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Background: Patients with heart failure (HF) represent a large population of patients who are at high risk for complications related to undiagnosed atrial fibrillation (AF). However, currently there are limited modalities available for early AF detection in this high‐risk population. An implantable cardiac monitor (ICM) is inserted subcutaneously and can provide long‐term arrhythmia information via remote monitoring. Methods and Results: Confirm‐AF is a prospective randomized, nonblinded, two arm, multicenter clinical trial to be performed in the United States, enrolling 477 patients with a history of HF hospitalization and left ventricular ejection fraction >35% from 30 medical sites. Patients will be randomized in a 2:1 fashion to undergo ICM implant with remote monitoring and symptom‐triggered mobile app transmissions versus (vs.) Non‐ICM management and follow‐up. The primary objective of this trial is to compare the time to first detection of AF lasting > 5 min using an Abbott ICM compared to non‐ICM monitoring in symptomatic HF patients. This article describes the design and analytic plan for the Confirm‐AF trial. Conclusions: The Confirm‐AF trial seeks to accurately define the burden of AF in high‐risk HF patients with LVEF > 35% using an Abbott ICM. A finding showing significantly higher incidence of AF along with improved clinical outcomes with ICM monitoring is expected to have substantial clinical implications and may change the method of monitoring high‐risk HF patients. [ABSTRACT FROM AUTHOR]

A study was conducted to evaluate the efficacy of cardiac-resynchronization therapy (CRT) in reducing the risk of mortality or heart-failure events in the case of patients with mild cardiac symptoms. Results indicated that CRT with implantable cardioverter-defibrillator (ICD) greatly reduced the risk of mortality or heart-failure events.

Patients who have had a heart attack and develop heart failure should receive an implantable defibrillator, according to a study of 1,232 patients. An implantable defibrillator can detect an abnormal heart rhythm and sends an electric shock to correct it. Otherwise, the arrhythmia could cause cardiac arrest.

Importance: Corticosteroids improve strength and function in boys with Duchenne muscular dystrophy. However, there is uncertainty regarding the optimum regimen and dosage.Objective: To compare efficacy and adverse effects of the 3 most frequently prescribed corticosteroid regimens in boys with Duchenne muscular dystrophy.Design, Setting, and Participants: Double-blind, parallel-group randomized clinical trial including 196 boys aged 4 to 7 years with Duchenne muscular dystrophy who had not previously been treated with corticosteroids; enrollment occurred between January 30, 2013, and September 17, 2016, at 32 clinic sites in 5 countries. The boys were assessed for 3 years (last participant visit on October 16, 2019).Interventions: Participants were randomized to daily prednisone (0.75 mg/kg) (n = 65), daily deflazacort (0.90 mg/kg) (n = 65), or intermittent prednisone (0.75 mg/kg for 10 days on and then 10 days off) (n = 66).Main Outcomes and Measures: The global primary outcome comprised 3 end points: rise from the floor velocity (in rise/seconds), forced vital capacity (in liters), and participant or parent global satisfaction with treatment measured by the Treatment Satisfaction Questionnaire for Medication (TSQM; score range, 0 to 100), each averaged across all study visits after baseline. Pairwise group comparisons used a Bonferroni-adjusted significance level of .017.Results: Among the 196 boys randomized (mean age, 5.8 years [SD, 1.0 years]), 164 (84%) completed the trial. Both daily prednisone and daily deflazacort were more effective than intermittent prednisone for the primary outcome (P < .001 for daily prednisone vs intermittent prednisone using a global test; P = .017 for daily deflazacort vs intermittent prednisone using a global test) and the daily regimens did not differ significantly (P = .38 for daily prednisone vs daily deflazacort using a global test). The between-group differences were principally attributable to rise from the floor velocity (0.06 rise/s [98.3% CI, 0.03 to 0.08 rise/s] for daily prednisone vs intermittent prednisone [P = .003]; 0.06 rise/s [98.3% CI, 0.03 to 0.09 rise/s] for daily deflazacort vs intermittent prednisone [P = .017]; and -0.004 rise/s [98.3% CI, -0.03 to 0.02 rise/s] for daily prednisone vs daily deflazacort [P = .75]). The pairwise comparisons for forced vital capacity and TSQM global satisfaction subscale score were not statistically significant. The most common adverse events were abnormal behavior (22 [34%] in the daily prednisone group, 25 [38%] in the daily deflazacort group, and 24 [36%] in the intermittent prednisone group), upper respiratory tract infection (24 [37%], 19 [29%], and 24 [36%], respectively), and vomiting (19 [29%], 17 [26%], and 15 [23%]).Conclusions and Relevance: Among patients with Duchenne muscular dystrophy, treatment with daily prednisone or daily deflazacort, compared with intermittent prednisone alternating 10 days on and 10 days off, resulted in significant improvement over 3 years in a composite outcome comprising measures of motor function, pulmonary function, and satisfaction with treatment; there was no significant difference between the 2 daily corticosteroid regimens. The findings support the use of a daily corticosteroid regimen over the intermittent prednisone regimen tested in this study as initial treatment for boys with Duchenne muscular dystrophy.Trial Registration: ClinicalTrials.gov Identifier: NCT01603407. [ABSTRACT FROM AUTHOR]

An implantable defibrillator may be more effective than anti-arrhythmic drugs in preventing life-threatening arrhythmias in patients who have had a heart attack. Researchers randomly assigned 196 patients with severe heart disease and a history of heart attack to receive either an implantable defibrillator or anti-arrhythmic drugs. All of the patients had a high risk of arrhythmia documented by the fact that doctors were able to induce an arrythmia under carefully controlled conditions. After an average of 27 months, those with the defibrillator had half the death rate of those taking anti-arrhythmic drugs.

