BACKGROUND AND PURPOSE:Using the clinical obesity concept recently proposed by the Lancet Diabetes & Endocrinology Commission, this study evaluated the impact of clinical obesity on new-onset atrial fibrillation (AF) in the general population. METHODS:Individuals who underwent first health examinations from June 2006 to October 2007 in Kailuan were included. Based on body mass index (BMI), waist circumference (WC), waist-to-height ratio (WHtR), waist-to-hip ratio (WHR), and presence of obesity-related organ/tissue dysfunction, participants were divided into no obesity, preclinical obesity, and clinical obesity groups. RESULTS:A total of 98 730 participants free from AF at baseline were identified. Of these, 1343 developed new-onset AF over a median follow-up of 16.97 years. The AF incidence densities were 0.67, 0.68, and 1.25 per 1000 person-years in the no obesity, preclinical, and clinical obesity groups, respectively. Compared to the no obesity group, the clinical obesity (HR: 1.29, 95% CI: 1.12-1.47) group showed increased risks of new-onset AF. Clinical obesity remained associated with higher new-onset AF risk in participants aged < 45 years (HR: 2.34, 95% CI: 1.42-3.86) and 45- < 60 years (HR: 1.40, 95% CI: 1.14-1.71). In men, clinical obesity was associated with 35% higher risks of new-onset AF (HR: 1.34, 95% CI: 1.16-1.55). No significant association was observed between clinical obesity and new-onset AF in participants with a history of using anti-hypertensive agents (HR: 0.98, 95% CI: 0.73-1.30). CONCLUSIONS:Clinical obesity is an independent risk factor for new-onset AF, with age- and sex-specific associations, while metabolic-targeted therapies were associated with attenuated obesity-associated new-onset AF risk.

Introduction: The presence of a chronic total occlusion (CTO) has been associated with increased risk of sudden cardiac death (SCD) and/or ventricular arrhythmias (VAs). This study aimed to evaluate the impact of CTO revascularization on SCD and/or VAs. Methods: A systematic review of the literature was performed to identify studies evaluating the association between CTO revascularization and risk of SCD and/or VAs. Results: Six studies were included in the final meta-analysis. The total sample size included 2,017 participants for the assessment of the primary outcome of interest and 868 participants for the assessment of the secondary outcome of interest. In 5 studies examining the association between CTO revascularization and risk of SCD and/or VAs, CTO revascularization was not associated with a statistically significant reduction in the risk of SCD and/or VAs (HR: 0.78; 95% CI: 0.38 to 1.60; p = 0.50, I2 = 87%). Conversely, in 2 studies examining the association between IRA-CTO revascularization and risk of SCD and/or VAs, IRA-CTO revascularization was associated with 79% lower risk of SCD and/or VAs (HR: 0.21; 95% CI: 0.10 to 0.43; p < 0.0001, I2 = 0%). Discussion: CTO revascularization overall was not associated with a lower risk of SCD and/or VAs. In contrast, IRA-CTO revascularization was associated with a lower risk of SCD and/or VAs. However, the study has several limitations, primarily due to the observational nature of the included studies. Conclusion: Successful revascularization of an IRA-CTO should be attempted to reduce the burden of VAs and reduce the risk of SCD.

Introduction:The PRESERVE EF study proposed a two-step algorithm for risk stratification in post-myocardial infarction (MI) patients with mid-range and preserved left ventricular ejection fraction (LVEF). This method assessed the performance of a two-step, programmed ventricular stimulation (PVS)-inclusive approach in identifying high-risk post-MI patients with LVEF ≥40%. This report presents findings from the 8-year follow-up. Methods:The primary endpoint was the occurrence of a major arrhythmic event, defined as sustained ventricular tachycardia/fibrillation, appropriate implantable cardioverter-defibrillator (ICD) activation, or sudden cardiac death (SCD). We included a total of 575 consecutive patients (mean age 57 years, LVEF 50.8%). Of them, 204 (35.5%) had at least one positive non-invasive risk factor. Forty-one of 152 patients undergoing PVS were inducible; 37 (90.2%) of them received an ICD. Results:During a mean follow-up of 106 ± 14.5 months, no SCDs were observed, while 12 ICDs (the major arrhythmic event prevalence in patients with ICD implantation reaching 29.3%) were appropriately activated. The updated performance metrics of the proposed approach were as follows: sensitivity 100% (95% CI: 73.5%-100%), specificity 94.8% (95% CI: 92.5-96.5%), positive predictive value 29.3% (95% CI: 17.2-45.0%), and negative predictive value 100% (95% CI: 99.3%-100%). Notably, events occurred only in patients with an LVEF 40%-50% and a history of ST-Elevation Myocardial Infarction. Conclusion:The PRESERVE EF study demonstrates that a simple, two-step, non-invasive risk factor-guided approach, followed by programmed ventricular stimulation, can effectively identify a subgroup of post-MI patients with preserved or mid-range LVEF ≥40 who are at high risk for major arrhythmic events. Clinical Trial Registration:Clinicaltrials.gov, identifier NCT02124018.

