Evaluation of Frontal QRS-T Angle in Children With ADHD and Healthy Controls.

INTRODUCTION: Conflicting findings exist regarding the link between attention deficit hyperactivity disorder (ADHD) and cardiovascular diseases. This study aimed to evaluate the frontal QRS-T (fQRS-T) angle and its correlation with symptom severity in children diagnosed with ADHD. METHODS: The study population consisted of 172 patients diagnosed with ADHD (120 drug naive and 52 drug positive) and 82 healthy controls. ADHD symptoms were assessed using the Atilla Turgay DSM-IV-Based Screening and Assessment Scale for Disruptive Conduct Disorders (T-DSM-IV-Scale). The fQRS-T angle and corrected QT (QTc) interval were obtained from the automated reports of 12-lead electrocardiography device for each patient. RESULTS: QTc interval and fQRS-T angle were significantly different among the groups. Post hoc analyses showed that QTc interval and fQRS-T angle of ADHD drug naive and ADHD drug positive patients were significantly higher than the healthy control groups. However, there was no significant difference between drug naive and drug positive patients regarding QTc interval and fQRS-T angle. Both QTc interval and fQRS-T angle showed positive correlations with the severity of ADHD symptoms (r = 0.263, p = .001 and r = 0.175, p = .023 respectively). CONCLUSION: We found that fQRS-T angle was significantly wider in children with ADHD. Therefore, we suggest that fQRS-T angle may help in cardiovascular risk assessment in children with ADHD.

Hypokalaemia in patients with type 2 diabetes and chronic kidney disease: the effect of finerenone - a FIDELITY analysis.

AIMS: Hypokalaemia is associated with cardiovascular events and mortality in patients with chronic kidney disease (CKD). This exploratory FIDELITY analysis, a prespecified pooled patient-dataset from FIDELIO-DKD and FIGARO-DKD, investigated the incidence and effect of hypokalaemia in patients with CKD and type 2 diabetes (T2D) treated with finerenone vs. placebo. METHODS: Outcomes include the incidence of treatment-emergent hypokalaemia (serum potassium < 4.0 or < 3.5 mmol/L) and the effect of finerenone on cardiovascular composite outcome (cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, or hospitalization for heart failure) and arrhythmia composite outcome (new diagnosis of atrial fibrillation/atrial flutter, hospitalization due to arrhythmia, or sudden cardiac death) by baseline serum potassium subgroups. RESULTS: In the FIDELITY population, treatment-emergent hypokalaemia with serum potassium < 4.0 and < 3.5 mmol/L occurred in 41.1% and 7.5%, respectively. Hazards of cardiovascular and arrhythmia composite outcomes were higher in patients with baseline serum potassium < 4.0 vs. 4.0-4.5 mmol/L (hazard ratio [HR] 1.16; 95% confidence interval [CI] 1.02-1.32, P = 0.022 and HR 1.20; 95% CI 1.00-1.44, P = 0.055, respectively). Finerenone reduced the incidence of hypokalaemia with serum potassium < 4.0 mmol/L (HR 0.63; 95% CI 0.60-0.66) and < 3.5 mmol/L (HR 0.46; 95% CI 0.40-0.53) vs. placebo. Finerenone lessened the hazard of cardiovascular and arrhythmia events vs. placebo, irrespective of baseline serum potassium. CONCLUSION: A substantial proportion of patients with CKD and T2D experienced hypokalaemia, which was associated with an increased hazard of adverse cardiovascular outcomes. Finerenone reduced the incidence of hypokalaemia. Finerenone reduced the hazard of cardiovascular and arrhythmia outcomes irrespective of serum potassium subgroups. Clinical trials registration: FIDELIO-DKD and FIGARO-DKD are registered with ClinicalTrials.gov, numbers NCT02540993 and NCT02545049, respectively (funded by Bayer AG).

Anterior pituitary hormone dysfunction among individuals with complete heart block requiring pacemaker.

