Background. Transcatheter aortic valve replacement (TAVR) is known to increase the incidence of conduction disturbances compared to surgical aortic valve replacement; however, there are limited data on the impact and duration of these conduction disturbances on longer term outcomes. Objective. To determine the differential impact of persistent versus nonpersistent new-onset conduction disturbances on TAVR-related complications and outcomes. Methods. This is a single-center retrospective analysis of 927 consecutive patients with aortic stenosis who underwent TAVR at Yale New Haven Hospital from July 2012 to August 2019. Patients with new-onset conduction disturbances within 7 days following TAVR were selected for this study. Persistent and nonpersistent disturbances were, respectively, defined as persisting or not persisting on all patient ECGs for up to 1.5 years after TAVR or until death. Results. Within 7 days after TAVR, conduction disturbances occurred in 42.3% (392/927) of the patients. Conduction disturbances persisted in 150 (38%) patients and did not persist in 187 (48%) patients, and 55 (14%) patients were excluded for having mixed (both persistent and nonpersistent) disturbances. Compared with nonpersistent disturbances, patients with persistent disturbances were more likely to receive a PPM within 7 days after the TAVR procedure (46.0% versus 4.3%, p<0.001) and had a greater unadjusted 1-year cardiac-related and all-cause mortality risk (HR 2.54, p=0.044 and HR 1.90, p=0.046, respectively). Conclusion. Persistent conduction disturbances were associated with a greater cardiac and all-cause mortality rate at one year following TAVR. Future research should investigate periprocedural factors to reduce persistent conduction disturbances and outcomes beyond one year follow-up.

HomeCirculation: Arrhythmia and ElectrophysiologyVol. 16, No. 5It's Not a Wash: Can the Pouch Be Beat? Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBIt's Not a Wash: Can the Pouch Be Beat? Kyle Gobeil, Rachel Lampert and Eric M. Bader Kyle GobeilKyle Gobeil Clinical Cardiac Electrophysiology, Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT. , Rachel LampertRachel Lampert https://orcid.org/0000-0003-3313-0939 Clinical Cardiac Electrophysiology, Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT. and Eric M. BaderEric M. Bader Correspondence to: Eric M. Bader, MD, Critical Cardiac Electrophysiology, Cardiovascular Medicine, Yale School of Medicine, 789 Howard Ave, Dana 319, New Haven, CT 06520. Email E-mail Address: [email protected] https://orcid.org/0000-0002-0445-8487 Clinical Cardiac Electrophysiology, Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT. Originally published20 Apr 2023https://doi.org/10.1161/CIRCEP.123.011952Circulation: Arrhythmia and Electrophysiology. 2023;16This article is a commentary on the followingRandomized Trial of Stand-Alone Use of the Antimicrobial Envelope in High-Risk Cardiac Device PatientsOther version(s) of this articleYou are viewing the most recent version of this article. Previous versions: April 20, 2023: Ahead of Print In recent decades, the use of cardiovascular implantable electronic devices (CIEDs) has increased for several life-saving indications. One of the most feared complications of CIEDs is device infection, with CIED Gobeil infection portending substantial morbidity, mortality, and cost.1 Registry data from implantable cardioverter defibrillators indicate that while overall periprocedural risk of CIED implantation has declined over the prior decade,2 the incidence of CIED infection has risen over a similar time period.3,4 Data from the National Inpatient Sample database show that procedures related to CIED infection have increased 135% from 2000 to 2012.1 Pocket infection most often requires full system removal, and, if any system components have been in place for a prolonged period, may require extraction, which can carry risk.5 Therefore, prevention of device infection has become a priority over the past decade.See Article by Ellis et alPrevention of CIED infection requires a comprehensive approach involving perioperative preparation, appropriate prophylactic