The development of advanced atrioventricular block (AVB) in patients on bradycardic and/or antiarrhythmic therapy (drug-related AVB) represents a clinical challenge, raising the question of whether the AVB is directly caused by these agents (drug-induced AVB) or if the offending drugs exacerbate an underlying conduction system disease. Traditionally, β-blockers, non-dihydropyridine calcium channel blockers, class Ic/III antiarrhythmics, and digoxin have been considered reversible causes of advanced AVB. However, recent evidence shows a weak cause-and-effect relationship between these drugs and AVB in the elderly, along with high recurrence rates of AVB despite initial resolution after drug discontinuation. This may also apply to patients on high doses of these medications, drug combinations, or with additional reversible factors such as hyperkalemia. Despite these considerations, the European Guidelines do not suggest permanent pacing for AVB due to transient causes that are correctable, including bradycardic/antiarrhythmic drug therapy. On the other hand, the American Guidelines recommend permanent pacing for selected patients with symptomatic second- or third-degree AVB who are on stable, necessary antiarrhythmic or β-blocker treatment, without waiting for drug washout or reversibility. Notably, an accumulating body of evidence indicates that true drug-induced AVB is rare, while recurrence rates are high. Therefore, early permanent pacing should be recommended, especially for frail elderly patients. Moreover, in patients with drug-related AVB and atrial tachyarrhythmias, adopting an early permanent pacing approach seems prudent when bradycardic and/or antiarrhythmic treatment is necessary. Finally, delays in permanent pacing are not justified when temporary pacing is needed, given the increased associated risks in such cases.

Brugada phenocopy (BrP) is the electrocardiographic appearance of a Brugada pattern due to various reversible causes that is completely resolved after the correction of the underlying abnormalities. In this short communication, we describe a 56-year-old man who had a transient BrP induced by hyponatremia due to thiazide diuretic therapy. A detailed review of the literature revealed that hyponatremia represents an uncommon cause of BrP while, in many of the published cases, concomitant electrolyte disturbances such as hyperkalemia were present. However, even isolated hyponatremia may provoke a BrP. Clinicians should be aware of this rare cause of BrP, which is reversible and has a favorable outcome.

Left ventricular thrombus is a relatively common and serious complication in patients with left ventricular systolic dysfunction, resulting in an increased risk of embolic events such as ischemic stroke and contributing to higher mortality rates.Current clinical guidelines recommend anticoagulation therapy for 3 to 6 months in patients with left ventricular thrombus; however, the evidence supporting this approach primarily derives from small-scale randomized trials or retrospective observation studies, which limit the generalizability of findings across diverse patient populations.Several critical aspects of left ventricular thrombus identification and management remain inadequately studied, and these areas include optimal time and detection imaging methods, anticoagulation strategies (treatment of choice and optimal duration), and the need for periodic re-evaluation.This review consolidates the current evidence, identifies gaps in left ventricular thrombus management, and proposes individualized strategies that consider factors like left ventricular function and bleeding risks.

