Conflict of interest policies and disclosure requirements among European Society of Cardiology National Cardiovascular Journals.

Disclosure of potential conflicts of interest (COIs) is used by biomedical journals to guarantee credibility and transparency of the scientific process. Conflict of interest disclosure, however, is not systematically nor consistently dealt with by journals. Recent joint editorial efforts paved the way towards the implementation of uniform vehicles for COI disclosure. This paper provides a comprehensive editorial perspective on classical COI-related issues. New insights into the current COI policies and practices among European Society of Cardiology National Cardiovascular Journals, as derived from a cross-sectional survey using a standardized questionnaire, are discussed.

Fostering diffusion of scientific contents of national society cardiovascular journals: the new ESC search engine.

European Society of Cardiology (ESC) National Society Cardiovascular Journals (NSCJs) are high-quality biomedical journals focused on cardiovascular diseases. The Editors' Network of the ESC devises editorial initiatives aimed at improving the scientific quality and diffusion of NSCJ. In this article we will discuss on the importance of the Internet, electronic editions and open access strategies on scientific publishing. Finally, we will propose a new editorial initiative based on a novel electronic tool on the ESC web-page that may further help to increase the dissemination of contents and visibility of NSCJs.

Conflict of interest policies and disclosure requirements among European Society of Cardiology National Cardiovascular Journals.

Disclosure of potential conflicts of interest (COI) is used by biomedical journals to guarantee credibility and transparency of the scientific process. COI disclosure, however, is not systematically nor consistently dealt with by journals. Recent joint editorial efforts paved the way towards the implementation of uniform vehicles for COI disclosure. This paper provides a comprehensive editorial perspective on classical COI-related issues. New insights into current COI policies and practices among European Society of Cardiology national cardiovascular journals, as derived from a cross-sectional survey using a standardised questionnaire, are discussed.

Conflict of interest policies and disclosure requirements among European Society of Cardiology National Cardiovascular Journals.

Disclosure of potential conflicts of interest (COI) is used by biomedical journals to guarantee credibility and transparency of the scientific process. Conflict of interest disclosure, however, is not systematically nor consistently dealt with by journals. Recent joint editorial efforts paved the way towards the implementation of uniform vehicles for COI disclosure. This paper provides a comprehensive editorial perspective on classical COI-related issues. New insights into the current COI policies and practices among European Society of Cardiology National Cardiovascular Journals, as derived from a cross-sectional survey using a standardised questionnaire, are discussed.

Statistics at a glance.

I still remember my first book on statistics: "Elementary statistics with applications in medicine and the biological sciences" by Frederick E. Croxton. For me, it has been the start of pursuing understanding statistics in daily life and in medical practice. It was the first volume in a long row of books. In his introduction, Croxton pretends that"nearly everyone involved in any aspect of medicine needs to have some knowledge of statistics". The reality is that for many clinicians, statistics are limited to a "P < 0.05 = ok". I do not blame my colleagues who omit the paragraph on statistical methods. They have never had the opportunity to learn concise and clear descriptions of the key features. I have experienced how some authors can describe difficult methods in a well understandable language. Others fail completely. As a teacher, I tell my students that life is impossible without a basic knowledge of statistics. This feeling has resulted in an annual seminar of 90 minutes. This tutorial is the summary of this seminar. It is a summary and a transcription of the best pages I have detected.

Tilt training and pacing: a report on 9 patients with neurally mediated syncope.

OBJECTIVE: In patients with neurally mediated syncope (NMS), pacing has been used to prevent bradycardia and syncope. However, recurrence due to the vasodepressor component remains a problem. METHODS: We report on tilt training in 9 patients with a pacemaker (PM) implantation. Patients were submitted to daily in-hospital tilt testing. They were instructed to continue this therapy at home. RESULTS: A negative tilt test was obtained in all patients. Six patients remained free from syncope. Recurrent syncope was observed in 3 patients. In 4 patients the pacemaker had been implanted before the start of the tilt training programme. Five patients had a pacemaker implanted after the administration of tilt training therapy. CONCLUSION: NMS also occurs in paced patients.Tilt training improves the clinical outcome by restoring the vasoconstrictor reserve capacity.

Tilt training increases the vasoconstrictor reserve in patients with neurally mediated syncope evoked by head-up tilt testing.

