Aims Despite well-established evidence linking alcohol consumption to an increased risk of atrial fibrillation (AF), a clear threshold for safe intake remains undefined. Most clinical guidelines recommend abstinence or moderation, but lack specificity regarding quantitative limits and evidence-based thresholds for primary prevention of AF. Methods and results We performed this systematic review, pairwise meta-analysis, and network meta-analysis to assess the association and dose-response relationship between varying quantities of alcohol consumption and incident AF. The predefined alcohol intake categories included: no intake, very low (<12 g/day), low (12.1-24 g/day), moderate (24.1-48 g/day), high (48.1-60 g/day), and very high (>60 g/day). The pairwise meta-analyses compared each intake category to no intake, and a frequentist network meta-analysis was conducted to integrate direct and indirect comparisons. Pooled risk ratio (RR) for AF incidence were estimated using random-effects models, and a subgroup analysis by sex was performed. Twenty-six studies with nearly 15 million participants were included. As compared to those with no alcohol intake, very high alcohol intake was associated with a 75% increased risk of incident AF (RR 1.75; 95% CI: 1.25-2.44, P = 0.04), intake below 48 g/day was associated with modestly lower AF risk, and the lowest risk was observed at <12 g/day (RR 0.72; 95% CI: 0.63-0.83). The weighted mean follow-up was approximately 6.4 years. Network meta-analysis confirmed these findings and demonstrated a significantly increased AF risk with very high compared to low (RR 1.91), moderate (RR 2.03), and high (RR 2.00) levels. Sex-stratified analyses showed similar results. Conclusion Alcohol consumption is associated with a nonlinear, threshold-dependent relationship with incident AF. While low to moderate intake may not increase AF risk, intake beyond 60 g/day significantly increases the AF risk. These findings may suggest that a more liberal approach to alcohol consumption, particularly at low to moderate levels, could be reasonable in the general population, though further prospective studies are needed to confirm causality and refine individual risk stratification.

Cardiac arrhythmia is increasingly encountered in patients with cancer, not only as a result of shared risk factors but also as a direct consequence of malignancy and its therapies. This evolving overlap has positioned arrhythmia management as a key component of cardio-oncology practice. This review outlines current strategies for managing atrial and ventricular arrhythmias, conduction disorders, and device-related considerations in patients with cancer. It emphasizes the importance of evaluating drug-drug interactions between antiarrhythmics, anticoagulants, and cancer therapies, particularly in the context of QT interval prolongation, bradycardia, or thrombocytopenia. Therapeutic decisions, such as initiating antiarrhythmics, pursuing ablation, or implanting cardiac devices, must weigh life expectancy, procedural risk, cancer stage, and overall treatment goals. Special attention is given to the timing and safety of electrophysiologic interventions in patients receiving chemotherapy, radiation, or hematopoietic stem cell transplantation. The review also explores emerging tools like remote monitoring and artificial intelligence to detect early arrhythmia, personalize therapy, and reduce complications. As cardiovascular and oncologic care become increasingly intertwined, multidisciplinary collaboration is essential to balance rhythm control with cancer treatment goals. The integration of cardiology, oncology, and electrophysiology expertise will be vital in optimizing outcomes for this high-risk population.

Background Increasing procedural volumes in the electrophysiology and cardiac catheterization laboratories (EP/CCLs) expose physicians, staff, and nurses to hazards from ionizing radiation and prolonged lead-apron use. Objectives To characterize the adverse health outcomes among contemporary EP/CCL workers and to evaluate an educational intervention to mitigate risk. Methods Two surveys were distributed 3 months apart to the American College of Cardiology chapters and assessed injuries and ailments, perceived risk awareness, and knowledge of potential interventions to mitigate harm. The initial survey was paired with a video on ergonomic strategies to prevent musculoskeletal (MSK) injury, radiation safety principles, and best practices for pregnant workers. Univariable logistic regression models were used to assess associations between each baseline variable separately and health outcomes related to occupational hazards. Results Of the 306 initial respondents, 70% were 31 to 60 years old, and 43% were women. Thirty-six percent were interventional cardiologists, 30% were nonphysician cardiovascular team members, 64% had >10 years' EP/CCL experience, and 43% wore lead >8 hours/day. Risk factors for MSK pain/injury included age ≥50 (adjusted OR [aOR]: 2.19; 95% CI: 1.15 to 4.16; P = 0.02), lead-apron use >4 hours/day (aOR: 2.39; 95% CI: 1.31-4.39; P = 0.05), and limited knowledge of mitigation strategies (aOR: 4.62; 95% CI: 1.62-11.45; P = 0.003). Among women with prior pregnancy, 41.5% reported worsening MSK discomfort due to occupational duties; 52.1% lacked opportunities to adjust procedural load; and 76% could not reduce work hours. On follow-up, 75.9% reported adopting ergonomic techniques from the video. Conclusions Occupational hazards remain prevalent in the modern EP/CCL. Focused educational interventions may help to reduce injuries and risks.