Background: The advent of subcutaneous implantable cardioverter defibrillators (S-ICDs) marked a significant milestone in the course of cardiac rhythm devices, particularly for patients who are deemed at high risk for ventricular arrhythmias and sudden cardiac death. This extracardiac approach makes the S-ICD an especially valuable option for young patients, those with difficult venous access, or those at high risk of infection. Although the S-ICD does not provide pacing for bradycardia or heart failure, it has shown efficacy in treating ventricular arrhythmias while minimizing complications associated with transvenous systems. Methods: The purpose of this multicenter retrospective analysis was to assess the real-world efficacy and safety of the S-ICD in a heterogeneous population. Results: The GASP registry consisted of 114 patients, 68% male, aged 41 ± 15 years, with a mean LVEF of 50%. In the follow-up of 35 months, inappropriate shocks occurred in 7% while appropriate shocks occurred in 6.2%. The most common reasons for inappropriate shocks were myopotentials and atrial tachyarrhythmias. Thirty-day complication-free rates were 97.3%, with the majority of patients requiring device extraction due to infection. Over the longer term, four patients required re-intervention due to local discomfort, while one device was extracted for infection. In a multivariate analysis, complications were not significantly higher in the sicker population, such as those with diabetes, kidney disease requiring dialysis, or heart failure. Conclusions: These findings support the growing role of the S-ICD as an alternative to the TV-ICD, especially in patients without pacing indications.

Implantable cardioverter defibrillators (ICDs) represent an established therapeutic strategy for the prevention of sudden cardiac death and reduction of mortality in high-risk patients, while ICDs with cardiac resynchronization therapy defibrillators improve morbidity, quality of life, and mortality in eligible patients with heart failure who are on optimal medical therapy. However, these devices may adversely affect the patients' psychological status after the delivery of shock therapies or even because of the fear of impending therapy. On the other hand, the potential of effective treatment of malignant arrhythmias may provide a 'safety' sensation in most treated patients without significant impairment in the quality of life during periods of clinical stability. During the past few years, an increasing number of reports have investigated psychological distress, including depression and anxiety status in ICD/cardiac resynchronization therapy defibrillator recipients. However, heterogeneous results have been reported while data on the variation of these psychological indexes over time in implanted patients are quite limited. Several intrinsic and extrinsic factors affect the psychological status of these patients while variations of these disturbances in specific populations are evident. Factors that seem to be associated with a greater risk for depression and anxiety in this setting include female gender, younger age, and device shock therapies. Moreover, depression and anxiety may have an adverse impact on patients' clinical outcomes exacerbating heart failure and increasing the arrhythmic risk. In this brief review article, we provide a concise and critical overview of the current literature on this topic, and we also discuss unresolved and conflicting issues delineating future perspectives.

Clonal hematopoiesis of indeterminate potential (CHIP) has emerged as a novel risk factor for cardiovascular diseases. CHIP is characterized by the expansion of hematopoietic stem cell clones harboring somatic mutations in genes such as TET2, DNMT3A, and ASXL1, which are implicated in inflammation, atrial remodeling, and hypercoagulability. These mutations foster a pro-inflammatory and pro-thrombotic environment conducive to arrhythmogenesis, thereby linking CHIP to the development and progression of atrial fibrillation (AF). Mechanistic insights indicate that CHIP contributes to atrial fibrosis, disrupts calcium signaling, and exacerbates oxidative stress, all of which heighten susceptibility to AF. Clinical studies, including epidemiological and Mendelian randomization analyses, further support the association between CHIP and an increased risk of both incident and progressive AF, with specific mutations such as TET2 and ASXL1 identified as significant contributors. Additionally, CHIP has been linked to adverse outcomes in AF, including elevated rates of heart failure, thromboembolism, and mortality. Understanding CHIP's role in AF pathophysiology offers opportunities for the development of precision medicine approaches, providing novel avenues for early intervention and targeted AF treatment. This review synthesizes current mechanistic and clinical evidence on the role of CHIP in AF, emphasizes its potential as a biomarker for risk stratification, and explores emerging therapeutic strategies targeting CHIP-associated pathways.

