Background Anatomic characterization of unidirectional accessory pathways (APs) is inherently limited to the localization of the downstream insertion site. The inability to define the full anatomic course of unidirectional pathways can limit the safety and effectiveness of ablation in the setting of complex pathways, slanted pathways, unstable catheter positioning at downstream insertions, or insertions near the conduction system. Objective We aimed to develop novel pacing maneuvers to localize upstream insertions of unidirectional APs. Methods Two methods were evaluated: localizing the shortest transit time from roving pacing sites to a fixed reference in the opposite chamber (upstream transit mapping); and identifying the site at which the latest atrial or ventricular extrastimulus reset atrioventricular reciprocating tachycardia (late reset mapping). Unidirectional APs were included to test utility and feasibility of the techniques, and bidirectional APs were included to test anatomic accuracy. Results A total of 13 patients were included, 8 unidirectional APs and 5 bidirectional APs. Blind side mapping was successfully performed in all cases and showed excellent spatial correlation to conventional mapping methods (mean, 4.2 mm; SD, 1.3 mm) as well as to the site of successful ablation (mean, 2.5 mm; SD, 2.9 mm). The upstream transit mapping method was critical for successful ablation after conventional techniques proved inadequate in 2 cases. Conclusion Two novel methods, upstream transit mapping and late reset mapping, were used to localize the previously unmappable upstream insertions of unidirectional pathways. These methods expand the diagnostic toolbox to facilitate successful ablation in challenging cases.

BACKGROUND Safe and effective management of venous vascular access is a key component of electrophysiology (EP) procedures. Recently, the Z-stitch method has been developed for effective venous hemostasis. However, the standard postprocedure protocol often includes prolonged bed rest, which may affect patient satisfaction. The ZEBRA (Z stitch Early Bed Rest Assessment) study aims to systematically investigate and quantify patient satisfaction metrics and safety parameters associated with the early mobilization after Z-stitch placement. OBJECTIVE This study primarily investigates whether early mobilization following Z-stitch placement in venous vascular access management during EP procedures enhances patient satisfaction without compromising safety. METHODS In this prospective, multicenter, randomized clinical trial, approximately 200 patients undergoing various EP procedures at Oregon Health and Science University and Veterans Affairs Portland Health Care System will be randomly assigned to either a 1- or 4-hour bed rest regimen post-Z stitch. Patient satisfaction will be assessed through survey, alongside monitoring for hematomas, bleeding complications, and other safety endpoints. The study in- cludes stratification fi cation based on heparin administration and sheath size to ensure robust and nuanced data analysis. RESULTS We anticipate that early mobilization will lead to higher patient satisfaction scores. We also expect to closely monitor and report the incidence of hematomas, pain medication use, healthcare costs, patient outcomes at 30 days, time to ambulation, and hospital readmissions or emergency visits related to groin complications. CONCLUSION The ZEBRA study is poised to fi ll a critical knowledge gap in postprocedure care in EP labs. By rigorously evaluating the impact of early mobilization on patient satisfaction and safety, this study could significantly fi cantly influence fl uence future guidelines and improve patient experiences in EP procedures.

BackgroundCardiovascular diseases are the leading cause of morbidity and mortality in the United States. Despite the complexity of cardiovascular disease etiology, we do not fully comprehend the interactions between non-modifiable factors (e.g., age, sex, and race) and modifiable risk factors (e.g., health behaviors and occupational exposures).ObjectiveWe examined proximal and distal drivers of cardiovascular disease and elucidated the interactions between modifiable and non-modifiable risk factors.MethodsWe used a machine learning approach on four cohorts (2005–2012) of the National Health and Nutrition Examination Survey data to examine the effects of risk factors on cardiovascular risk quantified by the Framingham Risk Score (FRS) and the Pooled Cohort Equations (PCE). We estimated a network of risk factors, computed their strength centrality, closeness, and betweenness centrality, and computed a Bayesian network embodied in a directed acyclic graph.ResultsIn addition to traditional factors such as body mass index and physical activity, race and ethnicity and exposure to heavy metals are the most adjacent drivers of PCE. In addition to the factors directly affecting PCE, sleep complaints had an immediate adverse effect on FRS. Exposure to heavy metals is the link between race and ethnicity and FRS.ConclusionHeavy metal exposures and race/ethnicity have similar proximal effects on cardiovascular disease risk as traditional clinical and lifestyle risk factors, such as physical activity and body mass. Our findings support the inclusion of diverse racial and ethnic groups in all cardiovascular research and the consideration of the social environment in clinical decision-making.