antibiotic selection, meticulous surgical technique, and thoughtful postoperative management. Long-standing standard of care includes preprocedure chlorhexidine skin preparation and preoperative antibiotics, for many years the only interventions shown to reduce CIED infection in randomized trials.6,7 Further attempts at reducing infection risk with escalating antibiotic regimens were examined in the PADIT trial, where no clinical benefit was seen with the addition of intraprocedural pocket washes or postprocedure antibiotic prophylaxis.8 It should be noted that in the PADIT trial, overall infection rate was low (1.03%). Despite the lack of randomized data supporting a clinical benefit, many operators continue to utilize an intraprocedural antibiotic pocket wash and postprocedure antibiotics. More recently, the WRAP-IT trial (Worldwide Randomized Antibiotic Envelope Infection Prevention Trial) examined the use of an absorbable, multifilament mesh envelope impregnated with minocycline and rifampin (TYRX-a; Medtronic, Inc, Minneapolis, MN) in a randomized fashion at the time of device implant. The authors of WRAP-IT reported a 40% reduction in infection resulting in system extraction or revision, long-term antibiotic therapy, and infection recurrence or death with the use of the pouch versus without.9 While this trial is not without critique, especially considering a number needed to treat of 200, the introduction of an antibacterial envelope represented an opportunity to alter the trajectory of CIED infection risk, particularly if used in patients at a higher risk for infection.The authors of the ENVELOPE trial10 sought to arm clinicians with additive randomized data to aid in decision-making around procedural technique, by targeting the use of intraoperative antibacterial pocket irrigation in conjunction with a 2-day postprocedural course of oral antibiotics—2 interventions that lack meaningful data. Importantly, the prespecified standard-of-care protocol included established preprocedural chlorhexidine skin preparation and intravenous antibiotics, as well as the use of a TYRX-a pouch in all patients, based on data from the WRAP-IT trial. While the TYRX-a pouch is not uniformly considered the standard of care in all implants, the current study cohort was comprised of those with known risk factors for device infection. Patients included were mostly male, elderly, and white. Most common risk factors for device infection in combined groups were chronic heart failure (72.3%), device generator change or extraction (63.6%), systemic anticoagulation (49.8%), and diabetes (45.7%). The primary end point of CIED infection requiring system removal at 6 months was reached in 11 of 1010 patients (1.1%), without a statistically significant difference between the 2 arms. As summarized by the authors, the major salient points of this report are as follows: (1) procedural antibiotic pocket wash and postoperative antibiotic regimen when added to proven measures as above did not reduce the rate of CIED infection at 6 months; (2) postoperative hematoma is an independent risk factor for CIED infection, particularly relevant for those on antiplatelet or anticoagulant therapy; and (3) prior CIED infection represented an independent risk factor for subsequent infection.The authors should be commended on expanding the body of evidence related to device infection prevention with randomized data. For years, implanters have been operating on anecdotal or observational data with respect to antibiotic pocket washing or postprocedural antibiotic course. These interventions are not without their own risks, such as higher risk of renal and infectious complications.11 Entrenched practices may be hard to give up, particularly in the face of complications that can be both devastating and not entirely within our control. The lack of added benefit with wash and postprocedure antibiotics seen in this trial leads us to consider that we may have already optimized the circumstances that we are able to influence directly at the time of implant. Perhaps, with the use of the pouch and meticulous surgical technique, we have finally overcome the