Association of admission serum sodium and outcomes following out-of-hospital cardiac arrest.

BACKGROUND: The prognostic association between dysnatremia and outcomes in out-of-hospital cardiac arrest (OHCA) is not well understood. Given hypernatremia is associated with poor outcomes in critical illness and hyponatremia may exacerbate cerebral edema, we hypothesized that dysnatremia on OHCA hospital admission would be associated with worse neurological outcomes. METHODS: We studied adults (≥19 years) with non-traumatic OHCA between 2009 and 2016 who were enrolled in the British Columbia Cardiac Arrest Registry and survived to hospital admission at 2 quaternary urban hospitals. We stratified cases by admission serum sodium into hyponatremic (<135 mmol/L), normonatremic (135-145 mmol/L), and hypernatremic (>145 mmol/L) groups. We used logistic regression models, adjusted for age, sex, shockable rhythm, admission serum lactate, and witnessed arrest, to estimate the association between admission sodium and favorable neurological outcome (cerebral performance category 1-2 or modified Rankin scale 0-3). RESULTS: Of 414 included patients, 63 were hyponatremic, 330 normonatremic, and 21 hypernatremic. In each respective group, 21 (33.3%), 159 (48.2%), and 3 (14.3%) experienced good neurological outcomes. In univariable models, hyponatremia (OR 0.53, 95% CI 0.30-0.93) and hypernatremia (OR 0.19, 95% CI 0.05-0.65) were associated with lower odds of good neurological outcomes compared to the normonatremia group. After adjustment, only hypernatremia was associated with lower odds of good neurological outcomes (OR 0.22, 95% CI 0.05-0.98). CONCLUSIONS: Hypernatremia at admission was independently associated with decreased probability of good neurological outcomes at discharge post-OHCA. Future studies should focus on elucidating the pathophysiology of dysnatremia following OHCA.

Variation and clinical consequences of wait-times for atrial fibrillation ablation: population level study in Ontario, Canada.

AIMS: Atrial fibrillation (AF) is the most common cardiac rhythm disorder. Emerging evidence supporting the efficacy of catheter ablation in managing AF has led to increased demand for this therapy, potentially outpacing the capacity to perform this procedure. Mismatch between demand and capacity for AF ablation results in wait-times which have not been comprehensively evaluated at a population level. Additionally, the consequences of such delays in AF ablation, namely the risk of hospitalization or adverse events, have not been studied. METHODS AND RESULTS: This observational cohort study included adults referred for catheter ablation to treat AF in Ontario, Canada, between 1 April 2016 and 31 March 2020. Wait-time was defined from referral to the earliest of ablation, death, off-list, or the study endpoint of 31 March 2022. The outcomes of interest included a composite of death, hospitalization for AF/heart failure, and emergency department visit for AF/heart failure. Our study cohort included 6253 patients referred for de novo AF ablation. The median wait-time for patients who received and who did not receive ablation was 218 days (IQR: 112-363) and 520 days (IQR: 270-763), respectively. Wait-time increased consistently for patients referred between October 2017 and March 2020. Mortality was rare, but significant morbidity was observed, affecting 19.2% of patients on the waitlist for AF ablation. Paroxysmal AF was associated with a statistically significant greater risk for adverse outcomes on the waitlist (HR 1.51, 95% CI 1.18-1.93). CONCLUSION: Wait-times for AF ablation are increasing and are associated with significant morbidity.

Importance of genetic testing in unexplained cardiac arrest.

AIMS: Genetic testing is recommended in specific inherited heart diseases but its role remains unclear and it is not currently recommended in unexplained cardiac arrest (UCA). We sought to assess the yield and clinical utility of genetic testing in UCA using whole-exome sequencing (WES). METHODS AND RESULTS: Survivors of UCA requiring external defibrillation were included from the Cardiac Arrest Survivor with Preserved Ejection fraction Registry. Whole-exome sequencing was performed, followed by assessment of rare variants in previously reported cardiovascular disease genes. A total of 228 UCA survivors (mean age at arrest 39 ± 13 years) were included. The majority were males (66%) and of European ancestry (81%). Following advanced clinical testing at baseline, the likely aetiology of cardiac arrest was determined in 21/228 (9%) cases. Whole-exome sequencing identified a pathogenic or likely pathogenic (P/LP) variant in 23/228 (10%) of UCA survivors overall, increasing the proportion of 'explained' cases from 9% only following phenotyping to 18% when combining phenotyping with WES. Notably, 13 (57%) of the 23 P/LP variants identified were located in genes associated with cardiomyopathy, in the absence of a diagnosis of cardiomyopathy at the time of arrest. CONCLUSIONS: Genetic testing identifies a disease-causing variant in 10% of apparent UCA survivors. The majority of disease-causing variants was located in cardiomyopathy-associated genes, highlighting the arrhythmogenic potential of such variants in the absence of an overt cardiomyopathy diagnosis. The present study supports the use of genetic testing including assessment of arrhythmia and cardiomyopathy genes in survivors of UCA.

