BACKGROUND:Implanted cardioverter-defibrillators (ICDs) have been used in patients with hypertrophic cardiomyopathy (HCM) to prevent sudden death, and have proven lifesaving for many patients. However, experience with ICD therapy has largely been derived from relatively small HCM cohorts confined to specific countries or regions of the world. Therefore, we sought to determine the effectiveness of ICDs in preventing sudden death due to life-threatening ventricular arrhythmias in a large international multicenter HCM population. METHODS:Databases from 25 HCM centers (8 in the United States, 9 in Europe, 4 in Asia, and 1 each in Australia, Africa, Mexico, and South America) were retrospectively interrogated to identify consecutive patients with HCM with ICDs (1992 to 2024) followed for 7±6 years (up to 32 years) for clinical outcomes. RESULTS:A total of 3387 patients were identified (63% men). They had a mean left ventricular thickness of 22±7 mm. The participants had received ICDs at a mean age of 47±17 years. Over follow-up, 550 patients (16%) experienced ≥1 appropriate ICD therapy (2.6%/y), including 86 of the 247 implanted for secondary prevention (35% [6.4%/y]) and 464 of the 3140 implanted for primary prevention (15% [2.2%/y]). Appropriate therapy occurred in the 464 primary prevention patients at a mean age of 49±17 years, with a median time to first appropriate therapy of 4 years after ICD implantation; 16% of these received their first appropriate therapy ≥10 years after implantation, and 47% experienced multiple interventions. Independent predictors of appropriate ICD therapy included unexplained syncope, left ventricular apical aneurysms, left ventricular systolic dysfunction, and nonsustained ventricular tachycardia on ambulatory monitoring. Of the 3140 primary prevention patients, 2946 survived (94%) and 194 died (6%) (0.8%/y), including 68 due to HCM (0.3%/y), predominantly of end-stage heart failure (n=43) or stroke (n=9). In contrast, 11 patients (0.4%) died suddenly, with device failures occurring in 2.4% of those with life-threatening ventricular tachyarrhythmias. Survival free from HCM-related mortality at 10 and 20 years was 97% and 91%, respectively. CONCLUSIONS:In this international multicenter study, the largest to date, including >3300 consecutive patients with HCM and ICDs, device therapy terminated potentially lethal ventricular tachyarrhythmias in 1 of 6 patients, with low HCM-related mortality rates for patients with ICDs. These novel data demonstrate the effectiveness of the ICD initiative, which has probably favorably altered the natural history of many patients with HCM worldwide.

IMPORTANCE:Asia faces a rapidly rising burden of cardiovascular disease (CVD). Preventive cardiology efforts may help address the CVD epidemic. OBSERVATIONS:Solutions to address the CVD burden include a cardiovascular risk assessment framework, improving health screening efforts, better cardiovascular risk factor management, novel innovation strategies encompassing targeted lifestyle measures, and strengthening governmental efforts. With the region's wide socioeconomic and other disparities, contextualizing and practical adaptation of various strategies into local practices, especially in low-middle-income countries, will determine the success of CVD prevention efforts. CONCLUSIONS:A differential approach addressing cardiovascular risk factor screening, prevention, and management that considers the context-specific socioeconomic, governmental, and cultural aspects in diverse Asian populations may help reduce the rapidly rising CVD trajectory in Asia.

IMPORTANCE:Asia is home to 60% of the world's population, including the world's 2 most populous countries, India (1.1B) and China (1.2B). With cardiovascular disease burden and mortality increasing, the role of preventive cardiology is increasingly important. OBSERVATIONS:The challenges in addressing the cardiovascular disease burden in Asia include unique cardiometabolic features of the different populations, heterogeneity of risk factors among Asian countries, differing levels of health literacy and socioeconomic status, suboptimal infrastructure to support preventive care especially in the primary care sector, high out-of-pocket costs, and environmental pollution. CONCLUSIONS:Asia is a large continent that comprises diverse populations with varying cultures, socioeconomic status, and health literacy levels. Effective preventive cardiology may require differential health care resource allocation and financing models.

