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Aims Risk stratification of sudden cardiac death (SCD) is challenging. Fragmented QRS (fQRS) is proposed as a non-invasive electrocardiogram marker associated with mortality and SCD. Results from individual studies including small numbers of patients are discrepant. We therefore performed a meta-analysis of studies evaluating fQRS as a risk stratification tool to predict all-cause mortality and SCD. Methods and results Electronic databases and bibliographies were systematically searched (1996–2014). Twelve studies (5009 patients) recruiting patients with coronary artery disease or non-ischaemic cardiomyopathy met our inclusion criteria. Fragmented QRS was associated with an all-cause mortality relative risk of 1.71 (CI 1.02–2.85) and a relative risk of SCD of 2.20 (CI 1.05–4.62). Subgroup analysis demonstrated greater mortality and SCD risk in those with left ventricular ejection fraction >35% and SCD risk in those with QRS duration

Atrial fibrillation (AF) is the most common sustained arrhythmia and an important source for mortality and morbidity on a population level. Despite the clear association between AF and death, stroke, and other cardiovascular events, there is no evidence that rhythm control treatment improves outcome in AF patients. The poor outcome of rhythm control relates to the severity of the atrial substrate for AF not only due to the underlying atrial remodelling process but also due to the poor efficacy and adverse events of the currently available ion-channel antiarrhythmic drugs and ablation techniques. Data suggest, however, an association between sinus rhythm maintenance and improved survival. Hypothetically, sinus rhythm may also lead to a lower risk of stroke and heart failure. The presence of AF, thus, seems one of the modifiable factors associated with death and cardiovascular morbidity in AF patients. Patients with a short history of AF and the underlying heart disease have not been studied before. It is fair to assume that abolishment of AF in these patients is more successful and possibly also safer, which could translate into a prognostic benefit of early rhythm control therapy. Several trials are now investigating whether aggressive early rhythm control therapy can reduce cardiovascular morbidity and mortality and increase maintenance of sinus rhythm. In the present paper we describe the background of these studies and provide some information on their design.

Aims Implantable cardioverter defibrillator (ICD) therapy improves survival in patients at high sudden cardiac death (SCD) risk. However, some patient groups fulfilling indications for ICD therapy may not gain significant benefit: patients whose absolute risk of SCD is low and patients whose risk of death even with an ICD is high. The value of biomarkers in identifying patients’ potential for survival benefit from ICD therapy is unknown. We performed a pilot study to investigate this. Methods and results Five established cardiovascular biomarkers were measured in patients with ICDs on the background of left ventricular dysfunction: N-terminal pro-brain natriuretic peptide [NT-proBNP], soluble ST2 [sST2], growth differentiation factor-15, C-reactive protein, and interleukin-6. The endpoints were all-cause mortality and survival with appropriate ICD therapy. One hundred and fifty-six patients were enrolled (age 69 years [Q1–Q3 62–77], 85% male, 76% ischaemic aetiology). During a follow-up of 15 ± 3 months, 12 patients died and 43 survived with appropriate ICD therapy. In a Cox proportional hazards model, the strongest predictors of death were Log sST2 ( P < 0.001), serum creatinine ( P < 0.001), and Log NT-proBNP ( P = 0.002). The strongest predictor of survival with appropriate ICD therapy was Log NT-proBNP ( P = 0.01). Conclusion The biomarkers NT-proBNP and sST2 are promising biomarkers for identifying patients with little potential to gain significant survival benefit from ICD therapy. However, their incremental benefit, in addition to currently available clinical risk prediction models, remains unclear. These results demand a confirmatory prospective cohort study, designed and powered to derive and validate prediction algorithms incorporating these markers.

Aim of the document Palpitations are among the most common symptoms that prompt patients to consult general practitioners, cardiologists, or emergency healthcare services.1–4 Very often, however, the diagnostic and therapeutic management of this symptom proves to be poorly efficacious and somewhat frustrating for both the patient and the physician. Indeed, in many cases a definitive, or at least probable, diagnosis of the cause of palpitations is not reached and no specific therapy is initiated.5,6 This means that many patients continue to suffer recurrences of their symptoms, which impair their quality of life and mental balance, lead to the potential risk of adverse clinical events, and induce continual recourse to healthcare facilities. These difficulties stem from the fact that palpitations are generally a transitory symptom. Indeed, at the moment of clinical evaluation, the patient is often asymptomatic and the diagnostic evaluation focuses on the search for pathological conditions that may be responsible for the symptom. This gives rise to some uncertainty in establishing a cause–effect relationship between any anomalies that may be detected and the palpitations themselves. Moreover, as palpitations may be caused by a wide range of different physiological and pathological conditions, clinicians tend to apply a number of instrumental investigations, laboratory tests, and specialist examinations, which are both time-consuming and costly. Comparable, for example, to syncope, such an approach is warranted in selected patients, whereas other patients with palpitations may not require such careful follow-up. The initial clinical assessment should, therefore, include an educated estimation of the likelihood of a relevant underlying arrhythmia in a patient with palpitations (‘gatekeeper' function). The current management of patients with palpitations is guided chiefly by the clinical experience of the physician. Indeed, the literature lacks specific policy documents or recommendations regarding the most appropriate diagnostic work-up to be adopted in individual …