INTRODUCTION:Cardiac resynchronization therapy (CRT) may affect the patients' psychological status differently in various populations. There are limited data regarding depression and anxiety in this setting, while there are no data regarding Greek patients. METHODS:We studied heart failure with reduced ejection fraction (HFrEF) patients, without conditions affecting psychological status, undergoing CRT. We used the Minnesota Living with Heart Failure Questionnaire (MLHFQ), the 9-item Patient Health Questionnaire (PHQ-9), and the 7-item Generalized Anxiety Disorder Scale (GAD-7) at baseline and 6- and 12-month postimplantation. RESULTS:After excluding seven patients who experienced defibrillator shocks, we analyzed 99 patients (median age: 72 years, 77% men). The baseline MLHFQ score was 37 (interquartile range [IQR]: 36); at 6 months, 1 (IQR: 8); and at 12 months, 0.5 (IQR: 10); p < 0.01. The baseline PHQ-9 score was 9 (IQR: 11); at 6 months, 0 (IQR: 2); and at 12 months, 0 (IQR: 2); p < 0.01. The baseline GAD-7 score was 8 (IQR: 16); at 6 months, 0 (IQR: 1.5); and at 12 months, 0 (IQR: 3); p <0.01. At baseline, 44% of patients had clinically significant depression (PHQ-9 score ≥10), and 45% clinically significant anxiety (GAD-7 score ≥10). The baseline PHQ-9 and GAD-7 scores correlated with the MLHFQ score. The logistic regression analysis revealed that clinically substantial depression at baseline (PHQ-9 ≥ 10) had a negative association with chronic kidney disease [OR: 0.55; p < 0.01]. CONCLUSIONS:Depression and anxiety markedly improved during the 12-month follow-up period after CRT device implantation in HFrEF patients who did not receive shock therapy.

Background and aimsPostoperative atrial fibrillation (POAF) is a frequent complication following cardiac surgery and is associated with adverse clinical outcomes. Our study aimed at determining the clinical and echocardiographic predictors of POAF in patients with cardiac surgery and management of this group of patients may improve their outcome.MethodsWe prospectively enrolled patients from the department of cardiovascular surgery in the Second Hospital of Tianjin Medical University from October 23, 2020 to October 30, 2022, without a history of atrial fibrillation. Cox regression was used to identify significant predictors of POAF.ResultsA total of 217 patients (79 [36.41 %] were female, 63.96 ± 12.32 years) were included. 88 (40.55 %) patients met the criteria for POAF. Cox regression showed that preoperative left atrial diameter (LAD) (HR: 1.040, 95 % CI 1.008–1.073, p = 0.013) and postoperative QRS/LVEDD (HR: 0.398, 95 % CI 0.193–0.824, p = 0.013) and E/e' (HR: 1.029, 95 % CI 1.002–1.057,p = 0.033) were predictors of POAF.ConclusionPreoperative LAD and postoperative QRS/LVEDD and E/e' were predictors of POAF in patients undergoing cardiac surgery.Trial registration sitehttp://www.chictr.org.cnRegistration numberChiCTR2200063344.

Atrial fibrosis is a hallmark of atrial cardiomyopathy and plays a pivotal role in the pathogenesis of atrial fibrillation (AF), contributing to its onset and progression. The mechanisms underlying atrial fibrosis are multifaceted, involving stretch-induced fibroblast activation, oxidative stress, inflammation, and coagulation pathways. Variations in fibrosis types-reactive and replacement fibrosis-are influenced by patient-specific factors such as age, sex, and comorbidities, complicating therapeutic approaches. The heterogeneity of fibrosis leads to distinct electrophysiological abnormalities that promote AF via reentrant activity and enhanced automaticity mechanisms. Despite advancements in imaging, such as late gadolinium enhancement CMR and electroanatomical mapping, challenges in accurately quantifying fibrosis persist. Emerging therapeutic strategies include antifibrotic agents targeting the renin-angiotensin-aldosterone system, novel pathways like TGF-β signaling, and cardio-metabolic drugs like SGLT2 inhibitors and GLP-1 receptor agonists. Innovative interventions, including microRNA modulation and lipid nanoparticle-based therapies, show promise but require validation. Knowledge gaps remain in correlating clinical outcomes with fibrosis patterns and optimizing diagnostic tools. Future research should focus on precise phenotyping, integrating advanced imaging with molecular biomarkers, and conducting robust trials to evaluate antifibrotic therapies' efficacy in reducing AF burden and related complications.

