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Aims Use of implantable cardioverter-defibrillators (ICD) for primary prevention of sudden cardiac death (SCD) in heart failure with reduced ejection fraction (HFrEF) is limited. We aimed to investigate barriers to ICD use in HFrEF while considering the predicted risk of mortality and SCD. Method and results Patients from the SwedeHF registered in 2011-2018 and with an indication for primary prevention ICD were analysed. The Seattle Proportional Risk and Seattle Heart Failure Models were used to predict the proportional SCD and all-cause mortality risk, respectively. A multivariable logistic regression model was fitted to identify independent predictors of ICD use/non-use; Cox regression models to evaluate the interaction between predicted SCD/mortality risk and ICD use for mortality. Of 13 475 patients, only 15.5% had an ICD. Those with higher predicted proportional SCD risk (>45%) had an similar to 80% higher likelihood to have an ICD. Other predictors of non-use were follow-up in primary versus specialty care, higher comorbidity burden and lower socioeconomic status. ICD use was associated with lower mortality only in patients with higher predicted SCD and lower mortality risk (34% and 37% relative risk reduction for 3-year all-cause and cardiovascular mortality, respectively). In this subgroup of patients, underuse of ICD was 81.8%. Conclusion In a contemporary registry, only 15.5% of patients with an indication for primary prevention ICD received the device. While a high predicted proportional SCD risk was appropriately linked to ICD use, the lack of specialized follow-up, higher comorbidity burden, and lower socioeconomic status were major unjustified impediments to implementation. Our findings suggest areas for improving ICD use for primary prevention of SCD in clinical practice. Funding Agencies|Boston Scientific; EU/EFPIA Innovative Medicines Initiative 2 Joint Undertaking BigData@Heart grant [116074]

Background To study the association between timing and success of electrical cardioversion (ECV) for the treatment of early recurrences (ERs) of atrial fibrillation post pulmonary vein isolation (PVI) on long-term rhythm outcome. Methods Data of 133 patients ablated for paroxysmal or persistent atrial fibrillation receiving ECV for ERs, i.e., atrial tachyarrhythmia recurrences within 90 days post ablation were analyzed. During 1-year follow-up, patients were screened for late recurrences (LRs), i.e., recurrences after the blanking period. Results In 114 patients (85.7%), ECV was successful compared to 19 patients (14.3%) with failed ECV. A higher body mass index (odds ratio (OR) 1.19 (95% CI 1.02–1.39), p = 0.029), a lower left ventricular ejection fraction (OR 1.07 (95% CI 0.99–1.15), p = 0.079), and performance of ECV > 7 days from ER onset (OR 2.99 (95% CI 1.01–8.87), p = 0.048) remained independently associated with ECV failure. During 1-year follow-up, the rate of LR was significantly higher among patients with failed ECV as compared to patients with successful ECV (hazard ratio (HR) 3.00 (95% CI, 1.79–5.03), p 7 days from ER onset had a significantly higher risk of developing LR as compared to patients with ECV performed within ≤ 7 days from ER onset (HR 1.73 (95% CI 1.15–2.62), p = 0.009). Performance of ECV > 7 days from ER onset (HR 1.76 (95% CI 1.16–2.67), p = 0.008) and failed ECV (HR 3.32 (95% CI 1.96–5.64), p Conclusions A failed ECV and performance of ECV > 7 days from ER onset were independently associated with LR.

Intracardiac echocardiography (ICE) is frequently used to guide electrophysiology procedures. The novel automated algorithm Cartosoundfam is a model-based algorithm which reconstructs a 3D anatomy of the left atrium (LA) based on a set of 2D intracardiac echocardiography (ICE) frames, without the need to manually annotate ultrasound (US) contours.The aim of this study was to determine the feasibility of the Cartosoundfam module in routine clinical setting.We included 16 patients undergoing LA mapping/catheter ablation. Two-dimensional US frames were acquired from the right atrium (RA) and the right ventricular outflow tract. The Cartosoundfam map was validated in two steps: (1) identification of anatomical structures (pulmonary veins [PV] and LA body and appendage) by alignment of the ablation catheter to the automated map; and (2) analysis of the automated lesion tags (Visitag) location in relation to the PV antrum of the Cartosoundfam map in nine patients with paroxysmal atrial fibrillation (AF) undergoing first time pulmonary vein isolation (PVI).Mean 2D US frames per patient were 29 ± 6 and acquisition time was 16 ± 4 min. All anatomical structures were correctly identified in all patients (step 1). In the step 2 validation, the median distance to the map was 2.0 (IQR: 2.4) mm and the majority of the Visitags were classified as satisfactory (69%) but all PV segments had some Visitags classified as unsatisfactory.The automated ICE-based algorithm correctly identified the LA anatomical structures in all patients with a 69% anatomical accuracy of the Visitags alignments to the PV antrum segments.

BackgroundSudden cardiac death (SCD) is a global public health issue, accounting for 10–20% of deaths in industrialized countries. Identification of modifiable risk factors may reduce SCD incidence.MethodsThis umbrella review systematically evaluates published meta-analyses of observational and randomized controlled trials (RCT) for the association of modifiable risk and protective factors of SCD.ResultsFifty-five meta-analyses were included in the final analysis, of which 31 analyzed observational studies and 24 analyzed RCTs. Five associations of meta-analyses of observational studies presented convincing evidence, including three risk factors [diabetes mellitus (DM), smoking, and early repolarization pattern (ERP)] and two protective factors [implanted cardiac defibrillator (ICD) and physical activity]. Meta-analyses of RCTs identified five protective factors with a high level of evidence: ICDs, mineralocorticoid receptor antagonist (MRA), beta-blockers, and sodium-glucose cotransporter-2 (SGLT-2) inhibitors in patients with HF. On the contrary, other established, significant protective agents [i.e., amiodarone and statins along with angiotensin-converting enzyme (ACE) inhibitors in heart failure (HF)], did not show credibility. Likewise, risk factors as left ventricular ejection fraction in HF, and left ventricular hypertrophy, non-sustain ventricular tachycardia, history of syncope or aborted SCD in pediatric patients with hypertrophic cardiomyopathy, presented weak or no evidence.ConclusionsLifestyle risk factors (physical activity, smoking), comorbidities like DM, and electrocardiographic features like ERP constitute modifiable risk factors of SCD. Alternatively, the use of MRA, beta-blockers, SGLT-2 inhibitors, and ICD in patients with HF are credible protective factors. Further investigation targeted in specific populations will be important for reducing the burden of SCD.Systematic Review Registrationhttps://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020216363, PROSPERO CRD42020216363.

Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): DFG (Deutsche Forschungsgemeinschaft) to G.O. Aims To investigate the association between catheter ablation and mortality as well as hospitalization for heart failure (HF) in patients with atrial fibrillation (AF) and HF across the ejection fraction (EF) spectrum in a contemporary cohort. Methods Between 2005 and 2019, patients with first-time catheter ablation for AF (ablation group) compared to only medical treated AF patients (medical therapy group) were identified from the Swedish Heart Failure Registry. The primary outcome (all-cause mortality/first HF hospitalization) was assessed by cox regression models in a 1:2 propensity score (PS) matched cohort and pre-specified EF subgroups (preserved EF [HFpEF] [EF≥50%], mildly reduced EF [HFmrEF] [EF 40% to 49%], reduced EF [HFrEF] [EF Results 452 patients in the ablation and 43766 patients in the medical therapy group were identified. After PS matching, 437 patients in the ablation group were compared to 874 patients in the medical therapy group. Over the entire follow-up, catheter ablation was associated with a lower risk of the primary outcome (Hazard ratio [HR] 0.71 [95%CI, 0.59-0.85]) and first cardiovascular (CV) hospitalization (HR 0.85 [95%CI, 0.72-0.99]) in PS matched analysis. Results were consistent across all EF subgroups. In HFpEF patients, catheter ablation was associated with a significantly lower risk of recurrent HF hospitalization (Incidence rate ratio (IRR) 0.17 [95%CI, 0.07-0.42]). Conclusion In this nationwide study, catheter ablation was associated with a significant lower risk of the primary outcome (all-cause mortality/first HF hospitalization) in HF patients with AF. This study advocates catheter ablation as a potent treatment option for AF in HF patients across all EF subgroups, including HFpEF.

Aims Iatrogenic cardiac tamponades are a rare but dreaded complication of invasive electrophysiology procedures (EPs). Their long-term impact on clinical outcomes is unknown. This study analysed the risk of death or serious cardiovascular events in patients suffering from EP-related cardiac tamponade requiring pericardiocentesis during long-term follow-up. Methods and results Out of 19 997 invasive EPs at the Karolinska University Hospital between January 1998 and September 2018, all patients with EP-related periprocedural cardiac tamponade were identified (n = 60) and matched (1:3 ratio) to a control group (n = 180). After a follow-up of 5 years, the composite primary endpoint — death from any cause, acute myocardial infarction, transitory ischaemic attack (TIA)/stroke, and hospitalization for heart failure — occurred in significantly more patients in the tamponade than in the control group [12 patients (20.0%) vs. 19 patients (10.6%); hazard ratio (HR) 2.53 (95% confidence interval, CI 1.15–5.58); P = 0.021]. This was mainly driven by a higher incidence of TIA/stroke in the tamponade than in the control group [HR 3.75 (95% CI 1.01–13.97); P = 0.049]. Death from any cause, acute myocardial infarction, and hospitalization for heart failure did not show a significant difference between the groups. Hospitalization for pericarditis occurred in significantly more patients in the tamponade than in the control group [HR 36.0 (95% CI 4.68–276.86); P = 0.001]. Conclusion Patients with EP-related cardiac tamponade are at higher risk for cerebrovascular events during the first 2 weeks and hospitalization for pericarditis during the first months after index procedure. Despite the increased risk for early complications tamponade patients have a good long-term prognosis without increased risk for mortality or other serious cardiovascular events.

Background: Adverse events in COVID-19 are difficult to predict. Risk stratification is encumbered by the need to protect healthcare workers. We hypothesize that artificial intelligence (AI) can help identify subtle signs of myocardial involvement in the 12-lead electrocardiogram (ECG), which could help predict complications. Objective: Use intake ECGs from COVID-19 patients to train AI models to predict risk of mortality or major adverse cardiovascular events (MACE). Methods: We studied intake ECGs from 1448 COVID-19 patients (60.5% male, aged 63.4 ± 16.9 years). Records were labeled by mortality (death vs discharge) or MACE (no events vs arrhythmic, heart failure [HF], or thromboembolic [TE] events), then used to train AI models; these were compared to conventional regression models developed using demographic and comorbidity data. Results: A total of 245 (17.7%) patients died (67.3% male, aged 74.5 ± 14.4 years); 352 (24.4%) experienced at least 1 MACE (119 arrhythmic, 107 HF, 130 TE). AI models predicted mortality and MACE with area under the curve (AUC) values of 0.60 ± 0.05 and 0.55 ± 0.07, respectively; these were comparable to AUC values for conventional models (0.73 ± 0.07 and 0.65 ± 0.10). There were no prominent temporal trends in mortality rate or MACE incidence in our cohort; holdout testing with data from after a cutoff date (June 9, 2020) did not degrade model performance. Conclusion: Using intake ECGs alone, our AI models had limited ability to predict hospitalized COVID-19 patients’ risk of mortality or MACE. Our models’ accuracy was comparable to that of conventional models built using more in-depth information, but translation to clinical use would require higher sensitivity and positive predictive value. In the future, we hope that mixed-input AI models utilizing both ECG and clinical data may be developed to enhance predictive accuracy.

Graphical Abstract.

Background/Introduction Catheter ablation of atrial fibrillation (AF) is associated with a complication risk. It is common practice to monitor patients overnight post-procedurally which is resource craving. Purpose To evaluate the incidence of procedural complications related to catheter ablation of AF to assess the potential feasibility and safety of same day discharge in a large cohort. Methods We performed an analysis of prospectively collected data of complications of all patients staying overnight after undergoing AF ablation between 2001 and 2020 at a tertiary centre. By studying medical records, we analysed complications occurring intraprocedurally until six hours post-ablation, and between six hours post-ablation until discharge the day after ablation procedure (up to 24 hours post-procedure). Results In 5414 AF ablations we identified a total of 108 (2.0%) major complications occurring intraprocedural or until discharge the day after procedure. Most major complications occurred early and were detected intraprocedurally or within six hours after completed procedure (n=96, 1.8%). Twelve (0.2%) major complications occurred between six hours post-ablation and until discharge the day after procedure. The most common of these were congestive heart failure (n=6) and transient ischemic attack (TIA, n=4). In addition, there were 61 (1.1%) minor complications which occurred in this time span. Factors independently associated with major complications intraprocedurally or within 24 hours were age (p=0.046), body mass index (BMI) ≥30 kg/m2 (p=0.009), significant valvular disease (p=0.001), cardiomyopathy (p Conclusion Very few complications occurred between six hours and until discharge after ablation of atrial fibrillation. Therefore, same-day discharge may be a safe option for a large proportion of patients. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Region Stockholm funding

Background Electrical cardioversion (ECV) is routinely used to restore sinus rhythm in patients with symptomatic atrial fibrillation. The European guidelines have been updated in recent years. Current information on differences in the risk for stroke after acute versus elective ECV is lacking. Methods And Results All patients with a first‐time acute or elective ECV in the Stockholm regional health care data warehouse from 2011 to 2018 were included. Cox regression analyses were performed evaluating ischemic or unspecified stroke within 30 days after ECV with adjustments for the CHA 2 DS 2 ‐VASc score, medical treatment, and year of inclusion. The study included 9139 patients, 3094 after acute and 6045 after elective ECV. The mean age was 65.9±11.3 years, 69.5% were men, and the mean CHA 2 DS 2 ‐VASc score was 2.4±1.7. Before the intervention, 49.6% of patients with an acute ECV and 96.4% of those with an elective ECV had claimed an oral anticoagulant prescription. Ischemic or unspecified stroke occurred in 26 (0.28%) patients within 30 days. The unadjusted risk was higher after acute compared with elective ECV (hazard ratio [HR], 2.29; 95% CI, 1.06–4.96), whereas there was no difference after multivariable adjustments (adjusted HR, 0.99; 95% CI, 0.36–2.72). Both non–vitamin K oral anticoagulants (adjusted HR, 0.28; 95% CI, 0.08–0.98) and warfarin (adjusted HR, 0.17; 95% CI, 0.05–0.53) were associated with a lower risk for stroke compared with no anticoagulation. Conclusions Acute ECV was associated with a higher unadjusted risk for stroke than elective ECV, but the risk was similar after adjustment for anticoagulant treatment. This study indicates the importance of anticoagulation before ECV according to recent European guidelines.

