Lina Marcantoni

Remote monitoring of implantable devices: Should we continue to ignore it?

The number of patients with implantable cardioverter defibrillators (ICDs) is increasing. In addition to improve survival, ICD can collect data related to device function and physiological parameters. Remote monitoring (RM) of these data allows early detection of technical or clinical problems and a prompt intervention (reprogramming device or therapy adjustment) before the patient require hospitalization. RM is not a substitute for emergency service and its consultation is now limited during working hours. Thus, a consent form is required to inform patients about benefits and limitations. The available studies indicate that remote monitoring is more effective than traditional calendar face to face based encounters. RM is safe, highly reliable, cost efficient, allows quick reply to failures, and reduces the number of scheduled visits and the incidence of inappropriate shocks with a positive impact on survival. It follows that RM has the credentials to be the standard of care for ICD management; however, unfortunately, there is a delay in physician acceptance and implementation. The recent observations from randomized IN-TIME study that showed a clear survival benefit with RM in heart failure patients have encouraged us to review both the negative and positive aspects of RM collected in a little more than a decade.

Correlation and prognostic role of neutrophil to lymphocyte ratio and SYNTAX score in patients with acute myocardial infarction treated with percutaneous coronary intervention: A six-year experience

BACKGROUND/PURPOSE The neutrophil/lymphocyte ratio (NLR) has been proposed as a prognostic marker in acute myocardial infarction (AMI). The aim of our study is to demonstrates the correlation between SYNTAX score (SXs) and NLR and its association with 1-year cardiovascular (CV) mortality in patients with ST-segment elevation myocardial infarction (STEMI) or non-ST-segment elevation myocardial infarction (NSTEMI) treated with percutaneous coronary intervention (PCI). METHODS/MATERIALS Over 6 consecutive years, (1st January 2010 and 1st January 2016) 6560 patients (4841 males and 1719 females, mean age 64.36±11.77years) were admitted for AMI and treated with PCI within 24-h. The study population was divided into tertiles based on the SXs. RESULTS Both in STEMI and NSTEMI groups, neutrophils and the SXs were significantly higher (p<0.0001) in upper versus lower among NLR tertiles and a significant correlation was found between the NLR and SXs (r=0.617, p<0.0001 and r=0.252, p<0.0001 for STEMI and NSTEMI groups, respectively). One-year CV mortality significantly raised up among the NLR tertiles in both STEMI and NSTEMI patients (p<0.0001). Multivariate analysis revealed that, after adjusting SXs and PAD, an NLR (≥3.9 and ≥2.7 for STEMI and NTEMI patients, respectively) was an independent significant predictor of 1-year CV mortality (OR 2.85, 95% CI 1.54-5.26, p=0.001 and OR 2.57, 95% CI 1.62-4.07, p<0.0001 for STEMI and NSTEMI respectively.) CONCLUSIONS: NLR significantly correlates with SXs and is associated with 1-year CV mortality in patients with STEMI or NSTEMI treated with PCI within 24-h.

Impact of remote monitoring on the management of arrhythmias in patients with implantable cardioverter-defibrillator.

Background In the last decade, there has been an exponential increase in cardioverter-defibrillator (ICD) implants. Remote monitoring systems, allow daily follow-ups of patients with ICD. Objective To evaluate the impact of remote monitoring on the management of cardiovascular events associated with supraventricular and ventricular arrhythmias during long-term follow-up. Methods A total of 207 patients undergoing ICD implantation/replacement were enrolled: 79 patients received remote monitoring systems and were followed up every 12 months, and 128 patients were followed up conventionally every 6 months. All patients were followed up and monitored for the occurrence of supraventricular and ventricular arrhythmia-related cardiovascular events (ICD shocks and/or hospitalizations). Results During a median follow-up of 842 days (interquartile range 476–1288 days), 32 (15.5%) patients experienced supraventricular arrhythmia–related events and 51 (24.6%) patients experienced ventricular arrhythmia–related events. Remote monitoring had a significant role in the reduction of supraventricular arrhythmia–related events, but it had no effect on ventricular arrhythmia–related events. In multivariable analysis, remote monitoring remained as an independent protective factor, reducing the risk of supraventricular arrhythmia–related events of 67% [hazard ratio, 0.33; 95% confidence interval (CI), 0.13–0.82; P = 0.017]. Conclusion Remote monitoring systems improved outcomes in patients with supraventricular arrhythmias by reducing the risk of cardiovascular events, but no benefits were observed in patients with ventricular arrhythmias.