Patch monitors for arrhythmia monitoring in patients for suspected inherited arrhythmia syndrome.

INTRODUCTION: Patients undergoing evaluation for an inherited arrhythmia syndrome undertake a series of ambulatory investigations including 24-h Holter monitor, exercise treadmill testing (ETT), and others. Patch monitors may simplify the evaluation, providing accurate arrhythmia evaluation and QT assessment. METHODS AND RESULTS: Patients referred for evaluation of an inherited arrhythmia syndrome underwent standard investigations, including 12-lead electrocardiography (ECG), 24-h Holter monitoring, ETT, along with supplemental monitoring using a 7-day ECG patch monitor. Heart rates (HR), corrected QT intervals (QTc), and ectopic burden were compared across monitoring modalities. Among 35 patients that wore the patch monitor, the median age was 39 years (54% male). There was intermediate correlation between resting HR across modalities (r = .58-.66) and poor correlation of peak HR (r = .27-.39). There was intermediate correlation between resting QTc intervals across modalities (r = .72-.77) but negligible correlation between QTc intervals at peak HR across modalities (r = -.01 to -.06). There was good correlation in PAC and PVC ectopic burden across the Holter and patch monitor. CONCLUSION: Patch monitors may simplify the evaluation of patients for an inherited arrhythmia syndrome and provide resting QT assessment over time. However, QTc interval comparison at peak HRs remains variable, and may be limited by the single-lead ECG vector when using the patch monitor. Apart from QTc intervals at peak HR, patch monitors demonstrated good correlation with the ECG and Holter monitor for other parameters.

ECG quiz - Where is the block?

A 68 year-old man presented with palpitations. A standard 12­lead ECG was performed and demonstrated significant conduction disease. Using findings on the index and prior ECGs, we review the differential diagnoses for his conduction abnormality. We discuss the possibility of phase III delay, phase IV delay, and "supernormal conduction" to explain the ECG findings. We explore each of these phenomena and review their relative likelihood as it applies to the case presented.

Implementation and evaluation of a novel, unofficial, trainee-organized hospital addiction medicine consultation service.

Background: To evaluate a novel, unofficial, trainee-organized, hospital addiction medicine consultation service (AMCS), we aimed to assess whether it was (1) acceptable to hospital providers and patients, (2) feasible to organize and deliver, and (3) impacted patient care. Methods: We performed a retrospective descriptive study of all AMCS consultations over the first 16 months. We determined acceptability via the number of referrals received from admitting services, and the proportion of referred patients who consented to consultation. We evaluated feasibility via continuation/growth of the service over time, and the proportion of referrals successfully completed before hospital discharge. As most referrals related to opioid use disorder, we determined impact through the proportion of eligible patients offered and initiated on opioid agonist therapy (OAT) in hospital, and the proportion of patients who filled their outpatient prescription or attended their first visit with their outpatient OAT prescriber. Results: The unofficial AMCS grew to involve six hospital-based residents and five supervising community-based addiction physicians. The service received 59 referrals, primarily related to injection opioid use, for 50 unique patients from 12 different admitting services. 90% of patients were seen before discharge, and 98% agreed to addiction medicine consultation. Among 34 patients with active moderate-severe opioid use disorder who were not already on OAT, 82% initiated OAT in hospital and 89% of these patients continued after discharge. Conclusions: Established in response to identified gaps in patient care and learning opportunities, a novel, unofficial, trainee-organized AMCS was acceptable, feasible, and positively impacted patient care over the first 16 months. This trainee-organized, unofficial AMCS could be used as a model for other hospitals that do not yet have an official AMCS.

Changes to the electrocardiogram during exercise in anorexia nervosa.