periprocedural risk of direct seeding of the pocket. If infections continue to occur, they may be a result of factors beyond our control at the time of implant. Fundamentally, the risk of hematologic spread of bacteria to the device is ever present as is pocket erosion and patient-level factors like anticoagulation use, diabetes, and renal failure.Limitation of this study includes a lower overall infection rate compared with most contemporary reports, but notably similar to the WRAP-IT and PADIT trials. The TYRX-a envelope was utilized in a manner that is outside the current standard of care, perhaps, in part, due to lagging of society guidelines. Most recent consensus guidelines on how to prevent, diagnose, and treat CIED infections come from the European Heart Rhythm Association, receiving endorsement from the Heart Rhythm Society, published in 2020.12 In this joint international statement, use of a pouch is recommended to be relegated to those undergoing pocket or lead revision, generator replacement, system upgrade, or an initial CRT-D implantation. This contrasts with the ENVELOPE study that expanded the at-risk group to also include patients with diabetes, chronic kidney disease, chronic heart failure, chronic corticosteroid use, fever, or leukocytosis within 24 hours before implant and those on systemic anticoagulation. The use of postprocedure antibiotics is also discouraged in the current guidelines,12 further confirmed in this study.Can we reach the holy grail of zero perioperative infections? Further directions may include identification of the ideal population for use of an antibiotic pouch. Could further advances in pouch construction, with longer lasting antibiotic effect or other design factors, take us closer? Other environmental measures? This study demonstrates the importance of careful randomized trials for infection prevention measures. In the meantime, the low infection rate in this study, while a limitation from the study-design perspective, is good news for patients.Article InformationDisclosures Dr Lampert has received research support from Medtronic, Boston Scientific, and Abbott/St Jude and advisory board reimbursement from Medtronic. The other authors report no conflicts.FootnotesFor Disclosures, see page 256.The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Correspondence to: Eric M. Bader, MD, Critical Cardiac Electrophysiology, Cardiovascular Medicine, Yale School of Medicine, 789 Howard Ave, Dana 319, New Haven, CT 06520. Email eric.bader@yale.eduReferences1. Joy PS, Kumar G, Poole JE, London B, Olshansky B. Cardiac implantable electronic device infections: who is at greatest risk?.Heart Rhythm. 2017; 14:839–845. doi: 10.1016/j.hrthm.2017.03.019CrossrefMedlineGoogle Scholar2. Dodson JA, Lampert R, Wang Y, Hammill SC, Varosy P, Curtis JP. Temporal trends in quality of care among recipients of implantable cardioverter-defibrillators: insights from the national cardiovascular data registry.Circulation. 2014; 129:580–586. doi: 10.1161/CIRCULATIONAHA.113.003747LinkGoogle Scholar3. Greenspon AJ, Patel JD, Lau E, Ochoa JA, Frisch DR, Ho RT, Pavri BB, Kurtz SM. 16-year trends in the infection burden for pacemakers and implantable cardioverter-defibrillators in the United States: 1993 to 2008.J Am Coll Cardiol. 2011; 58:1001–1006. doi: 10.1016/j.jacc.2011.04.033CrossrefMedlineGoogle Scholar4. Voigt A, Shalaby A, Saba S. Continued rise in rates of cardiovascular implantable electronic device infections in the United States: temporal trends and causative insights.Pacing Clin Electrophysiol. 2010; 33:414–419. doi: 10.1111/j.1540-8159.2009.02569.xCrossrefMedlineGoogle Scholar5. Maytin M, Jones SO, Epstein LM. Long-term mortality after transvenous lead extraction.Circ Arrhythm Electrophysiol. 2012; 5:252–257. doi: 10.1161/CIRCEP.111.965277LinkGoogle Scholar6. Darouiche RO, Wall MJ, Itani KM, Otterson MF, Webb AL, Carrick MM, Miller HJ, Awad SS, Crosby CT, Mosier MC, et al. Chlorhexidine–alcohol versus povidone–iodine for surgical-site antisepsis.N Engl J Med. 2010; 362:18–26. doi: 10.1056/NEJMoa0810988CrossrefMedlineGoogle Scholar7. de Oliveira JC, Martinelli M, Nishioka SAD, Varejão T, Uipe D, Pedrosa AAA, Costa R, D'Avila A, Danik SB. Efficacy of antibiotic prophylaxis before the implantation of pacemakers and cardioverter-defibrillators: results of a large, prospective, randomized, double-blinded, placebo-controlled trial.Circ Arrhythm Electrophysiol. 