Aim Data on ablation for atypical recurrent atrioventricular nodal reentry tachycardia (AVNRT) and long-term follow-up are generally sparse. Furthermore, the rate of recurrence and safety of cryoablation for atypical AVNRT has not been established. We compared patients cryoablated for atypical AVNRT and typical AVNRT during long-term follow-up. Methods All patients (n = 2612) who underwent catheter ablation for AVNRT at the Karolinska University Hospital between January 2009 and August 2019 were analyzed. A total of 91 patients undergoing first-time cryoablation for atypical AVNRT were included. A control group with first-time cryoablation for typical AVNRT was matched in a 1:1 ratio. Patients were followed-up for recurrences for a median of 5.0 years (interquartile range: 3.1-7.5 years). Results After 5 years, AVNRT recurrence occurred in 10 patients (11.0%) in the atypical AVNRT group and in 8 patients (8.8%) in the typical AVNRT group (hazard ratio: 1.31 [95% confidence interval: 0.52-3.32]; p = 0.568). The duration of the index procedure was significantly longer for atypical compared to typical AVNRT ablation (132.1 ± 49.2 min vs. 110.1 ± 38.8 min; p = 0.001). Transient AV blocks occurred in a similar fashion in the atypical compared to typical group (11 [12.1%] vs. 4 [4.9%]; p = 0.103). However, no ablation induced persistent AV block developed in either group. Conclusion Cryoablation for atypical AVNRT showed similar rate of recurrences and safety compared to typical AVNRT during long-term follow-up.

IntroductionSudden cardiac death (SCD) is the leading cause of death in patients with myocardial infarction (MI) and can be prevented by the implantable cardioverter defibrillator (ICD). Currently, risk stratification for SCD and decision on ICD implantation are based solely on impaired left ventricular ejection fraction (LVEF). However, this strategy leads to over- and under-treatment of patients because LVEF alone is insufficient for accurate assessment of prognosis. Thus, there is a need for better risk stratification. This is the study protocol for developing and validating a prediction model for risk of SCD in patients with prior MI.Methods and AnalysisThe EU funded PROFID project will analyse 23 datasets from Europe, Israel and the US (∼225,000 observations). The datasets include patients with prior MI or ischemic cardiomyopathy with reduced LVEFEthics and disseminationLocal ethical approval was obtained. The final model will be disseminated through scientific publications and a web-calculator. Statistical code will be published through open-source repositories.

The authors stopped a case of left atrial appendage occlusion because of miscolored brownish devices. The investigation demonstrated that devices may show a range of colors from a typical blue to a brownish hue, depending on oxide layer thickness, and this does not appear to have any impact on the performance of the device. (Level of Difficulty: Intermediate.), Central Illustration

Aims Trastuzumab and anthracyclines, often used in the treatment of breast cancer, may impair myocardial function, and reduce left ventricular ejection fraction (LVEF), potentially causing heart failure. Randomized controlled trials (RCTs) have evaluated the effects of beta-blockers (BBs), angiotensin receptor blockers (ARBs), and angiotensin-converting enzyme inhibitors (ACEI) on trastuzumab- and anthracycline-associated cardiotoxicity. We report a meta-analysis of these RCTs in patients with breast cancer. Methods and results The primary analysis was on the effect of BBs and ACEI/ARBs on LVEF in patients treated with either trastuzumab or anthracyclines. A secondary analysis was done investigating the effect of BBs or ACEI/ARBs on LVEF in trastuzumab and anthracycline treatments. Only RCTs were included using the search term ‘ARBs, ACEIs, BBs, anthracyclines, trastuzumab, and breast cancer’ in PubMed, Embase, and CENTRAL up to 31 March 2021. A meta-analysis was conducted to estimate the mean difference (MD) in LVEF between intervention and placebo groups at follow-up. A total of nine RCTs (n = 1362) were included in the analysis. All patients were women. BBs and ACEI/ARBs were shown to attenuate the decline in LVEF during trastuzumab and anthracycline treatments [MD: 2.4; 95% confidence interval (CI): 0.3–4.2 and MD: 1.5; 95% CI: –0.6 to 3.7]. Compared with placebo, LVEF was significantly higher in patients assigned to BB or ACEI/ARB on trastuzumab (MD: 2.3; 95% CI: 0.0–4.6) but not on anthracyclines (MD: 1.9; 95% CI: –0.5 to 4.2). Conclusion Both BB and ACEI/ARB therapies were associated with the preservation of LVEF during trastuzumab and anthracycline-containing regimens as compared with placebo, suggesting both to be beneficial.

Infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes coronavirus disease 2019 (COVID-19). SARS-CoV-2 triggers an immune response with local inflammation in the lung, which may extend to a systemic hyperinflammatory reaction. Excessive inflammation has been reported in severe cases with respiratory failure and cardiovascular complications. In addition to the release of cytokines, referred to as cytokine release syndrome or “cytokine storm,” increased pro-inflammatory lipid mediators derived from the omega-6 polyunsaturated fatty acid (PUFA) arachidonic acid may cause an “eicosanoid storm,” which contributes to the uncontrolled systemic inflammation. Specialized pro-resolving mediators, which are derived from omega-3 PUFA, limit inflammatory reactions by an active process called resolution of inflammation. Here, the rationale for omega-3 PUFA supplementation in COVID-19 patients is presented along with a brief overview of the study protocol for the trial “Resolving Inflammatory Storm in COVID-19 Patients by Omega-3 Polyunsaturated Fatty Acids - A single-blind, randomized, placebo-controlled feasibility study” (COVID-Omega-F). EudraCT: 2020-002293-28; clinicaltrials.gov: NCT04647604.

Contains fulltext : 238765.pdf (Publisher’s version ) (Closed access) With the global increase in device implantations, there is a growing need to train physicians to implant pacemakers and implantable cardioverter-defibrillators. Although there are international recommendations for device indications and programming, there is no consensus to date regarding implantation technique. This document is founded on a systematic literature search and review, and on consensus from an international task force. It aims to fill the gap by setting standards for device implantation.