BACKGROUND During the COVID-19 pandemic, professional societies recommended deferral of elective procedures for optimal resource utilization. OBJECTIVE We sought to assess changes in procedural trends and outcomes of electrophysiology (EP) procedures during the pandemic. METHODS National Inpatient Sample databases were used to identify all EP procedures performed in the United States (2016 -2020) by International Classi fi cation of Diseases, Tenth Revision codes. We evaluated trends in utilization, cost/revenue, and outcomes from EP procedures performed. RESULTS An estimated 1.35 million EP procedures (82% devices and 18% catheter ablations) were performed (2016 -2020) with significant yearly uptrend. During the pandemic, there was a substantial decline in EP procedure utilization from a 5 -year peak of 298 cases/million population in the second quarter of 2019 to a nadir of 220 cases in the second quarter of 2020. In 2020, the pandemic was associated with the loss of 50,233 projected EP procedures (39,337 devices and 10,896 ablations) with subsequent revenue loss of $7.06 billion. This deficit was driven by revenue deficit from dual-chamber permanent pacemaker (PPM) utilization ($2.88 billion, 49.3% of lost cases), ablation procedures ($1.84 billion, 21.7% of lost cases), and implantable cardioverterde fibrillator implantation ($1.36 billion, 12.0% of lost cases). To the contrary, there was a 9.4% increase in the utilization of leadless PPM. EP device implantation during the pandemic was associated with higher adverse in -hospital events (9.4% vs 8.0%; P < .001). CONCLUSION In the United States, the significant decline in EP procedures during the pandemic was primarily driven by the reduction in dual-chamber PPM utilization, followed by arrhythmia ablation and implantable cardioverter-defibrillator implantation. There was a substantial increase in leadless PPM utilization during the pandemic.

Cardiac physiologic pacing (CPP), encompassing cardiac resynchronization therapy (CRT) and conduction system pacing (CSP), has emerged as a pacing therapy strategy that may mitigate or prevent the development of heart failure (HF) in patients with ventricular dyssynchrony or pacing-induced cardiomyopathy. This clinical practice guideline is intended to provide guidance on indications for CRT for HF therapy and CPP in patients with pacemaker indications or HF, patient selection, pre-procedure evaluation and preparation, implant procedure management, follow-up evaluation and optimization of CPP response, and use in pediatric populations. Gaps in knowledge, pointing to new directions for future research, are also identified.

HomeCirculation: Cardiovascular Quality and OutcomesVol. 16, No. 8Just a Generator Exchange? Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBJust a Generator Exchange? Stacey J. Howell and Eric C. Stecker Stacey J. HowellStacey J. Howell https://orcid.org/0000-0003-4479-3770 Section of Cardiac Electrophysiology, Division of Cardiology, University of California San Francisco (S.J.H.). and Eric C. SteckerEric C. Stecker Correspondence to: Eric C. Stecker, MD, MPH, Knight Cardiovascular Institute, UHN-62, 3181 SW Sam Jackson Rd, Portland, OR 97201. Email E-mail Address: [email protected] Division of Cardiology, Knight Cardiovascular Institute, Oregon Health and Science University, Portland (E.C.S.). Originally published26 Jul 2023https://doi.org/10.1161/CIRCOUTCOMES.123.010266Circulation: Cardiovascular Quality and Outcomes. 2023;16:519–520This article is a commentary on the followingPatients' Perspectives Regarding Generator Exchanges of Implantable Cardioverter DefibrillatorsOther version(s) of this articleYou are viewing the most recent version of this article. Previous versions: July 26, 2023: Ahead of Print Implantable cardioverter defibrillator (ICD) generator exchange is typically regarded as a low-risk procedure that is the natural continuation of therapy for cardiac arrest prevention. Electrophysiologists regularly consider whether to revise leads or upgrade the device, but they rarely consider the fundamental question of whether the ICD is still needed. Even when patients have had substantial recovery of cardiac function and no concerning arrhythmias detected over the life of the prior ICD generator(s), the vast majority of patients undergo ICD replacement at the end of battery life. While generator exchanges are common, there is virtually no clinical evidence to support the assumption that routine replacement of ICDs at the time of battery depletion improves clinical outcomes among patients with primary prevention ICDs.See Article by MontembeauIn fact, there is reason to believe that generator exchange may not be necessary in large populations with primary prevention ICDs, such as those with nonischemic cardiomyopathy. Aside from SCD-HeFT (Sudden Cardiac Death in Heart Failure Trial), which demonstrated a survival benefit in nonischemic cardiomyopathy patients randomized to ICD compared with drug therapy during a median follow-up of <4 years,1 2 other randomized trials did not show benefit at short-to-intermediate follow-up.2,3 This begs the question of whether patients would derive benefit from primary prevention ICD at long-term follow-up, effectively at the time of and after battery depletion and ICD generator exchange. In fact, in the long-term (median, 11 years) follow-up of SCD-HeFT, patients with nonischemic cardiomyopathy had no survival benefit from primary prevention ICD.4,5It is perplexing that no large-scale randomized trials of ICD generator exchange have been performed, despite clinical equipoise and the large commitment of possibly unnecessary healthcare expenditures. One important barrier is clinicians' assumptions that patients would be uncomfortable with the possibility of being randomized to receive no generator exchange. That question has been directly assessed in the current issue of Circulation: Cardiovascular Quality and Outcomes. The work by Montembeau et al6 assessing patient perspectives regarding generator exchanges for primary prevention ICDs provides an essential foundation for long-overdue randomized trials evaluating primary prevention ICD generator exchange. Researchers interviewed 50 patients at a single institution who had received a primary prevention ICD between 2013 and 2021 and assessed their willingness and understanding of the need to undergo an ICD generator exchange. Investigators found that not all patients wanted a generator exchange and identified several factors crucial to decision-making. Individual patient sudden cardiac death (SCD) risk was an important factor: as hypothetical SCD risk decreased from 10% to 1%, the proportion of patients amenable to generator exchange decreased from nearly all patients to only two-thirds of patients. Physician recommendation, therapeutic inertia, and history of prior appropriate ICD therapy or lack of ICD therapy also impacted a patient's decision. Underscoring the trust patients put in their electrophysiologist, over half of the patients chose no generator exchange irrespective of SCD risk when presented with a scenario that the physician recommended against generator exchange. On the contrary, therapeutic inertia was a major driver for generator change even if SCD risk was low. Many patients' viewed ICD generator exchange as the default and did not know that declining generator exchange was an option.The current study is an essential first step to better understand the patients' desire for generator exchange in the setting of primary prevention ICD. The authors' use of hypothetical scenarios via a standard-gamble choice experiment was a creative and effective method to assess patient decision-making. A weakness of the cross-sectional interview study design is the somewhat low response rate (roughly third of approached patients), although this is comparable to other studies with this design. Furthermore, the generalizability of the study may be limited given that the patients were limited to a single institution and of predominantly one race. On the contrary, the investigators employed rigorous sampling to include patients with a range in the time since ICD implant and those with and without prior generator exchange, which strengthens the generalizability of the study.The key finding of the study that not all patients would want a generator exchange when the ICD battery is at the end of life is new. Together with the data that specific patient populations do not derive long-term benefit from ICD,4 it challenges the status quo that a primary prevention ICD is a lifelong commitment. Rather, ICD battery depletion should be an opportunity to educate our patients on their individual SCD risk at that point in time, clarify misunderstandings about ICDs, and provide an updated recommendation on their ongoing need for primary prevention ICD to guide their decision-making. This is supported by the fact that more than two-thirds of the study's patient population had not received an appropriate shock from their ICD, which is comparable to other reports.7 Furthermore, the current study highlights the urgent need for a trial to assess clinical outcomes in patients with nonischemic cardiomyopathy at the time of battery depletion who are randomized to ICD generator exchange and no ICD generator exchange.Montembeau et al have clearly demonstrated that ICD generator exchange should no longer be viewed as routine. Their data provides information to justify and plan long-overdue randomized trials, which would allow patients and clinicians to understand what benefit, if any, should be anticipated from ICD generator exchange. Even before