Heart failure (HF) patients with reduced ejection fraction (HFrEF), normal atrioventricular (AV) conduction and left bundle branch block (LBBB) respond well to cardiac resynchronization therapy (CRT). While guidelines give the strongest recommendation for patients with a QRS≥150 ms, evidence suggests that those with moderately wide QRS (120-149 ms) may also benefit from CRT. In select patients, including those with moderately wide QRS, adaptive CRT might offer better outcomes than conventional biventricular CRT. Asian HF patients often have moderately wide QRS, but the clinical benefit of adaptive versus conventional CRT in this population is not well-established. To test the hypothesis that adaptive CRT would increase the proportion of patients with an improved Clinical Composite Score (CCS) at 6 months compared to conventional CRT in Asian HFrEF patients with normal AV conduction, LBBB and moderately wide QRS. This randomized, multi-center, single-blinded trial enrolled Asian HF patients (between January 2020 and March 2023) receiving optimal medical therapy that had NYHA class II-IV HF symptoms, left ventricular EF ≤35%, PR interval ≤200ms, LBBB, and QRS 120-149 ms. Patients were implanted with a CRT device and 1:1 randomized to receive adaptive CRT or conventional CRT and followed for 12 months. The primary outcome was the proportion of patients with an improved CCS at 6-months. Secondary outcomes were change in NYHA class, hospitalization for worsening HF, and all-cause and cardiovascular (CV) mortality. A total of 171 Asian HFrEF patients from 8 countries were randomized to adaptive CRT (n=86) or conventional CRT (n=85). Baseline characteristics and medications were similar across therapy arms (Table 1). Mean follow-up was 11.8 and 12.1 months in the adaptive CRT and conventional CRT arms, respectively. The proportion of patients with an improved CCS at 6 months was 77% in the adaptive CRT arm and 80% in the conventional CRT arm (Figure 1; p=0.61). With both CRT therapy arms combined, the CCS at 6 months improved in 78.4% and was unchanged in 12.3%. At 6 months, 67.9% of adaptive CRT and 72.0% of conventional CRT patients had an improved NYHA class relative to baseline (p=0.47), while at 12 months, 79.8% of adaptive CRT and 72.3% of conventional CRT patients had improved (p=0.30). Compared to the conventional CRT arm, at 12 months the adaptive CRT arm had similar rates of HF hospitalization (9.4% v. 11.8%; p=0.64), all-cause mortality (7.1% vs. 5.9%; p=0.78) and CV mortality (3.5% vs. 2.3%; p=0.98). While adaptive CRT was not superior to conventional CRT, 90.6% of patients across both therapy arms benefited from CRT based on the CCS at 6 months. These findings indicate benefit of CRT in Asian HFrEF patients with normal AV conduction, LBBB, and QRS 120-149ms. A stronger level of recommendation for CRT may be warranted in this patient population.

BACKGROUND AND AIMS:To improve upon the estimation of 10-year cardiovascular disease (CVD) event risk for individuals without prior CVD or diabetes mellitus in the Asia-Pacific region by systematic recalibration of the SCORE2 risk algorithm. METHODS:The sex-specific and competing risk-adjusted SCORE2 algorithms were systematically recalibrated to reflect CVD incidence observed in four Asia-Pacific risk regions, defined according to country-level World Health Organization age- and sex-standardized CVD mortality rates. Using the same approach as applied for the original SCORE2 models, recalibration to each risk region was completed using expected CVD incidence and risk factor distributions from each region. RESULTS:Risk region-specific CVD incidence was estimated using CVD mortality and incidence data on 8 405 574 individuals (556 421 CVD events). For external validation, data from 9 560 266 individuals without previous CVD or diabetes were analysed in 13 prospective studies from 12 countries (350 550 incident CVD events). The pooled C-index of the SCORE2 Asia-Pacific algorithms in the external validation datasets was .710 [95% confidence interval (CI) .677-.744]. Cohort-specific C-indices ranged from .605 (95% CI .597-.613) to .840 (95% CI .771-.909). Estimated CVD risk varied several-fold across Asia-Pacific risk regions. For example, the estimated 10-year CVD risk for a 50-year-old non-smoker, with a systolic blood pressure of 140 mmHg, total cholesterol of 5.5 mmol/L, and high-density lipoprotein cholesterol of 1.3 mmol/L, ranged from 7% for men in low-risk countries to 14% for men in very-high-risk countries, and from 3% for women in low-risk countries to 13% for women in very-high-risk countries. CONCLUSIONS:The SCORE2 Asia-Pacific algorithms have been calibrated to estimate 10-year risk of CVD for apparently healthy people in Asia and Oceania, thereby enhancing the identification of individuals at higher risk of developing CVD across the Asia-Pacific region.

The burden of atrial fibrillation (AF) is increasing worldwide; however, most existing data on AF epidemiology are from Western regions. According to our analyses, the estimated absolute prevalence of AF in the Asia-Pacific region in 2023 was approximately 80 million, which is much higher than has been calculated for other global regions.

