Europace最新文献

Aims: The direct oral anticoagulant (DOAC) score was recently developed to predict bleeding risk in patients with atrial fibrillation (AF) receiving oral anticoagulants. However, limited data show inconsistent results comparing its performance to the conventional HAS-BLED score in Asian populations with non-valvular AF receiving DOACs.

Methods and results: We enrolled 21 142 patients with non-valvular AF receiving DOACs from a multicentre database in Taiwan (June 2012-December 2021). The primary endpoint was major bleeding events. Major bleeding events were defined according to the ISTH criteria. Areas under receiver operating characteristic curves (AUCs) were calculated for each score, with differences assessed using DeLong test. A total of 21 142 AF patients (mean age 75.9 ± 11.0 years; 41% female) treated with DOAC were included in the analysis. Major bleeding events occurred in 681 patients in 1-year follow-up (3.66%/year). There were 82(0.43%/year) intracranial haemorrhage event occurred. Both the DOAC and HAS-BLED scores are associated with a significant risk of major bleeding event, with only modest predictive performance (AUC < 0.7). The DOAC score showed a slightly but statistically significantly higher AUC compared with the HAS-BLED score [AUC: 0.670 (95% CI: 0.650-0.689) vs. 0.642 (0.623-0.663); P < 0.001]. Results from several reclassification analyses favoured the DOAC score. Both the two scores showed a good calibration for the low to intermediate risk categories, while the two bleeding risk scores both overestimate the risk of major bleeding risk for the high risk categories. Subgroup analyses indicated that the superiority of DOAC score over HAS-BLED score is primarily driven by elderly patients (≥75 years) and prediction in risk of gastrointestinal bleeding.

Conclusion: The DOAC score, which employs a more granular scoring system compared to the HAS-BLED score, may enable finer bleeding risk discrimination among Asian patients with non-valvular AF receiving DOAC therapy.

Aims: Patients with atrial fibrillation (AF) are at a high risk of adverse cardiovascular outcomes. Little is known about the specific population of AF patients with implanted pacemaker (PM) and their prognosis. Therefore, we aimed to compare the risks of adverse outcomes in AF patients with and without PM.

Methods and results: Data from two Swiss prospective, multicentre cohort studies (Swiss-AF, Beat-AF) (n = 3675) with yearly follow-ups (FUs) up to 8 years were analysed. The first main outcome was major adverse cardiovascular events (MACE), a composite of stroke or transient ischaemic attack, myocardial infarction, cardiovascular death, and systemic embolism. The second main outcome was hospitalization for heart failure (HF). Secondary outcomes were the individual components of MACE. We performed time-updated Cox regression analyses to investigate the association of PM and outcomes. Median age was 71.4 years, 28.8% female, 445 (12.1%) patients had a PM at baseline, and 238 additional patients (7.4%, 1.05%/year) received a PM over a median FU of 7 years. Patients with a PM had higher incidence rates for MACE and HF (5.97 and 5.08 per 100 patient-years, respectively), compared to patients without a PM (3.37 and 2.61 per 100 patient-years, respectively). After multivariable adjustment, we found no independent association of PM and MACE (aHR [95% CI] 1.12 [0.95-1.33; P = 0.183]) or HF (aHR [95% CI] 1.14 [0.94-1.37; P = 0.180]). We found consistent results for the individual components of MACE.

Conclusion: Patients with AF and a PM experienced an increased rate of adverse cardiovascular outcomes. However, the PM itself was not independently associated with these outcomes.

Few medical decisions have a greater impact on the life of patients affected by either long QT syndrome (LQTS) or catecholaminergic polymorphic ventricular tachycardia (CPVT) as the one to recommend an implantable cardioverter defibrillator (ICD) or not. If the decision is correct, a life might be saved or a litany of ICD-related complications might be avoided. If it is wrong, well you can fill in the blanks. Many physicians take the fastest and simplest road by recommending an ICD which represents 'double protection': for the patients and for themselves. Our opinion is that this requires a very careful consideration about the pros and cons and should be taken neither lightly nor quickly. Moreover, there is another side to this moon, which also requires more thought than usually assumed. As to LQTS and CPVT, the current data strongly indicate that when high risk patients are treated with either combination drug therapy comprising beta blockers and mexiletine (LQTS) or beta blockers and flecainide (CPVT) or triple therapy with left cardiac sympathetic denervation as the treatment intensifier, mortality is close to zero and most patients have no life-threatening events. Thus, we stand by our view that most patients still do not need and should not receive an ICD. However, sometimes patients are desperately worried for the fear of dying suddenly and ask for an ICD despite being at low risk. Their request should be listened to, respected, and considered with empathy because immortality cannot be guaranteed. We believe that both expertise and compassion are quintessential to practicing the science and art of medicine.

