ANMCO position paper: guide to the appropriate use of the wearable cardioverter defibrillator in clinical practice for patients at high transient risk of sudden cardiac death.

Extended risk stratification and optimal management of patients with a permanently increased risk of sudden cardiac death (SCD) are becoming increasingly important. There are several clinical conditions where the risk of arrhythmic death is present albeit only transient. As an example, patients with depressed left ventricular function have a high risk of SCD that may be only transient if there will be a significant recovery of function. It is important to protect the patients while receiving and titrating to the optimal dose the recommended drugs that may lead to an improved left ventricular function. In several other conditions, a transient risk of SCD can be observed even if the left ventricular function is not compromised. Examples are patients with acute myocarditis, during the diagnostic work-up of some arrhythmic conditions or after extraction of infected catheters while eradicating the associated infection. In all these conditions, it is important to offer a protection to these patients. The wearable cardioverter defibrillator (WCD) is of particular importance as a temporary non-invasive technology for both arrhythmia monitoring and therapy in patients with increased risk of SCD. Previous studies have shown the WCD to be an effective and safe therapy for the prevention of SCD caused by ventricular tachycardia/fibrillation. The aim of this ANMCO position paper is to provide a recommendation for clinical utilization of the WCD in Italy, based upon current data and international guidelines. In this document, we will review the WCD functionality, indications, clinical evidence, and guideline recommendations. Finally, a recommendation for the utilization of the WCD in routine clinical practice will be presented, in order to provide physicians with a practical guidance for SCD risk stratification in patients who may benefit from this device.

Ventricular Fibrillation Recurrences in Successfully Shocked Out-of-Hospital Cardiac Arrests.

Background and Objectives: The prognostic impact of ventricular fibrillation (VF) recurrences after a successful shock in out-of-hospital cardiac arrest (OOHCA) is still poorly understood, and some evidence suggests a potential pro-arrhythmic effect of chest compressions in this setting. In the present analysis, we looked at the short-term and long-term prognosis of VF recurrences in OOHCA. And their potential association with chest compressions. Materials and Methods: The Progetto Vita, prospectively collecting data on all resuscitation efforts in the Piacenza province (Italy), was used for the present analysis. From the 461 OOHCAs found in a shockable rhythm, only those with optimal ECG tracings and good audio recordings (160) were assessed. Rhythms other than VF post-shock were analyzed five seconds after shock delivery and survival to hospital admission, hospital discharge, and long-term survival data over a 14-year follow-up were collected. Results: Population mean age was 64.4 ± 16.9 years, and 31.9% of all patients were female. Mean time to EMS arrival was 5.9 ± 4.5 min. Short- and long-term survival without neurological impairment were higher in patients without VF recurrence when compared to patients with VF recurrence, independently from the pre-induction rhythm (p < 0.001). After shock delivery, VF recurrence was higher when chest compressions were resumed early after discharge and more vigorously. Conclusions: VF recurrences after a shock could worsen short and long-term survival. The potential pro-arrhythmic effect of chest compressions should be factored in when considering the real risks and benefits of this procedure.

Electrocardiographic features of 431 consecutive, critically ill COVID-19 patients: an insight into the mechanisms of cardiac involvement.

AIMS: Our aim was to describe the electrocardiographic features of critical COVID-19 patients. METHODS AND RESULTS: We carried out a multicentric, cross-sectional, retrospective analysis of 431 consecutive COVID-19 patients hospitalized between 10 March and 14 April 2020 who died or were treated with invasive mechanical ventilation. This project is registered on ClinicalTrials.gov (identifier: NCT04367129). Standard ECG was recorded at hospital admission. ECG was abnormal in 93% of the patients. Atrial fibrillation/flutter was detected in 22% of the patients. ECG signs suggesting acute right ventricular pressure overload (RVPO) were detected in 30% of the patients. In particular, 43 (10%) patients had the S1Q3T3 pattern, 38 (9%) had incomplete right bundle branch block (RBBB), and 49 (11%) had complete RBBB. ECG signs of acute RVPO were not statistically different between patients with (n = 104) or without (n=327) invasive mechanical ventilation during ECG recording (36% vs. 28%, P = 0.10). Non-specific repolarization abnormalities and low QRS voltage in peripheral leads were present in 176 (41%) and 23 (5%), respectively. In four patients showing ST-segment elevation, acute myocardial infarction was confirmed with coronary angiography. No ST-T abnormalities suggestive of acute myocarditis were detected. In the subgroup of 110 patients where high-sensitivity troponin I was available, ECG features were not statistically different when stratified for above or below the 5 times upper reference limit value. CONCLUSIONS: The ECG is abnormal in almost all critically ill COVID-19 patients and shows a large spectrum of abnormalities, with signs of acute RVPO in 30% of the patients. Rapid and simple identification of these cases with ECG at hospital admission can facilitate classification of the patients and provide pathophysiological insights.