BACKGROUND: Anorexia Nervosa (AN) is an eating disorder characterized by low body weight, distorted body image, and an intense fear of gaining weight. Electrocardiogram (ECG) changes, particularly in the QT interval, have been implicated in AN-associated sudden death but not well defined. OBJECTIVES: To characterize QT interval changes during exercise in anorexia nervosa. METHODS: The QT interval was evaluated in a prospective cohort undergoing structured exercise. Patients from the St. Paul's Hospital Provincial Adult Tertiary Eating Disorders Program underwent a 6-minute modified exercise test protocol. A single lead ECG patch recording device was used to record a Lead I equivalent, due to challenges applying standard ECG monitoring in subjects with low body mass. Heart rate (HR) and QT interval were assessed. RESULTS: Eighteen eating disorder patients (16 female) completed testing (age 31 ± 12 years, BMI 16.5 ± 3.8 kg/m2). Patients were compared to age- and sex-matched healthy controls. HR was similar between patients and controls (baseline: 65 (55-70)bpm vs. 69 (53-73)bpm, p = 0.83; maximum: 110 (94-139) bpm vs. 108 (93-141) bpm, p = 0.96; end recovery: 62 (54-68) bpm vs. 66 (55-75) bpm, p = 0.39). QTc intervals were similar between groups at baseline (381 ± 17 ms vs. 381 ± 46 ms, p = 0.93) and end recovery (397 ± 42 ms vs 398 ± 42 ms, p = 0.91). However, AN patients demonstrated QTc prolongation while controls showed QTc shortening at maximum HR (426 ± 70 ms vs. 345 ± 59 ms, p = 0.001). CONCLUSION: Low level exercise HR increases are similar between AN patients and controls, but the QTc interval fails to shorten, which may explain the increased arrhythmic risk in AN.

Clinical assessment of AF pattern is poorly correlated with AF burden and post ablation outcomes: A CIRCA-DOSE sub-study.

BACKGROUND: Contemporary guidelines recommend that atrial fibrillation (AF) be classified into paroxysmal and persistent AF based on clinical assessment, with these categorizations forming the basis of therapeutic recommendations. While pragmatic, clinical assessment may introduce misclassification errors, which may impact treatment decisions. We sought to determine the relationship between AF classification, baseline AF burden, and post-ablation arrhythmia outcomes. DESIGN: The current study is a sub-analysis of a prospective, parallel-group, multicenter, single-blinded randomized clinical trial. All 346 patients enrolled in CIRCA-DOSE received an implantable cardiac monitor a median of 72 days prior to ablation. AF was classified as low burden paroxysmal, high burden paroxysmal, or persistent based on clinical assessment prior to device implantation. Prior to ablation patients were re-classified using the same definitions based on device monitoring data. Correlation between classifications, AF burden, and post-ablation arrhythmia outcomes were assessed. RESULTS: There was poor agreement between clinical and device-based AF classification (Cohen's kappa: 0.192). AF classification derived from pre-ablation continuous monitoring reflected baseline and post-ablation AF burden with greater accuracy and with less overlap between the AF classes (P < 0.01 for all categorical comparisons). Patients objectively classified as "Low Burden" paroxysmal by continuous monitoring data had significantly greater freedom from recurrent AF/AT/AFL compared to those classified as "High Burden" paroxysmal (hazard ratio [HR] 0.57 for AF/AT/AFL recurrence) or persistent AF (HR 0.19 for AF/AT/AFL recurrence). CONCLUSIONS: Classification of AF pattern based on pre-ablation continuous cardiac rhythm monitoring better predicted AF burden and freedom from recurrent AF post ablation. Despite the use of standardized definitions, classification of AF based on clinical assessment did not predict baseline AF burden, post ablation AF burden, or freedom from recurrent AF post ablation. TRIAL REGISTRATION: ClinicalTrials.govNCT01913522.

Lung Microbiota Is Related to Smoking Status and to Development of Acute Respiratory Distress Syndrome in Critically Ill Trauma Patients.