2009; 2:29–34. doi: 10.1161/CIRCEP.108.795906LinkGoogle Scholar8. Krahn AD, Longtin Y, Philippon F, Birnie DH, Manlucu J, Angaran P, Rinne C, Coutu B, Low RA, Essebag V, et al. Prevention of arrhythmia device infection trial: the PADIT trial.J Am Coll Cardiol. 2018; 72:3098–3109. doi: 10.1016/j.jacc.2018.09.068CrossrefMedlineGoogle Scholar9. Tarakji KG, Mittal S, Kennergren C, Corey R, Poole JE, Schloss E, Gallastegui J, Pickett RA, Evonich R, Philippon F, et al; WRAP-IT Investigators. Antibacterial envelope to prevent cardiac implantable device infection.N Engl J Med. 2019; 380:1895–1905. doi: 10.1056/NEJMoa1901111CrossrefMedlineGoogle Scholar10. Ellis CR, Greenspon AJ, Andriulli JA, Gould PA, Carillo R, Kolek MJ, Donegan R, Amaral AP, Mittal S. Randomized trial of stand-alone use of the antimicrobial envelope in high-risk cardiac device patients.Circ Arrhythm Electrophysiol. 2023; 16:e011740. doi: 10.1161/CIRCEP.122.011740LinkGoogle Scholar11. Branch-Elliman W, O'Brien W, Strymish J, Itani K, Wyatt C, Gupta K. Association of duration and type of surgical prophylaxis with antimicrobial-associated adverse events.JAMA Surg. 2019; 154:590–598. doi: 10.1001/jamasurg.2019.0569CrossrefMedlineGoogle Scholar12. Blomström-Lundqvist C, Traykov V, Erba PA, Burri H, Nielsen JC, Bongiorni MG, Poole J, Boriani G, Costa R, Deharo J-C, et al. European Heart Rhythm Association (EHRA) international consensus document on how to prevent, diagnose, and treat cardiac implantable electronic device infections—endorsed by the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS), the Latin American Heart Rhythm Society (LAHRS), International Society for Cardiovascular Infectious Diseases (ISCVID), and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS).Eur Heart J. 2020; 41:2012–2032. doi: 10.1093/eurheartj/ehaa010CrossrefMedlineGoogle Scholar eLetters(0)eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. Authors of the article cited in the comment will be invited to reply, as appropriate.Comments and feedback on AHA/ASA Scientific Statements and Guidelines should be directed to the AHA/ASA Manuscript Oversight Committee via its Correspondence page.Sign In to Submit a Response to This Article Previous Back to top Next FiguresReferencesRelatedDetailsRelated articlesRandomized Trial of Stand-Alone Use of the Antimicrobial Envelope in High-Risk Cardiac Device PatientsChristopher R. Ellis, et al. Circulation: Arrhythmia and Electrophysiology. 2023;16 May 2023Vol 16, Issue 5 Advertisement Article InformationMetrics © 2023 American Heart Association, Inc.https://doi.org/10.1161/CIRCEP.123.011952PMID: 37078340 Originally publishedApril 20, 2023 KeywordsEditorialsincidenceinfectionmorbiditypreventionPDF download Advertisement SubjectsCatheter Ablation and Implantable Cardioverter-Defibrillator

Nationwide public health restrictions due to the coronavirus disease 2019 (COVID-19) pandemic have disrupted people's routine physical activities, yet little objective information is available on the extent to which physical activity has changed among patients with pre-existing cardiac diseases. Using remote monitoring data of 9,924 patients with pacemakers and implantable cardiac defibrillators (ICDs) living in New York City and Minneapolis/Saint Paul, we assessed physical activity patterns among these patients in 2019 and 2020 from January through October. We found marked declines in physical activity among patients with implantable cardiac devices during COVID-19-related restrictions and the reduction was consistent across age and sex subgroups. Moreover, physical activity among these vulnerable patients did not return to pre-restrictions levels several months after COVID-19 restrictions were eased. Our findings highlight the need to consider the unintended consequences of mitigation strategies and develop approaches to encourage safe physical activity during the pandemic.