In the originally published version of thismanuscript, there were several errors which are listed in this corrigendumas follows: In Table 4, The Level of Evidence for "For venous access, the cephalic or axillary vein should be considered as first choice" should read "B" instead of "C". In Table 10, the wording "TAVI in valve in valve vs. native valve procedure" should read "TAVI in native valve vs. valve-in-valve procedure". In the Supplementary Data, the wording in Table 14 should read "TAVI in native valve vs. valve-in-valve procedure" instead of "TAVI in valve in valve vs. native valve procedure". These errors have now been corrected.

Aims Iatrogenic cardiac tamponades are a rare but dreaded complication of invasive electrophysiology procedures (EPs). Their long-term impact on clinical outcomes is unknown. This study analyzed the risk of death or serious cardiovascular events in patients suffering from EP related cardiac tamponade requiring pericardiocentesis during long-term follow-up. Methods and results Out of 19997 invasive EPs at our university hospital between January 1998 and September 2018, all patients with EP related periprocedural cardiac tamponade were identified (n=60) and matched (1:3 ratio) to a control group (n=180). After a follow-up of 5 years, the composite primary end point - death from any cause, acute myocardial infarction, TIA/stroke and hospitalization for heart failure – occurred in significantly more patients in the tamponade than in the control group (12 patients (20.0%) vs 19 patients (10.6%); Hazard ratio (HR) 2.53 (95% CI, 1.15–5.58); p=0.021). This was mainly driven by a higher incidence of TIA/stroke in the tamponade than in the control group (HR 3.75 (95% CI, 1.01–13.97); p=0.049). Death from any cause, acute myocardial infarction and hospitalization for heart failure did not show a significant difference between the groups. Hospitalization for pericarditis occurred in significantly more patients in the tamponade than in the control group (HR 36.0 (95% CI, 4.68–276.86); p=0.001). Conclusion Patients with EP related cardiac tamponade are at higher risk for cerebrovascular events during the first two weeks and hospitalization for pericarditis during the first months after index procedure. Despite the increased risk for early complications tamponade patients have a good long-term prognosis without increased risk for mortality or other serious cardiovascular events. Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): German Research Foundation

Background Percutaneous coronary interventions (PCIs) are often aimed at the culprit vessel in acute coronary syndromes (ACSs) followed by revascularisation of other stenoses later in the index hospitalisation or shortly after discharge. PCI delay of non-culprit coronary vessels stenoses is supported by lower contrast fluid use and thrombocyte aggregation. Distinct coronary interventions increase the risk of both non- and coronary artery complications, e.g. acute abdominal and periphery artery bleeding, suggesting undertaking all PCIs at the same time. Purpose To assess the effect on mortality and re-myocardial infarction (MI) of immediate versus staged revascularisation in multivessel coronary disease, with the latter constrained to initial PCI of the culprit coronary vessel. Methods The syntax of “randomised controlled trial (RCT) & acute coronary syndrome & complete revascularisation” was undertaken in PubMed. Clinical characteristics were gathered at the index hospitalisation. The intervention scenario was acute coronary syndrome or not. Meta-analyses calculated relative risk (RR) reductions on outcomes of 1) mortality and 2) re-MI. Meta-regression assessed linear difference between interventional treatment benefits and baseline characteristics. Results A total of 148 studies was found. Of those, 8 was found eligible for further analyses and their baseline characteristics are shown in Table 1. Comparison of immediate versus staged revascularisation on mortality was nonsignificant (RR, 1.19; 95% CI: 0.78–1.81, p=0.43) (Figure 1). The impact of Immediate vs staged revascularisation on re-MI was also nonsignificant (RR, 0.83; 95% CI: 0.44–1.55, p=0.56). Meta-regression found no associations between the outcomes and study characteristics (not shown). Conclusion The intervention of immediate compared to staged revascularisation assessed on outcomes of all-cause mortality and re-MI were nonsignificant. Figure 1 Funding Acknowledgement Type of funding source: None

Aim To investigate the association of sinus heart rate pre- and post-ablation and recurrence rates in patients undergoing catheter ablation for atrial fibrillation. Methods Between January 2012 and December 2017, data of 482 patients undergoing their first pulmonary vein isolation (PVI) were included. All patients were followed-up for 12 months and were screened for any atrial tachyarrhythmia. Sinus heart rate measurements were recorded before (PRE), directly post ablation (POST) and 3 months post ablation (3M). Results In the total study population, the mean resting sinus heart rate at PRE (mean 57.9 bpm (95% CI, 57.1–58.7 bpm)) increased by over 10 bpm to POST (mean 69.4 bpm (95% CI, 68.5–70.3 bpm); p Conclusion Our study confirms the impact of PVI on cardiac autonomic function with a significant heart increase post-ablation. A heart rate ≥60bpm at 3M and a heart rate change ≥11 bpm (PRE to 3M) are associated with a favorable outcome in terms of recurrences. Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): German Research Foundation

Infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes coronavirus disease 2019 (COVID-19). SARS-CoV-2 triggers an immune response with local inflammation in the lung, which may extend to a systemic hyperinflammatory reaction. Excessive inflammation has been reported in severe cases with respiratory failure and cardiovascular complications. In addition to the release of cytokines, referred to as cytokine release syndrome or “cytokine storm,” increased pro-inflammatory lipid mediators derived from the omega-6 polyunsaturated fatty acid (PUFA) arachidonic acid may cause an “eicosanoid storm,” which contributes to the uncontrolled systemic inflammation. Specialized pro-resolving mediators, which are derived from omega-3 PUFA, limit inflammatory reactions by an active process called resolution of inflammation. Here, the rationale for omega-3 PUFA supplementation in COVID-19 patients is presented along with a brief overview of the study protocol for the trial “Resolving Inflammatory Storm in COVID-19 Patients by Omega-3 Polyunsaturated Fatty Acids - A single-blind, randomized, placebo-controlled feasibility study” (COVID-Omega-F). EudraCT: 2020-002293-28; clinicaltrials.gov: NCT04647604.

BACKGROUND Atrial fibrillation (AF) is the most common cardiac arrhythmia in the adult population. AF is associated with a poor quality of life (QoL) and, in many patients, current medical treatments are inadequate in alleviating AF symptoms (eg, palpitations). Patients often present with symptom preoccupation in terms of symptom fear, avoidance, and control behaviors. Internet-delivered cognitive behavior therapy is effective for treating other somatic disorders but has never been evaluated in patients with AF. OBJECTIVE The aim of this study is to evaluate the efficacy and feasibility of AF-specific internet-delivered cognitive behavior therapy. METHODS We conducted an uncontrolled pilot study in which 19 patients with symptomatic paroxysmal AF underwent internet-delivered cognitive behavior therapy. Participants completed self-assessments at pretreatment, posttreatment, and at a 6-month follow-up along with handheld electrocardiogram measurements with symptom registration. The treatment lasted 10 weeks and included exposure to physical sensations, reduction in avoidance behavior, and behavioral activation. RESULTS We observed large within-group improvements in the primary outcome, AF-specific QoL (Cohen d=0.80; Pd=1.24; P CONCLUSIONS This study presents preliminary evidence for the potential efficacy and feasibility of a novel approach in treating patients with symptomatic AF with internet-delivered cognitive behavior therapy. CLINICALTRIAL ClinicalTrials.gov NCT02694276; https://clinicaltrials.gov/ct2/show/NCT02694276

