Scrub typhus, caused by Orientia tsutsugamushi, often involves multiple organs, but its cardiovascular (CV) sequelae in survivors remain under-researched. This retrospective cohort study analyzed data from the National Health Insurance Research Database (NHIRD) spanning 2010-2015 to assess CV risks among scrub typhus survivors. Excluding those with prior CV events, we focused on outcomes such as acute myocardial infarction (AMI), heart failure hospitalization (HFH), strokes, new-onset atrial fibrillation (AF), aortic aneurysm or dissection, venous thromboembolism (VTE), and CV death. From 2,269 scrub typhus patients without previous CV events (mean age 47.8 +/- 16.1; 38.0% female), and a matched control group (n = 2,264), we observed a higher incidence of HFH, new-onset AF, and total CV events in the scrub typhus cohort. Adjusted hazard ratios (aHRs) were 1.97 (95% CI: 1.13-3.42) for HFH, 2.48 (95% CI: 1.23-5.0) for new-onset AF, and 1.43 (95% CI: 1.08-1.91) for total CV events. Other outcomes did not significantly differ. Scrub typhus survivors exhibit an increased risk of CV events, particularly HFH and new-onset AF, underscoring the importance of heightened physician awareness and post-infection cardiac surveillance.

BACKGROUND AND AIMS:Studies on the impact of syphilis on the cardiovascular system in large populations are limited. This study investigated the effects of syphilis on cardiovascular outcomes.METHODS:Medical records from 2010 to 2015 were retrieved from the Taiwan National Health Insurance Research Database, linked to the Notifiable Infectious Diseases database from the Taiwan Centers for Disease Control. Patients with syphilis were identified, excluding those with missing information, under 20 years of age, or with a history of human immunodeficiency virus infection, acute myocardial infarction, heart failure, aortic regurgitation, replacement of the aortic valve, aneurysm and/or dissection of the aorta, atrial fibrillation, ischaemic stroke, haemorrhagic stroke, and venous thromboembolism. Primary outcomes included new-onset acute myocardial infarction, heart failure, aortic regurgitation, aneurysm and dissection of the aorta, atrial fibrillation, ischaemic stroke, haemorrhagic stroke, venous thromboembolism, cardiovascular death, and all-cause mortality.RESULTS:A total of 28 796 patients with syphilis were identified from 2010 to 2015. After exclusions and frequency matching, 20 601 syphilis patients and 20 601 non-syphilis patients were analysed. The relative rate (RR) was utilized in the analysis, as the competing risk of death was not considered. Compared with patients without syphilis, patients with syphilis had increased risks of acute myocardial infarction (RR 38%, 95% confidence interval [CI] 1.19-1.60, P < .001), heart failure (RR 88%, 95% CI 1.64-2.14, P < .001), aortic regurgitation (RR 81%, 95% CI 1.18-2.75, P = .006), atrial fibrillation (RR 45%, 95% CI 1.20-1.76, P < .001), ischaemic stroke (RR 68%, 95% CI 1.52-1.87, P < .001), haemorrhagic stroke (RR 114%, 95% CI 1.74-2.64, P < .001), venous thromboembolism (RR 67%, 95% CI 1.23-2.26, P = .001), cardiovascular death (RR 155%, 95% CI 2.11-3.08, P < .001), and all-cause death (RR 196%, 95% CI 2.74-3.19, P < .001) but not for aneurysm and dissection of the aorta.CONCLUSIONS:This study demonstrates that patients with syphilis have a higher risk of cardiovascular events and all-cause mortality compared with those without syphilis.

Antiarrhythmic drugs such as flecainide are cornerstones of treatment for cardiac arrythmias including atrial fibrillation. While there are many benefits to antiarrhythmic drug therapy, there are also significant side effects. These side effects can be exacerbated by drug-drug interactions that affect the metabolism of antiarrhythmic drugs. Here, we report a rare case of flecainide induced encephalopathy in a patient who was concomitantly taking the selective serotonin reuptake inhibitor, fluoxetine, and the Class IC antiarrhythmic, flecainide.