such studies are conducted, their results emphasize the importance of discussing what benefit patients presume they would gain, and taking the time to ensure that generator change is within their goals of care.ARTICLE INFORMATIONSources of FundingNone.Disclosures None.FootnotesFor Sources of Funding and Disclosures, see page 520.The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Correspondence to: Eric C. Stecker, MD, MPH, Knight Cardiovascular Institute, UHN-62, 3181 SW Sam Jackson Rd, Portland, OR 97201. Email steckere@ohsu.eduREFERENCES1. Bardy GH, Lee KL, Mark DB, Poole JE, Packer DL, Boineau R, Domanski M, Troutman C, Anderson J, Johnson G, et al; Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) Investigators. Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure.N Engl J Med. 2005; 352:225–237. doi: 10.1056/NEJMoa043399CrossrefMedlineGoogle Scholar2. Kadish A, Dyer A, Daubert JP, Quigg R, Estes NAM, Anderson KP, Calkins H, Hoch D, Goldberger J, Shalaby A, et al; Defibrillators in Non-Ischemic Cardiomyopathy Treatment Evaluation (DEFINITE) Investigators. Prophylactic defibrillator implantation in patients with nonischemic dilated cardiomyopathy.N Engl J Med. 2004; 350:2151–2158. doi: 10.1056/NEJMoa033088CrossrefMedlineGoogle Scholar3. Køber L, Thune JJ, Nielsen JC, Haarbo J, Videbæk L, Korup E, Jensen G, Hildebrandt P, Steffensen FH, Bruun NE, et al; DANISH Investigators. Defibrillator implantation in patients with nonischemic systolic heart failure.N Engl J Med. 2016; 375:1221–1230. doi: 10.1056/NEJMoa1608029CrossrefMedlineGoogle Scholar4. Poole JE, Olshansky B, Mark DB, Anderson J, Johnson G, Hellkamp AS, Davidson-Ray L, Fishbein DP, Boineau RE, Anstrom KJ, et al; SCD-HeFT Investigators. Long-term outcomes of implantable cardioverter-defibrillator therapy in the SCD-HeFT.J Am Coll Cardiol. 2020; 76:405–415. doi: 10.1016/j.jacc.2020.05.061CrossrefMedlineGoogle Scholar5. Stecker EC, Nazer B, Dewland TA. Primary prevention ICDs in nonischemic cardiomyopathy: time to put the toothpaste back in the tube?J Am Coll Cardiol. 2020; 76:416–418. doi: 10.1016/j.jacc.2020.06.008CrossrefMedlineGoogle Scholar6. Montembeau S, Merchant F, Speight C, et al. Patients' perspectives regarding generator exchanges of implantable cardioverter-defibrillators.Circ Cardiovas Qual Outcomes. 2023; 16:509–518. doi: 10.1161/CIRCOUTCOMES.122.009827LinkGoogle Scholar7. Merchant FM, Jones P, Wehrenberg S, Lloyd MS, Saxon LA. Incidence of defibrillator shocks after elective generator exchange following uneventful first battery life.J Am Heart Assoc. 2014; 3:e001289. doi: 10.1161/JAHA.114.001289LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsRelated articlesPatients' Perspectives Regarding Generator Exchanges of Implantable Cardioverter DefibrillatorsSarah C. Montembeau, et al. Circulation: Cardiovascular Quality and Outcomes. 2023;16:509-518 August 2023Vol 16, Issue 8 Advertisement Article Information Metrics © 2023 American Heart Association, Inc.https://doi.org/10.1161/CIRCOUTCOMES.123.010266PMID: 37492957 Originally publishedJuly 26, 2023 KeywordsEditorialsarrhythmiasheart failureimplantable cardioverter defibrillatorsudden cardiac deathPDF download Advertisement Subjects Catheter Ablation and Implantable Cardioverter-Defibrillator Sudden Cardiac Death

Background Professional society practice guidelines conflict regarding their recommendations of dofetilide (DOF) and sotalol (STL) for treatment of arrhythmias in hypertrophic cardiomyopathy (HCM), and supporting data is sparse. We aim to assess safety and efficacy of DOF and STL on arrhythmias in HCM. Methods This was an observational study of HCM patients treated with DOF or STL for atrial fibrillation (AF) and ventricular arrhythmias (VA). Outcomes of drug discontinuation and arrhythmia recurrence were compared at 1 year and latest follow-up by Kaplan–Meier analysis. Predictors of drug failure were studied using uni- and multi-variable analyses. Drug-related adverse events were quantitated. Results Here we show that of our cohort of 72 patients (54 ± 14 years old, 75% male), 21 were prescribed DOF for AF, 52 STL for AF, and 18 STL for VA. At 1 year, discontinuation and recurrence rates were similar for DOF-AF (38% and 43%) and STL-AF (29% and 44%) groups. Efficacy data was similar at long-term follow-up of 1603 (IQR 994–4131) days, and for STL-VA. Drug inefficacy was the most common reason for discontinuation (28%) followed by side-effects (13%). Incidences of heart failure hospitalization (5%) and mortality (3%) were low. One STL-AF patient developed non-sustained torsades de pointes in the setting of severe pneumonia and acute kidney injury, but there were no other drug-related serious adverse events. Conclusions DOF and STL demonstrate modest efficacy and satisfactory safety when used for AF and VA in HCM patients.

