High Atrial Rate Episodes and Thromboembolic Risk in a Japanese Population

Kawakami et al report on the relationship between high atrial rate episodes (defined as episodes of atrial tachyarrhythmias of more than 6 minutes on atrial monitoring) in Japanese patients with pacemakers capable of continuous atrial monitoring.




The clinical significance of atrial high-rate
episodes (AHREs) detected by cardiac devices among
patients with implantable pacemakers has recently
emerged. However, the relationship between AHREs and
ischaemic stroke and systemic embolism (SE) is not well
understood in the Japanese population.


This study included 343 patients with
pacemakers capable of continuous atrial rhythm monitoring (167 males; mean age, 80±7 years). Atrial tachyarrhythmia detection was programmed to the nominal setting of each device, and AHRE was defined as any episode of sustained atrial tachyarrhythmia lasting for more than 6 min. Thromboembolic risk was defined based on the CHADS2 score.


During the follow-up period (52±30 months),
165 (48%) patients had at least one episode of AHREs,
and 19 (6%) patients experienced stroke/SE. Among
patients who experienced stroke/SE, 14 had AHREs
before the stroke/SE. AHREs were significantly associated with stroke/SE (HR 2.87; 95% CI 1.10 to 8.90; p=0.03). Subgroup analysis conducted to investigate the impact of the CHADS2 score severity on stroke/SE revealed that AHREs were not associated with stroke/SE in patients with low or intermediate thromboembolic
risk (CHADS2 score 0–2; n=217). In contrast, among
patients with high thromboembolic risk (CHADS2
score>2; n=126), there was a significant association
between AHREs and the incidence of stroke/SE (HR 3.73;
95% CI 1.06 to 13.1; p=0.04).


AHREs detected by pacemaker were associated with ischaemic stroke/SE in the Japanese population. However, this association was observed only in the high thromboembolic risk group.



2017 ACC Expert Consensus Decision Pathway on the Management of Mitral Regurgitation

The ACC has provided a consensus decision pathway on the management of mitral
regurgitation. This is a very instructive document.



Thiele et al report the results of the CULPRIT-SHOCK trial (DOI: 10.1056/NEJMoa1710261 ; editorial: DOI: 10.1056/NEJMe1713341).



In patients who have acute myocardial infarction with cardiogenic shock, early
revascularization of the culprit artery by means of percutaneous coronary intervention (PCI) improves outcomes. However, the majority of patients with cardiogenic shock have multivessel disease, and whether PCI should be performed immediately for stenoses in nonculprit arteries is controversial.


In this multicenter trial, we randomly assigned 706 patients who had multivessel
disease, acute myocardial infarction, and cardiogenic shock to one of two initial revascularization strategies: either PCI of the culprit lesion only, with the option of staged revascularization of nonculprit lesions, or immediate multivessel PCI. The primary end point was a composite of death or severe renal failure leading to renal-replacement therapy within 30 days after randomization. Safety end points included bleeding and stroke.


At 30 days, the composite primary end point of death or renal-replacement therapy had occurred in 158 of the 344 patients (45.9%) in the culprit-lesion-only PCI group and in 189 of the 341 patients (55.4%) in the multivessel PCI group (relative risk,0.83; 95% confidence interval [CI], 0.71 to 0.96; P = 0.01). The relative risk of death in the culprit-lesion-only PCI group as compared with the multivessel PCI group was 0.84 (95% CI, 0.72 to 0.98; P = 0.03), and the relative risk of renal-replacement therapy was 0.71 (95% CI, 0.49 to 1.03; P = 0.07). The time to hemodynamic stabilization, the risk of catecholamine therapy and the duration of such therapy, the levels of troponin T and creatine kinase, and the rates of bleeding and stroke did not differ
significantly between the two groups.


Among patients who had multivessel coronary artery disease and acute myocardial
infarction with cardiogenic shock, the 30-day risk of a composite of death or severe renal failure leading to renal-replacement therapy was lower among those who initially underwent PCI of the culprit lesion only than among those who underwent immediate multivessel PCI.


AHA Scientific Statement Cardiogenic Shock

A useful scientific statement on the management of cardiogenic shock is presented in Circulation: Circulation. 2017;136:00–00. DOI: 10.1161/CIR.0000000000000525


Categories: Uncategorized

Peripartum Cardiomyopathy Registry

Silwa et al report a worldwide registry of peripartum cardiomyopathy (European Journal of Heart Failure (2017) 19, 1131–1141 doi:10.1002/ejhf.780).