Adoption and outcomes for conduction system pacing (CSP), which includes His bundle pacing (HBP) or left bundle branch area pacing (LBBAP), in real-world settings are incompletely understood. We sought to describe real-world adoption of CSP lead implantation and subsequent outcomes. We performed an online cross-sectional survey on the implantation and outcomes associated with CSP, between November 15, 2020, and February 15, 2021. We described survey responses and reported HBP and LBBAP outcomes for bradycardia pacing and cardiac resynchronization CRT indications, separately. The analysis cohort included 140 institutions, located on 5 continents, who contributed data to the worldwide survey on CSP. Of these, 127 institutions (90.7%) reported experience implanting CSP leads. CSP and overall device implantation volumes were reported by 84 institutions. In 2019, the median proportion of device implants with CSP, HBP, and/or LBBAP leads attempted were 4.4% (interquartile range [IQR], 1.9–12.5%; range, 0.4–100%), 3.3% (IQR, 1.3–7.1%; range, 0.2–87.0%), and 2.5% (IQR, 0.5–24.0%; range, 0.1–55.6%), respectively. For bradycardia pacing indications, HBP leads, as compared to LBBAP leads, had higher reported implant threshold (median [IQR]: 1.5 V [1.3–2.0 V] vs 0.8 V [0.6–1.0 V], p = 0.0008) and lower ventricular sensing (median [IQR]: 4.0 mV [3.0–5.0 mV] vs. 10.0 mV [7.0–12.0 mV], p < 0.0001). In conclusion, CSP lead implantation has been broadly adopted but has yet to become the default approach at most surveyed institutions. As the indications and data for CSP continue to evolve, strategies to educate and promote CSP lead implantation at institutions without CSP lead implantation experience would be necessary.

BACKGROUND:Chronic hepatitis C virus (HCV) infection is associated with increased cardiovascular risks. We aimed to investigate the impact of direct acting antiviral (DAA) on HCV-associated cardiovascular events.METHODS:In this retrospective cohort study, patients with the diagnosis of chronic HCV were retrieved from multi-institutional electronic medical records, where diagnosis of HCV was based on serum HCV antibody and HCV-RNA test. The patients eligible for analysis were then separated into patients with DAA treatment and patient without DAA treatment. Primary outcomes included acute coronary syndrome, heart failure (HF), venous thromboembolism (VTE), stroke, cardiovascular death, major adverse cardiovascular event (MACE), and all-cause mortality. Outcomes developed during follow-up were compared between DAA treatment and non-DAA treatment groups.RESULTS:There were 41 565 patients with chronic HCV infection identified. After exclusion criteria applied, 1984 patients in the DAA treatment group and 413 patients in the non-DAA treatment group were compared for outcomes using inverse probability of treatment weighting. Compared to patients in non-DAA treatment group, patients in DAA treatment group were associated with significantly decreased HF (hazard ratio [HR]: 0.65, 95% confidence interval [CI]: 0.44-0.97, P = 0.035), VTE (HR: 0.19, 95% CI: 0.07-0.49, P = 0.001), MACE (HR: 0.73, 95% CI 0.59-0.92, P = 0.007), and all-cause mortality (HR: 0.50, 95% CI: 0.38-0.67, P < 0.001) at 3-year follow-up.CONCLUSIONS:Chronic HCV patients treated with DAA experienced lower rates of cardiovascular events and all-cause mortality than those without treatment. The reduction of VTE was the most significant impact of DAA treatment among the cardiovascular outcomes.

Multiple techniques have been developed in addition to pulmonary vein isolation (PVI) to improve the outcomes of catheter ablation in patients with persistent atrial fibrillation (AF). We sought to evaluate the long-term efficacy of alternative techniques used in our laboratory for the treatment of persistent AF, including spatiotemporal dispersion (SD) and low-voltage isolation (LVI). Consecutive patients with persistent AF who underwent catheter ablation with the studied techniques between July 2016 and December 2019 were included in the study. PVI alone was compared with PVI plus SD and PVI plus LVI in terms of long-term freedom from atrial tachycardia (AT) and AF recurrence. Follow-up data were obtained from clinical records and hospital visits, which included a 7-day Holter monitor and electrocardiograms. The study was approved by the institutional review board of Rhode Island Hospital. A total of 382 patients underwent catheter ablation at our institution during the study period. One hundred seventy-two patients had paroxysmal AF and were excluded from the study. The remaining 210 patients had persistent AF and were included in the study. One hundred and three patients underwent PVI alone, while 48 had the addition of LVI and 59 had SD. Additionally, freedom from AT/AF recurrence at 18 months was 68% in the group that underwent LVI, 49% in the SD group, and 40% in the group that underwent PVI alone (log-rank P = .014). Freedom from AF recurrence was 74% in the LVI group, 71% in the SD group, and 43% in the PVI-alone group (log-rank P = .002). On multivariate Cox regression, LVI and left atrial size were found to be independent predictors of recurrence (hazard ratio, 0.39; 95% confidence interval, 0.206-0.760; P = .005 and hazard ratio, 1.4; 95% confidence interval, 1.105-1.923; P = .008, respectively). LVI and SD in addition to PVI were associated with greater freedom from AT/AF recurrence at 18 months compared to PVI alone.