Background & objectives Neuronal hypoxia associated with conditions like traumatic brain injury and cardiac tachyarrhythmia has been implicated in causing hypopituitarism. Individuals with complete heart block (CHB) may be predisposed to develop anterior pituitary hormone dysfunction in the long term. The objective of this study was to investigate anterior pituitary hormone functions in individuals after CHB. Methods This prospective cohort study included 30 individuals (21 men and 9 women) with CHB requiring pacemaker implantation, who were evaluated at admission and then at a mean follow up of 12.4 ± 2.2 months to look for development of any degree of hypopituitarism. In addition to the measurement of hormones like follicle-stimulating hormone (FSH), luteinising hormone (LH), thyroid stimulating hormone (TSH), total tetra iodothyronines (TT4), free tetraiodothyronines (FT4), cortisol, insulin-like growth factor-1 (IGF-1), testosterone and estradiol, a fixed-dose glucagon stimulation test (GST) was performed to assess growth hormone (GH) and adrenocorticotrophic hormone (ACTH) axis. Results The mean age of the participants was 64.9 ± 11.3 yr. At follow up evaluation, 17 (56.7%) had low serum IGF-1, and among them, seven (23%) had growth hormone deficiency (GHD) (peak GH <1.0 ng/ml after GST). Six participants (20%) had ACTH deficiency (peak cortisol <9 ug/dl after GST) and one had TSH deficiency. None had prolactin (PRL) or gonadotropin deficiency. Overall, hormone deficiencies were observed in nine patients (30%). Interpretation & conclusions This pilot study detected loss of anterior pituitary hormones in a significant number of individuals of CHB at 12 months follow up. Unrecognised hypopituitarism may have resulted in significant morbidity and mortality in these individuals.

Atrial tachycardia originating from a right atrial free wall diverticulum: case report.

Background: Atrial tachycardia (AT) is an arrhythmic disorder originating from the atrium, independent of the atrioventricular node, and includes various types based on different mechanisms such as abnormal automaticity, triggered activity, and re-entry. These mechanisms are often related to specific anatomical structures. Focal AT, though relatively rare, typically arises from well-known locations in the left and right atria, such as the pulmonary veins, mitral valve annulus, crista terminalis, and coronary sinus ostium. Case summary: We report a rare case of AT originating from a diverticulum in the right atrial free wall. The patient experienced recurrent AT episodes resistant to standard treatments. Detailed electrophysiological mapping identified the unusual origin of the tachycardia from a right atrial free wall diverticulum. Catheter ablation was successfully performed, leading to the resolution of the arrhythmia, with the patient remaining symptom-free during follow-up. Discussion: This case expands the understanding of AT origins, highlighting the right atrial free wall diverticulum as a potential, though rare, source of tachycardia. The case emphasizes the importance of comprehensive electrophysiological mapping, especially in atypical presentations of AT. Successful ablation in this instance underscores the potential for targeted interventions even in uncommon anatomical sites. Further studies are needed to assess the prevalence and clinical significance of AT arising from such rare locations.

Detection of Ventricular Tachycardia by an Implantable Cardiac Monitor 8 Months Post-myocardial Infarction.

Following a non-ST-elevation myocardial infarction (MI), a 68-year-old hypertensive, severely obese woman with 45% left ventricular ejection fraction underwent an implantable cardiac monitor (ICM) insertion. After 8 months, the ICM remotely transmitted multiple non-sustained ventricular tachycardia episodes. Symptomatic during these events, the patient underwent an invasive electrophysiologic stimulation, which induced ventricular arrhythmia. Subsequently, implantable cardioverter-defibrillator implantation was recommended. Continuous remote monitoring via an ICM detected critical arrhythmias in this post-MI patient, facilitating timely intervention.

Associated Factors and Mortality of Arrhythmia in Emergency Department: A Narrative Review.