Community-based automated external defibrillator only resuscitation for out-of-hospital cardiac arrest patients.

BACKGROUND: Speed is the cornerstone of rescue for out-of-hospital cardiac arrest. As a consequence, community participation programs have been initiated to decrease response times. Even in the very best of these programs, however, short-term survival rates hover around 10% and long-term survival rates are half that. In most locales, survival is far worse. In Piacenza, Italy, responders have been trained for more than a decade to use publicly available automated external defibrillators (AEDs) and eschew the performance of cardiopulmonary resuscitation (CPR). It is known locally as "Progetto Vita." METHODS: From 2001 to 2014, we prospectively collected outcome data on all Progetto Vita-treated patients and all 3271 standard emergency medical services (EMS) patients. Progetto Vita rescuers simply accessed a public AED, turned it on, and only followed its instructions. Progetto Vita rescuers did not do CPR of any sort. If EMS arrived prior to initiation or even completion of the Progetto Vita protocol, EMS-supplanted Progetto Vita efforts and patients were not included in the Progetto Vita cohort. Follow-up was collected by each responder's data files, medical record review, and use of the Italian system death index. All cardiac arrest patients' death status was validated in 100% of patients through August 1, 2014. FINDINGS: Survival to hospital discharge occurred in 39 (41.4%) of the 95 patients treated by Progetto Vita and in 193 (5.9%) of the 3271 EMS patients. At 13-year follow-up, the Kaplan-Meier estimates of survival were 31.8% when AEDs only were used and 2.4% for standard EMS/CPR response. Estimates of survival are significantly better for Progetto Vita AED-only therapy when survival was stratified by time to respond, gender, location of cardiac arrest, and shockable rhythm. Relative to the 95 EMS patients with the fastest response times, Progetto Vita intervention was associated with a more than 2-fold increased rate of survival. INTERPRETATION: This is the first demonstration of excellent long-term survival from out-of-hospital cardiac arrest by promoting speed and ease of lay AED response without CPR.

[Public access defibrillation programs: Progetto Vita, current legal aspects and challenges for the future]. / Programmi di pubblico accesso alla defibrillazione: l'esperienza ultraventennale di Progetto Vita a Piacenza, aspetti legislativi attuali e sfide per il futuro.

Out-of-hospital cardiac arrest (OHCA) represents a significant healthcare issue that is often underestimated. OHCA predominantly affects the general population, with staggering numbers: 400 000 cases annually in Europe and 350 000 in the United States, contributing to 50% of cardiovascular-related deaths. The vast majority of OHCA cases begin with a shockable rhythm, making effective treatment possible through early defibrillation, even by non-medical personnel using automated external defibrillators (AEDs). Despite the availability of such devices, survival from OHCA remains below 10%, with no substantial improvements over the last 25 years. Public access defibrillation programs, which reduce response times with AEDs, have demonstrated a significant increase in survival chances for OHCA victims. Particularly, the "Progetto Vita" in Piacenza is an emblematic example of early defibrillation in Europe, tripling survival rates in OHCA patients treated by laypersons compared to patients treated with the traditional system. This experience contributed to the approval of Law 116, dated August 4, 2021, in Italy, aimed at promoting the distribution and use of AEDs in sports facilities, public venues, transportation, and public services. The law also emphasizes that AEDs can be used without the need for specific training, thus promoting wider usage. In this article, we will briefly examine the epidemiology of OHCA and delve into the organizational model of the "Progetto Vita", which aligns with the principles of Law 116/2021. The goal is to provide some insights into organizational aspects that could facilitate the nationwide expansion of early defibrillation programs in the near future.

