Publications by authors named "Brian Olshansky"

253 Publications

Recognition, Prevention, and Management of Arrhythmias and Autonomic Disorders in Cardio-Oncology: A Scientific Statement From the American Heart Association.

Circulation 2021 Jul 17;144(3):e41-e55. Epub 2021 Jun 17.

With the advent of novel cancer therapeutics and improved screening, more patients are surviving a cancer diagnosis or living longer with advanced disease. Many of these treatments have associated cardiovascular toxicities that can manifest in both an acute and a delayed fashion. Arrhythmias are an increasingly identified complication with unique management challenges in the cancer population. The purpose of this scientific statement is to summarize the current state of knowledge regarding arrhythmia identification and treatment in patients with cancer. Atrial tachyarrhythmias, particularly atrial fibrillation, are most common, but ventricular arrhythmias, including those related to treatment-induced QT prolongation, and bradyarrhythmias can also occur. Despite increased recognition, dedicated prospective studies evaluating true incidence are lacking. Moreover, few studies have addressed appropriate prevention and treatment strategies. As such, this scientific statement serves to mobilize the cardio-oncology, electrophysiology, and oncology communities to develop clinical and scientific collaborations that will improve the care of patients with cancer who have arrhythmias.
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http://dx.doi.org/10.1161/CIR.0000000000000986DOI Listing
July 2021

Managing Atrial Fibrillation in Patients With Heart Failure and Reduced Ejection Fraction: A Scientific Statement From the American Heart Association.

Circ Arrhythm Electrophysiol 2021 Jun 15;14(6):HAE0000000000000078. Epub 2021 Jun 15.

Atrial fibrillation and heart failure with reduced ejection fraction are increasing in prevalence worldwide. Atrial fibrillation can precipitate and can be a consequence of heart failure with reduced ejection fraction and cardiomyopathy. Atrial fibrillation and heart failure, when present together, are associated with worse outcomes. Together, these 2 conditions increase the risk of stroke, requiring oral anticoagulation in many or left atrial appendage closure in some. Medical management for rate and rhythm control of atrial fibrillation in heart failure remain hampered by variable success, intolerance, and adverse effects. In multiple randomized clinical trials in recent years, catheter ablation for atrial fibrillation in patients with heart failure and reduced ejection fraction has shown superiority in improving survival, quality of life, and ventricular function and reducing heart failure hospitalizations compared with antiarrhythmic drugs and rate control therapies. This has resulted in a paradigm shift in management toward nonpharmacological rhythm control of atrial fibrillation in heart failure with reduced ejection fraction. The primary objective of this American Heart Association scientific statement is to review the available evidence on the epidemiology and pathophysiology of atrial fibrillation in relation to heart failure and to provide guidance on the latest advances in pharmacological and nonpharmacological management of atrial fibrillation in patients with heart failure and reduced ejection fraction. The writing committee's consensus on the implications for clinical practice, gaps in knowledge, and directions for future research are highlighted.
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http://dx.doi.org/10.1161/HAE.0000000000000078DOI Listing
June 2021

Heart rate score, a measure related to chronotropic incompetence in pacemaker patients.

Heart Rhythm O2 2021 Apr 20;2(2):124-131. Epub 2021 Feb 20.

Cleveland Clinic, Cleveland, Ohio.

Background: Heart rate score (HrSc) ≥70% in cardiac resynchronization therapy defibrillator and implantable cardioverter-defibrillator subjects predicts 5-year mortality risk. A high HrSc suggests few sensed cardiac cycles above the programmed lower rate.

Objective: To determine if HrSc is related to chronotropic incompetence (CI) in pacemaker (PM) subjects.

Methods: HrSc is the percentage of all atrial-paced and sensed events in the single tallest 10 beats/min histogram bin programmed to DDD 60/min. The prospective LIFE study of PM subjects examined multiple treadmill-based measures of CI. The 1-month postimplant DDD 60/min PM rate histogram prior to treadmill was retrospectively analyzed for HrSc. Measures of CI were applied to submaximal treadmill data in the DDD mode. HrSc was compared to these CI measures and to clinical indications for PM.

