Improved ROSC rates in out-of-hospital cardiac arrest patients after introduction of a text message alert system for trained volunteers

Objective To evaluate whether a text message (TM) alert system for trained volunteers contributed to early cardiopulmonary resuscitation, the use of automated external defibrillators (AEDs), return of spontaneous circulation (ROSC) and survival in out-of-hospital cardiac arrest (OHCA) patients in a region with above-average survival rates. Design Data on all OHCA patients in 2012 (non-TM group) were compared with those of all OHCA patients in 2018 (TM group). The association of the presence of a TM alert system with ROSC and survival was assessed with multivariate regression analyses. Results TM responders reached 42 OHCA patients (15.9%) earlier than the first responders or ambulance. They connected 31 of these 42 OHCA patients (73.8%) to an AED before the ambulance arrived, leading to a higher percentage of AEDs being attached in 2018 compared to the 2012 non-TM group (55% vs 46%, p = 0.03). ROSC was achieved more often in the TM group (61.0% vs 29.4%, p < 0.01). Three-month and 1‑year survival did not differ significantly between the two groups (29.3% vs 24.3%, p = 0.19, and 25.9% vs 23.5%, p = 0.51). Multivariate regression analyses confirmed the positive association of ROSC with the TM alert system (odds ratio 1.49, 95% confidence interval 1.02‑2.19, p = 0.04). Conclusion A TM alert system seems to improve the chain of survival; because TM responders reached patients early, AEDs were attached more often and more OHCA patients achieved ROSC. However, the introduction of a TM alert system was not associated with improved 3‑month or 1‑year survival in a region with above-average survival rates.

Introduction of a new scoring tool to identify clinically stable heart failure patients

Introduction Heart failure (HF) poses a burden on specialist care, making referral of clinically stable HF patients to primary care a desirable goal. However, a structured approach to guide patient referral is lacking. Methods The Maastricht Instability Score—Heart Failure (MIS-HF) questionnaire was developed to objectively stratify the clinical status of HF patients: patients with a low MIS-HF (0–2 points, indicating a stable clinical condition) were considered for treatment in primary care, whereas high scores (> 2 points) indicated the need for specialised care. The MIS-HF was evaluated in 637 consecutive HF patients presenting between 2015 and 2018 at Maastricht University Medical Centre. Results Of the 637 patients, 329 (52%) had a low score and 205 of these 329 (62%) patients were referred to primary care. The remaining 124 (38%) patients remained in secondary care. Of the 308 (48%) patients with a high score (> 2 points), 265 (86%) remained in secondary care and 41 (14%) were referred to primary care. The primary composite endpoint (mortality, cardiac hospital admissions) occurred more frequently in patients with a high compared to those with a low MIS-HF after 1 year of follow-up (29.2% vs 10.9%; odds ratio (OR) 3.36, 95% confidence interval (CI) 2.20–5.14). No significant difference in the composite endpoint (9.8% vs 12.9%; OR 0.73, 95% CI 0.36–1.47) was found between patients with a low MIS-HF treated in primary versus secondary care. Conclusion The MIS-HF questionnaire may improve referral policies, as it helps to identify HF patients that can safely be referred to primary care.

No substantial excess all-cause mortality among cardiac implantable electronic device patients during the first COVID‑19 lockdown in the Leiden area

In the Netherlands, the coronavirus disease 2019 (COVID‑19) pandemic has resulted in excess mortality nationwide. Chronic heart disease patients are at risk for a complicated COVID‑19 course. The current study investigates all-cause mortality among cardiac implantable electronic device (CIED) patients during the first peak of the pandemic and compares the data to the statistics for the corresponding period in the two previous years. Data of adult CIED patients undergoing follow-up at the Leiden University Medical Centre were analysed. All-cause mortality between 1 March and 31 May 2020 was evaluated and compared to the data for the same period in 2019 and 2018. At the beginning of the first peak of the pandemic, 3,171 CIED patients (median age 70 years; 68% male; 41% ischaemic aetiology) were alive. Baseline characteristics of the 2019 (n = 3,216) and 2018 (n = 3,169) cohorts were comparable. All-cause mortality during the peak of the pandemic was 1.4% compared to 1.6% and 1.4% in the same period in 2019 and 2018, respectively (p = 0.84). During the first peak of the COVID‑19 pandemic, there was no substantial excess mortality among CIED patients in the Leiden area, despite the fact that this is group at high risk for a complicated course of a COVID‑19 infection. Strict adherence to the preventive measures may have prevented substantial excess mortality in these vulnerable patients.