Objective: Individuals with schizophrenia carry a high burden of cardiovascular disease and elevated rates of sudden cardiac arrest (SCA), but little published data is available regarding survival from SCA in this population. The authors compared cardiovascular disease burden and resuscitation outcomes following SCA in individuals with and without schizophrenia. Methods: Case-control analysis drawn from a prospective community-based study of SCA in a large community. The authors defined cases as having a pre-SCA history of schizophrenia, and controls as individuals with SCA without a history of schizophrenia. SCA cases with schizophrenia were compared to a 1:5 age-and sex-frequency matched sample of SCA cases without schizophrenia. Results: The 103 SCA schizophrenia cases were as likely as the 515 cases without schizophrenia to have resuscitation attempted (75% vs. 80%; p = 0.24) and had a shorter 911 call mean response time (5.8 min vs. 6.9 min, p < 0.001). However, they were significantly less likely to present with a shockable rhythm (ventricular fibrillation/pulseless ventricular tachycardia 16% vs. 43%, p < 0.001), and less likely to survive to hospital discharge (3% vs. 14%, p = 0.008). Pre-arrest cardiovascular disease burden was similar in patients with and without schizophrenia. Conclusions: Despite comparable resuscitation characteristics and cardiovascular disease burden, patients with schizophrenia had significantly lower rates of SCA survival. The paucity of previous research into this phenomenon warrants further investigation to identify factors that may improve survival.

Introduction: Patients with hypertrophic cardiomyopathy (HCM) often have atrial fibrillation (AF) and ventricular arrhythmias (VA) requiring rhythm control. In the 2014 AF Guidelines, class III anti-arrhythmic drugs are not recommended in patients with left ventricular hypertrophy, but in the 2020 HCM Guidelines, sotalol (STL) and dofetilide (DOF) are deemed “reasonable” for rhythm control, both based on limited data. Methods: We conducted an observational study (2001-2021) of patients with HCM who were treated with DOF or STL for AF and/or VA. Baseline characteristics and drug-related adverse events were analyzed from the electronic medical record, and rates of discontinuation and arrhythmia recurrence at 1 year and by time of chart review were compared using Kaplan Meier curves and log rank test. Results: There were 21 DOF and 52 STL HCM patients with AF, and 18 STL patients with VA. At 1 year, AF patients on DOF or STL had no significant difference in rates of AF recurrence (42.9% vs 44.2%, p=0.664) or drug discontinuation (38.1% vs 29.4%, p=0.582). Recurrence and discontinuation rates of VA on STL were comparable (Figure). Over a median follow up of 1603 days (IQR 994, 4131), there was a trend toward greater efficacy for STL with respect to less AF recurrence (p=0.085) and less frequent discontinuation (p=0.153; Figure). On univariate analysis, only NYHA class predicted AF recurrence. Reasons for discontinuation were most often for inefficacy or mild side-effects. One patient with prior alcohol septal ablation who was on STL for AF developed complete heart block followed by non-sustained torsades de pointes in the setting of a severe influenza infection and later underwent defibrillator implantation. There were no other cases of pro-arrhythmia or sudden death related to DOF. Conclusions: DOF and STL are modestly effective for the treatment of AF and VA in HCM patients, with a low rate of serious adverse events.

HomeCirculationVol. 146, No. 22Targeted Screening for Transthyretin Amyloid Cardiomyopathy in Patients With Atrial Fibrillation Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBTargeted Screening for Transthyretin Amyloid Cardiomyopathy in Patients With Atrial Fibrillation Pooja Prasad, Stacey Howell, Saket Sanghai, Eric Stecker, Charles A. Henrikson, Ahmad Masri and Babak Nazer Pooja PrasadPooja Prasad https://orcid.org/0000-0003-4178-8431 Division of Cardiovascular Medicine, Knight Cardiovascular Institute, Oregon Health and Science University, Portland (P.P., S.S., E.S., C.A.H., A.M., B.N.). , Stacey HowellStacey Howell University of California, San Francisco Cardiac Electrophysiology and Arrhythmia Service (S.H.). , Saket SanghaiSaket Sanghai https://orcid.org/0000-0002-1791-9895 Division of Cardiovascular Medicine, Knight Cardiovascular Institute, Oregon Health and Science University, Portland (P.P., S.S., E.S., C.A.H., A.M., B.N.). , Eric SteckerEric Stecker Division of Cardiovascular Medicine, Knight Cardiovascular Institute, Oregon