increased 2-year mortality among CS patients with ICDs.

Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR): 2020 Guidelines for the Prevention, Diagnosis and Treatment of Lyme Disease.

This evidence-based clinical practice guideline for the prevention, diagnosis, and treatment of Lyme disease was developed by a multidisciplinary panel representing the Infectious Diseases Society of America (IDSA), the American Academy of Neurology (AAN), and the American College of Rheumatology (ACR). The scope of this guideline includes prevention of Lyme disease, and the diagnosis and treatment of Lyme disease presenting as erythema migrans, Lyme disease complicated by neurologic, cardiac, and rheumatologic manifestations, Eurasian manifestations of Lyme disease, and Lyme disease complicated by coinfection with other tick-borne pathogens. This guideline does not include comprehensive recommendations for babesiosis and tick-borne rickettsial infections, which are published in separate guidelines. The target audience for this guideline includes primary care physicians and specialists caring for this condition such as infectious diseases specialists, emergency physicians, internists, pediatricians, family physicians, neurologists, rheumatologists, cardiologists and dermatologists in North America.

Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR): 2020 Guidelines for the Prevention, Diagnosis and Treatment of Lyme Disease.

This evidence-based clinical practice guideline for the prevention, diagnosis, and treatment of Lyme disease was developed by a multidisciplinary panel representing the Infectious Diseases Society of America (IDSA), the American Academy of Neurology (AAN), and the American College of Rheumatology (ACR). The scope of this guideline includes prevention of Lyme disease, and the diagnosis and treatment of Lyme disease presenting as erythema migrans, Lyme disease complicated by neurologic, cardiac, and rheumatologic manifestations, Eurasian manifestations of Lyme disease, and Lyme disease complicated by coinfection with other tick-borne pathogens. This guideline does not include comprehensive recommendations for babesiosis and tick-borne rickettsial infections, which are published in separate guidelines. The target audience for this guideline includes primary care physicians and specialists caring for this condition such as infectious diseases specialists, emergency physicians, internists, pediatricians, family physicians, neurologists, rheumatologists, cardiologists and dermatologists in North America.

Interleukin-1 blockade in cardiac sarcoidosis: study design of the multimodality assessment of granulomas in cardiac sarcoidosis: Anakinra Randomized Trial (MAGiC-ART).

BACKGROUND: Sarcoidosis is an inflammatory disease characterized by the formation of granulomas, which involve the heart in up to 25% of patients. Cardiac sarcoidosis can lead to life threatening arrhythmias and heart failure. While corticosteroids have been used as a treatment for over 50 years, they are associated with hypertension, diabetes, and weight gain, further increasing cardiovascular risk. Interleukin-1 (IL-1) is the prototypical proinflammatory cytokine that works to activate the nuclear transcription factor NF-kB, one of the targets of glucocorticoids. IL-1 also plays an important role also in the pathophysiology of heart disease including atherosclerosis, myocardial infarction, and myocarditis. METHODS: Building on a network of research collaborators developed in the Cardiac Sarcoidosis Consortium, we will investigate the feasibility and tolerability of treatment of CS with anakinra at two National Institute of Health Clinical and Translational Science Award (CTSA) hubs with expertise in cardiac sarcoidosis. In this pilot study, up to 28 patients with cardiac sarcoidosis will be recruited to compare the administration of an IL-1 blocker, anakinra, 100 mg daily on top of standard of care versus standard of care only for 28 days and followed for 180 days. Utilizing surrogate endpoints of changes in systemic inflammatory biomarkers and cardiac imaging, we aim to determine whether IL-1 blockade with anakinra can combat systemic and cardiac inflammation in patients with cardiac sarcoidosis. DISCUSSION: The current trial demonstrates an innovative collaborative approach to clinical trial development in a rare, understudied disease that disproportionately affects females and minorities. Trial Registration The trial was registered prospectively with ClinicalTrials.gov on July 12, 2019, identifier NCT04017936.