Heart Failure Management through Telehealth: Expanding Care and Connecting Hearts.

Heart failure (HF) is a leading cause of morbidity worldwide, imposing a significant burden on deaths, hospitalizations, and health costs. Anticipating patients' deterioration is a cornerstone of HF treatment: preventing congestion and end organ damage while titrating HF therapies is the aim of the majority of clinical trials. Anyway, real-life medicine struggles with resource optimization, often reducing the chances of providing a patient-tailored follow-up. Telehealth holds the potential to drive substantial qualitative improvement in clinical practice through the development of patient-centered care, facilitating resource optimization, leading to decreased outpatient visits, hospitalizations, and lengths of hospital stays. Different technologies are rising to offer the best possible care to many subsets of patients, facing any stage of HF, and challenging extreme scenarios such as heart transplantation and ventricular assist devices. This article aims to thoroughly examine the potential advantages and obstacles presented by both existing and emerging telehealth technologies, including artificial intelligence.

A COVID-19 specific multiparametric and ECG-based score for the prediction of in-hospital mortality: ELCOVID score.

We aimed to develop and validate a COVID-19 specific scoring system, also including some ECG features, to predict all-cause in-hospital mortality at admission. Patients were retrieved from the ELCOVID study (ClinicalTrials.gov identifier: NCT04367129), a prospective, multicenter Italian study enrolling COVID-19 patients between May to September 2020. For the model validation, we randomly selected two-thirds of participants to create a derivation dataset and we used the remaining one-third of participants as the validation set. Over the study period, 1014 hospitalized COVID-19 patients (mean age 74 years, 61% males) met the inclusion criteria and were included in this analysis. During a median follow-up of 12 (IQR 7-22) days, 359 (35%) patients died. Age (HR 2.25 [95%CI 1.72-2.94], p < 0.001), delirium (HR 2.03 [2.14-3.61], p = 0.012), platelets (HR 0.91 [0.83-0.98], p = 0.018), D-dimer level (HR 1.18 [1.01-1.31], p = 0.002), signs of right ventricular strain (RVS) (HR 1.47 [1.02-2.13], p = 0.039) and ECG signs of previous myocardial necrosis (HR 2.28 [1.23-4.21], p = 0.009) were independently associated to in-hospital all-cause mortality. The derived risk-scoring system, namely EL COVID score, showed a moderate discriminatory capacity and good calibration. A cut-off score of ≥ 4 had a sensitivity of 78.4% and 65.2% specificity in predicting all-cause in-hospital mortality. ELCOVID score represents a valid, reliable, sensitive, and inexpensive scoring system that can be used for the prognostication of COVID-19 patients at admission and may allow the earlier identification of patients having a higher mortality risk who may be benefit from more aggressive treatments and closer monitoring.

[Takotsubo syndrome with right ventricular involvement in biventricular arrhythmogenic cardiomyopathy]. / Sindrome Takotsubo con interessamento del ventricolo destro nella cardiomiopatia aritmogena biventricolare.

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a heritable heart muscle disorder with fibro-fatty replacement that involves the right ventricle and in the advanced phases could become biventricular. Takotsubo syndrome (TTS) is characterized by reversible systolic dysfunction occurring after a stressful event and independent of the underlying coronary artery disease. A 70-year-old female with family history of sudden cardiac death and a previous diagnosis of biventricular ARVC presented to the emergency department after experiencing chest pain and elevation of myocardial enzymes. The ECG showed sinus bradycardia and negative T-waves from V1-V3. Coronary arteries were free from stenosing atheromatous lesions at coronary angiography. Transthoracic echocardiography showed severe biventricular dysfunction due to left ventricular apical/peri-apical akinesis with apical ballooning pattern. Cardiac magnetic resonance confirmed the presence of transmural biventricular edema in the mid-apical segments in T2 weighted sequences involving both ventricles along with fibro-fatty replacement in post-contrast sequences. At discharge, a cardioverter-defibrillator was implanted. This case report shows that TTS diagnosis is challenging for the clinician due to the presence of structural cardiomyopathy with biventricular involvement. Second-line imaging modalities could be useful to identify the presence of myocardial edema and to recognize those conditions associated with poor prognosis.

Air pollution and out-of-hospital cardiac arrest risk: a 7-year study from a highly polluted area.