Background Scrub typhus is an infectious disease that affects multiple organs. However, the long-term cardiovascular (CV) risk in survivors remains unknown.Method A retrospective cohort study used administrative claims data from the National Health Insurance Research Database (NHIRD) to investigate the CV risk of scrub typhus survivors from January 1, 2010, to December 31, 2015. People who had prior CV events before the diagnosis of scrub typhus were excluded. The CV outcomes of interest were acute myocardial infarction (AMI), heart failure hospitalization (HFH), hemorrhagic or ischemic stroke, new-onset atrial fibrillation (AF), aneurysm or dissection of aorta, venous thromboembolism (VTE), and CV death.Result A total of 2,269 patients with scrub typhus and without a prior CV event were identified (mean age 47.8±16.1 years, 38.0% female). The health control cohort (n=2,264) was selected to compare by the frequency matching with age, gender, and co-morbidities with patients with scrub typhus. The incidence of HFH, new-onset AF, and total events was significantly higher among patients with scrub typhus than the control cohort with an adjusted hazard ratio (aHR) of 1.97, 95% confidence interval (CI) 1.13-3.42 for HFH; 2.48, 95% CI: 1.23-5.0 for new-onset AF; 1.43, 95% CI: 1.08-1.91 for total CV events, respectively. The event rates of other outcomes were similar between the two groups.Conclusion In the cohort study, survivors of scrub typhus are at heightened risk of subsequent CV events, especially for HFH and new-onset AF. These findings serve as an important reminder to physicians regarding the significant CV risk that remains present following acute scrub typhus infection.### Competing Interest StatementThe authors have declared no competing interest.### Funding StatementChang Gung Memorial Hospital Grant (CMRPG3L0781) and Ministry of Science and Technology Grant (MoST 108-2410-H-182A-002).### Author DeclarationsI confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.YesThe details of the IRB/oversight body that provided approval or exemption for the research described are given below:This study was conducted in accordance with the Declaration of Helsinki and the Declaration of Taipei on ethical considerations regarding health databases by the World Medical Association. The study protocol was approved, and informed consent was exempted by the Institutional Review Board of Chang Gung Medical Foundation (IRB No: 201901517B0) as all data converted from the original NHI's claim records were anonymized and due to tight regulations of on-site analysis at HWDC.I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.YesI understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).YesI have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.YesAll data generated or analyzed during this study are included in this published article.

Background: The echocardiographic parameter E/e' has been associated with cardiovascular (CV) events. However, few studies have analyzed multiple associated CV outcomes using E/e' in a diverse population of both inpatients and outpatients with and without cardiac diseases and risk factors.Methods: Medical records of 75,393 patients without atrial fibrillation (AF) with first available E/e' were retrieved from our hospital database. Patients with mitral valve disease were excluded, and the remainder were studied in protocol 1 (70,819 patients). Patients with hypertension, diabetes mellitus, hyperlipidemia, CV diseases, prior CV events, CV surgeries, and left ventricular ejection fraction <50% or missing left ventric-ular ejection fraction were further excluded, and the remaining patients were studied in protocol 2 (14,665 patients). The study outcomes are major adverse CV events (MACE), which included myocardial infarction (MI), AF, ischemic and hemorrhagic stroke (IHS), hospitalization for heart failure (HHF), and cardiac death. The primary outcomes were MACE and each of the MACE components.Results: At the end of maximal 5-year follow-up (median 22.18 months with interquartile range 7.20-49.08 months for MACE in protocol 1 and 23.46 months with interquartile range 8.15-49.02 months for MACE in protocol 2), compared with an E/e' value of <8, an intermediate value of E/e' 8 to 15 and a high value of E/e' >15 were significantly associated with MACE, MI, AF, IHS, HHF, and cardiac death in protocol 1 (all P < .0001). In protocol 2, an intermediate E/e' value of 8 to 15 and a high value of E/e' >15 were significantly associated with MACE, MI, AF, IHS, HHF, and CV death (all P < .05), except an intermediate value E/e' 8 to 15 was not associated with AF.Conclusions: In a diverse population of inpatients and outpatients with and without cardiac diseases and risk factors, the echocardiographic parameter E/e' was associated with CV events and is a useful marker of risk. (J Am Soc Echocardiogr 2023;36:284-94.)

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.

Impedance is often used to assess the integrity and electrical performance of a lead. Elevated lead impedance can be due to conductor fracture, header connection problems, and mineralization at the electrode- myocardial interface Here we present a case of isolated elevated high voltage lead impedance due to a rare cause.