Coronary obstruction during transcatheter aortic valve replacement (TAVR) poses a significant threat, prompting a closer examination of prevention and bailout strategies. Following TAVR deployment with a coronary artery obstruction complication and recognizing the complexities involved in engaging the left main coronary artery through TAVR cells. This case introduces the "Ping-pong" technique using a second guide catheter. When faced with difficulty in engaging the catheter through TAVR cells, an innovative solution is proposed. Inserting a wire into the valsalva and utilizing a rapid inflate-deflate balloon maneuver successfully facilitates catheter access into the left main, offering a promising intervention for challenging scenarios. In conclusion, this study emphasizes the severe implications of coronary obstruction during TAVR. The innovative "Ping-pong" technique and rapid inflate-deflate balloons emerge as valuable interventions, showcasing their potential in challenging catheter engagement scenarios. These insights offer a promising avenue for enhancing patient outcomes in TAVR procedures.

On May 27, 2022, the Asia Pacific Heart Rhythm Society and the Heart Rhythm Society convened a meeting of leaders from different professional societies of healthcare providers committed to arrhythmia care from the Asia Pacific region. The overriding goals of the meeting were to discuss clinical and health policy issues that face each country for providing care for patients with electrophysiologic issues, share experiences and best practices, and discuss potential future solutions. Participants were asked to address a series of questions in preparation for the meeting. The format of the meeting was a series of individual country reports presented by the leaders from each of the professional societies followed by open discussion. The recorded presentations from the Asia Summit can be accessed at https://www.heartrhythm365.org/URL/asiasummit-22. Three major themes arose from the discussion. First, the major clinical problems faced by different countries vary. Although atrial fibrillation is common throughout the region, the most important issues also include more general issues such as hypertension, rheumatic heart disease, tobacco abuse, and management of potentially life-threatening problems such as sudden cardiac arrest or profound bradycardia. Second, there is significant variability in the access to advanced arrhythmia care throughout the region due to differences in workforce availability, resources, drug availability, and national health policies. Third, collaboration in the area already occurs between individual countries, but no systematic regional method for working together is present.

Despite reductions in the mortality of Kawasaki disease with advances in its treatment, a proportion of patients still develop coronary artery dilatation that may persist even into adulthood. These lesions carry an increased risk of myocardial ischaemia and infarction. However, published clinical guidelines on the management and long-term follow up of patients with these late complications of Kawasaki disease are limited. The Asian Pacific Society of Cardiology convened an expert panel to review the available literature and develop consensus recommendations to guide clinicians in this area. The panel developed statements on the assessment and risk stratification of coronary artery disease, investigations for follow up, as well as considerations around treatment of stenotic lesions with medical therapy, percutaneous coronary intervention and coronary artery bypass grafting. Each statement was voted on by each panel member and consensus was reached when 80% of experts voted ‘agree’ or ‘neutral’. This process resulted in the development of consensus recommendations to guide cardiologists and internists in the follow up and management of patients with coronary artery lesions as a late complication of Kawasaki disease.

Abstract Aims The aim of the Mid‐Q Response study is to test the hypothesis that adaptive preferential left ventricular‐only pacing with the AdaptivCRT algorithm has superior clinical outcomes compared to conventional cardiac resynchronization therapy (CRT) in heart failure (HF) patients with moderately wide QRS duration (≥120 ms and <150 ms), left bundle branch block (LBBB), and normal atrioventricular (AV) conduction (PR interval ≤200 ms). Methods This prospective, multi‐center, randomized, controlled, clinical study is being conducted at approximately 60 centers in Asia. Following enrollment and baseline assessment, eligible patients are implanted with a CRT system equipped with the AdaptivCRT algorithm and are randomly assigned in a 1:1 ratio to have AdaptivCRT ON (Adaptive Bi‐V and LV pacing) or AdaptivCRT OFF (Nonadaptive CRT). A minimum of 220 randomized patients are required for analysis of the primary endpoint, clinical composite score (CCS) at 6 months post‐implant. The secondary and ancillary endpoints are all‐cause and cardiovascular death, hospitalizations for worsening HF, New York Heart Association (NYHA) class, Kansas City Cardiomyopathy Questionnaire (KCCQ), atrial fibrillation (AF), and cardiovascular adverse events at 6 or 12 months. Conclusion The Mid‐Q Response study is expected to provide additional evidence on the incremental benefit of the AdaptivCRT algorithm among Asian HF patients with normal AV conduction, moderately wide QRS, and LBBB undergoing CRT implant.