Results: The 1-month histogram demonstrated HrSc ≥70% in 43% of subjects. HrSc ≥70% correlated with a clinical diagnosis of sick sinus syndrome ( < .001). CI was present in 34%-88% of subjects by treadmill-based measures. Agreement between treadmill-based measures for CI was poor and varied from 39% to 83%. HrSc ≥70%, as a measure of CI, was most highly correlated with unpaced heart rate <70% of age-predicted maximum heart rate (67%) (odds ratio 3.7, < .001).

Conclusions: HrSc ≥70% correlates with treadmill measures of CI and clinical sick sinus syndrome. HrSc ≥70% is a measure of CI in PM subjects that is inexpensive, repeatable, and quantitative.
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http://dx.doi.org/10.1016/j.hroo.2021.02.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8183967PMC
April 2021

Marijuana use disorder and arrhythmias: what were they smoking?

Authors:
Brian Olshansky

Europace 2021 Jun 10. Epub 2021 Jun 10.

Department of Internal Medicine, Division of Cardiology, University of Iowa Hospitals, 200 Hawkins Drive, Iowa City, IA 52242, USA.

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http://dx.doi.org/10.1093/europace/euab135DOI Listing
June 2021

Sinus node dysfunction - A well-defined entity?

Authors:
Brian Olshansky

Int J Cardiol 2021 07 30;335:55-56. Epub 2021 Apr 30.

University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52242, USA. Electronic address:

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http://dx.doi.org/10.1016/j.ijcard.2021.04.050DOI Listing
July 2021

Implantable Cardioverter Defibrillator Lead Survival in Athletic Patients.

Circ Arrhythm Electrophysiol 2021 Mar 16;14(3):e009344. Epub 2021 Mar 16.

Yale University School of Medicine, Yale Center of Analytic Sciences, New Haven, CT (F.L., J.D., C. Brandt, C. Barth).

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http://dx.doi.org/10.1161/CIRCEP.120.009344DOI Listing
March 2021

Long-Haul Post-COVID-19 Symptoms Presenting as a Variant of Postural Orthostatic Tachycardia Syndrome: The Swedish Experience.

JACC Case Rep 2021 Apr 10;3(4):573-580. Epub 2021 Mar 10.

Department of Clinical Sciences, Faculty of Medicine, Lund University, Malmö, Sweden.

Major clinical centers in Sweden have witnessed an inflow of patients with chronic symptoms following initial outpatient care for coronavirus disease-2019 (COVID-19) infection, suggestive of postural orthostatic tachycardia syndrome. This report presents the first case series of 3 Swedish patients diagnosed with postural orthostatic tachycardia syndrome more than 3 months after the primary COVID-2019 infections. ().
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http://dx.doi.org/10.1016/j.jaccas.2021.01.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7946344PMC
April 2021

Predictors of myocardial recovery in arrhythmia-induced cardiomyopathy: A multicenter study.

J Cardiovasc Electrophysiol 2021 Apr 4;32(4):1085-1092. Epub 2021 Mar 4.

Section of Electrophysiology, Mercy Heart and Vascular Institute, Mason City, Iowa, USA.

Background: Arrhythmia-induced cardiomyopathy (AIC) is characterized by improvement in left ventricular ejection fraction (LVEF) following arrhythmia treatment. Predictors of recovery in LVEF are not well understood.

Objective: We evaluated predictors of AIC recovery in a large multicenter cohort.

Methods: In total, 243 patients (age 65 ± 11, 73% male) with AIC caused by atrial fibrillation (49%), atrial tachycardia (20%), and premature ventricular contractions (PVCs; 31%) were treated and included. LVEF was assessed before and after treatment. Patients were stratified by arrhythmia duration (known [KN, n = 132] vs. unknown [UKN, n = 111]), arrhythmia type, LVEF, and presence of structural heart disease (SHD).