Pulmonary vein atrial tachycardia (PVAT) is a rare arrhythmia that accounts for 3% of all atrial tachycardia types. On electrocardiogram, fast PVATs may be misinterpreted as atrial fibrillation at first glance. We present a case of PVAT refractory to pharmacological intervention in a 31-year-old, requiring ablation to terminate the arrhythmia.

IntroductionThe magnet-activated switch in implanted cardiac devices, including cardioverter-defibrillators and permanent pacemakers (PPM), is susceptible to interference from consumer devices with built-in magnets. For example, a recent case report showed that a patient's implanted cardioverter-defibrillator (ICD) magnet mode became activated owing to interaction with his e-cigarette.1Shea J.B. Aguilar M. Sauer W. Tedrow U. Unintentional magnet reversion of an implanted cardiac defibrillator by an electronic cigarette.HeartRhythm Case Rep. 2020; 6: 121-123Google Scholar While testing has shown that cellular phones and smart watches themselves have minimal interference with cardiac devices,2Lacour P. Parwani A.S. Schuessler F. et al.Are contemporary smartwatches and mobile phones safe for patients with cardiovascular implantable electronic devices?.JACC Clin Electrophysiol. 2020; 6: 1158-1166Google Scholar this has failed to account for the magnets used in the wristband of smart watches and fitness trackers. Fitness trackers are capable of tracking heart rate, step count, and other variables of interest to fitness-minded consumers. In 2019, the company Fitbit, manufacturer of several different devices, sold nearly 16 million units.3Tankovska H. Fitbit device unit sales worldwide 2010-2019.https://www.statista.com/statistics/472591/fitbit-devices-sold/Date accessed: October 8, 2020Google Scholar The popular Apple Watch also features these capabilities, with Garmin and Samsung producing models as well. These products are lightweight and low-profile and sometimes sold with a built-in magnet-clasped wristband. Though this magnet is small, most manufacturers have adopted the magnetic element neodymium, which is known to interfere with device functions.4Wolber T. Ryf S. Binggeli C. et al.Potential interference of small neodymium magnets with cardiac pacemakers and implantable cardioverter-defibrillators.Heart Rhythm. 2007; 4: 1-4Google Scholar We investigated whether these magnetic wristbands had clinically relevant effects on ICD function through ex vivo testing.Key Teaching Points•Magnets used in the wristbands of fitness trackers and smart watches can interfere with implanted cardiac devices; however, this is not widely appreciated by manufacturers of the watches or the cardiac devices.•Possible complications include implanted cardioverter-defibrillator deactivation and permanent pacemaker mode switch.•Patients should be counseled on this risk and advised to keep their wristbands at least 6 inches away from their cardiac devices, and not to wear them to sleep.Case reportA 55-year-old woman with history of sustained ventricular tachycardia secondary to arrhythmogenic right ventricular dysplasia was treated with a dual-chamber ICD for secondary prevention. She was recommended to avoid strenuous exercise to reduce arrhythmic risk. She subsequently purchased an Apple Watch with fitness tracking capabilities to monitor her heart rate, which she wore sometimes overnight. While asleep one night, she was awoken by several beeps emanating from her implanted cardiac device. Subsequent interrogation of the device showed no alerts or abnormal parameters. Upon further investigation, it was found that the device had reverted to magnet mode, owing to magnetic interference from the fitness watch's wristband. No other possible sources of interference were identified. This was replicated in the office, where interrogation of the ICD confirmed magnetic reversion when placed in proximity to the wristband. The watch itself did not have magnetic interference.Methods and materialsThe Medtronic Visia AF MRI S DF-1 single-chamber ICD (Medtronic, Minneapolis, MN) was used for testing. In the electrophysiology lab, sheets of commercial printer paper were stacked to create distance on top of the device that could be easily quantified, and the maximum distance where different magnets could deactivate the ICD was measured. This distance was then confirmed without any paper stacked on the device (Figure 1). Paper and air were chosen as the contact media as they are very weakly diamagnetic and thus do not significantly attenuate the magnetic field of the tested wristbands. This is similar to human tissue itself.5Di Luzio S. Obletter G. Comani S. Del Gratta C. Romani G.L. Magnetic mapping of DC fields related to tissue susceptibility in the human body.in: Williamson S.J. Hoke M. Stroink G. Kotani M. Advances in Biomagnetism. Springer, Boston, MA1989Google ScholarFitbit and Apple Watch wristbands (similar to the patient's in the described case) were used for testing. The results were compared against 2 clinical magnets: a donut magnet and a Medtronic programming head (Medtronic, Minneapolis, MN). The fitness trackers were oriented in the fashion in which they would come up against the ICD in real life, as if the volar aspect of a patient's wrist with the magnet clasped came into contact with their chest.ResultsThe Fitbit and Apple