Cryoablation (CRYO) of cavotricuspid isthmus (CTI)-dependent atrial flutter (AFL) has been shown to be non-inferior to radiofrequency ablation (RF) in terms of ablation success and is associated with less pain. However, procedural time has been significantly longer with CRYO compared to RF. A possible explanation for this could be that operators had less experience with CRYO than with RF. The purpose of this study was to test the hypothesis that in the hands of experienced operators, cryoablation of CTI-dependent AFL is effective with procedure-time similar to what is reported for RF.This prospective 2-center study included 184 patients with CTI-dependent AFL - median age 66 years (range 28-83), 159 men (86%). Cryoablation was performed using a 9 F, 8 mm tip catheter (Freezor MAX, Medtronic, Inc, MN, USA). Ablation endpoint was bidirectional CTI-block. Pain was evaluated with a visual analogue scale (VAS 0-10). All operators had experience of at least 25 previous CTI-ablations with CRYO.The acute success rate was 89%. Procedural time including an observation period of 30 min, was 115 ± 36 min which is similar to procedural times for RF in previous studies. Fluoroscopy time was 11 ± 9 min. Cryoablation was perceived as almost pain- free by the patients, VAS (mean) 1.8 ± 1.2. Success rate at 12-month follow-up (FU) was 88% in patients with primary success. No major adverse events occurred.Cryoablation of CTI-dependent AFL is effective, with a low level of procedure-related pain. In experienced hands, the procedure time in this prospective non-randomised trial seems to be in the level of reported procedure times for RF. The long-term relapse rate appears to be higher than for RF.

Objective: The preferential sites for focal atrial tachycardia (FAT) are mainly in the right atrium in both sexes. However, a limited number of studies have indicated that sex differences in the localization of FAT. This study investigated possible sex differences in the distribution of FAT in a large cohort of patients referred for ablation. Methods: From 2004 to 2019, 487 patients (298 women) were referred to our institution for ablation of FAT. A standard electrophysiological study was conducted, and isoproterenol or atropine was given when needed. Conventional catheter mapping, electroanatomic contact mapping, and noncontact mapping were used to assess the origin of ectopic atrial tachycardia. Results: Overall, 451 foci were successfully ablated in 436 patients (90%). Although the foci located along the crista terminalis were more common in women than in men (42% vs. 29%; p=0.023), the opposite were found in the foci located along the tricuspid annulus (5% vs. 11%; p=0.032) and the right atrial appendage (RAA) (1% vs. 3%; p=0.032). Other locations were similarly distributed in men and women. In addition, the presence of persistent FAT was more frequent in men than in women (22% vs. 5%; p

Aims The clinical effectiveness of primary prevention implantable cardioverter defibrillator (ICD) therapy is under debate. The EUropean Comparative Effectiveness Research to Assess the Use of Primary ProphylacTic Implantable Cardioverter Defibrillators (EU-CERT-ICD) aims to assess its current clinical value. Methods and results The EU-CERT-ICD is a prospective investigator-initiated non-randomized, controlled, multicentre observational cohort study performed in 44 centres across 15 European Union countries. We will recruit 2250 patients with ischaemic or dilated cardiomyopathy and a guideline indication for primary prophylactic ICD implantation. This sample will include 1500 patients at their first ICD implantation and 750 patients who did not receive a primary prevention ICD despite having an indication for it (non-randomized control group). The primary endpoint is all-cause mortality; the co-primary endpoint in ICD patients is time to first appropriate shock. Secondary endpoints include sudden cardiac death, first inappropriate shock, any ICD shock, arrhythmogenic syncope, revision procedures, quality of life, and cost-effectiveness. At baseline (and prior to ICD implantation if applicable), all patients undergo 12-lead electrocardiogram (ECG) and Holter ECG analysis using multiple advanced methods for risk stratification as well as detailed documentation of clinical characteristics and laboratory values. Genetic biobanking is also organized. As of August 2018, baseline data of 2265 patients are complete. All subjects will be followed for up to 4.5 years. Conclusions The EU-CERT-ICD study will provide a necessary update about clinical effectiveness of primary prophylactic ICD implantation. This study also aims for improved risk stratification and patient selection using clinical and ECG risk markers.

AIMS: Therapy with an implantable cardioverter defibrillator (ICD) is established for the prevention of sudden cardiac death (SCD) in high risk patients. We aimed to determine the effectiveness of primary prevention ICD therapy by analysing registry data from 14 centres in 11 European countries compiled between 2002 and 2014, with emphasis on outcomes in women who have been underrepresented in all trials. METHODS AND RESULTS: Retrospective data of 14 local registries of primary prevention ICD implantations between 2002 and 2014 were compiled in a central database. Predefined primary outcome measures were overall mortality and first appropriate and first inappropriate shocks. A multivariable model enforcing a common hazard ratio for sex category across the centres, but allowing for centre-specific baseline hazards and centre specific effects of other covariates, was adjusted for age, the presence of ischaemic cardiomyopathy or a CRT-D, and left ventricular ejection fraction ≤25%. Of the 5033 patients, 957 (19%) were women. During a median follow-up of 33 months (IQR 16-55 months) 129 women (13%) and 807 men (20%) died (HR 0.65; 95% CI: [0.53, 0.79], P-value

The objective of this pilot study was to describe the impact of paced heart rate on left ventricular (LV) mechanical dyssynchrony in synchronous compared to dyssynchronous pacing modes in patients with heart failure.Echocardiography was performed in 14 cardiac resynchronization therapy (CRT) patients at paced heart rates of 70 and 90 bpm in synchronous- (CRT), and dyssynchronous (atrial pacing + wide QRS activation) pacing modes. LV dyssynchrony was quantified using the 12-segment standard deviation model (Ts-SD) derived from Tissue Doppler Imaging. In addition, cardiac cycle intervals were assessed using cardiac state diagrams and stroke volume (SV) and filling pressure were estimated.Ts-SD decreased significantly with CRT at 90 bpm (25 ± 12 ms) compared to 70 bpm (35 ± 15 ms, p = .01), but remained unchanged with atrial pacing at different paced heart rates (p = .96). The paced heart rate dependent reduction in Ts-SD was consistent when Ts-SD was indexed to average Ts and systolic time interval. Cardiac state diagram derived analysis of cardiac cycle intervals demonstrated a significant reduction of the pre-ejection interval and an increase in diastole with CRT compared to atrial pacing. SV was maintained at the higher paced heart rate with CRT pacing but decreased with atrial pacing.Due to the small sample size in this pilot study general and firm conclusions are difficult to render. However, the data suggest that pacing at higher heart rates acutely reduces remaining LV dyssynchrony during CRT, but not during atrial pacing with dyssynchronous ventricular activation. These results need confirmation in a larger patient cohort.