Sudden cardiac death (SCD) remains a predominant mode of death in cardiovascular mortality. Despite advancements in guideline-recommended medical therapy and risk stratification, accurately identifying patients who would benefit most from implantable cardioverter-defibrillator (ICD) therapy over the long term remains a significant challenge. The wearable cardioverter-defibrillator (WCD) has emerged as a non-invasive bridge to either ICD implantation or recovery of left ventricular function. This expert review presents a comprehensive and up-to-date summary of clinical evidence on WCD use for SCD prevention and heart failure (HF) management. Specifically, it will address: (i) the concept and mechanism of the WCD; (ii) evidence from randomized and observational studies regarding efficacy, safety, and cost-effectiveness; (iii) integration of the WCD into HF management; and (iv) knowledge gaps and priorities for future research.

Aims: Pulsed-field ablation (PFA) is a non-thermal energy source for pulmonary vein isolation (PVI), offering advantages in safety and procedural efficiency. However, data comparing anterior mitral isthmus line (MIL) ablation using PFA vs. conventional radiofrequency ablation (RFA) are scarce. This study aimed to compare procedural characteristics, safety, and arrhythmia recurrence following PVI with additional anterior MIL ablation using PFA vs. RFA.

Methods and results: In this prospective, single-centre analysis from the SWISS-AF-PVI registry, 129 patients (median age 70 years, 40% female) undergoing PVI with anterior MIL ablation were included. Patients received either PFA with a pentaspline catheter (n = 61) or RFA using a 3.5 mm irrigated tip catheter (n = 68). Procedural parameters, complications, and arrhythmia recurrence were assessed over a median follow-up of 327 days. PFA significantly reduced total procedure time (71 vs. 108 min, P < 0.001), LA dwell time (53 vs. 80 min, P < 0.001), and ablation time (27 vs. 50 min, P < 0.001) compared to RFA. MIL ablation with PFA required fewer applications (14; 35 s vs. 473 s RFA, P < 0.001). Arrhythmia-free survival was similar between groups (PFA 48.8% vs. RFA 61.8%, P = 0.34). Among 34 patients undergoing redo procedures, incomplete MIL was found in 53%, with no significant difference between groups. Three major complications occurred.

Conclusion: Anterior MIL ablation using PFA is feasible, safe, and more time-efficient than RFA, with comparable mid-term arrhythmia outcomes. However, high rates of MIL reconnection and arrhythmia recurrence highlights the need to improve lesion durability.

Aims: Wolff-Parkinson-White (WPW) syndrome is a rare cardiac disorder that predisposes to supraventricular arrhythmias. Prognosis is usually benign, yet there is an increased lifetime risk of sudden death. While typically sporadic, familial clustering has been reported. This study aimed to assess the risk of WPW, arrhythmias, and mortality among siblings of individuals with WPW.

Methods and results: This population-based sibling cohort included 5 338 434 individuals born in Sweden (1932-2018), with 3172 WPW cases identified from the Swedish National Patient Registers. Familial risks among siblings were assessed using incidence rate ratios (IRRs) and adjusted subdistributional hazard ratios (SHRs). Sensitivity analyses excluded syndromic WPW and cases without electrophysiologic procedural confirmation. Although familial occurrence of WPW was exceedingly rare with only 14 of 3172 cases (0.4%; ≈0.0003% of the total population), siblings of affected individuals showed a significantly higher rate of WPW diagnosis (0.121 vs. 0.032 per 1000 person-years; IRR 3.83; 95% CI 2.27-6.46; P < 0.001) translating to an almost four-fold higher adjusted risk (SHR 3.79; 95% CI 1.81-7.97; P < 0.001). Risks of atrial fibrillation (SHR 1.19; 95% CI 1.05-1.35; P < 0.01) and ventricular arrhythmias (SHR 1.84; 95% CI 1.45-2.35; P < 0.001) were also higher, whereas all-cause mortality was comparable irrespective of sibling history (HR 1.01; 95% CI 0.92-1.11; P = 0.88).

Conclusion: WPW features familial aggregation and increased arrhythmic risk among siblings of affected individuals despite its extremely low absolute frequency in the general population. The evidence of a measurable hereditary component within an otherwise sporadic, non-syndromic condition points to a genetic contribution driven by complex inheritance patterns.