Results: Arrhythmia treatment was rhythm control in 95%. Median arrhythmia duration in the KN group was 47 months (25-75th percentile, 24-80 months). Post treatment LVEF was higher in KN group (55.9 ± 7 vs. 46.2 ± 12%; p < .0001) but the degree of LVEF improvement was similar (21.2 ± 9 vs. 19.4 ± 11; p = .16). Comparing highest quartile (longest arrhythmia duration) versus the rest of the KN group, the extent of LVEF improvement was similar (21.5 ± 8 vs. 21 ± 9%; p = .1). Patients in lowest index LVEF quartile (n = 74) had more PVC-induced AIC, greater EF improvement after treatment (24 ± 17 vs. 19 ± 7%; p < .0001) but lower post treatment EF (45 ± 14 vs. 54 ± 8%; p < .0001) versus other patients. Patients with SHD had lower index EF (28 ± 8 vs. 34 ± 8%; p < .0001) and lower final EF (47 ± 12 vs. 56 ± 7; p ≪ .0001). In multivariate regression, low index LVEF predicted myocardial recovery (odds ratio, 11.4; p < .005).

Conclusions: In this AIC cohort, LVEF improved regardless of arrhythmia duration or type but those with PVCs had lower index LVEF and had less recovery. Low index LVEF predicted LVEF recovery following arrhythmia treatment.
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http://dx.doi.org/10.1111/jce.14963DOI Listing
April 2021

Tilt testing remains a valuable asset.

Eur Heart J 2021 05;42(17):1654-1660

Cardiac Arrhythmia Center, Cardiovascular Division, University of Minnesota, Minneapolis, MN, USA.

Head-up tilt test (TT) has been used for >50 years to study heart rate/blood pressure adaptation to positional changes, to model responses to haemorrhage, to assess orthostatic hypotension, and to evaluate haemodynamic and neuroendocrine responses in congestive heart failure, autonomic dysfunction, and hypertension. During these studies, some subjects experienced syncope due to vasovagal reflex. As a result, tilt testing was incorporated into clinical assessment of syncope when the origin was unknown. Subsequently, clinical experience supports the diagnostic value of TT. This is highlighted in evidence-based professional practice guidelines, which provide advice for TT methodology and interpretation, while concurrently identifying its limitations. Thus, TT remains a valuable clinical asset, one that has added importantly to the appreciation of pathophysiology of syncope/collapse and, thereby, has improved care of syncopal patients.
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http://dx.doi.org/10.1093/eurheartj/ehab084DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8245144PMC
May 2021

The benefit of cardioneuroablation to reduce syncope recurrence in vasovagal syncope patients: a case-control study.

J Interv Card Electrophysiol 2021 Feb 1. Epub 2021 Feb 1.

Kansas City Heart Rhythm Institute and Research Foundation, Overland Park, KS, USA.

Background: Adequate and effective therapy for resistant vasovagal syncope patients is lacking and the benefit of cardioneuroablation (CNA) in this cohort is still debated. The aim of this study is to assess the long-term effect of CNA versus conservative therapy (CT) in a retrospectively followed cohort.

Methods: A total of 2874 patients underwent head-up tilt test (HUT) and 554 (19.2 %) were reported as positive, with VASIS type 2B response or > 3 s asystole in 130 patients. After exclusion of 29 patients under 18 years and over 65 years of age, 101 patients were included final analysis. Fifty-one patients (50.4%) underwent CNA and 50 (49.6%) patients received CT. After propensity score matching, 19 pairs of patients were successfully matched. The recurrence rate of syncope was compared between groups.

Results: During a median follow-up of 22 months (IQR, 13-35), syncope was seen in 12 (11.8%) cases. In the 19 propensity-matched patients, recurrent syncope was observed in 8 patients in the CT group and in 2 patients in the CNA group, respectively. In mixed effect Cox regression analysis, CNA was associated with less syncope recurrence risk at follow-up (HR 0.23, 95% CI 0.03-0.99, p = 0.049). The 4-year Kaplan-Meier syncope free rate was 0.86 (95% CI, 0.63-1.00) for CNA group and 0.50 (95% CI, 0.30-0.82) for CT group in the matched cohort.