Background Spinal cord stimulation (SCS) reduces sympathetic activity in animal models of heart failure with reduced ejection fraction (HF) but limited data exist of SCS in patients with HF. The aim of the present study was to test the primary hypothesis that SCS reduces cardiac sympathetic nerve activity in HF patients. Secondary hypotheses were that SCS improves left ventricular function and dimension, exercise capacity, and clinical variables relevant to HF. Methods HF patients with a SCS device previously participating in the DEFEAT-HF trial were included in this crossover study with 6-week intervention periods (SCS-ON and SCS-OFF). SCS (50 Hz, 210-μs pulse duration, aiming at T2–T4 segments) was delivered for 12 hours daily. Indices of myocardial sympathetic neuronal function (heart-to-mediastinum ratio, HMR) and activity (washout rate, WR) were assessed using 123I-metaiodobenzylguanidine (MIBG) scintigraphy. Echocardiography, exercise testing, and clinical data collection were also performed. Results We included 13 patients (65.3 ± 8.0 years, nine males) and MIBG scintigraphy data were available in 10. HMR was not different comparing SCS-ON (1.37 ± 0.16) and SCS-OFF (1.41 ± 0.21, P = 0.46). WR was also unchanged comparing SCS-ON (41.5 ± 5.3) and SCS-OFF (39.1 ± 5.8, P = 0.30). Similarly, average New York Heart Association class (2.4 ± 0.5 vs 2.3 ± 0.6, P = 0.34), quality of life score (24 ± 16 vs 24 ± 16, P = 0.94), and left ventricular dimension and function as well as exercise capacity were all unchanged comparing SCS-ON and SCS-OFF. Conclusion In patients with HF, SCS (12 hours daily, targeting the T2–T4 segments of the spinal cord) does not appear to influence cardiac sympathetic neuronal activity or function as assessed by MIBG scintigraphy.

Aims The transseptal approach is used for left atrial access during the ablation of atrial fibrillation (AF) and other left-sided arrhythmia substrates. Transseptal puncture (TP) is commonly performed with fluoroscopic guidance, contrast injection, and pressure monitoring. In many centres, additional techniques [intracardiac echocardiography (ICE), transoesophageal echocardiography (TEE), radiofrequency needle] are used to facilitate TP but its use adds costs. In this retrospective study, we studied the safety and complication rate when TP was routinely done with fluoroscopic guidance, contrast injection, and pressure monitoring using ICE or TEE only in selected cases. Methods and results This study analysed 4690 consecutive TP performed between 2000 and 2015: 3408 (72.6%) were ablation of AF, left-sided atrial flutter, or left-sided atrial tachycardia (non-AP group); 1153 (24.6%) were ablation of left-sided accessory pathway, AP group; and 129 (2.8%) were ablation of ventricular tachycardia. Transseptal puncture was done under fluoroscopy, pressure monitoring, and commonly using contrast media injection. In 27 procedures, ICE or TEE was used to guide the TP. We found 34 tamponades (Tx) that required pericardial drainage of which 28 (0.59%) could possibly be TP related and six could not. The total complication rate for all Tx was 0.72%. A higher rate of tamponades was observed in the AF (non-AP) group than in the AP group (0.88 vs. 0.17%, P

Cardiac resynchronization therapy (CRT) is increasingly used in heart failure treatment and management of these patients imposes significant challenges. Remote monitoring is becoming essential for CRT follow-up and allows close surveillance of device function and patient condition. It is helpful to reduce clinic visits, increase device longevity and provide early detection of device failure. Clinical effects include prevention of appropriate and inappropriate shocks and early detection of arrhythmias, such as atrial fibrillation. For modification of heart failure the addition of monitoring to CRT by means of device-based multiparameters may help to modify disease progression and improve survival.

Background Anticoagulation treatment reduces the risk of stroke but increases the risk of bleeding in atrial fibrillation (AF) patients. There is little data on survival after a stroke or a severe bleed. Objective To analyze 90-day mortality in AF patients after an ischemic stroke, an intracranial hemorrhage (ICH) or a gastrointestinal bleed (GIB) and assess associations with the type of antithrombotic treatment preceding the event. Methods From the Stockholm Healthcare database (n=2.3 million inhabitants) we selected all AF patients suffering from an ischemic stroke, an intracranial bleed, or a severe GIB requiring acute hospital care between July 2011 and August 2018 and assessed 90-day mortality rates. We assessed current use of warfarin, non-vitamin K oral anticoagulants (NOAC), or antiplatelet agents at the time of the event. We used a Cox regression to calculate adjusted hazard ratios (aHRs), adjusting for components of the Charlson Comorbidity Index, the CHADsVASc score, the HAS-BLED score, comedication, and year of inclusion, for the association between treatment preceding the event and mortality. In addition, we performed log-rank tests in propensity score matched cohorts. Results Of 105 313 patients with AF, 6 017 were included after an ischemic stroke, 3 006 after an ICH, and 4 291 after a GIB. 90-day mortality rates were 25.1%, 31.6% and 16.2%, respectively. Patients suffering from an ischemic stroke were the oldest at 81.6±9.8 (S.D:) years of age followed by patients suffering from an ICH (80.2±9.8 years) or a GIB (78.7±10.5 years). A large proportion of patients suffering ischemic stroke (72%) had no anticoagulant treatment preceding the event. After ICH, there was a significantly increased risk of mortality in warfarin compared to NOAC treated patients after adjusting for confounders (aHR: 1.36 CI: 1.04–1.78). Patients receiving antiplatelets or no treatment had significantly higher mortality rates than patients on NOAC treatment, both after an ischemic stroke and a GIB, but there was no significant difference between warfarin and NOACs (aHR 0.84 CI: 0.63–1.12 after ischemic stroke, aHR 0.91 CI: 0.66–1.25 after GIB). Propensity score matched analyses yielded similar results. Survival curves after event Conclusion Mortality rates are high in AF patients suffering from an ischemic stroke, an ICH, or a GIB. NOAC treatment was associated with a lower 90-day mortality after ICH than warfarin, but no such difference was found after ischemic stroke or GIB. After ischemic stroke and GIB, mortality rates were higher in antiplatelet treated and untreated patients compared to NOAC treated patients. Acknowledgement/Funding Swedish Heart Lung Foundation