Cardiac arrhythmias represent a major concern in the emergency department (ED), particularly given their association with significant morbidity and mortality. This narrative review examines the various factors influencing arrhythmias and their impact on patient outcomes in emergency settings. Managing complex supraventricular and ventricular arrhythmias (VAs) during acute myocardial infarction (AMI) and severe cardiovascular conditions remains challenging, despite advancements in diagnostic and therapeutic techniques. Ventricular arrhythmias frequently forecast worse outcomes during hospital stays and heighten the chances of sudden cardiac death and cardiac arrest, especially within the initial 30 days after a heart attack. The incidence of arrhythmias in ED is increasing due to demographic changes and higher rates of chronic illnesses such as diabetes, hypertension, and chronic kidney disease. These comorbidities, coupled with lifestyle factors such as smoking and alcohol consumption, complicate arrhythmia management, especially among older adults and males. Rapid and precise ECG interpretation in the ED is crucial for identifying specific arrhythmia types and initiating appropriate treatments. Atrial fibrillation (AF), the most prevalent form of rapid heart rhythm originating above the ventricles, notably impacts patient outcomes, particularly in cases of AMI and heart failure. In the ED, managing AF focuses on preventing strokes with thromboprophylaxis and employing risk assessment tools such as CHA2DS2-VASc and HAS-BLED scores. The analysis highlights how risk factors like hypertension, obesity, obstructive sleep apnea (OSA), and diabetes intricately influence the development and worsening of AF. Optimizing AF treatment outcomes requires a multidisciplinary approach involving cardiologists, emergency physicians, and critical care specialists. Future research should prioritize evaluating the effectiveness of preventive and therapeutic interventions for AF, integrating new risk factors and genetic insights to enhance prediction and management strategies. Understanding the factors contributing to arrhythmias and mortality in the ED underscores the importance of timely and accurate diagnostic and therapeutic measures to improve patient care and outcomes.

Pulsed-Field Ablation in Management of Ventricular Tachycardia: A Systematic Review of Case Reports and Clinical Outcomes.

BACKGROUND: Pulsed-field ablation (PFA) is a cutting-edge technique that employs non-thermal energy to cause cell death by inducing irreversible electroporation of cell membranes. This systematic review evaluates the PFA effectiveness as a potential alternative to radiofrequency and cryo-ablation for treating ventricular tachycardia. METHODS: PubMed, Embase, Scopus, and Web of Science were systematically searched using keywords related to ventricular tachycardia and pulsed-field ablation. Eligible Studies evaluating this therapeutic approach for ventricular tachycardia were included in the final analysis. RESULTS: We included six studies (five case reports and one case series) in our systematic review. Eight (88.8%) of procedures were successful with 100% long-term efficacy. No procedural complications or ventricular tachycardia (VT) recurrence were observed in the cases. CONCLUSION: The absence of complications, high effectiveness, and long-term success rate make PFAs a good VT treatment option. However, PFA safety and efficacy studies for VT treatment are scarce. Thus, larger investigations on this topic are urgently needed.

Characteristics of Patients with Spontaneous Coronary Artery Dissection Presenting with Sudden Cardiac Arrest in the United States and the Potential Role of Implantable Cardioverter Defibrillator Therapy.

Background: Spontaneous coronary artery dissection (SCAD) is a disease entity that often occurs in young, healthy women and can cause life-threatening ventricular arrhythmias and sudden cardiac arrest. However, the characteristics and outcomes of SCAD with cardiac arrest are not well characterized. Methods: This study investigated the baseline characteristics of SCAD patients with cardiac arrest using the National Inpatient Sample (NIS) database between 2016 and 2020. In addition, we also sought to determine the potential impact that implantable cardioverter defibrillator (ICD) therapy had on morbidity and mortality in SCAD patients presenting with cardiac arrest. Results: Our findings showed that the SCAD with cardiac arrest population had significantly higher comorbidities, including cardiac arrhythmias, congestive heart failure, pulmonary circulation disorders, liver diseases, solid tumors, coagulopathy, fluid disorders, chronic kidney disease (CKD), anemia secondary to deficiency, psychosis, neurological disorders, carotid artery disease, atrial fibrillation, ventricular arrhythmias (ventricular tachycardia (VT), ventricular fibrillation (VF)), and acute myocardial infarction (AMI), compared to the SCAD without cardiac arrest population. Likewise, for SCAD patients who did not have an ICD in place, we found increasing age, fluid and electrolyte disorders, uncomplicated diabetes, neurological disorders, peripheral vascular disease, pulmonary circulatory disorders, cardiac arrhythmias, and congestive heart failure to be associated with greater mortality. Conclusions: SCAD patients with certain comorbidities (e.g., pulmonary diseases, liver diseases, cancers, coagulopathy, and CKD) who presented with AMI or congestive heart failure should be monitored closely for ventricular arrhythmias as they have a higher chance of progressing to cardiac arrest. ICD therapy can be considered for these patients, but data on the success of this treatment option are limited, and more research needs to be performed to determine whether the benefits of this outweigh the risks.