Conclusions: In highly selected patients with HUT-induced cardioinhibitory response, CNA is associated with a significant reduction in syncope recurrence during follow-up when compared to CT.
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http://dx.doi.org/10.1007/s10840-020-00938-0DOI Listing
February 2021

Disparities in atrial fibrillation management: Is race to blame?

Int J Cardiol 2021 05 30;331:118-119. Epub 2021 Jan 30.

Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.

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http://dx.doi.org/10.1016/j.ijcard.2021.01.020DOI Listing
May 2021

Anticoagulant selection in relation to the SAMe-TTR score in patients with atrial fibrillation: The GLORIA-AF registry.

Hellenic J Cardiol 2021 Mar-Apr;62(2):152-157. Epub 2020 Dec 15.

University of Iowa, Mercy Hospital, Mason City, Iowa and Covenant Hospital, Waterloo, IA, USA.

Aim: The SAMe-TTR score helps identify patients with atrial fibrillation (AF) likely to have poor anticoagulation control during anticoagulation with vitamin K antagonists (VKA) and those with scores >2 might be better managed with a target-specific oral anticoagulant (NOAC). We hypothesized that in clinical practice, VKAs may be prescribed less frequently to patients with AF and SAMe-TTR scores >2 than to patients with lower scores.

Methods And Results: We analyzed the Phase III dataset of the Global Registry on Long-Term Oral Antithrombotic Treatment in Patients with Atrial Fibrillation (GLORIA-AF), a large, global, prospective global registry of patients with newly diagnosed AF and ≥1 stroke risk factor. We compared baseline clinical characteristics and antithrombotic prescriptions to determine the probability of the VKA prescription among anticoagulated patients with the baseline SAMe-TTR score >2 and ≤ 2. Among 17,465 anticoagulated patients with AF, 4,828 (27.6%) patients were prescribed VKA and 12,637 (72.4%) patients an NOAC: 11,884 (68.0%) patients had SAMe-TTR scores 0-2 and 5,581 (32.0%) patients had scores >2. The proportion of patients prescribed VKA was 28.0% among patients with SAMe-TTR scores >2 and 27.5% in those with scores ≤2.

Conclusions: The lack of a clear association between the SAMe-TTR score and anticoagulant selection may be attributed to the relative efficacy and safety profiles between NOACs and VKAs as well as to the absence of trial evidence that an SAMe-TTR-guided strategy for the selection of the type of anticoagulation in NVAF patients has an impact on clinical outcomes of efficacy and safety. The latter hypothesis is currently being tested in a randomized controlled trial.

Clinical Trial Registration: URL: https://www.clinicaltrials.gov//Unique identifier: NCT01937377, NCT01468701, and NCT01671007.
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http://dx.doi.org/10.1016/j.hjc.2020.11.009DOI Listing
December 2020

Mineral oil: safety and use as placebo in REDUCE-IT and other clinical studies.

Eur Heart J Suppl 2020 Oct 6;22(Suppl J):J34-J48. Epub 2020 Oct 6.

Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.

