Arrhythmia Risk During the 2016 US Presidential Election: The Cost of Stressful Politics.

Background Anger and extreme stress can trigger potentially fatal cardiovascular events in susceptible people. Political elections, such as the 2016 US presidential election, are significant stressors. Whether they can trigger cardiac arrhythmias is unknown. Methods and Results In this retrospective case-crossover study, we linked cardiac device data, electronic health records, and historic voter registration records from 2436 patients with implanted cardiac devices. The incidence of arrhythmias during the election was compared with a control period with Poisson regression. We also tested for effect modification by demographics, comorbidities, political affiliation, and whether an individual's political affiliation was concordant with county-level election results. Overall, 2592 arrhythmic events occurred in 655 patients during the hazard period compared with 1533 events in 472 patients during the control period. There was a significant increase in the incidence of composite outcomes for any arrhythmia (incidence rate ratio [IRR], 1.77 [95% CI, 1.42-2.21]), supraventricular arrhythmia (IRR, 1.82 [95% CI, 1.36-2.43]), and ventricular arrhythmia (IRR, 1.60 [95% CI, 1.22-2.10]) during the election relative to the control period. There was also an increase in specific types of arrhythmia, including atrial fibrillation (IRR, 1.50 [95% CI, 1.06-2.11]), supraventricular tachycardia (IRR, 3.7 [95% CI, 2.2-6.2]), nonsustained ventricular tachycardia (IRR, 1.7 [95% CI, 1.3-2.2]), and daily atrial fibrillation burden (P<0.001). No significant interaction was found for sex, race/ethnicity, device type, age ≥65 years, hypertension, coronary artery disease, heart failure, political affiliation, or concordance between individual political affiliation and county-level election results. Conclusions There was a significant increase in cardiac arrhythmias during the 2016 US presidential election. These findings suggest that exposure to stressful sociopolitical events may trigger arrhythmogenesis in susceptible people.

Atrial fibrillation future clinic. Novel platform to integrate smart device electrocardiogram into clinical practice.

Background: Direct-to-consumer devices allow patients to record electrocardiograms (ECG) and detect atrial fibrillation (AF). Clinical adoption of these devices has been limited owing to the lack of efficient workflow. Objective: To assess a new care model for following patients after AF ablation that uses a smartphone ECG coupled with a novel cloud-based platform. Methods: This was a pilot study to describe AF detection, healthcare utilization, use of additional ECGs and cardiac monitors, and changes in anxiety after AF ablation. Patients presenting 3-4 months after early successful AF ablation were randomized into a control group with standard clinical follow-up or a self-monitoring group using smartphone ECG (Kardia Mobile, KM) coupled with a cloud-based platform (KardiaPro, KP) that alerted the physician when AF was detected and followed for 6 months. Results: A total of 100 patients were randomized: 51 to the KM/KP group and 48 to the control group (1 withdrew). AF was detected in 18 patients (18.2%), 11 (21.6%) in the KM/KP group and 7 (14.6%) in the control group (P = .42). AF detection occurred at a median of 68 and 91 days in the KM/KP and control groups, respectively (P = .93). These differences were not statistically significant. Healthcare utilization and changes in anxiety were similar between the groups. More patients required additional ECGs or cardiac monitors in the control group (27.1%) compared to the KM/KP group (5.9%) (P = .004). Conclusions: Smartphone ECG with a cloud-based platform can be incorporated into the care of post-AF ablation patients without increasing anxiety and with less need for additional traditional monitors.

Management and outcomes in mitral valve prolapse with ventricular arrhythmias undergoing ablation and/or implantation of ICDs.

BACKGROUND: While there is an association between isolated mitral valve prolapse (MVP) and sudden cardiac arrest (SCA), the baseline characteristics and outcomes of patients with isolated MVP who experience ventricular arrhythmias (VAs) and then subsequently undergo catheter ablation and/or implantable cardioverter defibrillator (ICD) implantation are unknown. METHODS: We performed a retrospective review of all patients at the Cleveland Clinic with isolated MVP between 1997 and 2016 who underwent VA catheter ablation or secondary prevention ICD implantation. RESULTS: Of 617 screened patients, we identified 43 patients with isolated MVP and significant VA who underwent ICD placement (n = 13, 30%) or catheter ablation (n = 30, 70%). Both leaflets were most commonly involved (n = 22, 52%) with posterior MVP being next most common (n = 15, 36%). The most common foci of VA origin was the left ventricular papillary muscle (n = 9, 27%). Ablation was successful in the majority of cases (n = 20, 65%). At a mean follow-up of 2.5 years, 11 patients (26%) had recurrent VT. CONCLUSIONS: Patients with isolated MVP and VA were more likely to have bileaflet prolapse and at least moderate mitral regurgitation. VA originated more commonly from left-sided foci. While ablation was acutely successful in the majority of cases, there was still a moderate rate of VA recurrence. There is still more study needed on factors that will predict malignant VAs and management of these VAs in the MVP population.

Smartwatch Algorithm for Automated Detection of Atrial Fibrillation.