Watch wristband magnets could deactivate the ICD up to distances of 2.4 and 2.0 centimeters, respectively. Meanwhile, the clinical magnets in the donut and programming head could deactivate up to 8.0 and 7.0 centimeters, respectively (Table 1).Table 1Maximum distances, in centimeters, at which various magnets could deactivate the implanted cardioverter-defibrillatorMagnet typeDistance at which ICD deactivates (cm)Fitbit wristband2.4Apple Watch wristband2.0Donut magnet8.0Programming head7.0ICD = implanted cardioverter-defibrillator. Open table in a new tab DiscussionThe fitness tracker wristband magnets were considerably weaker than clinical-grade magnets; however, the magnetic field strength was still capable of deactivating the ICD at clinically relevant distances, as most devices are implanted subcutaneously. The implantable devices produced by all major manufacturers are potentially susceptible to this interference, as most of the devices utilize a magnet sensor. Older devices relied on a Reed switch, whereas newer devices may be equipped with alternative sensors including Hall-effect sensors or magnetosensitive resistors. Subcutaneous ICD devices may be also vulnerable, as their location of implantation allows closer interaction with the left wrist of the patient.While magnets could deactivate the ICD tachy-therapies, resulting in untreated sustained ventricular arrhythmia, the most feared complication on PPM devices is a switch to asynchronous pacing modes (DOO/VOO).6Jacob S. Panaich S.S. Maheshwari R. Hadded J.W. Padanilam B.J. John S.K. Clinical applications of magnets on cardiac rhythm management devices.Europace. 2011; 14: 1222-1230Google Scholar Such a switch could cause an R-on-T event, especially for those with intrinsic native rhythms, triggering a malignant arrhythmia.The manufacturers of these wristbands as well as the cardiac devices should include appropriate warnings in their user manuals and online resources. Some fitness tracker creators have issued appropriate warnings alongside their products. The Apple Watch user guide acknowledges that the wristband as well as charging apparatus are capable of interfering with ICDs and PPMs.7AppleApple Watch: User Guide. 2020..https://support.apple.com/guide/watch/important-safety-information-apdcf2ff54e9/watchosDate accessed: November 2, 2020Google ScholarConclusionWearable fitness tracker accessories can contain powerful magnets capable of interfering with ICD or PPM functions. Patients should be counseled on this and recommended to take appropriate precautions, such as choosing a nonmagnetic wristband, keeping magnetic wristbands at least 6 inches from the implanted device, and removing magnetic wristbands before going to bed. IntroductionThe magnet-activated switch in implanted cardiac devices, including cardioverter-defibrillators and permanent pacemakers (PPM), is susceptible to interference from consumer devices with built-in magnets. For example, a recent case report showed that a patient's implanted cardioverter-defibrillator (ICD) magnet mode became activated owing to interaction with his e-cigarette.1Shea J.B. Aguilar M. Sauer W. Tedrow U. Unintentional magnet reversion of an implanted cardiac defibrillator by an electronic cigarette.HeartRhythm Case Rep. 2020; 6: 121-123Google Scholar While testing has shown that cellular phones and smart watches themselves have minimal interference with cardiac devices,2Lacour P. Parwani A.S. Schuessler F. et al.Are contemporary smartwatches and mobile phones safe for patients with cardiovascular implantable electronic devices?.JACC Clin Electrophysiol. 2020; 6: 1158-1166Google Scholar this has failed to account for the magnets used in the wristband of smart watches and fitness trackers. Fitness trackers are capable of tracking heart rate, step count, and other variables of interest to fitness-minded consumers. In 2019, the company Fitbit, manufacturer of several different devices, sold nearly 16 million units.3Tankovska H. Fitbit device unit sales worldwide 2010-2019.https://www.statista.com/statistics/472591/fitbit-devices-sold/Date accessed: October 8, 2020Google Scholar The popular Apple Watch also features these capabilities, with Garmin and Samsung producing models as well. These products are lightweight and low-profile and sometimes sold with a built-in magnet-clasped wristband. Though this magnet is small, most manufacturers have adopted the magnetic element neodymium, which is known to interfere with device functions.4Wolber T. Ryf S. Binggeli C. et al.Potential interference of small neodymium magnets with cardiac pacemakers and implantable cardioverter-defibrillators.Heart Rhythm. 2007; 4: 1-4Google Scholar We investigated whether these magnetic wristbands had clinically relevant effects on ICD function through ex vivo testing.Key Teaching Points•Magnets used in the wristbands of fitness trackers and smart watches can interfere with implanted cardiac devices; however, this is not widely appreciated by manufacturers of the watches or the cardiac devices.•Possible complications include implanted cardioverter-defibrillator deactivation and permanent pacemaker mode switch.•Patients should be counseled on this risk and advised to keep their wristbands at least 6 inches away from their cardiac devices, and not to wear them to sleep.