Comparison between laser sheaths, femoral approach and rotating mechanical sheaths for lead extraction

Introduction Efficiency and safety are important features in the selection of lead extraction tools. We report our experience with different endovascular techniques to extract individual pacing and defibrillator leads. Methods This is a single-centre study of consecutive lead extraction procedures from 1997 until 2019. A total of 1725 leads were extracted in 775 patients. Direct traction sufficed for 588 leads, and 22 leads were primarily removed by surgery. The endovascular techniques used in the remainder were a laser sheath (190 leads), the femoral approach (717 leads) and rotating mechanical sheaths (208 leads). Results The three approaches were comparably effective in completely removing the leads (p = 0.088). However, there were more major complications with the laser sheath than with the femoral approach or rotating mechanical sheaths (8.4%, 0.5% and 1.2%, respectively). Therefore, the procedural result—extraction without major complications—was significantly better with both the femoral approach and rotating mechanical sheaths than with the laser sheath (p < 0.001). This result was confirmed after propensity score matching to compensate for differences between lead cohorts (p = 0.007). Cross-over to another endovascular tool was necessary in 7.9%, 7.1% and 8.2% of laser, femoral and rotating mechanical attempts, respectively. Conclusion All three endovascular lead extraction techniques showed comparable efficacy. However, there were significantly more major complications using the laser sheath compared to the femoral approach or rotating mechanical sheaths, leading us to abandon the laser technique. Importantly, no single endovascular technique sufficed to successfully extract all leads.

Care and referral patterns in a large, dedicated nurse-led atrial fibrillation outpatient clinic

Introduction Atrial fibrillation (AF) is the most common arrhythmia and imposes a high burden on the healthcare system. A nurse-led AF outpatient clinic may alleviate the burden on the cardiology outpatient clinic by triaging patients who need care by a cardiologist or general practitioner (GP). However, care and referral patterns after initial assessment in a nurse-led AF outpatient clinic are unknown. We examined the proportion of AF patients assessed in a nurse-led clinic without outpatient follow-up by a cardiologist. Methods All patients with AF referred to our tertiary medical centre underwent cardiac work-up in the nurse-led AF outpatient clinic and were prospectively followed. Data on patient characteristics, rhythm monitoring and echocardiography were collected and described. Odds ratio (OR) for continuing care in the nurse-led AF outpatient clinic was calculated. Results From 2014 to 2018, 478 consecutive individual patients were referred to the nurse-led AF outpatient clinic. After the initial cardiac work-up, 139 patients (29.1%) remained under nurse-led care and 121 (25.3%) were referred to a cardiologist and 218 (45.6%) to a GP. Patients who remained under nurse-led care were significantly younger, were more symptomatic, more often had paroxysmal AF and had less comorbidities than the other two groups. After multivariable testing, CHA2DS2-VASc score ≥ 2 was associated with discontinued nurse-led care (OR 0.57, 95% confidence interval 0.34–0.95). Conclusion After initial cardiac assessment in the nurse-led outpatient clinic, about half of the newly referred AF patients were referred back to their GP. This strategy may reduce the burden of AF patients on secondary or tertiary cardiology outpatient clinics.

Sex differences in treatment strategy for coronary artery aneurysms: Insights from the international Coronary Artery Aneurysm Registry

Introduction Sex disparities exist in coronary artery disease (CAD) in terms of risk profile, clinical management and outcome. It is unclear if differences are also present in coronary aneurysms, a rare variant of CAD. Methods Patients were selected from the international Coronary Artery Aneurysm Registry (CAAR; ClinicalTrials.gov: NCT02563626), and differences between groups were analysed according to sex. The CAAR database is a prospective multicentre registry of 1565 patients with coronary aneurysms (336 females). Kaplan-Meier method was used for event-free survival analysis for death, major adverse cardiac events (MACE: composite endpoint of death, heart failure and acute coronary syndrome) and bleeding. Results Female patients were older, were more often hypertensive and less frequently smoker. They were treated conservatively more often compared to male patients and received significantly less frequently aspirin (92% vs 88%, p = 0.002) or dual antiplatelet therapy (DAPT) (67% vs 58%, p = 0.001) at discharge. Median DAPT duration was also shorter (3 vs 9 months, p = 0.001). Kaplan-Meier analysis revealed no sex differences in death, MACE or bleeding during a median follow-up duration of 37 months, although male patients did experience acute coronary syndrome (ACS) more often during follow-up (15% vs 10%, p = 0.015). Conclusions These CAAR findings showed a comparable high-risk cardiovascular risk profile for both sexes. Female patients were treated conservatively more often and received DAPT less often at discharge, with a shorter DAPT duration. ACS was more prevalent among male patients; however, overall clinical outcome was not different between male and female patients during follow-up.