Background Increasing procedural volumes in the electrophysiology and cardiac catheterization laboratories (EP/CCLs) expose physicians, staff, and nurses to hazards from ionizing radiation and prolonged lead-apron use. Objectives To characterize the adverse health outcomes among contemporary EP/CCL workers and to evaluate an educational intervention to mitigate risk. Methods Two surveys were distributed 3 months apart to the American College of Cardiology chapters and assessed injuries and ailments, perceived risk awareness, and knowledge of potential interventions to mitigate harm. The initial survey was paired with a video on ergonomic strategies to prevent musculoskeletal (MSK) injury, radiation safety principles, and best practices for pregnant workers. Univariable logistic regression models were used to assess associations between each baseline variable separately and health outcomes related to occupational hazards. Results Of the 306 initial respondents, 70% were 31 to 60 years old, and 43% were women. Thirty-six percent were interventional cardiologists, 30% were nonphysician cardiovascular team members, 64% had >10 years' EP/CCL experience, and 43% wore lead >8 hours/day. Risk factors for MSK pain/injury included age >= 50 (adjusted OR [aOR]: 2.19; 95% CI: 1.15 to 4.16; P = 0.02), lead-apron use >4 hours/day (aOR: 2.39; 95% CI: 1.31-4.39; P = 0.05), and limited knowledge of mitigation strategies (aOR: 4.62; 95% CI: 1.62-11.45; P = 0.003). Among women with prior pregnancy, 41.5% reported worsening MSK discomfort due to occupational duties; 52.1% lacked opportunities to adjust procedural load; and 76% could not reduce work hours. On follow-up, 75.9% reported adopting ergonomic techniques from the video. Conclusions Occupational hazards remain prevalent in the modern EP/CCL. Focused educational interventions may help to reduce injuries and risks. (c) 2026 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

BACKGROUND:Leadless pacemakers are considered a low-risk alternative to single-lead pacemakers (SL-PPMs). In 2021, the FDA issued a warning regarding leadless pacemakers because of increased morbidity and mortality from perforation. Clinical outcome data is limited. The National Readmissions Database (NRD) is a nationally representative annualized sample of US hospitalizations that may shed insight on patient selection and procedural risks from leadless pacemaker implantation. OBJECTIVE:Determine patient selection, adverse events and mortality rates related to leadless pacemakers versus SL-PPM using the NRD. METHODS:NRD data was analyzed from January 2016 to December 2019. ICD-10 and ICD-CM 10 coding was used to identify patients and adverse outcomes. Predictors of mortality and cardiac perforation were determined by multivariable regression. RESULTS:Distribution of age and gender were similar between both groups. Patients receiving single-chamber leadless pacemakers were more likely to be dialysis dependent, have diabetes and obstructive sleep apnea. Mortality was higher in leadless pacemakers (5.3% vs. 1.9%, p < 0.001) with a higher incidence of adverse outcomes. A multivariable regression model found that dialysis dependence and pulmonary hypertension increased the risk for mortality in leadless pacemakers while obstructive sleep apnea and diabetes were associated with lower risk. Leadless pacemakers had an adjusted odds ratio of 2.74 and 2.92 for death and perforation respectively. CONCLUSIONS:Mortality rates were higher in patients receiving leadless pacemakers with a higher incidence of adverse outcomes in patients with dialysis dependence and pulmonary hypertension. Clinical benefits may be offset by increased risk of procedural mortality and adverse outcomes.