Mineral oil is often used as a clinical trial placebo. Pharmaceutical-grade mineral oil consists of a mixture of saturated hydrocarbons, with a purity and chemical structure that differs substantially from food-grade or technical-/industrial-grade mineral oils. Interest in mineral oil was piqued by suggestions that a portion of the substantially positive results of the Reduction of Cardiovascular Events with Icosapent Ethyl-Intervention Trial (REDUCE-IT) might be attributable to the theoretical negative effects of mineral oil rather than being due to the clinical benefits of icosapent ethyl. The objective of this review was to explore possible mineral oil safety and efficacy effects and contextualize these findings in light of the REDUCE-IT conclusions. A literature search identified studies employing mineral oil placebos. Eighty studies were identified and relevant data extracted. Adverse events associated with mineral oil were generally gastrointestinal and consistent with use as a lubricant laxative. Changes in triglycerides, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, high-sensitivity C-reactive protein, and other biomarkers were inconsistent and generally not statistically significant, or clinically meaningful with mineral oil, as were changes in blood pressure. There was no consistent evidence that mineral oil in the amounts used in the REDUCE-IT or Effect of Vascepa on Progression of Coronary Atherosclerosis in Patients With Elevated Triglycerides on Statin Therapy (EVAPORATE) trials affects absorption of essential nutrients or drugs, including statins. These results were then considered alongside publicly available data from REDUCE-IT. Based on available evidence, mineral oil does not appear to impact medication absorption or efficacy, or related clinical outcomes, and, therefore, does not meaningfully affect study conclusions when used as a placebo at the quantities used in clinical trials.
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http://dx.doi.org/10.1093/eurheartj/suaa117DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7537802PMC
October 2020

Guest Editorial.

J Atr Fibrillation 2020 Jun-Jul;13(1):2419. Epub 2020 Jun 30.

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http://dx.doi.org/10.4022/jafib.2419DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7533136PMC
June 2020

Device Autonomic Regulation Therapy in Patients with Heart Failure with Reduced Ejection Fraction.

J Atr Fibrillation 2020 Jun-Jul;13(1):2409. Epub 2020 Jun 30.

The University of Iowa Hospitals.

Heart failure with reduced ejection fraction (HFrEF) is a common, incompletely treatable, complex, progressive, and severe medical problem despite guideline-directed medical therapy. HFrEF is associated with sympathetic activation and parasympathetic inhibition; these reflexive processes may ultimately be maladaptive and exacerbate or even perpetuate the problem. Attempts to regulate autonomic tone during HFrEF in animal models and in humans has shown promise with beneficial effects that include improvement in symptoms, mitigation of arrhythmic events, reduction in mortality, and correction in hemodynamics. Several modalities to regulate autonomic tone such as unilateral parasympathetic nerve activation, baroreceptor activation, renal nerve ablation and spinal cord stimulation have been investigated. Although they demonstrated some benefit, the long-term efficacy in HFrEF has not been proven. Considering specific limitations of each modality, to draw definitive conclusions is impossible at this time. Here, we review the present state-of-the-art hiterature? of device of autonomic regulation therapy to affect outcomes in HFrEF.
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http://dx.doi.org/10.4022/jafib.2409DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7533145PMC
June 2020

Pacing Therapies for Vasovagal Syncope.

J Atr Fibrillation 2020 Jun-Jul;13(1):2406. Epub 2020 Jun 30.

Kansas City Heart Rhythm Institute (KCHRI), Overland Park, KS, USA.

Vasovagal Syncope (VVS) is mediated by a cardiac autonomic reflex with resultant bradycardia and hypotension, precipitating syncope. While benign and mostly well controlled, recurrent VVS can be debilitating and warrants intervention. Non-pharmacological management of VVS have had variable success. In patients with recurrent cardioinhibitory VVS, permanent pacing can be effective. The utility of pacing to preempt the syncopal depends on the prominent temporal role of bradycardia during the vasovagal reflex. Current guidelines recommend pacing as a therapy to consider in older patients with recurrent VVS. Although younger patients can benefit, one should be cautious given the long-term risk of complications. Available data appears to favor a dual chamber pacemaker with closed loop stimulation algorithm to prevent recurrent cardioinhibitory VVS. Several aspects, including mechanistic understanding of VVS and appropriate patient selection, remain unclear, and require further study.
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http://dx.doi.org/10.4022/jafib.2406DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7533132PMC
June 2020

REDUCE-IT INTERIM: accumulation of data across prespecified interim analyses to final results.

Eur Heart J Cardiovasc Pharmacother 2021 May;7(3):e61-e63

Cardiac Pacing and Electrophysiology, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Lerner College of Medicine of Case Western Reserve University, 9500 Euclid Avenue, Cleveland, OH 44195, USA.