Implantable cardioverter-defibrillator (ICD) therapy has emerged as the most effective treatment for life-threatening ventricular arrhythmias. Most studies indicate that ICD therapy in appropriately selected patients at high risk of sudden cardiac death (SCD) is associated with cost-effectiveness ratios similar to, or better than, other accepted treatments, including renal dialysis. The up-front costs of ICD therapy are admittedly high and as such, ICD implantation is more akin to an operation than a drug. As would be the case for a life-saving operation, the adoption of short time horizons is apt to lead to underestimations of cost effectiveness. As well as the time horizon, the underlying aetiology of the arrhythmic substrate, implantation technique, ICD battery life, and the presence of co-morbidities are important issues in maximizing cost effectiveness. Above all, we should consider that ICD therapy is the only available option for prolonging survival in patients who are at risk of SCD.

Although cardiac resynchronization therapy (CRT) has demonstrated to be an effective treatment for heart failure patients, up to 30-40% of the patients do not show a favourable response. Implantation of the left ventricular (LV) pacing lead is one of the determinants of CRT response. This procedure includes several challenging technical issues and strongly depends on the highly variable anatomy of the coronary sinus and tributaries. In addition, the final position of the LV pacing lead may target the latest activated areas of the left ventricle in order to obtain effective resynchronization. Furthermore, the presence of transmural myocardial scar at the region targeted by the LV lead may also determine the response to CRT. This review discusses all the issues related to LV lead implantation and the role of multimodality imaging to anticipate the implantation strategy. Finally, alternative LV pacing sites and their effect on clinical outcome and LV performance will be discussed.

Although the use of implantable cardioverter defibrillator (ICD) therapy has increased over the last decades, the reporting of ICD lead performance is inadequate. So far, there is neither a European nor worldwide registry on ICD leads. The published long-term results from national or multicentre registries encompass relatively small patient cohorts. Nevertheless, the failure of ICD leads may have substantial clinical consequences, including failure to sense, failure to pace, failure to defibrillate, inappropriate shocks, and even death of the patient. The reported ICD lead survival varies significantly between studies: 91-99% at 2 years, 85-95% at 5 years, and 60-72% at 8 years. Thus, the true incidence of lead malfunction cannot be defined as outlined in the present review. One current initiative of the European Heart Rhythm Association is to initiate and develop a Europe-wide registry to monitor, over a prolonged follow-up period, the performance of ICDs and ICD leads.

Aims To evaluate the impact of age on the clinical outcomes in a primary prevention implantable cardioverter defibrillator (ICD)/cardiac resynchronization therapy defibrillator (CRT-D) population. Methods and results A retrospective, multicentre analysis of patients aged 60 years and over with primary prevention ICD/CRT-D devices implanted between 1 January 2006 and 1 November 2014 was performed. Survival to follow-up with no therapy (T1), death prior to follow-up with no therapy (T2), delivery of appropriate therapy with survival to follow-up (T3), and delivery of appropriate therapy with death prior to follow-up (T4) were measured. In total, 424 patients were eligible for inclusion in the analysis, mean follow-up of 32.6 months during which time 44 patients (10.1%) received appropriate therapy. The sub-hazard ratio (SHR) for the cumulative incidence of appropriate therapy (T3) according to age at implant was 1.00 ( P = 0.851; 95% CI 0.96–1.04). The SHR for cumulative incidence of death (T2) according to age at implant was 1.06 ( P < 0.001; 95% CI 1.03–1.01). Age at implant, ischaemic aetiology, baseline haemoglobin, and the presence of diabetes mellitus were predictors of all-cause mortality. Conclusion Age has no impact on the time to appropriate therapy, but risk of death prior to therapy increases by 6% for every year increment. As the ICD population ages, the proportion who die without receiving appropriate therapy increases due to competing risks. Characterizing competing risks predictive of death independent of ICD indication would focus therapy on those with potential to benefit and reduce unnecessary exposure to ICD-related morbidity.

We congratulate Barra et al. on a thoughtful review of implantable cardioverter-defibrillators (ICDs) in the elderly.1 The article is timely given the increasing pressures of caring for an ageing population. It deals well with the issue of survival in elderly ICD recipients and the discussion on cost effectiveness is in line with what we had long suspected. We agree with many of the points raised in this review and would like to make two points: First, the comparison of an octogenarian ICD population with another (e.g. pacemaker) octogenarian ICD population is not valid as it is comparing two distinct entities, one …

Haemodialysis (HD) patients are at increased risk of vascular access complications with device therapy. We report a case of transvenous defibrillator lead extraction from the ipsilateral side as an HD fistula. The procedure was successfully performed using a hybrid approach, with extraction of the lead with a powered sheath, and surgical cut-down and closure of the subclavian vein defect.