AIMS: Tilt training is a useful therapeutic option in neurally mediated syncope (NMS). We tested the hypothesis that tilt training will restore orthostatic tolerance by increasing the degree of vasomotor reserve during sustained orthostatic stress. METHODS AND RESULTS In this follow-up study we enrolled 17 patients (age 31 +/- 22 years, 11 females) with a clinical diagnosis of NMS and two consecutive positive tilt tests. The head-up tilt test was repeated day after day: one session per day. All patients were instructed to continue a programme of daily standing training at home. Follow-up tilt testing was performed after a period of 6 weeks in 14 patients. ECG and finger arterial blood pressure (Portapres) were recorded during subsequent tilt testing. Left ventricular stroke volume (SV), cardiac output, and systemic vascular resistance were computed from the pressure pulsations (Modelflow). Spontaneous cardiac baroreflex sensitivity was estimated by cross-spectral analysis of heart rate (HR) and systolic blood pressure. In all patients, orthostatic tolerance was restored after 4.1 +/- 0.9 tilt sessions, median 4. The follow-up tilt test was also negative in all patients. This was accompanied by a significant rise in systemic vascular resistance to compensate for a postural reduction in SV in the sustained head-up tilt position. No evidence could be provided of altered baroreflex control of HR after tilt training. CONCLUSION: Tilt training restores orthostatic tolerance at least in part by increasing the amount of vasoconstriction that can ultimately be made available during sustained orthostatic stress. The increased vasoconstrictor reserve is preserved after 6 weeks of continued standing training at home.

Potential role of remote monitoring for scheduled and unscheduled evaluations of patients with an implantable defibrillator.

AIMS: Follow-up of implantable cardioverter defibrillator (ICD) patients, with regular in-office visits every 3-6 months, puts a significant burden on specialized electrophysiology clinics. New technology allows for remote monitoring of device function. We wanted to investigate its potential reliability and to which extent its use can reduce in-office visits. METHODS AND RESULTS: We retrospectively analysed data from 1739 prospectively coded ICD visits in a random set of 169 patients (followed between 2 month and 10.4 year in an academic centre). We defined (i) whether the visit was planned or not, (ii) what were the reasons for unplanned visits, (iii) whether any relevant finding was made, (iv) whether a remote monitoring system with the ability or not to detect pacing threshold would have been able to capture the problem, and (v) what actions were taken. The standard follow-up scheme consisted of in-office visits 1 month after implantation and then every 6 months, unless approaching battery depletion. From the 1739 visits, 1530 were performed according to clinical schedule (88%) and in 1197 of those (78.2%), no relevant finding was made. In 0.52% (n = 8) early post-implant pacing threshold increases would not have been detected by remote monitoring without the ability to determine thresholds (although two patients showed a high impedance). Moreover, in 6% of the planned visits, reprogramming would require a consecutive in-office visit (4%) or hospitalization (2%). Only 175 visits (9.6% of all) were conducted prior to the planned follow-up date due to patient symptoms [another 42 (2.4%) were due to planned surgery or safety warnings]. The proportion of relevant findings during unscheduled visits was significantly higher than during scheduled visits (80.6 vs. 21.8%; P < 0.0001) and a higher proportion of those was arrhythmia- and/or device-related (85.1 vs. 55.3%, P < 0.0001). Reprogramming was required more often (33.1 vs. 4%; P < 0.0001) and hospitalization rate was higher (18.3 vs. 2%; P < 0.0001), so that 51.4% of unscheduled visits would require in-office evaluation. Overall, remote follow-up would correctly exclude device function abnormalities or arrhythmic problems in 1402 (82.2%), identify an arrhythmic problem in 262 (15.3%), correctly identify a device-related problem in 35 (2.1%), but potentially miss an isolated pacing problem in 6 (0.46%). Clinical evaluation would diagnose a relevant clinical problem in the absence of any device interrogation abnormality in 170 patients (10%). CONCLUSION: ICD remote monitoring can potentially diagnose >99.5% of arrhythmia- or device-related problems if combined with clinical follow-up by the local general practitioner and/or referring cardiologist. It may provide a way to significantly reduce in-office follow-up visits that are a burden for both hospitals and patients.

The world survey of cardiac pacing and cardioverter-defibrillators: calendar year 2005 an International Cardiac Pacing and Electrophysiology Society (ICPES) project.