AIMS: Globally, nearly 20% of cardiovascular disease deaths were attributable to air pollution. Out-of-hospital cardiac arrest (OHCA) represents a major public health problem; therefore, the identification of novel OHCA triggers is of crucial relevance. The aim of the study was to evaluate the association between air pollution (short-, mid-, and long-term exposures) and OHCA risk, during a 7-year period in a highly polluted urban area in northern Italy, with a high density of automated external defibrillators (AEDs). METHODS AND RESULTS: Out-of-hospital cardiac arrests were prospectively collected from the 'Progetto Vita Database' between 1 January 2010 and 31 December 2017; day-by-day air pollution levels were extracted from the Environmental Protection Agency stations. Electrocardiograms of OHCA interventions were collected from the AED data cards. Day-by-day particulate matter (PM) 2.5 and 10, ozone (O3), carbon monoxide (CO), and nitrogen dioxide (NO2) levels were measured. A total of 880 OHCAs occurred in 748 days. A significant increase in OHCA risk with a progressive increase in PM2.5, PM10, CO, and NO2 levels was found. After adjustment for temperature and seasons, a 9% and 12% increase in OHCA risk for each 10 µg/m3 increase in PM10 (P < 0.0001) and PM2.5 (P < 0.0001) levels was found. Air pollutant levels were associated with both asystole and shockable rhythm risk, while no correlation was found with pulseless electrical activity. CONCLUSION: Short- and mid-term exposures to PM2.5 and PM10 are independently associated with the risk of OHCA due to asystole or shockable rhythm.

[ANMCO Position paper: Wearable cardioverter defibrillator appropriate use guidance for the management of patients at high transient risk of sudden cardiac death]. / Position paper ANMCO: Guida all'uso appropriato del defibrillatore indossabile nella pratica clinica per i pazienti ad elevato rischio transitorio di morte improvvisa.

Extended risk stratification and optimal management of patients with a permanently increased risk of sudden cardiac death (SCD) is becoming increasingly important. There are several clinical conditions where the risk of arrhythmic death is present albeit only transient. As an example, patients with depressed left ventricular function have a high risk of SCD that may be only transient when there is a significant recovery of function. It is important to protect the patients while receiving the recommended measures and drugs that may either lead or not to an improved left ventricular function. In several other conditions a transient risk of SCD can be observed even if the left ventricular function is not compromised. Examples are patients with acute myocarditis, during the diagnostic work-up of some arrhythmic conditions or after extraction of infected catheters while eradicating the associated infection. In all these conditions it is important to offer a protection to these patients. The wearable cardioverter-defibrillator (WCD) is of particular importance as a temporary non-invasive technology for both arrhythmia monitoring and therapy in patients with increased risk of SCD. Previous studies have shown the WCD to be an effective and safe therapy for the prevention of SCD caused by ventricular tachycardia/fibrillation. The aim of this ANMCO position paper is to provide a recommendation for clinical utilization of the WCD in Italy, based upon current data and international guidelines. In this document we will review the WCD functionality, indications, clinical evidence as well as guideline recommendations. Finally, a recommendation for the utilization of the WCD in routine clinical practice will be presented, in order to provide physicians with a practical guidance for SCD risk stratification in patients who may benefit from this device.

Ante-mortem characterization of sudden deaths as first-manifestation in Italy.

PURPOSE: There is a relative paucity of data on ante-mortem clinical characteristics of young (age 1 to 35 years) sudden death (SD) victims. The aim of the study was to characterize ante-mortem characteristics of SD victims, in a selected national cohort identified by a web search. METHODS: A dataset of all SD (January 2010 and December 2015) was built from national forensic data and medical records, integrated with Google search model. Families were contacted to obtain consent for interviews. Data were obtained on ante-mortem symptoms. ECG characteristics and autopsy data were available. RESULTS: Out of 301 SD cases collected, medical and family history was available in 132 (43.9%). Twenty-eight (21.1%) had a positive family history for SD. SD occurred during sport/effort in 76 (57.6%). One hundred twelve (85%) SD cases had no prior reported symptoms. Autopsy data were available in 100/132 (75.8%) cases: an extra cardiac cause was identified in 20 (20%). Among the 61 cases with a cardiac diagnosis, 21 (34%) had hypertrophic cardiomyopathy. Among the 19 (19%) victims without structural abnormalities, molecular autopsy identified pathogenic variants for channelopathies in 9 cases. Ten (10%) victims had no identifiable cause. CONCLUSIONS: Most SD were due to cardiac causes and occurred in previously asymptomatic patients. SD events mainly occurred during strenuous activity. In a minority of cases, no cause was identified. The web-based selection criteria, and incomplete data retrieval, need to be carefully taken into account for data interpretation and reproducibility.