During the coronavirus disease 2019 (COVID-19) pandemic, inpatient services for acute cardiac conditions including heart failure decreased markedly, while telemedicine services increased.1Bhatt AS Moscone A McElrath EE et al.Fewer hospitalizations for acute cardiovascular conditions during the COVID-19 pandemic.J Am Coll Cardiol. 2020; 76: 280-288Crossref PubMed Scopus (151) Google Scholar Little information is available on the extent to which cardiac status changed among patients with heart failure in this period. Implantable cardioverter defibrillators (ICDs) and cardiac resynchronization therapy defibrillators (CRT-Ds) implanted in patients with heart failure provide useful information on markers of cardiac status as measured by thoracic impedance, atrial fibrillation (AF), and device discharges.2Parthiban N Esterman A Mahajan R et al.Remote monitoring of implantable cardioverter-defibrillators: a systematic review and meta-analysis of clinical outcomes.J Am Coll Cardiol. 2015; 65: 2591-2600Crossref PubMed Scopus (149) Google Scholar We assessed trends in markers of cardiac status among patients with ICDs or CRT-D devices in New York City and Minneapolis/Saint Paul from 2019 to 2020, with an emphasis on the shutdown period.MethodsA deidentified dataset of individuals aged 18 years and older from New York City and Minneapolis/Saint Paul with ICDs and CRT-Ds transmitting between January 1, 2019, and December 31, 2020, was derived from Boston Scientific Corporation's LATITUDE database. These 2 cities were chosen for their data availability and asynchronous COVID-19 case burdens. Measured variables included daily thoracic impedance, nighttime heart rate (HR), respiration rate, HR variability, time in AF, percentages of patients with AF time greater than 1 hour, and HeartLogic index3Gardner RS Singh JP Stancak B et al.HeartLogic multisensor algorithm identifies patients during periods of significantly increased risk of heart failure events: results from the MultiSENSE study.Circ Heart Fail. 2018; 11e004669Crossref PubMed Scopus (50) Google Scholar for heart failure decompensation. We used remote monitoring data exclusively from scheduled regular data uploads to eliminate potential selection bias in event-based data uploads.We assessed the trends in daily thoracic impedance, AF, and device discharges using the 7-day moving average of these metrics in 2020. Data from 2019 were used as a comparator to account for seasonal variability. We considered 2-sided P values of les than .05 as statistically significant. Analyses were performed using R version 4.0.2. This study was approved by the Institutional Review Board at Yale University.ResultsThe study sample included 4555 patients, of whom 3146 were from New York City (mean age 68.0 ± 13.3 years, 32.2% women) and 1409 were from Minneapolis/Saint Paul (mean age 67.3 ± 13.5 years, 29.5% women). Of the 4555 patients in the analysis, 2701 (59.3%, 1893 in New York City and 808 in Minneapolis/Saint Paul) had ICDs and 1854 (40.7%, 1253 in New York City and 601 in Minneapolis/Saint Paul) had CRT-Ds. Three-quarters (74.8%) of patients in 2019 were also in the 2020 cohorts. There was little to no statistical or clinically meaningful change in thoracic impedance and AF burden in these patients during the COVID-19 shutdown period (Fig. 1). The average daily nighttime HR, HR variability, HeartLogic index, AF, and percentages of patients with daily AF time greater than one hour decreased slightly (relative change of <5%) from the date that the emergency declaration was announced (March 7, 2020, in New York City and March 13, 2020, in Minneapolis/Saint Paul) to the end of stay-at-home order (June 8, 2020, in New York City and May 18, 2020, in Minneapolis/Saint Paul). Conversely, average daily thoracic impedance increased slightly in the same time period. However, none of these changes were statistically significant (P > .05 for all). After the restrictions were lifted, these physiologic markers returned to the 2019 levels. The trends were similar in both New York City and Minneapolis/Saint Paul and were consistent across age and sex subgroups.DiscussionThere is little to no change in most markers of cardiac status among heart failure patients with implanted ICD or CRT-D devices in New York City and Minneapolis/Saint Paul during the COVID-19 pandemic, and this finding is consistent for all age and sex subgroups. All the changes in medical care, the stress of the pandemic, and the change in behaviors did not seem to have any major effect on this patient population. It is plausible that telemedicine mitigated some of the effects of a decrease in inpatient care.4Bitar H Alismail S. The role of eHealth, telehealth, and telemedicine for chronic disease patients during COVID-19 pandemic: a rapid systematic review.Digit Health. 