BACKGROUND: A worldwide cardiac pacing and implantable cardioverter-defibrillator (ICD) survey was undertaken for calendar year 2005 and compared to a similar survey conducted in 2001. RESULTS: There were contributions from 43 countries: 16 from Europe, 13 from the Asia Pacific region, four from the Middle East and Africa, and 10 from the Americas. The United States had the largest number of cardiac pacemaker implants (223,425). Virtually all countries showed increases in implant numbers over the 4 years. High-degree atrioventricular block and sick sinus syndrome remain the major indications for implantation of a cardiac pacemaker, although indications data were not available for large implanting regions such as Europe, Australia, and the United States. There remains a high percentage of VVI(R) pacing in the developing countries, although compared to the 2001 survey, virtually all countries had increased the percentage of DDDR implants, together with a fall in single-lead VDD implants. Pacing leads were predominantly transvenous, bipolar, and passive fixation. There was, however, an increased use of active fixation leads in both the atrium and ventricle. All countries surveyed showed a significant rise in the use of ICDs with the largest implanter being the United States (119,121) with 401 new implants per million population. CONCLUSIONS: Although the numbers of participating countries have fallen, there still remains a group of loyal enthusiastic survey coordinators. Recruitment of new coordinators will hopefully continue in order to obtain a fully global experience of cardiac pacing and ICD usage.

Appropriate and inappropriate implantable cardioverter defibrillator interventions during secondary prevention.

BACKGROUND: ICD therapy is established therapy for secondary prevention after aborted sudden death or ventricular tachycardia. Long-term data on the incidence of appropriate and inappropriate interventions are scarce. METHODS AND RESULTS: We retrospectively studied 391 patients with an ICD for secondary prophylaxis: 247 (63%) with ischaemic heart disease (IHD) and 144 without IHD (37%). Fifty-four patients were free from left ventricular structural disease. Mean follow-up was 30.8 months. Kaplan-Meier methodology was used for survival analysis. The use of beta-blockers was high and similar in both groups (85% IHD; 88% non-IHD; P = 0.36). The incidence of appropriate interventions was identical in IHD and non-IHD (42.7% and 47.8% at 4 y; HR 1.0, P = 0.99). There was a yearly rate of first intervention around 5% even in the fourth and fifth year after implantation. The incidence of inappropriate interventions was about half that of appropriate ICD interventions (21.4% at 4 y). It was higher in patients who also had received appropriate therapy (HR: 2.73 in the IHD group, 1.61 in the non-IHD group, P < 0.001 for both). Atrial fibrillation was the most common cause of inappropriate interventions in IHD, and sinus tachycardia in those without LV disease. The incidence of inappropriate interventions was not dependent on the type of ICD (VVI vs. DDD), in any group. CONCLUSIONS: Patients with an ICD for secondary prophylaxis have a high rate of appropriate interventions, and remain at risk for developing a first intervention several years after implantation. Inappropriate interventions constitute a significant burden. Taking preventive measures (AV nodal slowing drugs, device selection and programming, patient counseling regarding allowable physical activity) is required to optimize the quality-of-life adjusted life-saving potential of ICDs.

Endurance sports is a risk factor for atrial fibrillation after ablation for atrial flutter.

INTRODUCTION: Sports activity has been associated with the development of atrial arrhythmias. Atrial fibrillation (AF) is frequently observed after successful ablation for atrial flutter. Sports activity as a risk factor for AF development after flutter ablation has not been studied. METHODS: We analyzed outcome in 137 patients (83% men) after ablation for isthmus-dependent atrial flutter (excluding patients with concomitant ablation for atrial tachycardia or fibrillation). Sports activity before and after ablation was evaluated by detailed questionnaires. Endurance sports was defined as (semi-)competitive participation in cycling, running or swimming for > or =3 h/week (and for > or =3 years pre-ablation). Median follow-up was 2.5 years. Survival free of AF was evaluated with Kaplan-Meier curves and log-rank statistics. Multivariate analysis was based on Cox proportional hazard evaluation. RESULTS: Acute ablation success was 99% and flutter recurrence 4.4%. Thirty-one patients (23%) had been regularly engaged in endurance sports before ablation and 19 (14%) continued regular sports activity afterwards. Those performing sports were slightly younger. A history of endurance sports was a significant risk factor for post-ablation AF (univariate HR 1.96 (1.19-3.22), p<0.01, and multivariate HR 1.81 (1.10-2.98), p=0.02). Also continuation of endurance sports activity after ablation showed a trend for increased risk to develop AF despite a relatively small sample size (n=19; multivariate HR 1.68 (0.92-3.06), p=0.08). Cox proportional hazard calculations revealed a 10% and 11% increased risk for AF development per weekly hour sport performed before and after ablation respectively (p<0.01 for both). CONCLUSION: A history of endurance sports activity is associated with the development of AF after ablation of atrial flutter.