Nonischemic cardiomyopathy (NICM) is common and patients are at significant risk for early mortality secondary to ventricular arrhythmias. Current guidelines recommend implantable cardioverter-defibrillator (ICD) therapy to decrease sudden cardiac death (SCD) in patients with heart failure and reduced left ventricular ejection fraction. However, in randomized clinical trials comprised solely of patients with NICM, primary prevention ICDs did not confer significant mortality benefit. Moreover, left ventricular ejection fraction has limited sensitivity and specificity for predicting SCD. Therefore, precise risk stratification algorithms are needed to define those at the highest risk of SCD. This review examines mechanisms of sudden arrhythmic death in patients with NICM, discusses the role of ICD therapy and treatment of heart failure for prevention of SCD in patients with NICM, examines the role of cardiac magnetic resonance imaging and computational modeling for SCD risk stratification, and proposes new strategies to guide future clinical trials on SCD risk assessment in patients with NICM.

BackgroundPower-on reset (PoR) is most commonly due to electromagnetic interference. Full PoR results in a switch to an inhibited mode (VVI) pacing and resets pacing outputs to maximal unipolar settings, leading to extracardiac stimulation. MethodsWe present a case of PoR occurrence in the absence of electromagnetic interference, resulting in pectoral stimulation triggered by violation of the atrial rate limit. ConclusionsIt is useful for clinicians to recognizethe occurrence of PoR in the setting of atrial limit violation andthe appropriate management in such circumstances.

Introduction: SCN5A mutations are associated with numerous cardiovascular conditions, including dilated cardiomyopathy, atrial fibrillation, and sick sinus syndrome. Specific variants in patients with severe atrial dysfunction may be associated with increased risk of stroke even in young patients. Case: This case describes a previously healthy 38-year-old male of French descent who presented with intermittent palpitations and presyncope associated with atrial flutter followed by prolonged conversion pauses up to 7.5 seconds, then followed by junctional bradycardia. Echocardiogram showed a mildly dilated left atrium. Electrophysiology study demonstrated extensive scarring in the left atrium with normal sinus node function and right atrial voltage. No atrial fibrillation was noted. He was also found to have typical atrial flutter and mitral flutter. He underwent cavotricuspid isthmus ablation and mitral annular flutter ablation. Due to his vagal-mediated pauses and junctional rhythm, he also underwent cardioneuroablation aimed at partial denervation. Following this, he had further episodes of junctional rhythm on the days after exercise. He underwent further total cardioneuroablation and was found to have progressive scarring at the sinus node area and sinus node dysfunction, so a permanent pacemaker was placed. He underwent genetic testing which demonstrated SCN5A heterozygous missense pathogenic variant c.2823G>A. Conclusion: The SCN5a gene encodes the alpha subunit of the cardiac sodium channel, which is responsible for initiation and propagation of action potentials. SCN5A variants are associated with a number of cardiovascular conditions. There are reports of stroke in young French patients with severe atrial dysfunction and SCN5A mutations, including variant c.2823G>A, demonstrating that severe atrial dysfunction is a risk factor for stroke regardless of CHADS2VASc score, and specific SCN5A mutations may be associated with increased risk of stroke. Given these reports and absence of relevant guidelines, apixaban was continued indefinitely for prevention of stroke. At follow-up two months later, the patient resumed physical activity and reported symptomatic improvement, without any episodes of syncope or near syncope.

Procedural complications involving MICRA (leadless pacemaker) according to the Manufacturer and User Facility Device Experience (MAUDE) database were first reported by our group in 2019. Recently published U.S. registry structural heart data has suggested higher procedural complications related in women when compared with men. We reviewed data reported in the Nationwide Readmission Database from 2016-2018 to assess the risk of major adverse events (MAE) by gender in MICRA when compared with single-lead transvenous pacemakers (SL-PPM).

