Provocative Tesing for Brugada Syndrome, Long-QT Syndrome, and Catecholaminergic Polymorphic Ventricular Tachycardia

Obeyesekere et al provide a useful summary of provocative testing for Brugada syndrome, long QT syndrome and catecholaminergic polymorphic ventricular tachycardia (Circ Arrhythm Electrophysiol. 2011;4:958-964.).



Effect of Treatment Delay in Patients with STEMI with and without Hemodynamic Instability

Scholz et al report on the results of the FITT-STEMI trial (European Heart Journal (2018) 0, 1–10 doi:10.1093/eurheartj/ehy004).



The aim of this study was to investigate the effect of contact-to-balloon time on mortality in ST-segment elevation
myocardial infarction (STEMI) patients with and without haemodynamic instability.

Methods and results

Using data from the prospective, multicentre Feedback Intervention and Treatment Times in ST-Elevation Myocardial Infarction (FITT-STEMI) trial, we assessed the prognostic relevance of first medical contact-to-balloon time in n= 12 675 STEMI patients who used emergency medical service transportation and were treated with primary percutaneous coronary intervention (PCI). Patients were stratified by cardiogenic shock (CS) and out-of-hospital cardiac
arrest (OHCA). For patients treated within 60 to 180min from the first medical contact, we found a nearly linear relationship between contact-to-balloon times and mortality in all four STEMI groups. In CS patients with no OHCA, every 10-min treatment delay resulted in 3.31 additional deaths in 100 PCI-treated patients. This treatment delay-related increase in mortality was significantly higher as compared to the two groups of OHCA patients with shock (2.09) and without shock (1.34), as well as to haemodynamically stable patients (0.34, P< 0.0001).


In patients with CS, the time elapsing from the first medical contact to primary PCI is a strong predictor of an adverse outcome. This patient group benefitted most from immediate PCI treatment, hence special efforts to shorten contact-to-balloon time should be applied in particular to these high-risk STEMI patients.


PERC score rule out for very low risk patients

Freund et al report on the prospective validation of the PERC score in patients with very low risk for pulmonary embolism in patients presenting to the emergency department (JAMA. 2018;319(6):559-566. doi:10.1001/jama.2017.21904).



The safety of the pulmonary embolism rule-out criteria (PERC), an 8-item block of clinical criteria aimed at ruling out pulmonary embolism (PE), has not been assessed in a randomized clinical trial.


To prospectively validate the safety of a PERC-based strategy to rule out PE.


A crossover cluster–randomized clinical noninferiority trial in
14 emergency departments in France. Patients with a low gestalt clinical probability of PE were included from August 2015 to September 2016, and followed up until December 2016.


Each center was randomized for the sequence of intervention periods. In the PERC period, the diagnosis of PE was excluded with no further testing if all 8 items of the PERC rule were negative.


The primary end point was the occurrence of a thromboembolic event during the 3-month follow-up period that was not initially diagnosed. The noninferiority margin was set at 1.5%. Secondary end points included the rate of computed tomographic pulmonary angiography (CTPA), median length of stay in the emergency department, and rate of hospital admission.


Among 1916 patients who were cluster-randomized (mean age 44 years, 980 [51%] women), 962 were assigned to the PERC group and 954 were assigned to the control group. A total of 1749 patients completed the trial. A PE was diagnosed at initial presentation in 26
patients in the control group (2.7%) vs 14 (1.5%) in the PERC group (difference, 1.3%[95%CI, −0.1%to 2.7%]; P = .052). One PE (0.1%) was diagnosed during follow-up in the PERC group vs none in the control group (difference, 0.1%[95%CI, − to 0.8%]). The proportion of
patients undergoing CTPA in the PERC group vs control group was 13%vs 23%(difference, −10% [95%CI, −13%to −6%]; P < .001). In the PERC group, rates were significantly reduced for the median length of emergency department stay (mean reduction, 36 minutes [95%CI,
4 to 68]) and hospital admission (difference, 3.3%[95%CI, 0.1% to 6.6%]).


Among very low-risk patients with suspected PE, randomization to a PERC strategy vs conventional strategy did not result in an inferior rate of thromboembolic events over 3 months. These findings support the safety of PERC for very low-risk patients presenting to the emergency department.

High Resolution Late Gadolinium Enhanced CMR in Patients with Ventricular Arrhythmias

Hennig et al report on the value of high resolution three dimensional late gadolinium enhanced cardiac magnetic resonance imaging in patients with ventricular arrhythmias.