RATIONALE: Cigarette smoking is associated with increased risk of acute respiratory distress syndrome (ARDS) in patients after severe trauma; however, the mechanisms underlying this association are unknown. OBJECTIVES: To determine whether cigarette smoking contributes to ARDS development after trauma by altering community composition of the lung microbiota. METHODS: We studied the lung microbiota of mechanically ventilated patients admitted to the ICU after severe blunt trauma. To do so, we used 16S ribosomal RNA gene amplicon sequencing of endotracheal aspirate samples obtained on ICU admission (n = 74) and at 48 hours after admission (n = 30). Cigarette smoke exposure (quantified using plasma cotinine), ARDS development, and other clinical parameters were correlated with lung microbiota composition. MEASUREMENTS AND MAIN RESULTS: Smoking status was significantly associated with lung bacterial community composition at ICU admission (P = 0.007 by permutational multivariate ANOVA [PERMANOVA]) and at 48 hours (P = 0.03 by PERMANOVA), as well as with significant enrichment of potential pathogens, including Streptococcus, Fusobacterium, Prevotella, Haemophilus, and Treponema. ARDS development was associated with lung community composition at 48 hours (P = 0.04 by PERMANOVA) and was characterized by relative enrichment of Enterobacteriaceae and of specific taxa enriched at baseline in smokers, including Prevotella and Fusobacterium. CONCLUSIONS: After severe blunt trauma, a history of smoking is related to lung microbiota composition, both at the time of ICU admission and at 48 hours. ARDS development is also correlated with respiratory microbial community structure at 48 hours and with taxa that are relatively enriched in smokers at ICU admission. The data derived from this pilot study suggest that smoking-related changes in the lung microbiota could be related to ARDS development after severe trauma.

Changes on the electrocardiogram in anorexia nervosa: A case control study.

PURPOSE: Anorexia nervosa is a complex psychiatric condition with increased mortality. The electrocardiogram (ECG) may show repolarization changes which may associate with an increased risk of sudden death. Up to 80% of patients may be prescribed psychopharmacotherapies which alter the ECG, potentially compounding arrhythmic risk. This study aimed to describe and improve understanding of ECG changes in eating disorders and assess the effect of psychopharmacotherapies. METHODS: Adolescent patients diagnosed with anorexia nervosa were reviewed. ECGs were reviewed by blinded expert reviewers, and repolarization parameters were compared to healthy controls. Patients on and off psychopharmacotherapies were compared. RESULTS: Thirty-eight anorexia nervosa patients off psychopharmacotherapies were age matched to 53 healthy controls. Heart rate was lower in anorexia nervosa patients (56 vs. 74 bpm, p < 0.001). The absolute QT interval was longer in patients compared to controls (408 vs. 383 ms, p < 0.001), but the QTc by Hodges' formula was similar between groups (401 vs. 408 ms, p = 0.16). The prevalence of T-wave flattening and inversion was also similar between groups (13% vs. 4%, p = 0.12) and T-peak to T-end interval (Tpe) was shorter in patients compared to controls (p < 0.01). ECG parameters were similar between patients on and off psychopharmacotherapies aside from off-drug patients showing lower HR (56 vs. 65, p = 0.04). CONCLUSIONS: Autonomic and repolarization changes are evident on the ECG of anorexia nervosa patients, though the QTc interval was in fact similar between groups. Changes in T-wave morphology and duration may be promising metrics of repolarization effects of anorexia nervosa.

Joint associations of blood plasma proteins with overwinter survival of a large mammal.

In many wild animal populations, hosts are at risk of parasites and malnutrition and resource costs of defence may be difficult to afford. We postulate that proteins, important in homeostasis and immunity, play a complex but central role in condition dependence and resource costs of mammalian immune defence. To test this, we measured plasma concentrations of albumin, total proteins. Self-reactive antibodies and parasite-specific IgG in female Soay sheep. Using a principal component analysis, we found a new metric of condition reflecting individual variation in acquisition, assimilation and/or recycling of plasma proteins that predicted overwinter survival. Controlling for this metric, an age-dependent trade-off between antibody titres and protein reserves emerged, indicating costs of mounting an antibody response: younger individuals survived best when prioritising immunity while older individuals fared better when maintaining high-protein nutritional plane. These findings suggest fascinating roles for protein acquisition and allocation in influencing survival in wild animal populations.

Perceptions of interprofessionalism in health professional students participating in a novel community service initiative.

Interprofessional collaboration is integral to effective patient care in today's healthcare system. Early exposure to other professions in a hands-on manner during education can be helpful for future practice. However, opportunities for interprofessional education are typically faculty driven and remain limited. Thirty-eight students from different health professions at the University of British Columbia worked collaboratively to promote cardiovascular risk reduction in Vancouver's Downtown Eastside. Student attitudes toward interprofessionalism were assessed using the Interdisciplinary Education Perception Scale (IEPS). While 38 participants (55%) completed the survey prior to participation in this initiative, only 21 individuals completed the follow-up survey After participation, there were significant improvements in the competency and autonomy (p = 0.02) and perception of actual cooperation (p = 0.04). Students did not report any difference in their perceived need for cooperation after participation in the initiative. These results suggest that student-led community service initiatives can be an effective method for interprofessional education amongst health professional students.