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http://dx.doi.org/10.1093/ehjcvp/pvaa118DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8141294PMC
May 2021

Peripheral Arterial Disease in Patients with Atrial Fibrillation: The AFFIRM Study.

Am J Med 2021 04 18;134(4):514-518. Epub 2020 Sep 18.

Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Denmark. Electronic address:

Background: Peripheral arterial disease has been linked with worse outcomes in patients with atrial fibrillation. The aim of this study is to assess the impact of peripheral arterial disease on mortality and stroke in a cohort of patients with atrial fibrillation.

Methods: This was an ancillary analysis of the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial. A comparison of baseline characteristics was made between patients with atrial fibrillation with and without diagnosed peripheral arterial disease. Multivariate cox regression analysis was performed to compare the risk of stroke, death, and cardiovascular death among the two groups.

Results: The prevalence of peripheral arterial disease in the whole cohort of 4060 patients with atrial fibrillation was 6.7%. Patients with peripheral arterial disease tended to be older; had higher prevalence of diabetes mellitus, hypertension, and smoking; and were more likely to have a history of coronary artery disease, heart failure, cardiac surgery or cardiac intervention, and stroke or transient ischemic attack (all P < .05). After multivariate adjustment, peripheral arterial disease was significantly associated with overall higher mortality (hazard ratio 1.34, 95% confidence interval 1.06-1.70, P = .016) in patients with atrial fibrillation, but the rates of ischemic stroke were similar in the two groups (3.9% vs 3.5%, P = 0.874). Subgroup analysis confined to the patients with non-anticoagulated atrial fibrillation showed that peripheral arterial disease was an independent predictor of ischemic stroke (hazard ratio 3.37, 95% confidence interval 1.25-9.09, P < .016).

Conclusion: Peripheral arterial disease predicts higher mortality in atrial fibrillation, and was an independent predictor of ischemic stroke in patients with non-anticoagulated atrial fibrillation. Proactive surveillance and optimization of medical management in this group of patients is warranted, given the high risks associated with peripheral arterial disease where atrial fibrillation is also present.
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http://dx.doi.org/10.1016/j.amjmed.2020.08.026DOI Listing
April 2021

Is competitive atrial pacing a possible trigger for atrial fibrillation? Observations from the RATE registry.

Heart Rhythm 2021 01 30;18(1):3-9. Epub 2020 Jul 30.

Case Western Reserve University, Cleveland, Ohio.

Background: A high incidence of asymptomatic atrial tachycardia and atrial fibrillation (AT/AF) has been recognized in patients with cardiac implantable devices (CIED). The clinical significance of these AT/AF episodes remains unclear. Some "device-detected AT/AF" was previously shown to be triggered by competitive atrial pacing (CAP).

Objective: To investigate and characterize a potential association between CAP and AT/AF in the largest series of observations to date.

Methods: RATE, a multicenter registry, included 5379 patients with CIEDs followed for approximately 2 years. Electrograms (EGMs) from 1352 patients with AT/AF, CAP, or both were analyzed by experienced adjudicators to assess a causal relationship between AT/AF and CAP onset, duration, and morphology.

Results: In 225 patients, 1394 episodes of both AT/AF and CAP were present in the same tracing. CAP and AT/AF were strongly associated (P ≤ .02). AT/AF occurred during the course of the study in 71% of patients with CAP. In 62% of the episodes, expert adjudication concluded that CAP triggered AT/AF. The duration and morphology of triggered and spontaneous AT/AF episodes differed. Spontaneous AT/AF episodes were associated with constant EGM morphology, and were either long or extremely short. CAP-triggered AT/AF more often had variable and shorter cycle length EGMs. The incidence of short AT/AF events was higher among triggered episodes (25% vs 12.8%, P < .002).

Conclusion: Device-triggered AT/AF due to CAP is likely more common than previously recognized. This AT/AF entity differs from spontaneous AT/AF in duration and morphology. Clinical implications of spontaneous and device-triggered AT/AF may be different.
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http://dx.doi.org/10.1016/j.hrthm.2020.07.028DOI Listing
January 2021

Long-Term Outcomes of Implantable Cardioverter-Defibrillator Therapy in the SCD-HeFT.