The 2023 European Task Force Criteria for Diagnosis of Arrhythmogenic Cardiomyopathy: Historical Background and Review of Main Changes.

Arrhythmogenic cardiomyopathy (ACM) is a cardiac disease featured by non-ischemic myocardial scarring linked to ventricular electrical instability. As there is no single gold-standard test, diagnosing ACM remains challenging and a combination of specific criteria is needed. The diagnostic criteria were first defined and widespread in 1994 and then revised in 2010, approaching and focusing primarily on right ventricular involvement without considering any kind of left ventricular variant or phenotype. Years later, in 2020, with the purpose of overcoming previous limitations, the Padua Criteria were introduced by an international expert report. The main novel elements were the introduction of specific criteria for left ventricular variants as well as the use of cardiac magnetic resonance for tissue characterization and scar detection. The last modifications and refinement of these criteria were published at the end of 2023 as the European Task Force criteria, by a "head-quarter" of ACM international experts, proving the emerging relevance of this condition besides its difficult diagnosis. In this review, emphasizing the progress in understanding the aetiology of the cardiomyopathy, an analysis of the new criteria is presented. The introduction of the term "scarring/arrhythmogenic cardiomyopathy" sets an important milestone in this field, underlying how non-ischemic myocardial scarring-typical of ACM-and arrhythmic susceptibility could be the main pillars of numerous different phenotypic variants regardless of etiology.

Smart watch applications in atrial fibrillation detection: Current state and future directions.

INTRODUCTION: Atrial fibrillation (Afib) is a prevalent chronic arrhythmia associated with severe complications, including stroke, heart failure, and increased mortality. This review explores the use of smartwatches for Afib detection, addressing the limitations of current monitoring methods and emphasizing the potential of wearable technology in revolutionizing healthcare. RESULTS/OBSERVATION: Current Afib detection methods, such as electrocardiography, have limitations in sensitivity and specificity. Smartwatches with advanced sensors offer continuous monitoring, improving the chances of detecting asymptomatic and paroxysmal Afib. The review meticulously examines major clinical trials studying Afib detection using smartwatches, including the landmark Apple Heart Study and ongoing trials such as the Heart Watch, Heartline, and Fitbit Heart Study. Detailed summaries of participant numbers, smartwatch devices used, and key findings are presented. It also comments on the cost-effectiveness and scalability of smartwatch-based screening, highlighting the potential to reduce healthcare costs and improve patient outcomes. CONCLUSION/RELEVANCE: The integration of wearable technology into healthcare can lead to earlier diagnosis, improved patient engagement, and enhanced cardiac health monitoring. Despite ethical considerations and disparities, the potential benefits outweigh the challenges. This review calls for increased awareness, collaboration with insurance companies, and ongoing research efforts to optimize smartwatch accuracy and encourage widespread adoption of Afib detection. With insights from major trials, this review serves as a comprehensive reference for healthcare professionals and policymakers, guiding future strategies in the early diagnosis and management of atrial fibrillation.

Dofetilide for the treatment of premature ventricular complexes and ventricular tachycardia in patients with structural heart disease.