2021; 720552076211009396PubMed Google ScholarOur result of the nonsignificant trends in markers of cardiac status among heart failure patients is consistent with prior studies. In a previous study of 49 heart failure patients with wireless implantable hemodynamic monitoring in New York City, Oliveros et al5Oliveros E Mahmood K Mitter S Pinney SP Lala A. Pulmonary artery pressure monitoring during the COVID-19 pandemic in New York City.J Card Fail. 2020; 26: 900-901Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar found that there was no significant difference in the mean pulmonary artery diastolic pressures before and during COVID-19, nor was there a difference in the mean HR. However, we further extended the literature by assessing a wider range of decompensation markers in a larger sample of heart failure patients over a longer period of time.Limitations of our study include a reliance on data produced by the device, the lack of details on comorbidities, medications, and health care utilization. We were also limited to these 2 cities because of data availability.In conclusion, this study provides unprecedented information that the cardiac health of heart failure patients with ICDs or CRT-D devices did not substantively change during the period of the pandemic with marked restrictions and disruptions in medical care delivery. During the coronavirus disease 2019 (COVID-19) pandemic, inpatient services for acute cardiac conditions including heart failure decreased markedly, while telemedicine services increased.1Bhatt AS Moscone A McElrath EE et al.Fewer hospitalizations for acute cardiovascular conditions during the COVID-19 pandemic.J Am Coll Cardiol. 2020; 76: 280-288Crossref PubMed Scopus (151) Google Scholar Little information is available on the extent to which cardiac status changed among patients with heart failure in this period. Implantable cardioverter defibrillators (ICDs) and cardiac resynchronization therapy defibrillators (CRT-Ds) implanted in patients with heart failure provide useful information on markers of cardiac status as measured by thoracic impedance, atrial fibrillation (AF), and device discharges.2Parthiban N Esterman A Mahajan R et al.Remote monitoring of implantable cardioverter-defibrillators: a systematic review and meta-analysis of clinical outcomes.J Am Coll Cardiol. 2015; 65: 2591-2600Crossref PubMed Scopus (149) Google Scholar We assessed trends in markers of cardiac status among patients with ICDs or CRT-D devices in New York City and Minneapolis/Saint Paul from 2019 to 2020, with an emphasis on the shutdown period. MethodsA deidentified dataset of individuals aged 18 years and older from New York City and Minneapolis/Saint Paul with ICDs and CRT-Ds transmitting between January 1, 2019, and December 31, 2020, was derived from Boston Scientific Corporation's LATITUDE database. These 2 cities were chosen for their data availability and asynchronous COVID-19 case burdens. Measured variables included daily thoracic impedance, nighttime heart rate (HR), respiration rate, HR variability, time in AF, percentages of patients with AF time greater than 1 hour, and HeartLogic index3Gardner RS Singh JP Stancak B et al.HeartLogic multisensor algorithm identifies patients during periods of significantly increased risk of heart failure events: results from the MultiSENSE study.Circ Heart Fail. 2018; 11e004669Crossref PubMed Scopus (50) Google Scholar for heart failure decompensation. We used remote monitoring data exclusively from scheduled regular data uploads to eliminate potential selection bias in event-based data uploads.We assessed the trends in daily thoracic impedance, AF, and device discharges using the 7-day moving average of these metrics in 2020. Data from 2019 were used as a comparator to account for seasonal variability. We considered 2-sided P values of les than .05 as statistically significant. Analyses were performed using R version 4.0.2. This study was approved by the Institutional Review Board at Yale University. A deidentified dataset of individuals aged 18 years and older from New York City and Minneapolis/Saint Paul with ICDs and CRT-Ds transmitting between January 1, 2019, and December 31, 2020, was derived from Boston Scientific Corporation's LATITUDE database. These 2 cities were chosen for their data availability and asynchronous COVID-19 case burdens. Measured variables included daily thoracic impedance, nighttime heart rate (HR), respiration rate, HR variability, time in AF, percentages of patients with AF time greater than 1 hour, and HeartLogic index3Gardner RS Singh JP Stancak B et al.HeartLogic multisensor algorithm identifies patients during periods of significantly increased risk of heart failure events: results from the MultiSENSE study.Circ Heart Fail. 2018; 11e004669Crossref PubMed Scopus (50) Google Scholar for heart failure decompensation. We used remote monitoring data exclusively from scheduled regular data uploads to eliminate potential selection bias in event-based data uploads. We assessed the trends in daily thoracic impedance, AF, and device discharges using the 7-day moving average of these metrics in 2020. Data from 2019 were used as a comparator to account for seasonal variability. We considered 2-sided P values of les than .05 as statistically significant. Analyses were performed using R version 4.0.2. This study was approved