Background Trastuzumab and anthracyclines are conventional chemotherapies used in breast cancer. Unfortunately, they are associated with a decrease in left ventricular function potentially leading to heart failure (HF). In order to prevent this, randomised controlled trials (RCTs) assess the preventive effect of concomitant beta-blocker (BB), angiotensin receptor blocker (ARB) and angiotensin converting enzyme inhibitor (ACEI) therapy during chemotherapy. Purpose To assess the preventive effect of BB, ARB or ACEIs on left ventricular ejection fraction (LVEF) during trastuzumab and anthracycline treatment in patients without HF. Methods Our primary outcomes were the effect of BBs or ARB/ACEIs during 1) trastuzumab and 2) anthracycline treatment. Secondary outcomes were the distinct effects of 1) BBs and 2) ARB/ACEIs in either trastuzumab or anthracycline treatments. Through the search term “(RCTs), prevention, cancer chemotherapy and cardiotoxicity” in PubMed, studies were selected, excluding those without randomising to a BB, ARB/ACEI and a placebo control group during chemotherapy. Means of the LVEF and the standard deviation (SD) post-chemotherapy were applied. Meta-analyses estimated the standardised mean difference (SMD) in the LVEF. Heterogeneity was calculated as the I2. Results A total of 7 studies (Table 1) were included in the analysis. Between 93 and 100% were woman. Age varied from 41 to 51 years. Treatment time varied from 12 to 52 weeks. Concomitant BB or ARB/ACEI therapy during trastuzumab treatment was not associated with the LVEF, significantly (Fig. 1A; p=0.07). Oppositely, in the anthracycline regime the LVEF remained significant higher in the concomitant BB and ARB/ACEI groups as compared to controls (Fig. 1B). BB and ARB/ACEI separation in the analysis showed both to influence the LVEF positively independent of chemotherapy (P=0.03 & p=0.005). Table 1 Study reference Year Chemotherapies Preventive drugs Pituskin et al., “Multidisciplinary Approach to Novel Therapies in Cardio-Oncology Research (MANTICORE 101-Breast): A Randomized Trial for the Prevention of Trastuzumab-Associated Cardiotoxicity.” 2017 Trastuzumab Perindopril. bisoprolol Gulati et al., “Prevention of Cardiac Dysfunction during Adjuvant Breast Cancer Therapy (PRADA).” 2016 Trastuzumab Candesartan, metoprolol Boekhout et al., “Angiotensin II-Receptor Inhibition With Candesartan to Prevent Trastuzumab-Related Cardiotoxic Effects in Patients With Early Breast Cancer: A Randomized Clinical Trial.” 2016 Trastuzumab Candesartan Janbabai et al., “Effect of Enalapril on Preventing Anthracycline-Induced Cardiomyopathy.” 2017 Anthracycline Enalapril Nabati et al., “Cardioprotective Effects of Carvedilol in Inhibiting Doxorubicin-Induced Cardiotoxicity.” 2017 Anthracycline Carvedilol Tashakori Beheshti et al., “Carvedilol Administration Can Prevent Doxorubicin-Induced Cardiotoxicity: A Double-Blind Randomized Trial.” 2016 Anthracycline Carvedilol Kaya et al., “Protective Effects of Nebivolol against Anthracycline-Induced Cardiomyopathy: A Randomized Control Study.” 2013 Anthracycline Nebivolol Figure 1 Conclusions Concomitant BB and ARB/ACEI therapy both favoured maintenance of the LVEF during trastuzumab and anthracyclines regimens as compared to controls.

Background Troponin levels may be elevated after long-distance running, probably due to increased membrane permeability of cardiomyocytes. It is believed that elevated troponin post exercise, in contrast to acute coronary syndromes, normalize within 24 (−48) hours. This phenomenon has been mainly studied in young and elite athletes. However, participation in endurance exercise is increasingly popular among elderly and recreational sportsmen. Purpose To assess troponin levels in master athletes before and up to 7 days after long-distance running. Method We studied 97 participants (56 males and 41 females, matched for age) in the world's largest cross-country race (30 km, Lidingöloppet). They were ≥45 years (53±5 years). Baseline evaluation included a physical exam, blood pressure, BMI, NT-proBNP and an ECG. Blood tests were taken at baseline, immediately after as well as 1d, 4d and 7d after the race, including high sensitive troponin T (TnT), creatinine and high sensitive CRP. Elevated TnT was defined as ≥15 ng/l. Results After the race TnT had increased from 5±3 ng/l at baseline to 46±32 ng/l (range 11–180; p Conclusion TnT is elevated in the vast majority of male and female master athletes after participation in a 30 km cross country race. To our knowledge, this is the first report showing that TnT levels can be still significantly elevated four days after endurance running. Prolonged TnT values above the diagnostic threshold for myocardial infarction were predominantly seen in males. Our findings are relevant to the clinical management of patients with increased troponin values after endurance exercise. Acknowledgement/Funding Hjärt och lungfonden (Swedish heart- and lung fund). Governmental grants.

Background Daily body weight (BW) is a mainstay in the management of patients with chronic heart failure (HF). Guidelines recommend to take action if BW increases more than 2kg within 3 days. However, the evidence behind the 2kg/3d rule is unclear and studies have shown poor diagnostic performance of this algorithm. Purpose To assess the diagnostic value of different BW thresholds and time intervals to alert for imminent HF decompensation. Methods We studied 184 patients with HF (age 71±10 yr, EF 26±11%). 43% had been hospitalized for HF during the preceding year. They were assessed by daily BW using digital scales with direct data transfer to a central data base. The mean follow-up was 286 days. To decrease day-to-day variability, BW was analysed based on a daily moving average over 3 days. We retrospectively calculated the sensitivity and false-positive rate of BW thresholds at 1.5, 2.0, 2.5, 3.0 and 3.5 kg and time intervals between 2 and 30 days. Threshold crossings occurring within 30 days prior to a hospitalization for decompensated HF were deemed a positive alert. Results The sensitivity of 2kg/3d was poor (13%). Prolonging the time interval of weight changes markedly improved sensitivity. Increasing the weight threshold decreased the false positive rate. Greatest sensitivity (60%) was achieved using a 14 day interval at a weight threshold of 1.5 kg. However, this was associated with a high rate of false alerts (3.1 per patient/year). A weight threshold of 3.5 kg resulted in excellent specificity (0.3 false alerts per patient/year), however sensitivity was low (20%, 20 day time interval). Conclusion Monitoring daily BW using a 2kg/3d algorithm is associated with poor diagnostic performance. Generally, by analyzing stable trends over time (moving average) and using prolonged time intervals, BW monitoring with digital scales can achieve a clinically meaningful diagnostic performance. This new approach to BW monitoring may improve early detection of imminent HF decompensation.

Background: Most randomized trials on implantable cardioverter-defibrillator (ICD) use for primary prevention of sudden cardiac death in heart failure with reduced ejection fraction enrolled patients >20 years ago. We investigated the association between ICD use and all-cause mortality in a contemporary heart failure with reduced ejection fraction cohort and examined relevant subgroups. Methods: Patients from the Swedish Heart Failure Registry fulfilling the European Society of Cardiology criteria for primary-prevention ICD were included. The association between ICD use and 1-year and 5-year all-cause and cardiovascular (CV) mortality was assessed by Cox regression models in a 1:1 propensity score–matched cohort and in prespecified subgroups. Results: Of 16 702 eligible patients, only 1599 (10%) had an ICD. After matching, 1305 ICD recipients were compared with 1305 nonrecipients. ICD use was associated with a reduction in all-cause mortality risk within 1 year (hazard ratio, 0.73 [95% CI, 0.60–0.90]) and 5 years (hazard ratio, 0.88 [95% CI, 0.78–0.99]). Results were consistent in all subgroups including patients with versus without ischemic heart disease, men versus women, those aged Conclusions: In a contemporary heart failure with reduced ejection fraction population, ICD for primary prevention was underused, although it was associated with reduced short- and long-term all-cause mortality. This association was consistent across all the investigated subgroups. These results call for better implementation of ICD therapy.