BACKGROUND: The Kardia Band (KB) is a novel technology that enables patients to record a rhythm strip using an Apple Watch (Apple, Cupertino, California). The band is paired with an app providing automated detection of atrial fibrillation (AF). OBJECTIVES: The purpose of this study was to examine whether the KB could accurately differentiate sinus rhythm (SR) from AF compared with physician-interpreted 12-lead electrocardiograms (ECGs) and KB recordings. METHODS: Consecutive patients with AF presenting for cardioversion (CV) were enrolled. Patients underwent pre-CV ECG along with a KB recording. If CV was performed, a post-CV ECG was obtained along with a KB recording. The KB interpretations were compared to physician-reviewed ECGs. The KB recordings were reviewed by blinded electrophysiologists and compared to ECG interpretations. Sensitivity, specificity, and K coefficient were measured. RESULTS: A total of 100 patients were enrolled (age 68 ± 11 years). Eight patients did not undergo CV as they were found to be in SR. There were 169 simultaneous ECG and KB recordings. Fifty-seven were noninterpretable by the KB. Compared with ECG, the KB interpreted AF with 93% sensitivity, 84% specificity, and a K coefficient of 0.77. Physician interpretation of KB recordings demonstrated 99% sensitivity, 83% specificity, and a K coefficient of 0.83. Of the 57 noninterpretable KB recordings, interpreting electrophysiologists diagnosed AF with 100% sensitivity, 80% specificity, and a K coefficient of 0.74. Among 113 cases where KB and physician readings of the same recording were interpretable, agreement was excellent (K coefficient = 0.88). CONCLUSIONS: The KB algorithm for AF detection supported by physician review can accurately differentiate AF from SR. This technology can help screen patients prior to elective CV and avoid unnecessary procedures.

Acute ST-elevation myocardial infarction in patients hospitalized for noncardiac conditions.

BACKGROUND: Major advances have been made in the treatment of ST-elevation myocardial infarction (STEMI) in outpatients. In contrast, little is known about outcomes in STEMI that occur in patients hospitalized for a noncardiac condition. METHODS AND RESULTS: This was a retrospective, single-center study of inpatient STEMIs from January 1, 2007, to July 31, 2011. Forty-eight cases were confirmed to be inpatient STEMIs of a total of 139 410 adult discharges. These patients were older and more often female and had higher rates of chronic kidney disease and prior cerebrovascular events compared with 227 patients with outpatient STEMIs treated during the same period. Onset of inpatient STEMI was heralded most frequently by a change in clinical status (60%) and less commonly by patient complaints (33%) or changes on telemetry. Coronary angiography and percutaneous coronary intervention were performed in 71% and 56% of patients, respectively. The median time to obtain ECG (41 [10, 600] versus 5 [2, 10] minutes; P<0.001), ECG to angiography time (91 [26, 209] versus 35 [25, 46] minutes; P<0.001) and ECG to first device activation (FDA) (129 [65, 25] versus 60 [47, 76] minutes; P<0.001) were longer for inpatient versus outpatient STEMI. Survival to discharge was lower for inpatient STEMI (60% versus 96%; P<0.001), and this difference persisted after adjusting for potential confounders. CONCLUSIONS: Patients who develop a STEMI while hospitalized for a noncardiac condition are older and more often female, have more comorbidities, have longer ECG-to-FDA times, and are less likely to survive than patients with an outpatient STEMI.

Relation of pulse and systolic and mean blood pressure to severe renal artery stenosis in patients undergoing concurrent coronary and renal angiography.

Abrupt onset of renal ischemia is associated with increased blood pressure (BP), but it is unknown whether BP remains elevated in patients with chronic severe atherosclerotic renal artery stenosis (RAS). Patients undergoing coronary angiography who had concurrent renal angiography were divided into 3 groups: severe (stenosis ≥70% diameter reduction), moderate (10%-69%), and minimal RAS. Aortic BP was measured at the time of angiography. Renal angiography was performed in 762 (5.4%) of 14,181 patients undergoing coronary angiography. The mean age was 62 ± 12 years, 52% were women, 93% had hypertension, and 42% had diabetes mellitus. Minimal, moderate, or severe RAS was found in 62%, 30%, and 9% of patients. Patients with minimal RAS were younger, less likely to have hypercholesterolemia or coronary artery disease, and had a lower creatinine than patients with severe RAS. Severe RAS was associated with a lower diastolic BP and mean BP and a higher pulse pressure (PP), but there was no difference in systolic BP or the number of antihypertensive medications between the 3 groups. The degree of RAS had a weak positive correlation with PP, a weak negative correlation with diastolic BP, and almost no correlation with systolic BP or mean BP. In multivariate linear regression analysis, there was an association between severity of RAS and PP but not with mean BP or systolic BP. In conclusion, PP, but not systolic BP, diastolic BP, mean BP, or number of antihypertensive medications, was elevated in patients with severe RAS.

Simultaneous occurrence of a single coronary artery and persistent left superior vena cava.

We present a case of simultaneous occurrence of 2 rare congenital anomalies. A 57-year-old woman undergoing evaluation of dyspnea was found to have a single coronary artery and persistent left superior vena cava. The incidence of single coronary artery is 0.024% to 0.066% in the general population. Persistent left superior vena cava occurs in 0.3% of those without other congenital anomalies and in up to 5% when other anomalies are present. The likelihood of both anomalies occurring as a random event in 1 patient is approximately 1 in 10 million. Patient characteristics and data are presented, with a discussion on the epidemiology, incidence, diagnosis and pathologic implications of each anomaly.