Health and Science University, Portland (P.P., S.S., E.S., C.A.H., A.M., B.N.). , Charles A. HenriksonCharles A. Henrikson https://orcid.org/0000-0002-3381-8437 Division of Cardiovascular Medicine, Knight Cardiovascular Institute, Oregon Health and Science University, Portland (P.P., S.S., E.S., C.A.H., A.M., B.N.). , Ahmad MasriAhmad Masri https://orcid.org/0000-0002-6390-6526 Division of Cardiovascular Medicine, Knight Cardiovascular Institute, Oregon Health and Science University, Portland (P.P., S.S., E.S., C.A.H., A.M., B.N.). and Babak NazerBabak Nazer Correspondence to: Babak Nazer, MD, Knight Cardiovascular Institute, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239. Email E-mail Address: [email protected] https://orcid.org/0000-0002-4078-9064 Division of Cardiovascular Medicine, Knight Cardiovascular Institute, Oregon Health and Science University, Portland (P.P., S.S., E.S., C.A.H., A.M., B.N.). Originally published28 Nov 2022https://doi.org/10.1161/CIRCULATIONAHA.122.060596Circulation. 2022;146:1730–1732Atrial fibrillation (AF) and atrial flutter (AFL) are common in patients with transthyretin cardiac amyloidosis (ATTR-CM) and can present years before diagnosis of ATTR-CM.1 Prior data from our amyloidosis center, which serves both urban and rural parts of the Pacific Northwest, demonstrated an AF/AFL prevalence of 73% among patients with wild type or hereditary ATTR-CM2—a treatable cause of heart failure if recognized in a timely fashion.3 Technetium-99m pyrophosphate scintigraphy (Tc-99m PYP) is a simple, noninvasive diagnostic option3 that allows for screening of ATTR-CM in broader populations, however, there is paucity of data regarding screening for ATTR-CM in patients with AF/AFL. Thus, we instituted a 2-phase prospective systematic screening strategy that incorporated Tc-99m PYP to determine the yield of previously undiagnosed ATTR-CM in patients with AF/AFL and left ventricular (LV) hypertrophy (LVH).From January 2021 through June 2021 (phase I), all patients referred to an academic medical center's electrophysiology clinic for AF/AFL were screened for the following criteria: age >60 years; and LV wall thickness ≥12 mm (measured by echocardiography and based on previous data relating to clinical characteristics of ATTR-CM patients with AF/AFL).2 There were no exclusions related to the duration of AF/AFL or classification (atypical vs typical) of AFL. Patients with cardiomyopathy of established etiology and patients with previously completed Tc-99m PYP or cardiac magnetic resonance imaging were excluded. Tc-99m PYP was offered to patients who met screening criteria. Screening with Tc-99m PYP was performed as part of a clinical initiative between our center's electrophysiologists and cardiologists with expertise in nuclear and Tc-99m PYP imaging, utilizing shared decision-making with patients. Retrospective data collection was part of an institutional review board–approved study. In patients with a positive Tc-99m PYP scan, light chain amyloidosis was excluded using serum and urine immunofixation and serum-free light chains. During phase II (July 2021 to January 2022), in an attempt to increase specificity of echocardiographic parameters used for screening, the criteria for LVH was restricted to LV wall thickness ≥15 mm with no changes to other exclusion and inclusion criteria. All scans were completed at Oregon Health and Science University. The data, analytic methods, and study materials will be made available to other researchers for purposes of reproducing the results or replicating the procedure upon written request to the corresponding author.Among 801 consecutive patients in phase I, 95 (11.9%) met the inclusion criteria and were offered Tc-99m PYP, while 58 (7.2%) proceeded to undergo the scan. Only 1 patient ([1.7%] 91 years of age; interventricular septal thickness 14 mm; posterior wall thickness 17 mm; without clinical heart failure) was diagnosed with ATTR-CM based on grade III Tc-99m PYP uptake and tafamidis was subsequently initiated. During phase II of the study, 11 of 806 (1.4%) consecutive patients met inclusion criteria and were offered Tc-99m PYP; 7 (0.9%) underwent the scan, all of which were negative. The mean age for the 65 patients in both phases who underwent Tc-99m PYP was 73.9±6.9 years and 73.8% were male. A summary of patient characteristics can be seen in the Table.Table. Characteristics of Patients With AF/AFL Who Completed Tc-99m PYPCharacteristicsTc-99m PYP completed (n=65)Tc-99mPYP not completed (n=41)All patients (n=106)Age, mean±SD, y73.9±6.972.8±8.173.5±7.4Men, n (%)48 (73.8%)25 (60.9%)23 (68.9%)Heart failure diagnosis*36.9%29.2%34.0%Body mass index, mean±SD, kg/m230.7±7.1931.1±6.230.9±6.8Peripheral neuropathy, including diabetic neuropathy27.7%31.7%29.2%Spinal stenosis26.2%7.31%18.9%Carpal tunnel syndrome23.1%22.0%22.6%Obstructive coronary artery disease18.5%12.2%16.0%Diabetes20.0%26.8%22.6%Hypertension75.4%78.0%76.4%Chronic kidney disease15.4%14.6%15.1%Obstructive sleep apnea40.0%51.2%44.3%Median CHA2DS2-VASc score† (IQR)3 (2–4)3 (2–4)3(2–4)Median serum creatinine, mg/dL (IQR)0.975 (0.89–1.10)0.94 (0.76–1.18)0.97 (0.82–1.12)Stroke/transient ischemic attack history4.6%12.2%7.5%Implantable cardioverter-defibrillator or permanent pacemaker12.3%19.5%15.2%Both AF and AFL21.5%24.4%22.6%AF only76.9%65.9%72.6%AFL only1.5%9.8%4.7%Classification of AF/AFL Paroxysmal43.1%41.5%42.5% Persistent50.8%46.3%49.1% Longstanding persistent4.6%2.4%3.8% Permanent1.5%9.8%4.7%Echocardiography Left ventricular ejection fraction, mean±SD, %58.2±10.558.5±9.858.3±10.2 Left atrial volume index, mean±SD, mL/m243.2±17.048.4±25.745.3±21.0 Left ventricular posterior wall thickness, mean±SD, mm13.2±2.712.2±1.612.2±2.8 Septal wall thickness, mean±SD, mm12.3±3.3712.6±1.712.9±2.3 Left ventricular internal dimension, diastole, mean±SD, cm4.64±0.684.67±0.754.65±0.71 Left ventricular internal dimension, systole, mean±SD, cm3.28±0.723.19±0.753.25±0.73AF/AFL therapy Antiarrhythmic therapy50.8%29.3%42.5% Beta blocker or calcium channel blocker therapy81.5%68.3%76.4% Oral anticoagulation90.8%82.9%87.7% Digoxin0%0%0%AF indicates atrial fibrillation; AFL, atrial flutter; IQR, interquartile range; and Tc-99m PYP, technetium-99m Pyrophosphate Scintigraphy.*Including reduced and preserved ejection fraction.†CHA2DS2-VaSc score indicates scoring method to predict thromboembolic risk with AF/AFL based on congestive heart failure (1 point), hypertension (1 point), age (1 point >65; 2 points >75), diabetes (1 point), stroke/TIA (2 points), vascular disease (1 point), female sex (1 point).In the present study, where systematic screening for ATTR-CM in patients with LVH and AF/AFL was instituted, routine screening of more than 1600 AF/AFL patients resulted in 65 patients undergoing Tc-99m PYP—of which only 1 patient was diagnosed with ATTR-CM. While AF/AFL is common in patients with ATTR-CM,1,2 the reverse was not true in our cohort.In a systematic screening study similar to ours that studied patients with heart failure and preserved ejection fraction rather than AF, prevalence of ATTR-CM increased from 1.3% to 6.3% when applying our LVH criteria (LV wall thickness ≥12 mm).4 In contrast, our practice of screening patients with AF and LVH was low yield despite 40% of our cohort carrying a diagnosis of heart failure. One possibility is that while amyloid-related LVH is closely related to heart failure and preserved ejection fraction, LVH in patients with AF is more likely to be secondary to other common shared risk factors such as hypertension, obstructive sleep apnea, and chronic kidney disease. Another possibility is that Tc-99m PYP is not sensitive enough to identify early ATTR-CM. Screening a larger cohort of patients would allow us to add additional echocardiographic parameters, such as global longitudinal strain, diastolic parameters, and biomarkers, to our screening criteria, potentially improving the yield of Tc-99m PYP.One limitation was the significant number of patients who met criteria for Tc-99m PYP but did not undergo scanning. We modified the degree of LV wall thickness required when we recognized the low yield of Tc-99m PYP in phase I. The dual-phase nature of our study combined with the partial capture of Tc-99m PYP scans among patients meeting criteria preempt quantitative prevalence conclusions. While we did not systematically collect the race of the patients in our cohort, our Oregonian population is predominantly White; therefore, the generalizability of these findings to a more heterogenous population is limited, especially considering cardiac amyloidosis is more prevalent in individuals of West African descent.3 Although our center's standard diagnostic approach is to simultaneously tests for light chain amyloid cardiomyopathy and ATTR-CM, in this community-based screening study, we did not screen for light chain amyloid cardiomyopathy because of its markedly low baseline prevalence.5In conclusion, in an academic medical center's electrophysiology clinic, routine screening for ATTR-CM in patients with AF/AFL and LVH was of low yield regardless of the degree of LVH. Our study suggests that ATTR-CM is an uncommon etiology of AF/AFL.Article