The purpose of this study is to describe disease presentation, co-morbidities, diagnosis and initial therapeutic management of patients with peripartum cardiomyopathy (PPCM) living in countries belonging to the European Society of Cardiology (ESC) vs. non-ESC countries.

Methods and results

Out of 500 patients with PPCM entered by 31 March 2016, we report on data of the first 411 patients with completed case record forms (from 43 countries) entered into this ongoing registry. There were marked differences in socio-demographic parameters such as Human Development Index, GINI index on inequality, and Health Expenditure in PPCM patients from ESC vs. non-ESC countries (P < 0.001 each). Ethnicity was Caucasian (34%), Black African (25.8%), Asian (21.8%), and Middle Eastern backgrounds (16.4%). Despite the huge disparities in socio-demographic factors and ethnic backgrounds, baseline characteristics are remarkably similar. Drug therapy initiated post-partum included ACE inhibitors/ARBs and mineralocorticoid receptor antagonists with identical
frequencies in ESC vs. non-ESC countries. However, in non-ESC countries, there was significantly less use of beta-blockers (70.3% vs. 91.9%) and ivabradine (1.4% vs. 17.1%), but more use of diuretics (91.3% vs. 68.8%), digoxin (37.0% vs. 18.0%), and bromocriptine (32.6% vs. 7.1%) (P < 0.001). More patients in non-ESC vs. ESC countries continued to have symptomatic heart failure after 1 month (92.3% vs. 81.3%, P < 0.001). Venous thrombo-embolic events, arterial embolizations, and cerebrovascular accidents were documented in 28 of 411 patients (6.8%). Neonatal death rate was 3.1%.


PPCM occurs in women from different ethnic backgrounds globally. Despite marked differences in socio-economic background, mode of presentation was largely similar. Embolic events and persistent heart failure were common within 1 month post-diagnosis and required intensive, multidisciplinary management.



Cardiac Arrest and Death in US Triathlon

Harris et al presents the characteristics including autopsy findings of US Triathlon participants (Ann Intern Med. doi:10.7326/M17-0847).



Reports of race-related triathlon fatalities have
raised questions regarding athlete safety.
Objective: To describe death and cardiac arrest among triathlon


Case series.


United States.


Participants in U.S. triathlon races from 1985 to


Data on deaths and cardiac arrests were assembled
from such sources as the U.S. National Registry of Sudden
Death in Athletes (which uses news media, Internet
searches, LexisNexis archival databases, and news clipping services)
and USA Triathlon (USAT) records. Incidence of death or
cardiac arrest in USAT-sanctioned races from 2006 to 2016 was


A total of 135 sudden deaths, resuscitated cardiac arrests,
and trauma-related deaths were compiled; mean age of
victims was 46.7 ± 12.4 years, and 85% were male. Most sudden
deaths and cardiac arrests occurred in the swim segment (n =
90); the others occurred during bicycling (n = 7), running (n =
15), and postrace recovery (n = 8). Fifteen trauma-related deaths
occurred during the bike segment. Incidence of death or cardiac
arrest among USAT participants (n = 4 776 443) was 1.74 per
100 000 (2.40 in men and 0.74 in women per 100 000; P <
0.001). In men, risk increased substantially with age and was
much greater for those aged 60 years and older (18.6 per
100 000 participants). Death or cardiac arrest risk was similar for
short, intermediate, and long races (1.61 vs. 1.41 vs. 1.92 per
100 000 participants). At autopsy, 27 of 61 decedents (44%) had
clinically relevant cardiovascular abnormalities, most frequently
atherosclerotic coronary disease or cardiomyopathy.
Limitations: Case identification may be incomplete and may
underestimate events, particularly in the early study period. In
addition, prerace medical history is unknown in most cases.


Deaths and cardiac arrests during the triathlon are
not rare; most have occurred in middle-aged and older men.
Most sudden deaths in triathletes happened during the swim
segment, and clinically silent cardiovascular disease was present
in an unexpected proportion of decedents.


Tachycardiomyopathy Educational Paper

Martin and Lambiase present an educational paper on tachycardiomyopathy (http:// dx. doi. org/ 10. 1136/heartjnl- 2016- 310391). See CASTLE AF at ESC 2017.