Background Atrial fibrillation (AF) is the most common cardiac arrhythmia in the adult population. AF is associated with a poor quality of life (QoL) and, in many patients, current medical treatments are inadequate in alleviating AF symptoms (eg, palpitations). Patients often present with symptom preoccupation in terms of symptom fear, avoidance, and control behaviors. Internet-delivered cognitive behavior therapy is effective for treating other somatic disorders but has never been evaluated in patients with AF. Objective The aim of this study is to evaluate the efficacy and feasibility of AF-specific internet-delivered cognitive behavior therapy. Methods We conducted an uncontrolled pilot study in which 19 patients with symptomatic paroxysmal AF underwent internet-delivered cognitive behavior therapy. Participants completed self-assessments at pretreatment, posttreatment, and at a 6-month follow-up along with handheld electrocardiogram measurements with symptom registration. The treatment lasted 10 weeks and included exposure to physical sensations, reduction in avoidance behavior, and behavioral activation. Results We observed large within-group improvements in the primary outcome, AF-specific QoL (Cohen d=0.80; P Conclusions This study presents preliminary evidence for the potential efficacy and feasibility of a novel approach in treating patients with symptomatic AF with internet-delivered cognitive behavior therapy. Trial Registration ClinicalTrials.gov NCT02694276; https://clinicaltrials.gov/ct2/show/NCT02694276

Aims Symptom severity assessed by NYHA functional class and QRS duration are essential criteria for selection of heart failure (HF) patients for CRT. This study assessed the relationship between NYHA class, QRS duration, and survival in a nationwide HF registry. Methods and results We studied 13 423 patients with HF in NYHA class II–IV and LVEF

Background Decompensation is frequent in heart failure (HF) patients and predicts poor prognosis. Hypothesis Volume-overload events in HF patients are preceded by changes in intrathoracic impedance (Z) and body weight (BW); monitoring these parameters may be useful to predict decompensation. Methods Forty-three HF patients (LVEF 25% ± 12%) with a recent HF event and an implantable cardioverter-defibrillator providing daily Z were equipped with telemonitoring scales submitting daily BW. Changes in BW and Z 30 days prior to major (HF hospitalization) and minor (ambulatory adjustment of diuretics) were analyzed. Results During median of 427 days follow-up 25 major and 41 minor events occurred. Z decreased by −4.8 (95% confidence interval [CI]: CI −6.7 to −3.0) and −4.3 (95% CI: −5.5 to −3.2) within 30 days prior to major and minor events respectively (P

Aims Implantable device telemonitoring (DTM) is a diagnostic adjunct to traditional face-to-face hospital visits. Remote device follow-up and earlier diagnoses facilitated by DTM should reduce healthcare utilization. We explored whether DTM reduces healthcare utilization over standard of care (SoC), without compromising patient outcomes. Methods and results This systematic review and meta-analysis of 11 randomized controlled trials on DTM in patients with heart failure consisted of 5702 patients, with a median of 117 [interquartile range (IQR) 76–331] patients per study [age 65 years (IQR 63–67)] and follow-up range of 12–36 months. DTM was associated with a reduction in total number of visits [planned, unplanned, and emergency room (ER)] [relative risk (RR) 0.56; 95% confidence interval (CI) 0.43–0.73, P < 0.001]. Rates of cardiac hospitalizations (RR 0.96; 95% CI 0.82–1.12, P = 0.60) and the composite endpoints of ER, unplanned hospital visits, or hospitalizations (RR 0.99; 95% CI 0.68–1.43, P = 0.96) was similar between the DTM and the SoC groups. An increase in the total number of ER or unscheduled visits (RR 1.37; 95% CI 1.11–1.70, P = 0.004) was observed. This effect was consistent and statistically significant for all studies. Total and cardiac mortality were similar between the groups (DTM RR 0.90; 95% CI 0.69–1.16, P = 0.41; and DTM RR 0.93; 95% CI 0.51–1.69, P = 0.80). Monetary costs favoured DTM (10–55% reduction in five studies). Conclusions Compared with SoC, DTM is associated with a marked reduction in planned hospital visits. In addition, DTM was associated with lower monetary costs, despite a modest increase in unplanned hospital and ER visits. DTM did not compromise survival.

Implantable cardioverter-defibrillator (ICD) for primary prevention of sudden cardiac death may be underused in patients with heart failure and reduced ejection fraction (HFrEF). Aim was to investigate predictors of ICD non-use in a contemporary HFrEF cohort. Patients from the Swedish Heart Failure

The introduction of NOACs has put a focus on stroke prevention in atrial fibrillation (AF). The number of patients in Stockholm diagnosed with non-valvular AF increased from 41 008 in 2011 to 51 266 in 2017 and their treatment has been markedly improved. Between 2011 and 2017 total oral anticoagulant treatment increased from 51.6% (warfarin) to 77.3% (31% warfarin, 46.3% NOACs) and aspirin decreased from 31.6% to 7.2%. Treatment was especially improved among patients with CHA2DS2-VASc scores ≥2 and elderly high risk patients. We found an excellent persistence with OAC treatment (88% at 1 year and 83% at 2 years). A comparative effectiveness study showed that NOACs were at least as effective and safe as warfarin even among patients ≥80 years or with previous serious bleeds. After a gradual introduction of NOACs with many educational activities apixaban is now the first-line choice for stroke prevention in AF in Stockholm. Swedish guideline goals are fulfilled and outcomes are improved.

Background and Purpose- The purpose of this study was to investigate the impact of improved antithrombotic treatment in atrial fibrillation after the introduction of non-vitamin K antagonist oral anticoagulants on the incidence of stroke and bleeding in a real-life total population, including both primary and secondary care. Methods- All resident and alive patients with a recorded diagnosis for atrial fibrillation during the preceding 5 years in the Stockholm County Healthcare database (Vårdanalysdatabasen) were followed for clinical outcomes during 2012 (n=41 008) and 2017 (n=49 510). Results- Pharmacy claims for oral anticoagulants increased from 51.6% to 73.8% (78.7% among those with CHA

Remote monitoring (RM) has become a new standard of care in the follow-up of patients with implantable pacemakers and defibrillators. While it has been consistently shown that RM enables earlier detection of clinically actionable events compared with traditional in-patient evaluation, this advantage did not translate into improved patient outcomes in clinical trials of RM except one study using daily multiparameter telemonitoring in heart failure (HF) patients. Therefore, this review, focusing on RM studies of implantable cardioverter-defibrillators and cardiac resynchronization therapy defibrillators in patients with HF, discusses possible explanations for the differences in trial outcomes. Patient selection may play an important role as more severe HF and concomitant atrial fibrillation have been associated with improved outcomes by RM. Furthermore, the technical set-up of RM may have an important impact as a higher level of connectivity with more frequent data transmission can be linked to better outcomes. Finally, there is growing evidence as to the need of effective algorithms ensuring a fast and well-structured clinical response to the events detected by RM. These factors re-emphasize the potential of remote management of device patients with HF and call for continued clinical research and technical development in the field.