InformationSources of FundingDr Nazer is supported by the National Institutes of Health (No. K08-HL138156 and R01-HL160712).Nonstandard Abbreviations and AcronymsAFatrial fibrillationAFLatrial flutterATTR-CMtransthyretin cardiac amyloidosisLVleft ventricularLVHleft ventricular hypertrophyTc-99m PYPtechnetium-99m pyrophosphate scintigraphyDisclosures Dr Masri receives research grants from Pfizer, Akcea, Ionis, and Ultromics; and advisor/consulting fees from Eidos, Pfizer, Ionis, BMS, Attralus, Tenaya, and Cytokinetics. Dr Nazer receives investigator-initiated research grants from Galaxy Medical, Biosense-Webster, and Siemens; and advisor/consulting fees from Boston Scientific, Biosense-Webster, and Edwards Life Sciences. The other authors report no conflicts relevant to this article.FootnotesFor Sources of Funding and Disclosures, see page 1732.Circulation is available at www.ahajournals.org/journal/circCorrespondence to: Babak Nazer, MD, Knight Cardiovascular Institute, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239. Email [email protected]eduReferences1. Donnellan E, Wazni O, Kanj M, Elshazly MB, Hussein A, Baranowski B, Hanna M, Patel D, Trulock K, Martyn M, et al. Atrial fibrillation ablation in patients with transthyretin cardiac amyloidosis.Europace. 2020; 22:259–264. doi: 10.1093/europace/euz314CrossrefMedlineGoogle Scholar2. Dale Z, Chandrashekar P, Al-Rashdan L, Kim M, Masri A, Nazer B. Management strategies for atrial fibrillation and flutter in patients with transthyretin cardiac amyloidosis.Am J Cardiol. 2021; 157:107–114. doi: 10.1016/j.amjcard.2021.07.028CrossrefMedlineGoogle Scholar3. Kittleson MM, Maurer MS, Ambardekar AV, Bullock-Palmer RP, Chang PP, Eisen HJ, Nair AP, Nativi-Nicolau J, Ruberg FL; American Heart Association Heart Failure and Transplantation Committee of the Council on Clinical Cardiology. Cardiac amyloidosis: evolving diagnosis and management: a scientific statement from the American Heart Association.Circulation. 2020; 142:e7–e22. doi: 10.1161/CIR.0000000000000792LinkGoogle Scholar4. AbouEzzeddine OF, Davies DR, Scott CG, Fayyaz AU, Askew JW, McKie PM, Noseworthy PA, Johnson GB, Dunlay SM, Borlaug BA, et al. Prevalence of transthyretin amyloid cardiomyopathy in heart failure with preserved ejection fraction.JAMA Cardiol. 2021; 6:1267–1274. doi: 10.1001/jamacardio.2021.3070CrossrefMedlineGoogle Scholar5. Quock TP, Yan T, Chang E, Guthrie S, Broder MS. Epidemiology of AL amyloidosis: a real-world study using US claims data.Blood Adv. 2018; 2:1046–1053. doi: 10.1182/bloodadvances.2018016402CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails November 29, 2022Vol 146, Issue 22 Advertisement Article InformationMetrics © 2022 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.122.060596PMID: 36441818 Originally publishedNovember 28, 2022 Keywordshypertrophy, left ventricularamyloidosisatrial fibrillationatrial flutterPDF download Advertisement SubjectsAtrial FibrillationCardiomyopathyCardiovascular DiseaseDiagnostic TestingNuclear Cardiology and PET

OBJECTIVE:To investigate the association between type 1 diabetes mellitus (T1D) and type 2 diabetes mellitus (T2D) with risk of sudden cardiac arrest (SCA). METHODS:In a prospective community-based study of SCA from February 1, 2002, through November 30, 2019, we ascertained 2771 cases age 18 years of age or older and matched them to 8313 controls based on geography, age, sex, and race/ethnicity. We used logistic regression to evaluate the independent association between diabetes, T1D, T2D, and SCA. RESULTS:Patients had a mean age of 64.5±15.9 years, were 33.3% female and 23.9% non-White race. Overall, 36.7% (n=1016) of cases and 23.8% (n=1981) of controls had diabetes. Among individuals with diabetes, the proportion of T1D was 6.5% (n=66) among cases and 2.0% among controls (n=40). Diabetes was associated with 1.5-times higher odds of SCA. Compared with those without diabetes, the odds ratio and 95% CI for SCA was 4.36 (95% CI, 2.81 to 6.75; P<.001) in T1D and 1.45 (95% CI, 1.30 to 1.63; P<.001) in T2D after multivariable adjustment. Among those with diabetes, the odds of having SCA were 2.41 times higher in T1D than in T2D (95% CI, 1.53 to 3.80; P<.001). Cases of SCA with T1D were more likely to have an unwitnessed arrest, less likely to receive resuscitation, and less likely to survive compared with those with T2D. CONCLUSION:Type 1 diabetes was more strongly associated with SCA compared with T2D and had less favorable outcomes following resuscitation. Diabetes type could influence the approach to risk stratification and prevention of SCA.