ECG parameters predict left ventricular conduction delay in patients with left ventricular dysfunction

BACKGROUND Estimating left ventricular electrical delay (Q-LV) from a 12-lead ECG may be important in evaluating cardiac resynchronization therapy (CRT). OBJECTIVE The purpose of this study was to assess the impact of Q-LV interval on ECG configuration. METHODS One hundred ninety-two consecutive patients undergoing CRT implantation were divided electrocardiographically into 3 groups: left bundle branch block (LBBB), right bundle branch block (RBBB), and nonspecific intraventricular conduction delay (IVCD). The IVCD group was further subdivided into 81 patients with left (L)-IVCD and 15 patients with right (R)-IVCD (resembling RBBB, but without S wave in leads I and aVL). The Q-LV interval in the different groups and the relationship between ECG parameters and the maximum Q-LV interval were analyzed. RESULTS Patients with LBBB presented a long Q-LV interval (147.7 ± 14.6 ms, all exceeding cutoff value of 110 ms), whereas RBBB patients presented a very short Q-LV interval (75.2 ± 16.3 ms, all <110 ms). Patients with an IVCD displayed a wide range of Q-LV intervals. In L-IVCD, mid-QRS notching/slurring showed the strongest correlation with a longer Q-LV interval, followed, in decreasing order, by QRS duration >150 ms and intrinsicoid deflection >60 ms. Isolated mid-QRS notching/slurring predicted Q-LV interval >110 ms in 68% of patients. The R-IVCD group presented an unexpectedly longer Q-LV interval (127.0 ± 12.5 ms; 13/15 patients had Q-LV >110 ms). CONCLUSION Patients with LBBB have a very prolonged Q-LV interval. Mid-QRS notching in lateral leads strongly predicts a longer Q-LV interval in L-IVCD patients. Patients with R-IVCD constitute a subgroup of patients with a long Q-LV interval.

Air pollution and ST-elevation myocardial infarction treated with primary percutaneous coronary angioplasty: A direct correlation

PURPOSE The relationships between air pollutant concentration levels and admission for primary percutaneous coronary intervention (PCI) in patients with ST-elevation myocardial infarction (STEMI) have never been assessed. METHODS We retrospectively reviewed 4 consecutive years of medical and instrumental data (1st January 2012 to 1st March 2016) to identify patients admitted with STEMI and subsequently treated with primary PCI in our third referral center. Daily atmospheric pressure data (in hectopascal [hPa]) and air pollutant concentration levels were obtained from the regional meteorological service which had a monitoring site in our city (Rovigo, Italy). Pollutants investigated were nitrogen dioxide (NO2), particulate matter ≤10μm (PM10), ozone (O3), sulfur dioxide (SO2) and carbon monoxide (CO). Safety air concentration levels for the air pollutants were also considered. RESULTS PCI in STEMI patients was more frequent when AP was higher than 1013.15hPa (61.8% vs 38.2%, p<0.001). The incidences of STEMI patients when NO2, PM10 and O3 levels overcame the safe threshold were 83.1%, 52% and 8.5%, respectively. A positive correlation was found between the daily number of STEMI subsequently treated with primary PCI and the air pollutant levels of the same day for NO2 (r=0.205, p=0.001), PM10 (r=0.349, p<0.0001) and O3 (r=0.191, p=0.002). CONCLUSIONS A direct and significant correlation exists between the number of daily STEMI patients and the NO2, PM10 and O3 air concentration levels of the same day.

Burden of costs associated with heparin-induced thrombocytopenia: is time to remove unfractionated heparin from the drug formularies in medical institutions?

Heparin-induced thrombocytopenia (HIT) represents a serious complication of heparin therapy. Despite generally safe, heparin use can trigger a transient and life-threatening immune-mediated response in which immunoglobulin G antibodies set off immunological complexes against platelet factor 4 (PF4) (1). This determines a highly pro-thrombotic state through different pathways: intensive platelet aggregation, augmented thrombin generation and intravascular platelet aggregation.

Improved acute haemodynamic response to cardiac resynchronization therapy using multipoint pacing cannot solely be explained by better resynchronization

BACKGROUND The recently developed quadripolar left ventricular (LV) leads have been developed to increase the benefit of cardiac resynchronization therapy (CRT). These leads offer the option to stimulate the LV on multiple sites (multipoint pacing, MPP). Invasive haemodynamic measurements have shown that MPP increases haemodynamic response. PURPOSE To investigate whether the beneficial effect of MPP can be explained by better electrical resynchronization. METHODS Different LV lead locations were tested during biventricular (BiV) pacing and MPP in 29 CRT candidates. The 12-lead electrocardiogram (ECG) and the invasive LV pressure curves were measured simultaneously. The Kors matrix was used to convert the ECG into a vectorcardiogram (VCG). The acute haemodynamic benefit of MPP was compared with the reduction in QRS duration and VCG-derived QRS area. RESULTS Out of the 29 patients, three patients were excluded due to missing LV pressures or ECG measurements. In the remaining 26 patients MPP resulted in a significant haemodynamic improvement compared to BiV pacing without a significant change in QRS duration and QRS area. In only 5 out of the 26 patients the QRS area decreased during MPP compared to BiV pacing. In 17 patients MPP did not change QRS duration and significantly increased QRS area but moved the direction of the maximal QRS vector (azimuth) more opposite from baseline compared to BiV pacing. In 4 patients the QRS area was small during baseline, indicating limited electrical dyssynchrony. CONCLUSION The acute haemodynamic benefit of MPP over BiV pacing is achieved by either electrical resynchronization (reduction in QRS area) or by a rotation of the maximal QRS vector, indicating a more LV dominated activation sequence. The latter property was found in two-thirds of the cohort studied.