OBJECTIVE:Implantable loop recorders (ILRs) are increasingly being used for long-term cardiac monitoring in different clinical settings. The aim of this study was to investigate the real-world performance of ILRs-including the time to diagnosis-in unselected patients with different ILR indications. METHODS AND RESULTS:In this multicenter, observational study, 871 patients with an indication of pre-syncope/syncope (61.9%), unexplained palpitations (10.4%), and atrial fibrillation (AF) detection with a history of cryptogenic stroke (CS) (27.7%) underwent ILR implantation. The median follow-up was 28.8 ± 12.9 months. In the presyncope/syncope group, 167 (31%) received a diagnosis established by the device. Kaplan-Meier estimates indicated that 16.9% of patients had a diagnosis at 6 months, and the proportion increased to 22.5% at 1 year. Of 91 patients with palpitations, 20 (22%) received a diagnosis based on the device. The diagnosis was established in 12.2% of patients at 6 months, and the proportion increased to 13.3% at 1 year. Among 241 patients with CS, 47 (19.5%) were diagnosed with AF. The diagnostic yield of the device was 10.4% at 6 months and 12.4% at 1 year. In all cases, oral anticoagulation was initiated. Overall, ILR diagnosis altered the therapeutic strategy in 26.1% of the presyncope/syncope group, 2.2% of the palpitations group, and 3.7% of the CS group in addition to oral anticoagulation initiation. CONCLUSION:In this real-world patient population, ILR determines diagnosis and initiates new therapeutic management for nearly one-fourth of patients. ILR implantation is valuable in the evaluation of patients with unexplained presyncope/syncope, CS, and palpitations.

AbstractAimsThe left bundle branch block (LBBB) is a strong predictor of response to cardiac resynchronization therapy (CRT). However, a significant number of patients do not respond to the treatment. The study sought to evaluate the impact of the stricter Strauss criteria for left bundle branch block (St‐LBBB) on CRT response, hospitalizations, ventricular arrhythmia (VA) events and mortality.MethodsThis study is a retrospective analysis of prospectively collected data on heart failure (HF) patients with LBBB admitted for CRT implantation. Patients were divided into two groups according to the fulfilment or not of St‐LBBB criteria.ResultsThe study included 82 patients with ischaemic (ICM) and non‐ischaemic (NICM) cardiomyopathy [46 (56%) with St‐LBBB and 36 (44%) with non‐St‐LBBB]. Patients with St‐LBBB showed higher CRT response rates compared with those with non‐St‐LBBB (P < 0.01), while the group with NICM exhibited the greatest benefit (P < 0.01). St‐LBBB CRT responders displayed significantly lower rates of HF hospitalization (P < 0.0001) compared with the non‐St‐LBBB group. According to Kaplan–Meier time curves, this was primarily evident in patients with NICM (P < 0.0001). CRT responders displayed significantly fewer VA events (P < 0.001) and lower mortality rates (P < 0.0001) than non‐responders. Kaplan–Meier estimates demonstrated a significantly lower incidence of VAs in NICM patients with St‐LBBB (P = 0.049) compared with ICM patients with St‐LBBB (P = 0.25). Lower mortality rates were observed in CRT responders than non‐responders (P < 0.0001), with the group of NICM with St‐LBBB criteria exhibiting the greatest benefit (P = 0.0238).ConclusionsPatients with NICM and St‐LBBB present the greatest benefit concerning CRT response, HF hospitalizations, VA events and mortality. Although St‐LBBB criteria seem to improve patient selection for CRT, more data are needed to elucidate the role of St‐LBBB criteria in this setting.

Atrial fibrillation (AF) is the most common arrhythmia in clinical practice and it is associated with increased morbidity and mortality. AF is linked with inflammatory signalling while inflammation and oxidative stress promote atrial remodelling, favouring the development and perpetuation of the arrhythmia. On the other hand, ankylosing spondylitis (AS) is considered a chronic inflammatory rheumatic condition with flares and remissions that affects the axial skeleton and mainly young people. AS has been associated with an increased risk of valvular and aorta disease but its relationship with AF has not been studied well. Recent epidemiological evidence indicates an association between AS and AF. This brief review provides a concise overview of all available data regarding the association between AS and AF including the predictive role of electrocardiographic and echocardiographic markers. Several unresolved issues including the thromboembolic risk in this setting and the potential role of anti-inflammatory interventions are also discussed.