BACKGROUND: Dofetilide is a class III antiarrhythmic agent approved for the treatment of atrial fibrillation and atrial flutter. Given the efficacy of other class III agents, it has been used off-label for the treatment of premature ventricular complexes (PVCs) and ventricular tachycardias (VTs). OBJECTIVE: The purpose of this study was to determine the efficacy and safety of dofetilide for ventricular arrythmias (VAs). METHODS: In this retrospective cohort study, 81 patients (59 men; age = 60 ± 14 years; LVEF = 0.34 ± 0.16) were admitted for dofetilide initiation to treat PVCs (29), VTs (42) or both (10). A ≥ 80% decrease in PVC burden was defined as a satisfactory response. An ICD was present in 72 patients (89%). Another antiarrhythmic was previously used in 50 patients (62%). Prior catheter ablation had been performed in 33 patients (41%). RESULTS: During intitiation, dofetilide was discontinued in 12 patients (15%) due to QT prolongation (8) and inefficacy to suppress VAs (4). Among the 32 patients with PVCs who successfully started dofetilide, the mean PVC burden decreased from 20 ± 10% to 8 ± 8% at a median follow-up of 2.6 months (p < .001). PVC burden was reduced by ≥80% in only 11/32 patients (34%). During 7 ± 1 years of follow-up, 41/69 patients (59%) continued to have VAs and received appropriate ICD therapies for monomorphic VTs (35) and polymorphic VT/VF (6) at a median of 8.0 (IQR 2.6-33.2) months. Dofetilide had to be discontinued in 50/69 patients (72%) due to inefficacy or intolerance. The composite outcome of VT/VF recurrence, heart transplantation, or death occurred in 6/12 patients (50%) without dofetilide and 49/69 patients (71%) with dofetilide. The event free survival was similar between patients treated with and without dofetilide (log-rank p = .55). CONCLUSIONS: Treatment with dofetilide was associated with a decrease in PVCs, however clinically significant suppression occurred in a minority of patients. Dofetilide failed to suppress the occurrence of VTs in a majority of patients.

Acute Alcohol Consumption and Arrhythmias in Young Adults: The MunichBREW II Study.

BACKGROUND: and aims: Acute excessive alcohol intake may cause the holiday heart syndrome, characterized by cardiac arrhythmias including atrial fibrillation. Since underlying data are scarce, the study aimed to prospectively investigate the temporal course of occurring cardiac arrhythmias following binge drinking in young adults. METHODS: A total of 202 volunteers planning acute alcohol consumption with expected peak breath alcohol concentrations (BAC) of ≥1.2 g/kg were enrolled. The study comprised 48-hour electrocardiogram (ECG) monitoring covering baseline (hour 0), 'drinking period' (hours 1-5), 'recovery period' (hours 6-19), and two control periods corresponding to 24 hours after the 'drinking' and 'recovery periods', respectively. Acute alcohol intake was monitored by BAC measurements during the 'drinking period'. ECGs were analyzed for mean heart rate, atrial tachycardia, premature atrial complexes (PAC), premature ventricular complexes (PVC), and heart rate variability (HRV) measures. RESULTS: Data revealed an increase in heart rate and an excess of atrial tachycardias with increasing alcohol intake. HRV analysis indicated an autonomic modulation with sympathetic activation during alcohol consumption and the subsequent 'recovery period', followed by parasympathetic predominance thereafter. PACs occurred significantly more frequently in the 'control periods', whereas PVCs were more frequent in the 'drinking period'. Ten participants experienced notable arrhythmic episodes, including atrial fibrillation and ventricular tachycardias, primarily during the 'recovery period'. CONCLUSIONS: The study demonstrates the impact of binge drinking on heart rate alterations and increased atrial tachycardias during 'drinking period', and the occurrence of clinically relevant arrythmias during the 'recovery period', emphasizing the holiday heart syndrome as a health concern.

Machine Learning-Based Clustering Using a 12-Lead Electrocardiogram in Patients With a Implantable Cardioverter Defibrillator to Identify Future Ventricular Arrhythmia.