Use of a Sheath and Stylet for a Difficult Dorsal Root Ganglion Stimulation Lead Extraction: A Case Report.

Dorsal root ganglion stimulation (DRG-S) is a relatively new neuromodulation technique that has shown promising results in the treatment of chronic pain conditions. We present a case of a difficult lead extraction during the explantation of a DRG-S device. The lead was unable to be removed despite multiple attempts until a sheath and stylet were used to facilitate extraction. As DRG-S utilization becomes more widespread, DRG-S device explantation will inevitably become more common. The technique described in this report may be beneficial in certain cases of difficult DRG-S lead extraction.

Relationship between wait times and post-atrial fibrillation ablation outcomes: A population-based study.

BACKGROUND: Rhythm control is a cornerstone of atrial fibrillation (AF) management. Shorter time between diagnosis of AF and receipt of catheter ablation is associated with greater rates of therapy success. Previous work considered diagnosis-to-ablation time as a binary or categorical variable and did not consider the unique risk profile of patients after a referral for ablation was made. OBJECTIVE: The purpose of this study was to comprehensively assess the impact of diagnosis-to-ablation and referral-to-ablation time on postprocedural outcomes at a population level. METHODS: This observational cohort study included patients who received catheter ablation to treat AF in Ontario, Canada. Patient demographics, medical comorbidities, AF diagnosis date, ablation referral date, and ablation date were collected. The primary outcomes of interest included a composite of death and hospitalization/emergency department visit for AF, heart failure, or ischemic stroke. Multivariable Cox models assessed the impact of diagnosis-to-ablation and referral-to-ablation times on the primary outcome. RESULTS: Our cohort included 7472 patients who received ablation for de novo AF between April 1, 2016, and March 31, 2022. Median [interquartile range] diagnosis-to-ablation time was 718 [399-1274] days and median referral-to-ablation time was 221 [117-363] days. Overall, 911 patients (12.2%) had the composite endpoint within 1 year of ablation. Increasing diagnosis-to-ablation time was associated with a greater incidence for the primary outcome (hazard ratio [HR]1.02; 95% confidence interval [CI] 1.01-1.02 per month). Increasing referral-to-ablation time did not impact the primary outcome (HR 1.00; 95% CI 0.98-1.01 per month). CONCLUSION: Delays between AF diagnosis and ablation referral may contribute to adverse postprocedural outcomes and provide an opportunity for health system quality improvements.

Surviving the Shocks: A Contemporary of Short-coupled Ventricular Fibrillation.

A young man presented following successful cardiac resuscitation after an out-of-hospital cardiac arrest. During his admission, he had multiple runs of short-coupled ventricular fibrillation with a similar morphology premature ventricular complex (PVC) trigger. He was brought to the electrophysiology laboratory, and, with a high dose of isoprenaline, the PVC was localised to the moderator band. Ablation induced short runs of ventricular tachycardia before elimination of the PVC. He subsequently underwent subcutaneous implantable cardiac defibrillator implantation before his discharge.

Applying Artificial Intelligence for Phenotyping of Inherited Arrhythmia Syndromes.

Inherited arrhythmia disorders account for a significant proportion of sudden cardiac death, particularly among young individuals. Recent advances in our understanding of these syndromes have improved patient diagnosis and care, yet certain clinical gaps remain, particularly within case ascertainment, access to genetic testing, and risk stratification. Artificial intelligence (AI), specifically machine learning and its subset deep learning, present promising solutions to these challenges. The capacity of AI to process vast amounts of patient data and identify disease patterns differentiates them from traditional methods, which are time- and resource-intensive. To date, AI models have shown immense potential in condition detection (including asymptomatic/concealed disease) and genotype and phenotype identification, exceeding expert cardiologists in these tasks. Additionally, they have exhibited applicability for general population screening, improving case ascertainment in a set of conditions that are often asymptomatic such as left ventricular dysfunction. Third, models have shown the ability to improve testing protocols; through model identification of disease and genotype, specific clinical testing (eg, drug challenges or further diagnostic imaging) can be avoided, reducing health care expenses, speeding diagnosis, and possibly allowing for more incremental or targeted genetic testing approaches. These significant benefits warrant continued investigation of AI, particularly regarding the development and implementation of clinically applicable screening tools. In this review we summarize key developments in AI, including studies in long QT syndrome, Brugada syndrome, hypertrophic cardiomyopathy, and arrhythmogenic cardiomyopathies, and provide direction for effective future AI implementation in clinical practice.