Purpose of Review The risk of cardiac implantable electronic device (CIED) interference from cell phones was previously thought to be low based on older studies. Current generation of smartphones have incorporated more magnets for optimization of wireless charging, attachment of accessories, and convenience functionalities. These magnets have the potential to cause CIEDs to inadvertently revert into magnet mode. The purpose of this review is to summarize recent findings on smartphones and their accessories causing interference on CIEDs. Recent Findings Recent reports have demonstrated that the iPhone 12 series and accessories have the capability to cause CIED magnetic interference. Summary Current generation of smartphones, smartwatches, wireless headphones, and accessories have the potential to cause CIEDs to revert into magnet mode in both in vivo and ex vivo experiments. The risk of a clinically significant event is unlikely as long as the Food and Drug Administration (FDA) recommendations are followed; keeping smartphones and accessories at least six inches away from CIEDs.

Introduction Atrioventricular nodal reentrant tachycardia (AVNRT) and atrioventricular reentrant tachycardia (AVRT) are frequently associated with atrial fibrillation (AF). Targeting the slow or accessory pathways has been advocated as therapy for coexisting AF. But in practice, AF has frequently recurred after ablation, possibly because of various risk factors. The objective of this study is to investigate these risk factors and check for their significance in AF recurrence. Materials and methods A systematic review of Medline, Cochrane, and ClinicalTrials.gov databases was conducted. Articles that studied AF recurrence after either AVNRT or AVRT ablation were reviewed. Publication bias was adequately assessed, and the random method was applied for all dichotomous values. Finally, the odds ratio (OR) and confidence intervals (CI) were calculated for each risk factor. Results Four studies were included, with a total of 1,308 participants. Only 218 participants had dual tachycardia (AF with either AVNRT or AVRT). The mean follow-up time was 29 +/- 3.3 months. The mean age was 56 +/- 15 years. Age constituted the only significant risk factor for AF recurrence (OR: 3.4, CI: 2.1-5.3, p<0.001). Atrial vulnerability did not significantly correlate with a higher risk of AF recurrence (OR: 4.8, CI: 0.7-29, p<0.008). Again, neither male gender (OR: 1.5, CI: 0.8-2.8, p<0.16) nor left atrial diameter (OR: 1.5, CI: 0.2-10, p<0.67) were significant risk factors for recurrence of AF. Conclusion Older age was the only significant predictor of AF recurrence after ablation of AVNRT or AVRT. Further studies are needed to determine the age cut-off at which concomitant pulmonary vein isolation would be beneficial in patients undergoing ablation of AVNRT/AVRT.

BACKGROUND:The Biotronik DX lead is an attractive option due to its floating atrial bipole and its noninferiority compared to dual-chamber defibrillators.METHODS:We describe the case of atrial undersensing by the DX lead resulting in failure of the device to appropriately treat a slow ventricular tachycardia.CONCLUSION:This case underlies the importance of understanding the limitations to each lead technology as well as the underlying assumptions inherent to detection enhancement algorithms.

Cardiac resynchronization therapy is an established treatment modality in heart failure. Though non-response is a serious issue. To address this issue, a good understanding of the electrical activation during left bundle branch block, biventricular, as well as right- and left ventricular pacing is needed. This way by interpreting the 12-lead electrocardiogram, possible reasons for suboptimal treatment can be identified and addressed. This article reviews the literature on QRS morphology in cardiac resynchronization therapy and its meaning in optimization of therapy.

Cardiac papillary fibroelastomas are the most common primary valvular tumors. Generally benign, they account only for about 10% of all primary cardiac neoplasms, can occur in normal or diseased hearts, and are associated strongly with open heart surgery and radiotherapy. They are, in most cases, incidental findings, but can be discovered after syncope. We report the case of an elderly female, who was referred for syncope and was found to have a large fibroelastoma at the mitral valve annulus, intermittently obstructing the left ventricular inflow tract, and mimicking the presentation of left atrial myxoma. This case illustrates another potential mechanism of syncope in patients with fibroelastomas.

Gastroduodenal artery (GDA) aneurysms are rare but a potentially fatal condition if rupture occurs. They represent about 1.5% of all visceral artery (VAA) aneurysms and are divided into true and pseudoaneurysms depending on the etiologic factors underlying their development. Atherosclerosis and pancreatitis are the two most common risk factors. Making the diagnosis can be complex and often requires the use of Computed Tomography and angiography. The later adds the advantage of being a therapeutic option to prevent or stop bleeding. If this fails, surgery is still regarded as the standard for accomplishing a definite treatment.