BACKGROUND: Implantable cardioverter defibrillators (ICDs) reduce mortality associated with ventricular arrhythmia in high-risk patients with cardiovascular disease. Machine learning (ML) approaches are promising tools in arrhythmia research; however, their application in predicting ventricular arrhythmias in patients with ICDs remains unexplored. We aimed to predict and stratify ventricular arrhythmias requiring ICD therapy using 12-lead electrocardiograms (ECGs) in patients with an ICD. METHODS AND RESULTS: This retrospective analysis included 200 adult patients who underwent ICD implantation at a single center. Patient demographics, clinical features, and 12-lead ECG data were collected. Unsupervised learning techniques, including K-means and hierarchical clustering, were used to stratify patients based on 12-lead ECG features. Dimensionality reduction methods were also used to optimize clustering accuracy. The silhouette coefficient was used to determine the optimal method and number of clusters. Of the 200 patients, 59 (29.5%) received appropriate therapy. The mean age of patients was 62.3 years, and 81.0% were male. The mean follow-up period was 2,953 days, with no significant intergroup differences. Hierarchical clustering into 3 clusters proved to be the most accurate (silhouette coefficient=0.585). Kaplan-Meier curves for these 3 clusters revealed significant differences (P=0.026). CONCLUSIONS: We highlight the potential of ML-based clustering using 12-lead ECGs to help in the risk stratification of ventricular arrhythmia. Future research in a larger multicenter setting may provide further insights and refine ICD indications.

REM sleep-related bradyarrhythmia syndrome.

Rapid eye movement sleep-related bradyarrhythmia syndrome is a rare condition marked by abnormal sinus arrest or atrioventricular conduction disturbance blocks during REM sleep unassociated with sleep disordered breathing. We present a case of a young man without a cardiovascular history exhibiting pauses of up to 9.7 seconds during polysomnography (PSG). Initially referred for suspected obstructive sleep apnea due to nocturnal awakenings with shortness of breath, confusion, and dizziness. PSG results were unremarkable apart from electrocardiogram findings revealing prolonged sinus pauses related to REM sleep. Evaluation via extended 14-day patch monitor revealed an overall normal sinus rhythm with the lowest heart rate recorded at 14 beats per minute and 412 pauses exceeding 2 seconds, with the longest pause lasting 12.5 seconds during nocturnal hours. A permanent pacemaker was considered, but after shared decision making with the patient, the decision was to continue monitoring without any intervention.

Novel heterozygous mutation of CACNA2D1 gene in a Chinese family with arrhythmia.

BACKGROUND: Primary electrical disorders (PEDs) are a group of cardiac rhythm abnormalities that occur in the absence of detectable structural heart disease and are a significant cause of sudden cardiac death (SCD). The initiation of cardiac muscle contraction and relaxation is orchestrated by the action potential (AP), generated through ionic changes across the membrane. Mutations in the AP-related gene CACNA2D1 have been identified as a causative factor for PED. METHODS: We recruited a Chinese family with a history of arrhythmia. The proband has experienced palpitations and chest tightness for over 40 years, with symptoms worsening over the past year. Whole exome sequencing (WES) was used to determine the genetic etiologies in this family. RESULTS: A novel heterozygous missense mutation (NM_000722.3: c.1685G > C;p.G562A) of CACNA2D1 gene was detected. Genotyping of the proband's parents indicated that the arrhythmia phenotype in the proband was caused by a de novo mutation. CONCLUSIONS: WES was utilized to explore the genetic etiology in a family with arrhythmia, leading to the identification of a novel mutation in the CACNA2D1 gene. This study not only expands the mutation spectrum of the CACNA2D1 gene but also contributes to genetic counseling and clinical diagnosis for this family.

An Uncommon Cause of Syncope and Left Atrial Appendage Thrombus: Speech-Induced Atrial Tachycardia.

An 83-year-old, previously healthy woman experienced frequent episodes of syncope following conversations. Speech-induced atrial tachycardia complicated by left atrial appendage thrombus was diagnosed as a potential etiology. She was successfully treated via catheter ablation. This is the first case report suggesting an association between arrhythmia, syncope, and atrial thrombus formation.