[Screening for atrial fibrillation in the general population: experience from a cardiovascular risk campaign in the Emilia-Romagna Region]. / Screening della fibrillazione atriale nella popolazione generale: esperienza della campagna educazionale sul rischio cardiovascolare della Regione Emilia-Romagna.

BACKGROUND: Atrial fibrillation (AF) is a major cause of cerebral ischemia, and its early detection may impact on health. Both invasive and non-invasive devices can be used for the diagnosis of AF. The aim of our study was to estimate the prevalence of AF using a single-lead ECG device (MyDiagnostickTM) on an adult, asymptomatic population during a screening campaign. METHODS: A total of 2547 subjects underwent AF screening. RESULTS: The device detected an arrhythmia in 42 subjects (1.65%), and AF was confirmed on 12-lead ECG in 14 (0.55%) of them. The prevalence of confirmed AF increased in subjects over 65 years of age (1.21%) or with a CHA2DS2-VASc score ≥2 in males or ≥3 in females (1.33%). Furthermore, heart failure (odds ratio [OR] 8.62, 95% confidence interval [CI] 1.87-39.6, p=0.006) and diabetes (OR 4.55, 95% CI 1.25-16.5, p=0.021) significantly increased the risk of AF. CONCLUSIONS: During a screening campaign, the diagnosis of AF increases when subjects with a high thromboembolic risk are selected.

The Combination of Chest Computed Tomography and Standard Electrocardiogram Provides Prognostic Information and Pathophysiological Insights in COVID-19 Pneumonia.

AIMS: Several studies have unveiled the great heterogeneity of COVID-19 pneumonia. Identification of the "vascular phenotype" (involving both pulmonary parenchyma and its circulation) has prognostic significance. Our aim was to explore the combined role of chest computed tomography (CT) scan and electrocardiogram (ECG) at hospital admission in predicting short-term prognosis and to draw pathophysiological insights. METHODS AND RESULTS: We analyzed the chest CT scan and ECG performed at admission in 151 consecutive COVID-19 patients admitted between 20 March and 4 April 2020. All-cause mortality within 30 days was the primary endpoint. Median age was 71 years (IQR: 62-76). Severe pneumonia was present in 25 (17%) patients, and 121 (80%) had abnormal ECG. During a median follow-up of 7 days (IQR: 4-13), 54 (36%) patients died. Deceased patients had more severe pneumonia than survivors did (80% vs. 64%, p = 0.044). ECG in deceased patients showed more frequently atrial fibrillation/flutter (17% vs. 6%, p = 0.039) and acute right ventricular (RV) strain (35% vs. 10%, p < 0.001), suggesting the "vascular phenotype". ECG signs of acute RV strain (HR 2.46, 95% CIs 1.36-4.45, p = 0.0028) were independently associated with all-cause mortality in multivariable analysis, and in the likelihood ratio test, showed incremental prognostic value over chest CT scan, age, and C-reactive protein. CONCLUSIONS: Combining chest CT scan and ECG data improves risk stratification in COVID-19 pneumonia by identifying a distinctive phenotype with both parenchymal and vascular damage of the lung. Patients with severe pneumonia at chest CT scan plus ECG signs of acute RV strain have an extremely poor short-term prognosis.

Treatment for COVID-19-a cohort study from Northern Italy.

Multicentre, retrospective cohort study with multivariable Cox proportional-hazards modelling and survival-time inverse-probability-weighting, evaluating the impact of different treatments on survival of proven COVID-19 patients admitted to two Hospitals in the province of Piacenza, Italy. Use of tocilizumab and of high doses of low molecular weight heparin, but not of antivirals (either alone or in combination), azithromycin, and any corticosteroid, was independently associated with lower mortality. Our results support further clinical evaluation of high doses of low molecular weight heparin and tocilizumab as COVID-19 therapeutics.

