Àngel Moya-Mitjans

Prognostic value of the electrocardiogram in patients with syncope: Data from the Group for Syncope Study in the Emergency Room (GESINUR)

BACKGROUND The Group for Syncope Study in the Emergency Room (GESINUR) was a Spanish multicenter, prospective, observational study that evaluated the clinical presentation and acute management of loss of consciousness in Spain. Several studies have shown that an abnormal ECG is a poor prognostic factor in patients with syncope. However, the prognostic significance of each ECG abnormality is not well known. OBJECTIVE The purpose of this study was to study the association between specific ECG abnormalities and mortality in patients with syncope from the GESINUR study. METHODS All patients in the GESINUR study who had syncope and had available, readable ECG and 12-month follow-up data were included in this retrospective observational study (n = 524, age 57 ± 22 years, 50.6% male). ECG abnormalities were analyzed and assessed to evaluate whether an association with all-cause mortality existed at 12 months. RESULTS ECGs were classified as abnormal in 344 patients (65.6%). Thirty-three patients died during follow-up (6.3%), but only 1 due to sudden cardiovascular death. Atrial fibrillation (odds ratio [OR] 6.8, 95% confidence interval [CI] 2.8-16.3, P <.001), intraventricular conduction disturbances (OR 3.8, 95% CI 1.7-8.3, P = .001), left ventricular hypertrophy ECG criteria (OR 6.3, 95% CI 1.5-26.3, P = .011), and ventricular pacing (OR 21.8, 95% CI 4.1-115.3, P <.001) were the only independent ECG predictors of all-cause mortality. CONCLUSION Although an abnormal ECG in patients with syncope is a common finding, only the presence of atrial fibrillation, intraventricular conduction disturbances, left ventricular hypertrophy ECG criteria, and ventricular pacing is associated with 1-year all-cause mortality.

Plan of Action for Inherited Cardiovascular Diseases: Synthesis of Recommendations and Action Algorithms.

The term inherited cardiovascular disease encompasses a group of cardiovascular diseases (cardiomyopathies, channelopathies, certain aortic diseases, and other syndromes) with a number of common characteristics: they have a genetic basis, a familial presentation, a heterogeneous clinical course, and, finally, can all be associated with sudden cardiac death. The present document summarizes some important concepts related to recent advances in sequencing techniques and understanding of the genetic bases of these diseases. We propose diagnostic algorithms and clinical practice recommendations and discuss controversial aspects of current clinical interest. We highlight the role of multidisciplinary referral units in the diagnosis and treatment of these conditions.

Differences in the yield of the implantable loop recorder between secondary and tertiary centers

BACKGROUND The implantable loop recorder (ILR) is a useful tool for diagnosis of syncope or palpitations. Its easy use and safety have extended its use to secondary hospitals (those without an Electrophysiology Lab). The aim of the study was to compare results between secondary and tertiary hospitals. METHODS National prospective and multicenter registry of patients with an ILR inserted for clinical reasons. Data were collected in an online database. The follow-up ended when the first diagnostic clinical event occurred, or 1 year after implantation. Data were analyzed according to the center of reference; hospitals with Electrophysiology Lab were considered Tertiary Hospitals, while those hospitals without a lab were considered Secondary Hospitals. RESULTS Seven hundred and forty-three patients (413 [55.6%] men; 65 ± 16 year-old): 655 (88.2%) from Tertiary Centers (TC) and 88 (11.8%) from Secondary Centers (SC). No differences in clinical characteristics between both groups were found. The electrophysiologic study and the tilt table test were conducted more frequently in Tertiary Centers. Follow-up was conducted for 680 (91.5%) patients: 91% in TC and 94% in SC. There was a higher rate of final diagnosis among SC patients (55.4% vs. 30.8%; p < 0.001). Tertiary Hospital patients showed a trend towards a higher rate of neurally mediated events (20% vs. 4%), while bradyarrhythmias were more frequent in SC (74% vs. 60%; p = 0.055). The rate of deaths and adverse events was similar in both populations. CONCLUSIONS Patients with an ILR in SC and TC have differences in terms of the use of complementary tests, but not in clinical characteristics. There was a higher rate of diagnosis in Secondary Hospital patients.