Aims: Subcutaneous implantable cardioverter-defibrillators (S-ICDs) are effective in patients who require protection from sudden cardiac death while avoiding the long-term risks associated with transvenous leads. However, data on their real-world performance in paediatric and young patients remain limited. This study aims to evaluate the safety and efficacy of S-ICDs in a large, multicentre cohort of paediatric and young patients across Europe, with a focus on contemporary implantation practices and clinical outcomes.

Methods and results: This is an international, multicentre, observational, retrospective registry on S-ICD outcome in paediatric and young adult patients with congenital heart defects (CHD), cardiomyopathies, channelopathies, and idiopathic ventricular fibrillation (IVF). Data were collected on implantation techniques, acute and long-term outcomes, including defibrillation efficacy, inappropriate (IAS) and appropriate shocks, and complications. Follow-up data were analysed to assess device performance and safety. A total of 223 patients (mean age: 15 ± 3 years; 59% male, 53% cardiomyopathies, 18% channelopathies, 15% IVF, 14% CHD) were included. Most patients underwent implantation using an intermuscular (65%) and two-incision technique (88%). Acute defibrillation success was 100%, and no intraoperative complications occurred. The median follow-up was 28 (IQR: 12-55) months. Appropriate shocks were delivered in 41 (18%) patients (26% rate at 5 years). The first shock was effective in 92% of discrete episodes. The IAS and the complication rates were 20% and 5% at 5 years. Older age, intermuscular pocket, and two-incision technique were associated with fewer complications.

Conclusion: This multicentre S-ICD European registry in paediatric and young patients demonstrated favourable outcomes, low IAS, and complication rates.

In most patients with atrial fibrillation (AF), effective stroke prevention necessitates long-term (often lifelong) oral anticoagulant therapy (OAC). However, the effectiveness of OAC therapy in a clinical setting (i.e. outside the controlled environment of randomized clinical trials) is strongly influenced by patients' adherence and persistence with prescribed therapy. However, suboptimal adherence to OAC remains a substantial problem in routine practice-available evidence suggests that patients do not take their OAC one out of every four days, and approximately one in three to four patients is poorly adherent to OAC. In addition, around 15% of high-risk OAC-eligible patients with AF refuse to take OAC for a variety of patient-specific reasons. Poor adherence to OAC therapy is associated with adverse clinical outcomes [such as stroke or systemic embolism, hospitalization, mortality, bleeding (particularly with vitamin K antagonist therapy)] and increased economic costs. In this overview, we summarize important aspects of the adherence to medication concept, including the definition and measurement of adherence, the determinants and prevalence of OAC non-adherence, the clinical importance of achieving and maintaining good adherence, strategies to improve adherence to OAC, and alternative treatment options for effective thromboprophylaxis in patients with AF who are non-adherent to OAC therapy.

Aims: Evaluate the prognostic significance of arrhythmias and conduction disorders on ambulatory ECG in recently diagnosed genetic vs. non-genetic dilated cardiomyopathy (DCM).

Objective: To compare the prevalence of abnormalities on ambulatory ECG monitoring between genetic and non-genetic DCM patients and evaluate the predictive value for malignant ventricular adverse events (MVAEs).

Methods and results: Clinical and ambulatory ECG data were collected from 354 genotyped DCM probands, with a median follow-up of 8 years (IQR: 5-9 years). The malignant ventricular adverse event was defined as ventricular fibrillation, sustained ventricular tachycardia, anti-tachy pacing, appropriate device therapy, or sudden cardiac death. C-statistics assessed the predictive performance of the regression models. In total, 123 (35%) patients carried a (likely) pathogenic variant. Abnormalities on ambulatory ECG were more frequent in genetic DCM patients (80%) compared to non-genetic DCM (67%; P = 0.013). Permanent atrial fibrillation (perAF), paroxysmal supraventricular tachycardia (parox-SVT), and non-sustained ventricular tachycardia (NSVT) were more frequent in genetic DCM patients (P = 0.041, <0.001, and <0.001). Structural cardiac parameters showed minimal group differences. Using Cox proportional hazard analyses to predict MVAE, ambulatory ECG variables (perAF, AV-block, NSVT, >500 premature ventricular complexes (PVCs)/24 h) had an area under the curve (AUC) of 0.768 in genetic and 0.628 in non-genetic DCM patients (P = 0.044). The premature ventricular complex burden was only predictive for MVAE in genetic DCM. Adding clinical variables provided little incremental predictive value for genetic vs. non-genetic DCM (AUC Δ+0.004 vs. Δ+0.150, respectively).

Conclusion: Ambulatory ECG monitoring abnormalities are prevalent in genetic DCM patients. In contrast to non-genetic DCM patients, ambulatory ECG parameters have an important predictive value to determine the risk of MVAE in genetic DCM patients.