Time course of effects of cardiac resynchronization therapy in chronic heart failure: benefits in patients with preserved exercise capacity.

OBJECTIVES: To assess in patients with chronic heart failure the effect of cardiac resynchronization therapy (CRT) over 12 months' follow-up the time course of the changes in functional and neurohormonal indices and to identify responders to CRT. METHODS: Eighty-nine patients (74.1 +/- 1 years, left ventricular ejection fraction [LVEF] < 35%), QRS complex duration >150 ms, in stable New York Heart Association (NYHA) class III or IV on optimal medical treatment were prospectively randomized either in a control (n = 45) or CRT (n = 44) group and underwent clinical evaluation, cardiopulmonary exercise testing (CPET), 2D-Echo, heart rate variability (HRV), carotid baroreflex (BRS), and BNP assessments before and at 6- and 12-month follow-up. RESULTS: In the CRT group, improvement of cardiac indices and BNP concentration were evident at medium term (over 6 months) follow-up, and these changes persisted on a longer term (12 months) (all P < 0.05). Instead CPET indices and NYHA class improved after 12 months associated with restoration of HRV and BRS (all P < 0.05). We identified 26 responders to CRT according to changes in LVEF and diameters. Responders presented less depressed hemodynamic (LVEF 25 +/- 1.0 vs 22 +/- 0.1%), functional (peak VO(2) 10.2 +/- 0.2 vs 6.9 +/- 0.3 ml/kg/min), and neurohormonal indices (HRV 203.6 +/- 15.7 vs 147.6 +/- 10.ms, BRS 4.9 +/- 0.2 vs 3.6 +/- 0.3 ms/mmHg) (all P < 0.05). In the multivariate analysis, peak VO(2) was the strongest predictor of responders. CONCLUSIONS: Improvement in functional status is associated with restoration of neurohormonal reflex control at medium term. Less depressed functional status (peak VO(2)) was the strongest predictor of responders to CRT.

Outcomes after sudden cardiac arrest in sports centres with and without on-site external defibrillators.

OBJECTIVE: Sudden cardiac arrest (SCA) is a rare but tragic event during amateur sports activities. Our aim is to analyse whether availability of automated external defibrillators (AEDs) in amateur sports centres could impact on SCA survival. METHODS: This is an observational study. During an 18-year period, data regarding exercise-related SCA in sports centres were prospectively collected. Survival rates and time to response were compared between centres with an AED already available and centres where an AED was not already present. RESULTS: Out of 252 sports facilities, 207 (82%) acquired an AED during follow-up while 45 (18%) did not. From 1999 to 2014, there were 26 SCAs (24 (92%) men, 54±17 years old) with 15 (58%) of them in centres with on-site AED. Neurologically intact survival rates were 93% in centres with on-site AED and 9% in centres without (P<0.001). Presence of on-site AED, presence of shockable rhythm, first assistance by a lay bystander and time to defibrillation were all related to neurological intact survival, but the presence of on-site AED was the only independent predictor in the multivariate analysis. The use of on-site AED resulted in a lower time to first shock when compared with emergency medical system-delivered AED (3.3±1.4min vs 7.3±3.2 min; P=0.001). CONCLUSIONS: The presence of on-site AEDs is associated with neurologically intact survival after an exercise-related SCA. Continuous efforts are recommended in order to introduce AEDs in sports and fitness centres, implement educational programmes and increase common awareness about SCA.

Tripling survival from sudden cardiac arrest via early defibrillation without traditional education in cardiopulmonary resuscitation.