Abstract Funding Acknowledgements Type of funding sources: None. Background Suicide and euthanasia accounts for 14.3% of deaths in those with psychiatric conditions. The rest are attributed to preventable causes such as cardiovascular disease, respiratory disease, and infections. Several psychotropic medications have been associated with sudden death due to their effect on prolonging QT interval, resulting in the development of a polymorphic ventricular arrhythmia, Torsades de Pointes (TdP). TdP may be self-limiting or lead to sudden cardiac arrest and death. Purpose This study aims to evaluate the cardiotoxic effects of psychotropic medications. Method This is a descriptive retrospective study of patients submitted to the local psychiatric wards within one year. Patients with psychotropic drug prescriptions were included while patients below 18 years old, pregnant, or did not have ECG performed were excluded. The control group consisted of sex- and age- matched patients with ECG conducted for occupational health purposes. Multiple regression models were conducted to investigate the predictors of significant ECG differences. Result Of the 154 psychiatric inpatients admitted, exclusions were 44 patients due to exclusion criteria and 19 patients due to difficulty in physical file access. The study population (n = 91) had a mean age of 36.7 years old with 40.7% female and 59.3% male. The predominant diagnoses were schizophrenia and delusional disorders (58.2%). 86 psychiatric patients (94.5%) were prescribed antipsychotic drugs (APD). A significantly higher proportion of psychiatric patients has a history of smoking (p < 0.001), alcohol consumption (p = 0.001), and illicit drug use (p < 0.001). They also exhibited significantly more co-morbid illnesses including hypertension (p = 0.022), hyperlipidaemia (p = 0.013), diabetes (p = 0.026) and thyroid disease (p = 0.023) than the control population. Psychiatric patients had a significantly higher mean heart rate (79.9 vs 69.6 ms; p < 0.001) and QTc interval (452.2 vs 418.6ms; p < 0.001). Mean QTc interval was significantly longer for psychiatric patients in both male (454.2 vs 414.5ms; p < 0.001) and female (449.3 vs 425.6 ms; p = 0.029) gender. Psychotropic drug use is a significant predictor for both prolonged heart rate (p < 0.001) and prolonged QTc interval (p < 0.001). Electrolyte imbalance is a significant predictor of prolonged QTc interval only (p = 0.036). One year follow of both groups detected only 1 psychiatric patient with palpitation. Conclusion Psychiatric patients on psychotropic medications have a longer baseline heart rate and QTc interval, which was not associated with MACE at 1 year. None of the underlying comorbidities and lifestyle choices were significant predictors of this. Electrolyte abnormalities and psychotropic drug use significantly predicted QTc prolongation. However, these findings were largely driven by APD use. A follow-up study of a longer period is recommended to investigate whether patients with prolonged QTc interval are of higher risk of MACE occurrence.

Introduction Our aims were to characterize the differences in transit time flow measurement (TTFM) between failed and normal grafts, and to determine the association between TTFM and related clinical factors and the likelihood of graft failure and major adverse cardiac events (MACE) following coronary artery bypass grafting. Material and methods A retrospective observational analysis was performed on 279 patients admitted between 2017 and 2019, to compare the differences in TTFM between failed and normal grafts, and the association between TTFM and major adverse cardiac events (MACE) – specifically angina, myocardial infarction, and death. Results There were no differences in TTFM between failed and normal grafts. There was a greater number of failed grafts with pulsatility index (PI) > 5 compared to PI ≤ 5 (χ2 = 4.021, p = 0.045). Multivariate analysis showed no significant association between TTFM and MACE. Increased risk of graft failure is associated with the female gender (p = 0.031), history of congestive heart failure (p = 0.025), and poor renal function (p = 0.034). Increased risk of MACE is associated with a history of coronary intervention (p = 0.041), left coronary dominance (p = 0.018), and renal function (p = 0.009). Conclusions Patency of graft is influenced by gender, congestive heart failure, and renal function, while MACE is influenced by history of coronary intervention and renal function.

Cardiac arrest outcomes in Brunei Darussalam have not been previously reported. The mean (SD) time of arrest to cardiopulmonary resuscitation in hospital was 1.6 min (2.31 min; range 0–6 min) compared to the mean (SD) time of arrest to first cardiopulmonary resuscitation out of hospital of 19 min (23.91 min; range 0–87 min). The majority (71.2%) were out-of-hospital cardiac arrests (OHCA) (versus in-hospital cardiac arrests (IHCA)). One-year median survival for cardiac arrests was 1.4% which is below survival rates reported by other groups previously. Median 1-month survival rates were 25% for IHCA versus 5% for OHCA. Survival rates at 1 month for shockable rhythms were better (40%; p<0.001) for IHCA versus 16.7% for OHCA. Survival from cardiac arrests is low in Brunei Darussalam. This is associated with low rates of bystander cardiopulmonary resuscitation and may need to be addressed to improve outcomes.