Ventricular fibrillation is a life-threatening arrhythmia that can result in sudden cardiac death and almost always requires emergency electrical defibrillation. This paper presents a unique case of a 74-year-old woman with spontaneous termination of a 2-min 13-s ventricular fibrillation episode without organization before termination. (Level of Difficulty: Advanced.).

AbstractObjectiveThis study assesses the mortality outcomes of non‐vitamin K antagonist oral anticoagulants (NOACs) in cancer patients with venous thromboembolism (VTE) and atrial fibrillation (AF).MethodsMedical records of cancer patients receiving NOACs for VTE or AF between January 1, 2011, and December 31, 2016, were retrieved from Taiwan's National Health Institute Research Database. NOACs were compared using the inverse probability of treatment weighting (IPTW) method. The primary outcome was cancer‐related death. Secondary outcomes were all‐cause mortality, major bleeding, and gastrointestinal (GI) bleeding.ResultsAmong 202,754 patients who received anticoagulants, 3591 patients (dabigatran: 907; rivaroxaban: 2684) with active cancers were studied. Patients who received dabigatran were associated with lower risks of cancer‐related death at one year (HR = 0.71, 95% CI = 0.54–0.93) and at the end of follow‐ups (HR = 0.79, 95% CI = 0.64–0.98) compared with rivaroxaban. Patients who received dabigatran were also associated with lower risks of all‐cause mortality (HR = 0.81, 95% CI = 0.67–0.97), major bleeding (HR = 0.64, 95% CI = 0.47–0.88), and GI bleeding (HR = 0.57, 95% CI = 0.39–0.84) at the end of follow‐ups compared with rivaroxaban.ConclusionCompared with rivaroxaban, the use of dabigatran may be associated with a lower risk of cancer‐related death and all‐cause mortality.

BACKGROUND: Benefits of patients with end-stage renal disease and atrial fibrillation undergoing peritoneal dialysis (PD) or hemodialysis are unknown. METHODS AND RESULTS: Patients undergoing dialysis were retrieved from Taiwan National Health Insurance Research Database during 2001 to 2013 and separated into PD or hemodialysis. Primary outcomes were ischemic stroke/systemic embolism, major bleeding, and intracranial hemorrhage (ICH). An inverse probability of treatment weighting based on propensity score was used to reduce the confounding. The risk of outcomes between PD and hemodialysis was compared using Cox proportional hazard model for fatal outcomes or Fine and Gray subdistribution hazard model which considered death a competing risk, respectively. A total of 7916 patients with end-stage renal disease with atrial fibrillation undergoing PD or hemodialysis during 2001 to 2013 were identified. After exclusion criteria, 363 patients receiving PD and 5302 patients receiving hemodialysis were analyzed. At 1-year follow-up, the risk of ICH was significantly lower in the PD group compared with the hemodialysis group (0.2% versus 0.9%; subdistribution hazard ratio [SHR], 0.31; 95% CI, 0.17-0.57). At 3-year follow-up, the risks of major bleeding and ICH were significantly lower in the PD group compared with the hemodialysis group (major bleeding: 1.8% versus 3.2%; SHR, 0.68; 95% CI, 0.53-0.87; ICH: 0.5% versus 2%; SHR, 0.32; 95% CI, 0.21-0.48). At 5-year follow-up, ischemic stroke/systemic embolism, major bleeding, and ICH were significantly lower in the PD group compared with the hemodialysis group (ischemic stroke/systemic embolism: 12.4% versus 17.7%, SHR, 0.87; 95% CI, 0.79-0.96; major bleeding: 2.6% versus 4.1%; SHR, 0.79; 95% CI, 0.64-0.97; ICH: 0.5% versus 2.6%; SHR, 0.25; 95% CI, 0.17-0.37). CONCLUSIONS: In patients with end-stage renal disease and atrial fibrillation, dialytic modalities by PD or hemodialysis impacted these patients differently. There were overall reduced ischemic stroke/systemic embolism, major bleeding, and ICH at 5-year follow-up in patients undergoing PD compared with hemodialysis.