Tilt training: a new challenge in the treatment of neurally mediated syncope.

Clinical experience with repeated tilt testing and standing training has shown that this procedure can be used as a new therapy for the restoration of abnormal autonomic orthostatic reflexes. The introduction of tilt training therapy for neurally mediated syncope is a new and effective treatment. This new therapy has been used recently in several centres with excellent results. Since syncope is a severe social handicap for the patient, successful therapy will normalise the functional status and restore self-confidence. The use of tilt training can be considered as first-line therapy in this disorder. In the majority of the studies on tilt training, patients remain free of syncope during active treatment with this therapy. In about 50% of the patients with neurally mediated syncope already the second consecutive tilt test became negative. This therapeutic effect of in-hospital repeated tilt tests is sustained by continued standing training at home.

Long-term symptomatic benefit after radiofrequency catheter ablation for atrial flutter despite a high incidence of post-procedural atrial fibrillation.

OBJECTIVE: A high proportion of patients develops atrial fibrillation (AF) after ablation for atrial flutter (AFL). Radiofrequency ablation for AFL therefore would only be useful if it leads to a better quality of life despite this high incidence of AF post-ablation. METHODS: All patients who underwent AFL ablation in our centre before March 2002 (n=203) were contacted by letter a median of 2.3 years after their ablation. Sixty-eight percent answered the questionnaire polling the perceived benefits of the procedure. The results were stratified according to the presenting arrhythmia before the ablation: only AFL, predominantly AFL, predominantly AF or class Ic-III AFL. RESULTS: Despite a 60% incidence of AF, 84% considered the procedure to be beneficial during the 1st year and 77% during the 2nd year post-ablation. Patients with predominantly AF before the procedure showed significantly less overall improvement than the 3 other groups (50% and 33% after I year and 2 years, p< 0.01) and a smaller reduction in palpitations (50% and 29% after I year and 2 years, p < 0.01). The benefit of an ablation was also significantly less in patients who developed AF post-ablation than in patients who were completely arrhythmia free (75% versus 98% 1st year, 58% versus 91% 2nd year; p 0.01); nevertheless 75% of these patients reported fewer palpitations and 56% tolerated symptoms better than before. CONCLUSIONS: Despite a high incidence of AF after AFL ablation, the majority of patients considered the intervention beneficial. Only in patients with predominantly AF before ablation the procedure does not seem beneficial.

Epicardial pacing: a single-centre study on 321 leads in 138 patients.

OBJECTIVE: This study presents the long-term outcome of 321 epicardial leads in 138 patients. METHODS AND RESULTS: All leads were Medtronic CapsureEpi model 4965 steroid eluting leads. The 1-, 3-, and 5-year patient survival was 91%, 83% and 77%, respectively.Twenty-seven patients died. In 25/27 deaths a pacing-related death could be excluded. Strangulation of the heart by an abandoned epicardial lead was the cause of death in one child. One other patient died suddenly at the age of 3 years. Failures occurred in 57 of 321 epicardial leads (18%). For all 321 leads, the 1-, 3- and 5-year freedom from failure was 91%, 85% and 71%, respectively. The cumulative proportion of patients without any lead defect was 85% after I year, 76% after 3 years and 62% after 5 years. The percentage of patients without serious adverse events at 1, 3, and 5 years was 97%, 91%, 85%, respectively. Lead fracture was the cause of failure in 15 leads of 9 patients. An important increase in pacing threshold occurred in 35 leads of 30 patients. Other failures were: diaphragmatic stimulation, infection, excessive traction and strangulation. Eighteen failures were repaired by 11 surgical interventions in 9 patients.Thirty-nine defects were corrected non-invasively in 31 patients. CONCLUSIONS: The use of steroid-eluting epicardial leads has proven to be an adequate option. In paediatric cardiology, the epicardial approach remains an indispensable tool for achieving a life-long pacing.