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Giuseppe BORIANI

Professore Ordinario
Dipartimento di Scienze Biomediche, Metaboliche e Neuroscienze sede Policlinico

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Pubblicazioni

2024 - A call to action: The need to apply guidelines recommendations with ABC or SOS to improve stroke prevention and cardiovascular outcomes in patients with atrial fibrillation [Articolo su rivista]
Boriani, G.; Tartaglia, E.; Imberti, J. F.
abstract

2024 - A global analysis of implants and replacements of pacemakers and cardioverter-defibrillators before, during, and after the COVID-19 pandemic in Italy [Articolo su rivista]
Zecchin, M.; Ciminello, E.; Mari, V.; Proclemer, A.; D'Onofrio, A.; Zanotto, G.; De Ponti, R.; Capovilla, T. M.; Laricchiuta, P.; Biondi, A.; Sampaolo, L.; Pascucci, S.; Sinagra, G.; Boriani, G.; Carrani, E.; Torre, M.
abstract

At the beginning of the COVID-19 emergency, non-urgent surgical procedures had to be deferred, but also emergencies were reduced. To assess the global trend of pacemaker (PM) and implantable cardiac-defibrillator (ICD) procedures performed in Italy before, during, and after the first COVID-19 emergency, all the Italian hospital discharge records related to PM/ICD procedures performed between 2012 and 2021, sent to the National Institute of Health, were reviewed. Compared to 2019, in 2020, there was a reduction of first PM implants (52,216 to 43,962, −16%; p < 0.01), but not replacements (16,591 to 17,331, + 4%; p = 0.16). In particular, in April 2020, there was a drop of first implants (− 53,4% vs the average value of April 2018 and April 2019; p < 0.01), while the reduction of replacements was less evident (−32.6%; p = NS). In 2021, PM procedures increased to values similar to the pre-pandemic period. A reduction of ICD procedures was observed in 2020 (22,355, −7% toward 2019), mainly in April 2020 (− 46% vs April 2018/April 2019; p = 0.03). In 2021, the rate of ICD procedures increased (+ 14% toward 2020). A non-significant reduction of “urgent” procedures (complete atrioventricular block for PM and ventricular fibrillation for ICD), even in April 2020, was observed. In 2020, there was a reduction of first PM implants and ICDs, offset by increased activity in 2021. No decrease in PM replacements was observed, and the drop in “urgent” PM and ICD procedures was not statistically significant.

2024 - Alcohol Intake and Risk of Hypertension: A Systematic Review and Dose-Response Meta-Analysis of Nonexperimental Cohort Studies [Articolo su rivista]
Cecchini, M.; Filippini, T.; Whelton, P. K.; Iamandii, I.; Di Federico, S.; Boriani, G.; Vinceti, M.
abstract

BACKGROUND: Alcohol consumption has been associated with higher blood pressure and an increased risk of hypertension. However, the possible exposure thresholds and effect-modifiers are uncertain. METHODS: We assessed the dose-response relationship between usual alcohol intake and hypertension incidence in nonexperimental cohort studies. After performing a systematic literature search through February 20, 2024, we retrieved 23 eligible studies. We computed risk ratios and 95% CI of hypertension incidence using a nonlinear meta-analytic model based on restricted cubic splines, to assess the dose-response association with alcohol consumption. RESULTS: We observed a positive and almost linear association between alcohol intake and hypertension risk with risk ratios of 0.89 (0.84-0.94), 1.11 (1.07-1.15), 1.22 (1.14-1.30), and 1.33 (1.18-1.49) for 0, 24, 36 and 48 g/d, respectively, using 12 g alcohol/d as the reference value. In sex-specific analyses, the association was almost linear in men over the entire range of exposure but only observed above 12 g/d in women, although with a steeper association at high levels of consumption compared with men. The increased risk of hypertension above 12 to 24 g alcohol/d was similar in Western and Asian populations and considerably greater in White than in Black populations, mainly due to the positive association in women at moderate-to-high intake. CONCLUSIONS: Overall, our results lend support to a causal association between alcohol consumption and risk of hypertension, especially above an alcohol intake of 12 g/d, and are consistent with recommendations to avoid or limit alcohol intake. Sex and ethnicity appear to be major effect-modifiers of such association.

2024 - An international physician survey of current ablation practices in atrial fibrillation: An AIM-AF substudy [Articolo su rivista]
Saksena, S.; Slee, A.; Merino, J. L.; Goette, A.; Boriani, G.; Kowey, P. R.; Piccini, J. P.; Reiffel, J. A.; Blomstrom-Lundqvist, C.; Camm, A. J.
abstract