by the Institutional Review Board at Yale University. ResultsThe study sample included 4555 patients, of whom 3146 were from New York City (mean age 68.0 ± 13.3 years, 32.2% women) and 1409 were from Minneapolis/Saint Paul (mean age 67.3 ± 13.5 years, 29.5% women). Of the 4555 patients in the analysis, 2701 (59.3%, 1893 in New York City and 808 in Minneapolis/Saint Paul) had ICDs and 1854 (40.7%, 1253 in New York City and 601 in Minneapolis/Saint Paul) had CRT-Ds. Three-quarters (74.8%) of patients in 2019 were also in the 2020 cohorts. There was little to no statistical or clinically meaningful change in thoracic impedance and AF burden in these patients during the COVID-19 shutdown period (Fig. 1). The average daily nighttime HR, HR variability, HeartLogic index, AF, and percentages of patients with daily AF time greater than one hour decreased slightly (relative change of <5%) from the date that the emergency declaration was announced (March 7, 2020, in New York City and March 13, 2020, in Minneapolis/Saint Paul) to the end of stay-at-home order (June 8, 2020, in New York City and May 18, 2020, in Minneapolis/Saint Paul). Conversely, average daily thoracic impedance increased slightly in the same time period. However, none of these changes were statistically significant (P > .05 for all). After the restrictions were lifted, these physiologic markers returned to the 2019 levels. The trends were similar in both New York City and Minneapolis/Saint Paul and were consistent across age and sex subgroups. The study sample included 4555 patients, of whom 3146 were from New York City (mean age 68.0 ± 13.3 years, 32.2% women) and 1409 were from Minneapolis/Saint Paul (mean age 67.3 ± 13.5 years, 29.5% women). Of the 4555 patients in the analysis, 2701 (59.3%, 1893 in New York City and 808 in Minneapolis/Saint Paul) had ICDs and 1854 (40.7%, 1253 in New York City and 601 in Minneapolis/Saint Paul) had CRT-Ds. Three-quarters (74.8%) of patients in 2019 were also in the 2020 cohorts. There was little to no statistical or clinically meaningful change in thoracic impedance and AF burden in these patients during the COVID-19 shutdown period (Fig. 1). The average daily nighttime HR, HR variability, HeartLogic index, AF, and percentages of patients with daily AF time greater than one hour decreased slightly (relative change of <5%) from the date that the emergency declaration was announced (March 7, 2020, in New York City and March 13, 2020, in Minneapolis/Saint Paul) to the end of stay-at-home order (June 8, 2020, in New York City and May 18, 2020, in Minneapolis/Saint Paul). Conversely, average daily thoracic impedance increased slightly in the same time period. However, none of these changes were statistically significant (P > .05 for all). After the restrictions were lifted, these physiologic markers returned to the 2019 levels. The trends were similar in both New York City and Minneapolis/Saint Paul and were consistent across age and sex subgroups. DiscussionThere is little to no change in most markers of cardiac status among heart failure patients with implanted ICD or CRT-D devices in New York City and Minneapolis/Saint Paul during the COVID-19 pandemic, and this finding is consistent for all age and sex subgroups. All the changes in medical care, the stress of the pandemic, and the change in behaviors did not seem to have any major effect on this patient population. It is plausible that telemedicine mitigated some of the effects of a decrease in inpatient care.4Bitar H Alismail S. The role of eHealth, telehealth, and telemedicine for chronic disease patients during COVID-19 pandemic: a rapid systematic review.Digit Health. 2021; 720552076211009396PubMed Google ScholarOur result of the nonsignificant trends in markers of cardiac status among heart failure patients is consistent with prior studies. In a previous study of 49 heart failure patients with wireless implantable hemodynamic monitoring in New York City, Oliveros et al5Oliveros E Mahmood K Mitter S Pinney SP Lala A. Pulmonary artery pressure monitoring during the COVID-19 pandemic in New York City.J Card Fail. 2020; 26: 900-901Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar found that there was no significant difference in the mean pulmonary artery diastolic pressures before and during COVID-19, nor was there a difference in the mean HR. However, we further extended the literature by assessing a wider range of decompensation markers in a larger sample of heart failure patients over a longer period of time.Limitations of our study include a reliance on data produced by the device, the lack of details on comorbidities, medications, and health care utilization. We were also limited to these 2 cities because of data availability.In conclusion, this study provides unprecedented information that the cardiac health of heart failure patients with ICDs or CRT-D devices did not substantively change during the period of the pandemic with marked restrictions and disruptions in medical care delivery. There is little to no change in most markers of cardiac status among heart failure patients with implanted ICD or CRT-D devices in New York City and Minneapolis/Saint Paul during the COVID-19 pandemic, and this finding is consistent for all age and sex subgroups. All the changes in medical care, the stress of the pandemic, and the change in behaviors did not seem to have any major effect on this patient population. It is plausible that telemedicine mitigated some of the effects of a decrease in inpatient care.4Bitar H Alismail S. The role of eHealth, telehealth, and telemedicine for chronic disease patients during COVID-19 pandemic: a rapid systematic review.Digit Health. 