HomeCirculation: Heart FailureVol. 14, No. 10Cardiomyopathy and Refractory Tachycardia in a Patient With Hereditary Amyloidosis Free AccessCase ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplementary MaterialsFree AccessCase ReportPDF/EPUBCardiomyopathy and Refractory Tachycardia in a Patient With Hereditary Amyloidosis Esseim Sharma, MD, Philip Stockwell, MD and Michael Wu, MD Esseim SharmaEsseim Sharma Correspondence to: Esseim Sharma, MD, Rhode Island Hospital, 593 Eddy St, APC 814, Providence, RI 02903. Email E-mail Address: [email protected] https://orcid.org/0000-0003-4091-5208 Brown University, Providence, RI. , Philip StockwellPhilip Stockwell https://orcid.org/0000-0001-7350-921X Brown University, Providence, RI. and Michael WuMichael Wu https://orcid.org/0000-0002-0233-0957 Brown University, Providence, RI. Originally published31 Aug 2021https://doi.org/10.1161/CIRCHEARTFAILURE.120.008129Circulation: Heart Failure. 2021;14:e008129Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: August 31, 2021: Ahead of Print A 32-year-old male of Portuguese descent with a history of type 1 diabetes and hypertension was admitted to the hospital with complaints of acutely worsening diffuse body pain, paresthesias, palpitations, and fatigue over the past month. On exam, he was noted to be significantly orthostatic. His blood pressure decreased from 95/65 mm Hg supine to 70/50 mm Hg standing, while his heart rate response was blunted with an increase from 110 to 120 beats per minute (bpm), suggestive of dysautonomia.1 A workup for these complaints included an echocardiogram, which revealed a depressed left ventricular ejection fraction of 42% (Movie I in the Data Supplement). Cardiac catheterization showed no coronary artery disease. During his hospitalization, he was noted to be persistently tachycardic up to 150 beats per minute, with significant heart rate variability on telemetry. Metabolic, drug, and endocrine workup were unrevealing as to the cause of his cardiomyopathy or tachycardia. His hemoglobin A1c was 9.9, and his thyroid-stimulating hormone was within normal limits. He was started on guideline-directed medical therapy for nonischemic cardiomyopathy, including an angiotensin-converting enzyme inhibitor and metoprolol succinate 400 mg daily. Despite this high dose of beta-blockade, he was noted to have a resting heart >100 beats per minute on outpatient ambulatory monitoring, and he complained of worsening palpitations, fatigue, and shortness of breath.The patient's ECG (Figure 1) demonstrated a tachycardia, which appeared to be sinus in cause because of the presence of p-waves that were positive in leads II and aVF and biphasic in V1.2 However, the presence of persistent tachycardia despite maximal doses of beta-blockers in the setting of an idiopathic nonischemic cardiomyopathy was concerning for a tachycardia-induced cardiomyopathy because of an arrhythmia other than sinus tachycardia, as sinus tachycardia causing nonischemic cardiomyopathy has been rarely reported in the literature.3,4 A persistent atrial tachycardia originating near the sinus node would be an alternative explanation for the tachycardia. Thus, before further therapeutic measures were taken, an invasive electrophysiology study was performed.Download figureDownload PowerPointFigure 1. ECG on 400 mg of metoprolol succinate daily.The invasive electrophysiology study revealed that the arrhythmia was consistent with sinus tachycardia (Figure 2, Movie II in the Data Supplement). The patient was started on ivabradine 5 mg twice daily with improvement of his resting heart rate to 80 beats per minute. A repeat echocardiogram a month after initiation of Ivabradine showed normalization of left ventricular ejection fraction to 60%, with normal chamber sizes, mild concentric hypertrophy, and normal diastolic function (Movie III in the Data Supplement).Download figureDownload PowerPointFigure 2. Electroanatomical activation map of the right atrium created during the invasive electrophysiological study, while the patient was in the tachycardia of interest. Red denotes the areas of earliest activation, while purple denotes areas with the most delayed activation. This activation map is consistent with sinus tachycardia.Despite improvement in his left ventricular ejection fraction, the patient continued to have worsening fatigue as well as severe, painful paresthesias. He also developed significant presyncopal symptoms because of orthostasis, erectile dysfunction, gastrointestinal dysmotility, and xerostomia. He was referred to neurology where an electromyogram and nerve conduction study was performed. These findings along with his history suggested a predominantly small fiber neuropathy with severe autonomic involvement, complicated by a concomitant large fiber neuropathy. While diabetic polyneuropathy was