Troponin assessment in patients admitted to the emergency department with atrial fibrillation: which role in daily clinical practice?

Atrial fibrillation (AF) is the most common dysrhythmia observed and managed by emergency physicians in daily clinical practice. According to the latest epidemiological studies, the prevalence of AF rises with the aging of the general population [1], with clear implications in resource utilization and health costs. Moreover, it has been estimated that the number of patients with AF will rise to about 5.6 million in 2050 from its current number of 2.3 million cases [2]. Frequently, AF patients are admitted to the emergency department (ED) after the dysrhythmia onset, and, more in general, about 80% of the AF subjects will be admitted into a cardiological or internal medicine unit during the course of their illness [3]. Previous investigations and trials involving AF subjects have mainly investigated and elucidated clinical and therapeutical aspects of the disease, as the link between AF and the risk or the prevention of ischemic stroke. Conversely, data regarding the prognostic role of elevated cardiac troponin (cTn) values in AF patients, during both the shortand long-term period, are scarce. Nowadays, there are few recommendations about the use of cTn levels in the management of AF patients. Indeed, the latest European guidelines on the management of AF have considered this clinical issue only marginally [5]. Specifically, the aforementioned consensus document suggests the evaluation of cardiac biomarkers (both cTn and/or brain natriuretic peptide—BNP) to improve the estimation of stroke and bleeding events (level of evidence IIb-B) without giving any suggestions about the possible prognostic role, even in the shortand long-term period, after the dysrhythmia onset. Augusto et al. [6] have recently presented intriguing data in their retrospective, single-center analysis. Among 383 consecutive AF patients (137 male, mean age 71.3 ± 12.7 years) admitted into the ED, 348 (90.9%) received at least one determination of cTn as a standard of care. A further sub-analysis, which divided the entire cohort into three groups, according to the cTn levels [defined as normal levels (≤ 0.05 ng/ml), mild (> 0.05 − 0.5 ng/ml) and marked cTn elevation (> 0.5 ng/ml)], demonstrates that the majority of AF patients have normal cTn I values (74.7%) at admission, but at the same time, a non-negligible proportion (19.0%) had a mild cTn I elevation. Comparing patients with normal and those with mild cTnI elevation, a non-significant trend towards higher adverse events [defined as the occurrence of acute coronary syndrome (ACS) (p = 0.20), the need of coronary artery revascularization (p = 0.20), allcause mortality (p = 0.2), and the incidence of ischemic stroke (p = 0.39)] occurs. It is undeniable that the prognostic role of cTn levels in AF patients represents a relevant and underestimated topic in the field of both cardiovascular and emergency medicine. The assessment of cTn levels is generally requested to diagnose acute myocardial infarction (AMI) [7–9] as a possible cause or consequence of AF in patients admitted to the ED. However, the cTn prognostic role remains unclear in this scenario. Doubtless, the study conducted by Augusto et al., gives important preliminary results, but, at the same time, presents some intrinsic limitations. These are: the relatively small number of patients enrolled, the retrospective and monocentric design of the study, as well the short-period of follow-up (30 days after the admission), and the definition of “mild troponin elevation,” which has received different definitions over the years. That latter aspect makes difficult any comparison with other data presented over the past few years. However, the results of Augusto et al. are in accordance with the ARISTOTLE trial [4], which reports that serum levels of high-sensitive cTn are often increased in AF patients, and that high levels are independently associated * Francesco Zanon franc.zanon@iol.it

A migrant left ventricular lead

We report the case of 70-year-old woman with Reel syndrome and cardiac resynchronization therapy device who experienced severe device malfunction. Reel syndrome was misdiagnosed for several months and the patient manifested fatigue, discomfort and diaphragmatic stimulation.

073_17041p Hisian Pacing With Apical Back-Up On Demand Is Safe And Effective

Hisian pacing might entail a higher threshold than conventional pacing methods. Back-up stimulation on demand allows managing the risk of capture loss with the lowest energy cost. His-bundle and apical back-up leads were connected, respectively, to the V1 and V2 channels of a suitable three-chamber