2021; 720552076211009396PubMed Google Scholar Our result of the nonsignificant trends in markers of cardiac status among heart failure patients is consistent with prior studies. In a previous study of 49 heart failure patients with wireless implantable hemodynamic monitoring in New York City, Oliveros et al5Oliveros E Mahmood K Mitter S Pinney SP Lala A. Pulmonary artery pressure monitoring during the COVID-19 pandemic in New York City.J Card Fail. 2020; 26: 900-901Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar found that there was no significant difference in the mean pulmonary artery diastolic pressures before and during COVID-19, nor was there a difference in the mean HR. However, we further extended the literature by assessing a wider range of decompensation markers in a larger sample of heart failure patients over a longer period of time. Limitations of our study include a reliance on data produced by the device, the lack of details on comorbidities, medications, and health care utilization. We were also limited to these 2 cities because of data availability. In conclusion, this study provides unprecedented information that the cardiac health of heart failure patients with ICDs or CRT-D devices did not substantively change during the period of the pandemic with marked restrictions and disruptions in medical care delivery. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Hospitalizations for acute cardiac conditions have markedly declined during the coronavirus disease 2019 (COVID-19) pandemic, yet the cause of this decline is not clear. Using remote monitoring data of 4,029 patients with implantable cardiac defibrillators (ICDs) living in New York City and Minneapolis/Saint Paul, we assessed changes in markers of cardiac status among these patients and compared thoracic impedance and arrhythmia burden in 2019 and 2020 from January through August. We found no change in several key disease decompensation markers among patients with implanted ICD devices during the first phase of COVID-19 pandemic, suggesting that the decrease in cardiovascular hospitalizations in this period is not reflective of a true population-level improvement in cardiovascular health.

Chest pain is a common presenting complaint in the primary care setting. Imaging plays a key role in the evaluation of the multiple organ systems that can be responsible for chest pain. With numerous imaging modalities available, determination of the most appropriate test and interpretation of the findings can be a challenge for the clinician. In this 2-part series, we offer resources to guide primary care physicians in the selection of imaging studies and present the imaging findings of various causes of nonemergent chest pain. In Part 2, we focus on the radiologic appearance of common noncardiac sources of chest pain, including gastrointestinal, pulmonary, and musculoskeletal etiologies.

Chest pain is a common presenting complaint in the primary care setting. Imaging plays a key role in the evaluation of the multiple organ systems that can be responsible for chest pain. With numerous imaging modalities available, determination of the most appropriate test and interpretation of the findings can be a challenge for the clinician. In this 2-part series, we offer resources to guide primary care physicians in the selection of imaging studies and present the imaging findings of various causes of nonemergent chest pain. In Part 1, we focus on a discussion of the basic concepts of each imaging technique and the appearance of common cardiovascular etiologies of chest pain.

Endocardial Fibroelastosis (EFE) is caused by avid proliferation of fibroelastic tissue, often associated with atrial fibrillation (AF) and intracardiac thrombus formation. A 68-year-old Nigerian male with medical history significant for AF and right heart failure presented with dizziness. Physical

Conclusions: Vasodilator therapy has clinical benefit in a relatively compliant Caucasian patient population as an adjunct to beta and renin-angiotensin blockade. These results further call into question the idea of race-based therapy and should be correlated with a prospective, randomized control trial. Conclusions: Vasodilator therapy has clinical benefit in a relatively compliant Caucasian patient population as an adjunct to beta and renin-angiotensin blockade. These results further call into question the idea of race-based therapy and should be correlated with a prospective, randomized control trial.