Diagnostic accuracy of on-site coronary computed tomography-derived fractional flow reserve in the diagnosis of stable coronary artery disease

Purpose Invasive fractional flow reserve (FFR), the reference standard for identifying significant coronary artery disease (CAD), can be estimated non-invasively by computed tomography-derived fractional flow reserve (CT-FFR). Commercially available off-site CT-FFR showed improved diagnostic accuracy compared to coronary computed tomography angiography (CCTA) alone. However, the diagnostic performance of this lumped-parameter on-site method is unknown. The aim of this cross-sectional study was to determine the diagnostic accuracy of on-site CT-FFR in patients with suspected CAD. Methods A total of 61 patients underwent CCTA and invasive coronary angiography with FFR measured in 88 vessels. Significant CAD was defined as FFR and CT-FFR below 0.80. CCTA with stenosis above 50% was regarded as significant CAD. The diagnostic performance of both CT-FFR and CCTA was assessed using invasive FFR as the reference standard. Results Of the 88 vessels included in the analysis, 34 had an FFR of ≤ 0.80. On a per-vessel basis, the sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 91.2%, 81.4%, 93.6%, 75.6% and 85.2% for CT-FFR and were 94.1%, 68.5%, 94.9%, 65.3% and 78.4% for CCTA. The area under the receiver operating characteristic curve was 0.91 and 0.85 for CT-FFR and CCTA, respectively, on a per-vessel basis. Conclusion On-site non-invasive FFR derived from CCTA improves diagnostic accuracy compared to CCTA without additional testing and has the potential to be integrated in the current clinical work-up for diagnosing stable CAD.

Initial experience, feasibility and safety of permanent left bundle branch pacing: results from a prospective single-centre study

Background Left bundle branch (LBB) pacing is a novel pacing technique which may serve as an alternative to both right ventricular pacing for symptomatic bradycardia and cardiac resynchronisation therapy (CRT). A substantial amount of data is reported by relatively few, highly experienced centres. This study describes the first experience of LBB pacing in a high-volume device centre. Methods Success rates (i.e. the ability to achieve LBB pacing), electrophysiological parameters and complications at implant and up to 6 months of follow-up were prospectively assessed in 100 consecutive patients referred for various pacing indications. Results The mean age was 71 ± 11 years and 65% were male. Primary pacing indication was atrioventricular (AV) block in 40%, CRT in 42%, and sinus node dysfunction or refractory atrial fibrillation prior to AV node ablation in 9% each. Baseline left ventricular ejection fraction was < 50% in 57% of patients, mean baseline QRS duration 145 ± 34 ms. Overall LBB pacing was successful in 83 of 100 (83%) patients but tended to be lower in patients with CRT pacing indication (69%, p = ns). Mean left ventricular activation time (LVAT) during LBB pacing was 81 ms and paced QRS duration was 120 ± 19 ms. LBB capture threshold and R‑wave sense at implant was 0.74 ± 0.4 mV at 0.4 ms and 11.9 ± 5.9 V and remained stable at 6‑month follow-up. No complications occurred during implant or follow-up. Conclusion LBB pacing for bradycardia pacing and resynchronisation therapy can be easily adopted by experienced implanters, with favourable success rates and safety profile.

Recurrence of atrial fibrillation after pulmonary vein isolation in dependence of arterial stiffness

Background Arterial stiffness (AS) has emerged as a strong predictor of cardiovascular (CV) diseases. Although increased AS has been described as a predictor of atrial fibrillation (AF), its role as a risk marker for AF recurrence has not yet been elucidated. Methods Patients with AF who underwent pulmonary vein isolation (PVI) were included in this study. Presence of AS was evaluated by measuring aortic distensibility (AD) of the descending aorta by transoesophageal echocardiography. Results In total, 151 patients (mean ± standard deviation (SD) age 71.9 ± 9.8 years) were enrolled and followed for a median duration of 21 months (interquartile range 15.0–31.0). During follow-up, AF recurred in 94 (62.3%) patients. AF recurrence was seen more frequently in patients with permanent AF (27% vs 46%, p = 0.03) and in those who had undergone prior PVI (9% vs 23%, p = 0.02). AD was significantly reduced in patients with AF recurrence (mean ± SD 2.6 ± 2.3 vs 1.5 ± 0.7 × 10−3 mm Hg−1, p < 0.0001), as well as left atrial volume index (LAVI) (mean ± SD 29 ± 12 vs 44 ± 15 ml/m2, p < 0.0001). Multivariable analysis revealed LAVI (odds ratio (OR) 2.9, 95% confidence interval (CI) 1.2–3.4) and AS (OR 3.6, 95% CI 2.8–4.1) as independent risk factors of AF recurrence. Conclusion Increased AS and left atrial size were independent predictors of AF recurrence after PVI. AD as surrogate marker of AS seemed to reflect the overall CV risk. In addition, AD was significantly correlated with left atrial size, which suggests that increased AS leads to atrial remodelling and thus to AF recurrence. Trial registration German registry for clinical studies (DRKS), DRKS00019007.