A risk score to predict the absence of left ventricular reverse remodeling: Implications for the timing of ICD implantation in primary prevention

BACKGROUND A prophylactic implantable cardioverter defibrillator (ICD) in patients with heart failure and reduced left ventricular ejection fraction (HFrEF) is only indicated when left ventricular ejection fraction (LVEF) reassessment remains ≤35% after 3-6 months on optimal pharmacological therapy. However, LVEF may not improve during this period and the patient may be exposed to an unnecessary risk of sudden cardiac death. This study aimed to determine the incidence and predictors of the absence of left ventricular reverse remodeling (LVRR) after pharmacological treatment optimization in patients with HFrEF to design a risk score of absence of LVRR. METHODS Consecutive outpatients with LVEF ≤35% were included in this observational prospective study. Up-titration of angiotensin-converting enzyme (ACE) inhibitors/angiotensin II receptor blockers (ARBs), beta-blockers, mineralocorticoid receptor antagonists (MRAs), and ivabradine was performed in our Heart Failure (HF) Unit. The absence of LVRR was defined as the persistence of an LVEF ≤35% at the 6-month follow-up. RESULTS One hundred and twenty patients were included. At the 6-month follow-up, 64%, 76%, 72%, and 7% of patients were at 100% of the target dose of ACE inhibitors/ARBs, beta-blockers, MRAs, and ivabradine, respectively. LVRR was observed in 48% of the patients. Ischemic cardiomyopathy, prolonged HF duration, and larger left ventricular end-diastolic diameter index (LVEDDI) were independent predictors of the absence of LVRR. The risk score based on these predictors showed a c-statistic value of 0.81. CONCLUSIONS Pharmacological treatment optimization is associated with LVRR in approximately half of cases, reducing potential ICD indications in parallel. However, ischemic cardiomyopathy, prolonged HF duration, and larger LVEDDI predict the absence of LVRR and favor ICD implantation without delay. The risk score based on the former predictors may help the clinician with the timing of ICD implantation.

Diagnostic Yield and Economic Assessment of a Diagnostic Protocol With Systematic Use of an External Loop Recorder for Patients With Palpitations

INTRODUCTION AND OBJECTIVES To assess the diagnostic yield and cost-effectiveness of a diagnostic protocol based on the systematic use of latest-generation external loop recorders (ELRs) compared with the classic diagnostic strategy for patients with recurrent unexplained palpitations. METHODS Two cohorts of consecutive patients referred for diagnosis of unexplained palpitations to the outpatient clinic of the arrhythmia unit were compared: a prospective cohort after the implementation of a new diagnostic protocol based on the systematic use of ELRs, and another, retrospective, cohort before the implementation of the protocol. The cost of diagnosis was calculated based on the number of complementary examinations, visits to outpatient clinics, or emergency department visits required to reach a diagnosis, and its costs according the prices published for the local health system. RESULTS One hundred and forty-nine patients were included (91 in the ELR group, 58 in the control group). The diagnostic yield was higher in the ELR group (79 [86.8%] definitive diagnoses in the ELR group vs 12 [20.7%] in the control group, P < .001). The cost per diagnosis was €375.13 in the ELR group and €5184.75 in the control group (P < .001). The cost-effectiveness study revealed that the systematic use of ELR resulted in a cost reduction of €11.30 for each percentage point of increase in diagnosis yield. CONCLUSIONS In patients with recurrent unexplained palpitations, evaluation by means of a study protocol that considers the systematic use of a latest-generation ELR increases diagnostic yield while reducing the cost per diagnosis.

Current Situation of the Treatment of Arrhythmias in Children in Spain. Finding a Place of its Own

Ferran Rosés-Noguer* and Ángel Moya-Mitjans a Servei de Cardiologia Pediàtrica, Hospital Universitari Vall d’Hebron, Barcelona, Spain b Paediatric Cardiology Department, Royal Brompton Hospital, NHS Fundation Trust, London, United Kingdom Unitat d’Arı́tmies, Servei de Cardiologia, Hospital Universitari Vall d’Hebron, Barcelona, Spain d Instituto de Medicina y Cardiologı́a, Unitat d’Arı́tmies, Hospital Universitari Dexeus, Barcelona, Spain

EditorialAutomatic External Defibrillator in Sudden Out-of-hospital Cardiac Arrest: In Search of Effective TreatmentDesfibrilador externo automático en la muerte súbita extrahospitalaria: en busca del tratamiento eficaz