J Am Coll Cardiol 2020 07;76(4):405-415

Department of Medicine, Division of Cardiology, Seattle Institute for Cardiac Research, Seattle, Washington.

Background: The SCD-HeFT (Sudden Cardiac Death in Heart Failure Trial) randomized 2,521 patients with moderate heart failure (HF) to amiodarone, placebo drug, or implantable cardioverter-defibrillator (ICD) therapy. Original trial follow-up ended October 31, 2003. Over a median 45.5-month follow-up, amiodarone, compared with placebo, did not affect survival, whereas randomization to an ICD significantly decreased all-cause mortality by 23%.

Objectives: This study sought to describe the extended treatment group survival of the SCD-HeFT cohort.

Methods: Mortality outcomes for the 1,855 patients alive at the end of the SCD-HeFT trial were collected between 2010 and 2011. These data were combined with the 666 deaths from the original study to compare long-term outcomes overall and for key pre-specified subgroups.

Results: Median (25th to 75th percentiles) follow-up was 11.0 (10.0 to 12.2) years. On the basis of intention-to-treat analysis, the ICD group had overall survival benefit versus placebo drug (hazard ratio [HR]: 0.87; 95% confidence interval [CI]: 0.76 to 0.98; p = 0.028). When treatment benefit was examined as a function of time from randomization, attenuation of the ICD benefit was observed after 6 years (p value for the interaction = 0.0015). Subgroup analysis revealed long-term ICD benefit varied according to HF etiology and New York Heart Association (NYHA) functional class: ischemic HF HR: 0.81; 95% CI: 0.69 to 0.95; p = 0.009; nonischemic HF HR: 0.97; 95% CI: 0.79 to 1.20; p = 0.802; NYHA functional class II HR: 0.76; 95% CI: 0.65 to 0.90; p = 0.001; NYHA functional class III HR: 1.06; 95% CI: 0.86 to 1.31; p = 0.575.

Conclusions: Follow-up of SCD-HeFT patients to 11 years demonstrated heterogenous treatment-related patterns of long-term survival with ICD benefit most evident at 11 years for ischemic HF patients and for those with NYHA functional class II symptoms at trial enrollment. (SCD-HeFT 10 Year Follow-up [SCD-HeFT10 Yr]; NCT01058837).
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http://dx.doi.org/10.1016/j.jacc.2020.05.061DOI Listing
July 2020

Editorial commentary: The autonomic nervous system is our friend.

Authors:
Brian Olshansky

Trends Cardiovasc Med 2021 07 1;31(5):303-304. Epub 2020 Jun 1.

University of Iowa Hospitals, 200 Hawkins Drive, Iowa City, IA 52242, United States. Electronic address:

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http://dx.doi.org/10.1016/j.tcm.2020.05.005DOI Listing
July 2021

The Mysterious Case of an Athletic Woman with Recurrent Syncope and a "Normal" Heart.

J Innov Card Rhythm Manag 2019 Jul 15;10(7):3744-3749. Epub 2019 Jul 15.

Department of Cardiology, University of Iowa, Iowa City, IA, USA.

A 53-year-old female with a history of sports participation presented to a community hospital emergency department for collapse. She was given a LifeVest wearable cardioverter-defibrillator (WCD) (Zoll Medical Corp., Chelmsford, MA, USA) and scheduled to undergo cardiac magnetic resonance imaging (MRI) with gadolinium enhancement at a tertiary center. However, before the scheduled MRI scan could be performed, she developed tachycardia, for which the WCD alarmed. A dual-chamber implantable cardioverter-defibrillator was subsequently implanted. Assessment of a patient with syncope requires consideration of the idea that a life-threatening and recurrent arrhythmia may be a cause for the problem. However, current guidelines do not cover the routine use of WCDs in syncope. Additionally, the patient described here did not clearly meet United States Food and Drug Administration indications for the provision of an external defibrillator. We present this case to provoke discussion among colleagues regarding this patient's treatment plan.
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http://dx.doi.org/10.19102/icrm.2019.100701DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7252779PMC
July 2019

The electrocardiogram: are we at the dawn of a new era?