The Impact of the COVID-19 Pandemic on Cardiac Electrophysiology Training: A Survey Study.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic has resulted in a significant decrease in volume of electrophysiology (EP) procedures. There has been concern that trainees may not achieve the procedural numbers required to graduate as independent electrophysiologists within the usual timeline. We sought to determine the impact of the COVID-19 pandemic on the percentage of clinical cardiac EP (CCEP) fellows in jeopardy of not meeting procedural volume requirements and overall sentiments regarding preparedness of fellows for independent practice. METHODS: We surveyed CCEP fellows and program directors about baseline procedural volumes, curriculum changes due to the pandemic, and attitudes about preparedness for board examinations and independent practice. RESULTS: Ninety-nine fellows and 27 program directors responded to the survey. Ninety-eight percent of responding fellows reported a decrease in procedural volume as a result of the pandemic. Program directors reported an overall decrease in annual number of ablations and device procedures performed by each fellow during the 2019-2020 academic year compared to the preceding year. Despite this, a minority of fellows and program directors reported concerns about meeting Accreditation Council for Graduate Medical Education procedural requirements for devices (9% and 4%, respectively) and ablation (19% and 9%) or preparedness for independent practice after a 2-year fellowship. CONCLUSIONS: The COVID-19 pandemic has resulted in a decrease in procedural volume for CCEP trainees, but the majority of fellows and program directors do not anticipate major barriers to timely graduation. This may change with COVID-19 resurgence and further interruptions in training.

Subcutaneous implantable cardioverter defibrillator oversensing and shock delivery due to chest compressions during CPR.

We report the case of a patient who received both appropriate and inappropriate shocks from an entirely subcutaneous implantable defibrillator (S-ICD). The inappropriate shocks were due to oversensing of chest compressions in the setting of a profound postshock bradycardia. It is important to recognize that the therapy from the S-ICD can not only be withheld, as previously described, but can also be inappropriately delivered during chest compressions.

Technician-Supported Remote Interrogation of CIEDs: Initial Use in US Emergency Departments and Perioperative Areas.

BACKGROUND: Interrogation/interpretation of cardiac implantable electronic devices (CIEDs) is frequently required in the emergency department (ED) or perioperative areas (OR) where resources to do this are often not available. CareLink Express (CLE; Medtronic, plc, Mounds View, MN, USA) is a technician-supported real-time remote interrogation system for Medtronic CIEDs. Using data from 136 US locations, this retrospective study was designed to assess CLE efficiency compared to traditional device management, and examine its findings. METHODS: All 7,044 US CLE transmissions from the ED and OR (January 2012-October 2014) were compared to 217 traditional requests where CIED interrogations/interpretations were performed by calling industry representatives to these sites. RESULTS: CLE reduced the time to device interrogation/interpretation by 78%: 100 ± 140-22 ± 14 minutes, P < 0.0001, improving response time and consistency; ED: 82 ± 103-23 ± 18 minutes, P, ≤ 0.01; OR: 127 ± 181-17 ± 10 minutes, P < 0.0001. Actionable events (AE) (arrhythmia, device/lead abnormalities) were infrequent: 9.1% overall (ED: 9.9%; OR: 4.1%). Only 6.5% of patients with syncope/presyncope and 13.6% with a perceived shock had AE. AEs were more common in those with suspected device problems (30.4%) or audible alerts (52.6%). They were more likely in patients not enrolled in long-term remote monitoring (23.9% vs 8.2%, P < 0.0001) and in those with older CIED systems (7.4% in year 1 vs 31.0% after 10 years). CONCLUSIONS: The many patients with CIEDs, and the ability to quickly identify the minority with high-risk AE from the no/low-risk majority, strongly support CLE use in the ED and OR, sites which are expensive and prioritize efficiency.

HRS/NSA 2014 Survey of Atrial Fibrillation and Stroke: Gaps in Knowledge and Perspective, Opportunities for Improvement.