Out-of-hospital cardiac arrest (OHCA) is a frequent cause of death, with an annual incidence of approximately 420 000 people in the United States, 275 000 in Europe, and 24 500 in Spain. On the initial cardiac rhythm analysis of OHCA patients, ventricular fibrillation (VF) is seen in 23% to 64% of cases. This percentage varies according to where the incident occurs, being lower when it takes place in the individual’s home than when it occurs in a public place, although in general it has decreased in the last 20 years. Conceptually, given that the main cause of OHCA is ischemic heart disease, cardiac arrest can often be considered a failure of cardiovascular prevention and identification of at-risk patients. Nevertheless, once OHCA has taken place, given that it can occur unexpectedly, in any situation and generally outside the health care setting, the challenge lies in responding as quickly and appropriately as possible. To achieve this goal, the ‘‘chain of survival’’ has been developed, which consists of 4 linked steps: immediate recognition of a possible cardiac arrest, early initiation of basic cardiopulmonary resuscitation (CPR) performed by bystanders, rapid defibrillation, and advanced life support. Performing early, high-quality CPR is the best predictor of increased 30-day survival and, most importantly, of a good neurological status at discharge. In recent years, the survival rate of patients with OHCA has improved, which has been associated with 2 features: public education programs and the development, distribution, and use of external automatic defibrillator (AED) systems. However, despite this improvement, overall survival remains low, as does the percentage of patients with a good neurological status at discharge (between 11.4% and 16.5%). Therefore, despite the evidence on the usefulness of developing and using AED systems, there are still several aspects that require clarification regarding their use, such as the best and most accessible locations for these devices, the role of training and their use by nonhealth care professionals and–in particular–the optimal timing for their use and how this interacts with CPR. Weisfeldt et al. proposed that there are 3 phases during the cardiac arrest process that may relate to the findings when treating patients and the effectiveness of different treatments: the first of these is the electrical phase, the first 4 minutes, when immediate defibrillation is the most effective treatment; the second is the circulatory phase, from 4 to 10 minutes, when high-quality CPR is most effective, and the third, which is beyond 10 minutes, is the metabolic phase, when treatments should also aim to correct metabolic abnormalities. All this is critical to understanding the response to different treatments according to the time elapsed since the onset of the OHCA, as it is well-established that AED is most effective when used early, in the first 4 or 5 minutes, and that, after this time, performing a period of CPR increases the number of patients with a shockable rhythm and therefore improves the outcomes of AED use. In the current issue of Revista Española de Cardiologı́a, LomaOsorio et al. present data on their initial experience with the ‘‘Girona Territori Cardioprotegit’’ program, a public initiative on defibrillation implemented in the province of Girona, Spain, where 747 AEDs have been distributed, 577 of which are in fixed locations and distributed throughout the region, and 170 of which are mobile and form part of the police, fire brigade, and basic ambulance equipment. The authors highlight that, although no official lay training programs were organized for this project, there were public awareness campaigns, courses aimed at students, and an official course for the professionals who drive the vehicles carrying these devices. The main specific objective of the study was to perform a descriptive analysis of the rhythms recorded by the AEDs in incidences of OHCA and to evaluate their performance. Independently of the results, the study provides data on real-world use that help us understand AED use in our setting and improve implementation strategies. The first interesting finding is that 91% of AED activations were classified as correct uses, 6% as intermediate, defined as activations in a patient who had not lost consciousness or had recovered consciousness before AED use; and only 3% (7 cases) were Rev Esp Cardiol. 2018;71(2):64–66

Narrow Complex Tachycardia with Irregular Ventricular and Atrial Intervals: What Is the Mechanism?

A 46-year-old woman with recurrent episodes of supraventricular tachycardia was referred for electrophysiological study and catheter ablation. Her 12-lead electrocardiogram was normal and she had no structural heart disease. After informed consent was obtained, electrophysiological testing was performed in the drug-free, postabsortive nonsedated state. Two multipolar catheters were introduced into the right femoral vein and placed in the coronary sinus and in the His bundle region. Baseline conduction intervals were within normal limits: atrial-His (A-H) interval 65 ms and His-ventricle (H-V) interval 44 ms. There was decremental retrograde ventriculoatrial (VA) conduction with a concentric atrial activation pattern. Programmed atrial stimulation from the coronary sinus revealed dual atrioventricular (AV) nodal conduction physiology, and a nonsustained narrow complex tachycardia was reproducibly induced with a previous jump in the A-H interval (Fig. 1). Following isoproterenol administration, runs of tachycardia were longer but still nonsustained, so pacing maneuvers during tachycardia could not be performed. Figure 2 shows a long run of tachycardia, with apparent V-A dissociation (fewer atrial than ventricular beats) and irregular atrial and ventricular cycle lengths. Atrial activation was concentric in the coronary sinus catheter, with earliest activation simultaneous at the His bundle region and the coronary sinus ostium. What is the most likely mechanism of this tachycardia?