Authors:
Brian Olshansky

Eur Heart J 2020 06;41(21):2000-2002

Department of Cardiology/Internal Medicine, University of Iowa Hospitals, Iowa City, IA, USA.

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http://dx.doi.org/10.1093/eurheartj/ehaa294DOI Listing
June 2020

Comprehensive Management With the ABC (Atrial Fibrillation Better Care) Pathway in Clinically Complex Patients With Atrial Fibrillation: A Post Hoc Ancillary Analysis From the AFFIRM Trial.

J Am Heart Assoc 2020 05 6;9(10):e014932. Epub 2020 May 6.

Liverpool Centre for Cardiovascular Science University of Liverpool and Liverpool Heart & Chest Hospital Liverpool United Kingdom.

Background For patients with atrial fibrillation, a comprehensive care approach based on the Atrial fibrillation Better Care (ABC) pathway can reduce the occurrence of adverse outcomes. The aim of this paper was to investigate if an approach based on the ABC pathway is associated with a reduced risk of adverse events in "clinically complex" atrial fibrillation patients, including those with multiple comorbidities, polypharmacy, and prior hospitalizations. Methods and Results We performed a post hoc analysis of the AFFIRM (Atrial Fibrillation Follow-up Investigation of Rhythm Management) trial. The principal outcome was the composite of all-cause hospitalization and all-cause death. An integrated care approach (ABC group) was used in 3.8% of the multimorbidity group, 4.0% of the polypharmacy group, and 4.8%, of the hospitalized groups. In all "clinically complex" groups, the cumulative risk of the composite outcome was significantly lower in patients managed consistent with the ABC pathway versus non-ABC pathway-adherent (all <0.05). Cox regression analysis showed a reduction of composite outcomes in ABC pathway-adherent versus non-ABC pathway-adherent for multimorbidity (hazard ratio [HR], 0.61, 95% CI, 0.44-0.85), polypharmacy (HR, 0.68, 95% CI, 0.47-1.00), and hospitalization (HR, 0.59, 95% CI, 0.42-0.85) groups. Secondary analyses showed that the higher number of ABC criteria fulfilled the larger associated reduction in relative risk, even for secondary outcomes considered. Conclusions Use of an ABC consistent pathway is associated with fewer major adverse events in patients with atrial fibrillation who have multiple comorbidities, use of polypharmacy, and prior hospitalization.
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http://dx.doi.org/10.1161/JAHA.119.014932DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7660878PMC
May 2020

Guidance for cardiac electrophysiology during the COVID-19 pandemic from the Heart Rhythm Society COVID-19 Task Force; Electrophysiology Section of the American College of Cardiology; and the Electrocardiography and Arrhythmias Committee of the Council on Clinical Cardiology, American Heart Association.

Heart Rhythm 2020 Sep 1;17(9):e233-e241. Epub 2020 Apr 1.

Cooper Medical School of Rowan University, Camden, New Jersey.

Coronavirus disease 2019 (COVID-19) is a global pandemic that is wreaking havoc on the health and economy of much of human civilization. Electrophysiologists have been impacted personally and professionally by this global catastrophe. In this joint article from representatives of the Heart Rhythm Society, the American College of Cardiology, and the American Heart Association, we identify the potential risks of exposure to patients, allied healthcare staff, industry representatives, and hospital administrators. We also describe the impact of COVID-19 on cardiac arrhythmias and methods of triage based on acuity and patient comorbidities. We provide guidance for managing invasive and noninvasive electrophysiology procedures, clinic visits, and cardiac device interrogations. In addition, we discuss resource conservation and the role of telemedicine in remote patient care along with management strategies for affected patients.
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http://dx.doi.org/10.1016/j.hrthm.2020.03.028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7118697PMC
September 2020