BACKGROUND: The prevalence of atrial fibrillation (AF) is substantial and increasing. Stroke is common in AF and can have devastating consequences. Oral anticoagulants are effective in reducing stroke risk, but are underutilized. OBJECTIVE: We sought to characterize the impact of stroke on AF patients and their caregivers, gaps in knowledge and perspective between physicians and patients, and barriers to effective communication and optimal anticoagulation use. METHODS: A survey was administered to AF patients with and without history of stroke, caregivers of stroke survivors, and physicians across the range of specialties caring for AF and stroke patients. RESULTS: While AF patients (n = 499) had limited knowledge about stroke, they expressed great desire to learn more and take action to reduce their risk. They were often dissatisfied with the education they had received and desired high-quality written materials. Stroke survivors (n = 251) had poor functional outcomes and often underestimated the burden of caring for them. Caregivers (n = 203) also wished they had received more information about reducing stroke risk before their survivor's event. They commonly felt overwhelmed and socially isolated. Physicians (n = 504) did not prescribe anticoagulants as frequently as recommended by guidelines. Concerns about monitoring anticoagulation and patient compliance were commonly reported barriers. Physicians may underestimate patient willingness to take anticoagulants. CONCLUSION: We identified significant knowledge gaps among patients, caregivers, and physicians in relation to AF and stroke. Furthermore, gaps in perspective often lead to suboptimal communication and decision making. Increased education and better communication between all stakeholders are needed to reduce the impact of stroke in AF.

Compliance with remote monitoring of ICDS/CRTDS in a real-world population.

BACKGROUND: Remote monitoring (RM) of defibrillators (implantable cardioverter defibrillators [ICDs]) and cardiac resynchronization therapy devices (CRTDs) has been shown to be cost effective, convenient, and associated with reduced mortality and a reduction in the time to physician intervention for actionable events. However, patient compliance with monitoring over time and what factors might influence such compliance have not been well described. This study sought to identify factors contributing to patient noncompliance with RM of ICDs and CRTDs in a large real-world population. METHODS: Deidentified data on U.S. patients enrolled in the Medtronic CareLink RM system were used to compare patients with no (noncompliant, n = 14,848) and with ≥ 2 RM transmissions (compliant, n = 103,284) during a 14-month period. RESULTS: Overall noncompliance with RM was 21%. Younger age (≤ 40), female sex, wanded device, Medicare Census Division, and small clinic size all predicted patient noncompliance (P < 0.01). Device type (ICD vs CRTD) did not (P = 0.52). Multivariate analysis suggested clinically important predictors of noncompliance to be: age ≤ 40, odds ratio (OR) 2.64 (95% confidence interval, 2.42-2.88); Medicare Census Division (Mountain vs West North Central), OR 2.15 (1.96-2.37); and small clinic size (1-4 vs >100 patients), OR 4.38 (3.92-4.91). CONCLUSIONS: There is room for improvement in RM usage among enrolled patients. Younger patients, smaller clinics, and certain geographic areas may be targets for research into interventions to further improve the use of RM.

Efficacy and safety of implantable cardiac defibrillators for treatment of ventricular arrhythmias in patients with cardiac sarcoidosis.

AIMS: Implantable cardiac defibrillator (ICD) implantation is a class IIA recommendation for patients with cardiac sarcoidosis (CS). However, little is known about the efficacy and safety of ICDs in this population. The goal of this multicentre retrospective data review was to evaluate the efficacy and safety of ICDs in patients with CS. METHODS AND RESULTS: Electrophysiologists at academic medical centres were asked to identify consecutive patients with CS and an ICD. Clinical information, ICD therapy history, and device complications were collected for each patient. Data were collected on 235 patients from 13 institutions, 64.7% male with mean age 55.6 ± 11.1. Over a mean follow-up of 4.2 ± 4.0 years, 85 of 234 (36.2%) patients received an appropriate ICD therapy (shocks and/or anti-tachycardia pacing) and 67 of 226 (29.7%) received an appropriate shock. Fifty-seven of 235 patients (24.3%) received a total of 222 inappropriate shocks. Forty-six adverse events occurred in 41 of 235 patients (17.4%). Patients who received appropriate ICD therapies were more likely to be male (73.8 vs. 59.6%, P = 0.0330), have a history of syncope (40.5 vs. 22.5%, P = 0.0044), lower left ventricular ejection fraction (38.1 ± 15.2 vs. 48.8 ± 14.7%, P ≤ 0.0001), ventricular pacing on baseline electrocardiogram (16.1 vs. 2.1%, P = 0.0002), and a secondary prevention indication (60.7 vs. 24.5%, P < 0.0001) compared with those who did not receive appropriate ICD therapies. CONCLUSION: Patients with CS and ICDs are at high risk for ventricular arrhythmias. This population also has high rates of inappropriate shocks and device complications.