<h1> Abstract</h1>

Cardiac magnetic resonance (CMR) is recommended as a second-line method to diagnose ventricular arrhythmia
(VA) substrate. We assessed the diagnostic yield of CMR including high-resolution late gadolinium-enhanced (LGE)

<h2>Methods and results</h2>
Consecutive patients with sustained ventricular tachycardia (VT), non-sustained VT (NSVT), or ventricular fibrillation/ aborted sudden death (VF/SCD) underwent a non-CMR diagnostic workup according to current guidelines, and CMR including LGE imaging with both a conventional breath-held and a free-breathing method enabling higher
spatial resolution (HR-LGE). The diagnostic yield of CMR was compared with the non-CMR workup, including the incremental value of HR-LGE. A total of 157 patients were enrolled [age 54 ± 17 years; 75% males; 88 (56%) sustained VT, 52 (33%) NSVT, 17 (11%) VF/SCD]. Of these, 112 (71%) patients had no history of structural heart disease (SHD). All patients underwent electrocardiography and echocardiography, 72% coronary angiography, and 51% exercise testing. Pre-CMR diagnoses were 84 (54%) no SHD, 39 (25%) ischaemic cardiomyopathy (ICM), 11
(7%) non-ischaemic cardiomyopathy (NICM), 3 (2%) arrhythmogenic right ventricular cardiomyopathy (ARVC), 2 (1%) hypertrophic cardiomyopathy (HCM), and 18 (11%) other. CMR modified these diagnoses in 48 patients (31% of all and 43% of those with no SHD history). New diagnoses were 9 ICM, 28 NICM, 8 ARVC, 1 HCM, and
2 other. CMR modified therapy in 19 (12%) patients. In patients with no SHD after non-CMR tests, SHD was found in 32 of 84 (38%) patients. Eighteen of these patients showed positive HR-LGE and negative conventional LGE. Thus, HR-LGE significantly increased the CMR detection of SHD (17–38%, P < 0.001).

CMR including HR-LGE imaging has high diagnostic value in patients with VAs. This has major prognostic and therapeutic implications, particularly in patients with negative pre-CMR workup.



Marrouche et al report the full results of the CASTLE-AF trial. This randomized clinical trial assessed the effect of catheter ablation in patients with symptomatic atrial fibrillation and heart failure with LVEF<35%.



Mortality and morbidity are higher among patients with atrial fibrillation and heart failure than among those with heart failure alone. Catheter ablation for atrial fibrillation has been proposed as a means of improving outcomes among patients with heart failure who are otherwise receiving appropriate treatment.


We randomly assigned patients with symptomatic paroxysmal or persistent atrial
fibrillation who did not have a response to antiarrhythmic drugs, had unacceptable side effects, or were unwilling to take these drugs to undergo either catheter ablation (179 patients) or medical therapy (rate or rhythm control) (184 patients) for atrial fibrillation in addition to guidelines-based therapy for heart failure. All the patients had New York Heart Association class II, III, or IV heart failure, a left ventricular ejection fraction of 35% or less, and an implanted defibrillator. The primary end point was a composite of death from any cause or hospitalization for
worsening heart failure.


After a median follow-up of 37.8 months, the primary composite end point occurred
in significantly fewer patients in the ablation group than in the medicaltherapy group (51 patients [28.5%] vs. 82 patients [44.6%]; hazard ratio, 0.62; 95% confidence interval [CI], 0.43 to 0.87; P = 0.007). Significantly fewer patients in the ablation group died from any cause (24 [13.4%] vs. 46 [25.0%]; hazard ratio, 0.53; 95% CI, 0.32 to 0.86; P = 0.01), were hospitalized for worsening heart failure (37 [20.7%] vs. 66 [35.9%]; hazard ratio, 0.56; 95% CI, 0.37 to 0.83; P = 0.004), or died from cardiovascular causes (20 [11.2%] vs. 41 [22.3%]; hazard ratio, 0.49; 95% CI, 0.29 to 0.84; P = 0.009).


Catheter ablation for atrial fibrillation in patients with heart failure was associated with a significantly lower rate of a composite end point of death from any cause or hospitalization for worsening heart failure than was medical therapy.


VO2 Max Equations

This post is based on this paper.

The following was created in Wolfram Language:
VO2Max Form

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Cardiopulmonary Resuscitation

Harris and Kudenchuk present an excellent review of cardiopulmonary resuscitation with practical clinical implications (Harris AW,
Kudenchuk PJ. Heart doi:10.1136/heartjnl-2017-312696).



  • Chest compression rate (AHA recommendation: 100–120/min)
  • Chest compression depth (AHA recommendation: 5–6 cm)
  • Chest compression fraction and minimising pauses (AHA
    recommendation: chest compression fraction ≥60%, minimise
    pauses in chest compressions)
  • Chest recoil (AHA recommendation: allow full chest recoil)
  • Controlled ventilation, avoiding hyperventilation (30:2 chest
    compression:ventilation ratio prior to advanced airway; 10
    breaths/min with advanced airway)