Detection of myocardial ischemia with or without symptoms of angina after heart attack does not appear to be a useful predictor of future heart attacks. Myocardial ischemia refers to a deficiency of blood to the heart caused by the blocking or narrowing of arteries. Using rest electrocardiogram, exercise electrocardiogram and scintigraphy imaging, 936 patients who had been hospitalized for either heart attack or unstable angina in the previous six months were tested for myocardial ischemia. Of all the test results, only ST depression during the rest electrocardiogram was associated with an increased risk of recurrent heart attack. Exercise-induced ST depression in combination with reduced exercise capacity was significantly associated with an increased risk of heart attack, however. Myocardial ischemia was not associated with an increased risk nor was its presence or absence useful in determining prognosis., Objective.--To determine the clinical significance of silent and symptomatic myocardial ischemia detected by noninvasive testing in stable postcoronary patients. Design.--Cohort study with a mean 23-month follow-up. Setting.--Ambulatory outpatients after recent hospitalization for an acute coronary event. Patients.--Nine hundred thirty-six patients (76% male; mean age, 58 years) who were clinically stable 1 to 6 months after hospitalization for acute myocardial intarction or unstable angina. Interventions.--Noninvasive testing involved rest, ambulatory, and exercise electrocardiograms and stress thallium-201 scintigraphy. Main Outcome Measures.---Cox regression analysis was used to evaluate the risk (hazard ratio) of first recurrent priman] events (cardiac death, nonfatal infarction, or unstable angina) or restricted events (cardiac death or nonfatal infarction) associated with ischemic noninvasive test results. Results.--ST segment depression on the rest electrocardiogram was the only noninvasive test variable that identified a significantly increased risk (P=.05) for first recurrent priman] events (hazard ratio; 95% confidence limits): rest electrocardiogram ST depression (1.5; 1.00, 2.25); ambulatory electrocardiogram ST depression (0.86; 0.49, 1.51 ); exercise electrocardiogram ST depression (1.13; 0.82, 1.56); and stress thallium-201 reversible defects (1.3; 0.96, 1.74). Test results were similar for first recurrent restricted events, and in patients with and without angina. Significantly increased risk (P Conclusion.--Detection of silent or symptomatic myocardial ischemia by noninvasive testing in stable patients 1 to 6 months after an acute coronan] event is not useful in identifying patients at increased risk for subsequent coronan] events. (JAMA. 1993;269:2379-2385)

Importance: The incidence of chemotherapy-induced cardiomyopathy is increasing and is associated with poor clinical outcomes.Objective: To assess the association of cardiac resynchronization therapy (CRT) with improvement in cardiac function, as well as clinical improvement in patients with chemotherapy-induced cardiomyopathy.Design, Setting, and Participants: The Multicenter Automatic Defibrillator Implantation Trial-Chemotherapy-Induced Cardiomyopathy was an uncontrolled, prospective, cohort study conducted between November 21, 2014, and June 21, 2018, at 12 tertiary centers with cardio-oncology programs in the United States. Thirty patients were implanted with CRT owing to reduced left ventricular ejection fraction (LVEF≤35%), New York Heart Association class II-IV heart failure symptoms, and wide QRS complex, with established chemotherapy-induced cardiomyopathy and were followed up for 6 months after CRT implantation. The date of final follow-up was February 6, 2019.Exposures: CRT implantation according to standard of care.Main Outcomes and Measures: The primary end point was change in LVEF from baseline to 6 months after initiating CRT. Secondary outcomes included all-cause mortality and change in left ventricular end-systolic volume and end-diastolic volume.Results: Among 30 patients who were enrolled (mean [SD] age, 64 [11] years; 26 women [87%]; 73% had a history of breast cancer; 20% had a history of lymphoma or leukemia), primary end point data were available for 26 patients and secondary end point data were available for 23 patients. Patients had nonischemic cardiomyopathy with left bundle branch block, median LVEF of 29%, and a mean QRS duration of 152 ms. Patients with CRT experienced a statistically significant improvement in mean LVEF at 6 months from 28% to 39% (difference, 10.6% [95% CI, 8.0%-13.3%]; P < .001). This was accompanied by a reduction in LV end-systolic volume from 122.7 to 89.0 mL (difference, 37.0 mL [95% CI, 28.2-45.8]) and reduction in LV end-diastolic volume from 171.0 to 143.2 mL (difference, 31.9 mL [95% CI, 22.1-41.6]) (both P < .001). Adverse events included a procedure-related pneumothorax (1 patient), a device pocket infection (1 patient), and heart failure requiring hospitalization during follow-up (1 patient).Conclusions and Relevance: In this preliminary study of patients with chemotherapy-induced cardiomyopathy, CRT was associated with improvement in LVEF after 6 months. The findings are limited by the small sample size, short follow-up, and absence of a control group.Trial Registration: ClinicalTrials.gov Identifier: NCT02164721. [ABSTRACT FROM AUTHOR]