initially thought to be the etiology, the patient endorsed a strong family history of polyneuropathy in his maternal grandfather. Genetic testing revealed that the patient was heterozygous for an autosomal dominant mutation in the transthyretin amyloid protein (ATTR) known as Val30Met, which is the most common mutation causing familial amyloid polyneuropathy.5 A cardiac 99 m technetium-pyrophosphate (99mTc-PyP) scan was performed, which was not consistent with cardiac ATTR amyloidosis. A fat pad biopsy showed amyloid deposition with Congo Red staining, consistent with amyloidosis.Improvement in the patient's tachycardia with ivabradine allowed for eventual discontinuation of metoprolol. Gene-silencing therapy with Patisiran infusions was begun for his severe polyneuropathy. Genetic testing of his first-degree relatives revealed that his mother was also positive for the Val30Met mutation.DiscussionThis patient's presentation was consistent with small and large fiber polyneuropathy as well as dysautonomia because of familial amyloid polyneuropathy from hereditary ATTR-Val30Met. The Val30Met mutation is the most common inherited form of ATTR familial amyloid polyneuropathy. The presentation can be variable and often depends on whether it is an endemic or sporadic mutation. In endemic forms, which have been described in foci from Portugal, Japan, and Sweden, patients typically present before the age of 40 with progressive sensorimotor and autonomic neuropathy; cardiac conduction disturbances can be seen as a result of this neuropathy without structural cardiac abnormalities.6 This early-onset Val30Met mutation is not associated with cardiomyopathy. Cardiac involvement, including diastolic dysfunction, left ventricular hypertrophy, and late gadolinium enhancement on MRI, has been increasingly recognized in patients with the late-onset form, which typically presents after the age of 60 with a much more variable clinical presentation.7–9In this case, we postulate that the patient developed a tachycardia-induced cardiomyopathy from vagal dysfunction caused by hereditary ATTR-Val30Met amyloidosis affecting the vagus nerve leading to persistent sinus tachycardia. Successful treatment of his tachycardia with ivabradine led to resolution of his cardiomyopathy.Sources of FundingNone.Supplemental MaterialsMovies I–IIIDisclosures None.FootnotesFor Sources of Funding and Disclosures, see page 1156.The Data Supplement is available at https://www.ahajournals.org/doi/suppl/10.1161/CIRCHEARTFAILURE.120.008129.Correspondence to: Esseim Sharma, MD, Rhode Island Hospital, 593 Eddy St, APC 814, Providence, RI 02903. Email esseim.[email protected]orgReferences1. Gibbons CH, Schmidt P, Biaggioni I, Frazier-Mills C, Freeman R, Isaacson S, Karabin B, Kuritzky L, Lew M, Low P, et al.. The recommendations of a consensus panel for the screening, diagnosis, and treatment of neurogenic orthostatic hypotension and associated supine hypertension.J Neurol. 2017; 264:1567–1582. doi: 10.1007/s00415-016-8375-xCrossrefMedlineGoogle Scholar2. Spodick DH, Raju P, Bishop RL, Rifkin RD. Operational definition of normal sinus heart rate.Am J Cardiol. 1992; 69:1245–1246. doi: 10.1016/0002-9149(92)90947-wCrossrefMedlineGoogle Scholar3. Winum PF, Cayla G, Rubini M, Beck L, Messner-Pellenc P. A case of cardiomyopathy induced by inappropriate sinus tachycardia and cured by ivabradine.Pacing Clin Electrophysiol. 2009; 32:942–944. doi: 10.1111/j.1540-8159.2009.02414.xCrossrefMedlineGoogle Scholar4. Sağ S, Çoşkun H, Baran İ, Güllülü S, Aydinlar A. 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Heart failure and cardiac involvement as isolated manifestation of familial form of transthyretin amyloidosis resulting from Val30Met mutation with no clinical signs of polyneuropathy.Circ Heart Fail. 2009; 2:512–515. doi: 10.1161/CIRCHEARTFAILURE.109.853697LinkGoogle Scholar8. Ripoll-Vera T, Buades J, Cisneros E, Gómez Y, Núñez J, Raya M. Cardiac Involvement in a patient cohort with Val30Met mutation Transthyretin Amyloidosis.Rev Esp Cardiol (Engl Ed). 2019; 72:92–94. doi: 10.1016/j.rec.2017.11.017CrossrefMedlineGoogle Scholar9. Kristen AV, Maurer MS, Rapezzi C, Mundayat R, Suhr OB, Damy T; THAOS investigators. Impact of genotype and phenotype on cardiac biomarkers in patients with transthyretin amyloidosis - report from the Transthyretin Amyloidosis Outcome Survey (THAOS).PLoS One. 2017; 12:e0173086. doi: 10.1371/journal.pone.0173086CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails October 2021Vol 14, Issue 10 Advertisement Article InformationMetrics © 2021 American Heart Association, Inc.https://doi.org/10.1161/CIRCHEARTFAILURE.120.008129PMID: 34461744 Originally publishedAugust 31, 2021 Keywordshypertensionblood pressurecardiomyopathyheart rateoutpatientPDF download Advertisement SubjectsArrhythmiasCardiomyopathyGenetics