BACKGROUND: Early defibrillation is the most important intervention affecting survival from sudden cardiac arrest (SCA). To improve public access to early defibrillation, we established Piacenza Progetto Vita (PPV), the first system of out-of-hospital early defibrillation by first-responder volunteers. METHODS AND RESULTS: The system serves a population of 173 114 residents in the Piacenza region of Italy. Equipment for the system comprises 39 semiautomatic external biphasic defibrillators (AEDs): 12 placed in high-risk locations, 12 in lay-staffed ambulances, and 15 in police cars; 1285 lay volunteers trained in use of the AED, without traditional education in cardiac pulmonary resuscitation, responded to all cases of suspected SCA, in coordination with the Emergency Medical System (EMS). During the first 22 months, 354 SCA occurred (72+/-12 years, 73% witnessed). The PPV volunteers treated 143 SCA cases (40.4%), with an EMS call-to-arrival time of 4.8+/-1.2 minutes (versus 6.2+/-2.3 minutes for EMS, P=0.05). Overall survival rate to hospital discharge was tripled from 3.3% (7 of 211) for EMS intervention to 10.5% (15 of 143) for PPV intervention (P=0.006). The survival rate for witnessed SCA was tripled by PPV: 15.5% versus 4.3% in the EMS-treated group (P=0.002). A "shockable" rhythm was present in 23.8% (34 of 143) of the PPV patients versus 15.6% (33 of 211) of the EMS patients (P=0.055). The survival rate from shockable dysrhythmias was higher for PPV versus EMS: 44.1% (15 of 34) versus 21.2% (7 of 33), P=0.046. The neurologically intact survival rate was higher in PPV-treated versus EMS-treated patients: 8.4% (12 of 143) versus 2.4% (5 of 211), P=0.009. CONCLUSIONS: Broad dissemination of AEDs for use by nonmedical volunteers enabled early defibrillation and tripled the survival rate for out-of-hospital SCA.

Transient QRS amplitude attenuation is associated with clinical recovery in patients with takotsubo cardiomyopathy.

BACKGROUND/OBJECTIVES: Low voltage QRS complexes (LQRSV) and amplitude attenuation of QRS voltage (AAQRS) have been described in takotsubo (TC) patients, and postulated as valuable pre-angiographic markers. The aim of this observational study is to evaluate potential diagnostic and prognostic features of QRS amplitude in TC and acute coronary syndrome (ACS) patients. METHODS: Fifty-eight patients with TC were matched with 58 patients with ACS according to age, gender, and presence or absence of ST elevation at hospital admission. A 12-lead ECG was recorded within 12h after symptoms onset, the day after coronary angiography (CA) and before hospital discharge. When available, ECGs prior and subsequent to the acute event were also collected. RESULTS: QRS amplitude showed a time related trend, with a first phase characterized by an initial decrease in amplitude in both groups and a second phase, with a progressive recovery of QRS amplitude in TC patients up to pre-event levels, while QRS amplitude in ACS patients remained substantially unchanged from admission onwards. Rise in AAQRS during hospitalization showed a positive linear association with systolic function recovery and both troponin I and CK-MB decrease (all p<0.01) in TC patients. A 20% increase of mean AAQRS from admission is able to predict LVEF recovery and troponin I and CK-MB normalization in TC patients with good sensitivity and specificity. CONCLUSIONS: LQRSV and AAQRS are not reliable in differentiating ACS from TC. However, QRS amplitude attenuation in TC is transient, and is linearly associated with systolic function recovery and cardiac biomarkers normalization.

Out-of-hospital early defibrillation successfully challenges sudden cardiac arrest: the Piacenza Progetto Vita project.

BACKGROUND: Early defibrillation is the most important intervention influencing survival following sudden cardiac arrest (SCA). In order to improve public access to early defibrillation, in North America several experiences of out-of-hospital early defibrillation by non-medical volunteers have been successfully implemented and demonstrated to improve survival. METHODS: Since 1999, in Piacenza, we have established "Progetto Vita", the first experience of out-of-hospital early defibrillation by non-medical volunteers in a medium-size European city. Thirty-nine semiautomatic external defibrillators were placed in Piacenza, Italy (266,531 inhabitants) and distributed in 12 high-risk locations, 12 lay-staffed ambulances and 15 police-cars. A total of 1285 lay volunteers were trained by the emergency medical system to intervene in all cases of suspected SCA. RESULTS: During the first 15 months, 203 codes for suspected SCA were dispatched; 197 were confirmed SCA. The overall survival was 5.6% (11/197): survival improved from 2.9% (4/134) with emergency medical system intervention to 11.1% (7/63) when the "Progetto Vita" was activated (p < 0.05). The survival rate on "shockable" rhythm was 43.7% in the group of patients treated by volunteers vs 16.6% in those treated by emergency medical system aid (p = 0.05). CONCLUSIONS: The widespread use of semiautomatic external defibrillators allows early defibrillation by non-medical volunteers and more than triples the survival rate following out-of-hospital SCA.