Background: Practice guidelines recommend ablation (ABL) in atrial fibrillation (AF) for rhythm control. Guidance for antiarrhythmic drugs (AADs) post-ABL is limited. Objective: The purpose of this study was to determine AAD and ABL practices in the United States and Europe. Methods: An online survey of experienced cardiologists (CDs) (n = 360) and interventional electrophysiologists (EPs) (n = 269) was conducted. AAD- and ABL-related survey questions and responses were analyzed. Results: ABL was preferred more often as first-line AF therapy (Rx) by US CDs/EPs (P ≤.001). ABL was selected to avoid AAD Rx by 46% (50% CDs, 40% EPs); to prevent AF progression by 41% (36% CDs, 47% EPs); and for superior efficacy by 28% (27% CDs, 30% EPs). ABL was used by 9% in asymptomatic AF (9% CDs, 10% EPs), by 14% in subclinical AF (13% CDs, 14% EPs), and by 17% for first AF event (15% CDs, 18% EPs). Primary ABL was preferred in heart failure by 38%. Comorbidities, age, and left atrial size were limitations for ABL by 48%, 40%, and 38%, respectively. AADs were used after ABL for AF/atrial tachycardia (AT) prophylaxis by 34% for 3–6 months and 29% for 1–2 months. AADs were given for a single AF recurrence by 34%, bridging to re-ABL by 32%, and long-term Rx by 34%. AF/AT post-ABL was most often managed with amiodarone (42%–48%). Conclusion: ABL was frequently preferred over AADs in symptomatic AF but notably also was used for asymptomatic and subclinical AF. Post-ABL AAD Rx for AF prophylaxis or recurrence was frequent, with empiric amiodarone being the most often selected AAD.

2024 - Antiarrhythmic drugs in the era of atrial fibrillation ablation [Articolo su rivista]
Boriani, G.; Mei, D. A.; Imberti, J. F.
abstract

2024 - Apixaban for Stroke Prevention in Subclinical Atrial Fibrillation [Articolo su rivista]
Healey, J. S.; Lopes, R. D.; Granger, C. B.; Alings, M.; Rivard, L.; Mcintyre, W. F.; Atar, D.; Birnie, D. H.; Boriani, G.; Camm, A. J.; Conen, D.; Erath, J. W.; Gold, M. R.; Hohnloser, S. H.; Ip, J.; Kautzner, J.; Kutyifa, V.; Linde, C.; Mabo, P.; Mairesse, G.; Mazuecos, J. B.; Nielsen, J. C.; Philippon, F.; Proietti, M.; Sticherling, C.; Wong, J. A.; Wright, D. J.; Zarraga, I. G.; Coutts, S. B.; Kaplan, A.; Pombo, M.; Ayala-Paredes, F.; Xu, L.; Simek, K.; Nevills, S.; Mian, R.; Connolly, S. J.
abstract

BACKGROUND Subclinical atrial fibrillation is short-lasting and asymptomatic and can usually be detected only by long-term continuous monitoring with pacemakers or defibrillators. Subclinical atrial fibrillation is associated with an increased risk of stroke by a factor of 2.5; however, treatment with oral anticoagulation is of uncertain benefit. METHODS We conducted a trial involving patients with subclinical atrial fibrillation lasting 6 minutes to 24 hours. Patients were randomly assigned in a double-blind, doubledummy design to receive apixaban at a dose of 5 mg twice daily (2.5 mg twice daily when indicated) or aspirin at a dose of 81 mg daily. The trial medication was discontinued and anticoagulation started if subclinical atrial fibrillation lasting more than 24 hours or clinical atrial fibrillation developed. The primary efficacy outcome, stroke or systemic embolism, was assessed in the intention-to-treat population (all the patients who had undergone randomization); the primary safety outcome, major bleeding, was assessed in the on-treatment population (all the patients who had undergone randomization and received at least one dose of the assigned trial drug, with follow-up censored 5 days after permanent discontinuation of trial medication for any reason). RESULTS We included 4012 patients with a mean (±SD) age of 76.8±7.6 years and a mean CHA2DS2-VASc score of 3.9±1.1 (scores range from 0 to 9, with higher scores indicating a higher risk of stroke); 36.1% of the patients were women. After a mean follow-up of 3.5±1.8 years, stroke or systemic embolism occurred in 55 patients in the apixaban group (0.78% per patient-year) and in 86 patients in the aspirin group (1.24% per patient-year) (hazard ratio, 0.63; 95% confidence interval [CI], 0.45 to 0.88; P = 0.007). In the on-treatment population, the rate of major bleeding was 1.71% per patient-year in the apixaban group and 0.94% per patient-year in the aspirin group (hazard ratio, 1.80; 95% CI, 1.26 to 2.57; P = 0.001). Fatal bleeding occurred in 5 patients in the apixaban group and 8 patients in the aspirin group. CONCLUSIONS Among patients with subclinical atrial fibrillation, apixaban resulted in a lower risk of stroke or systemic embolism than aspirin but a higher risk of major bleeding.

2024 - Apixaban vs Aspirin According to CHA2DS2-VASc Score in Subclinical Atrial Fibrillation: Insights From ARTESiA [Articolo su rivista]
Lopes, R. D.; Granger, C. B.; Wojdyla, D. M.; Mcintyre, W. F.; Alings, M.; Mani, T.; Ramasundarahettige, C.; Rivard, L.; Atar, D.; Birnie, D. H.; Boriani, G.; Amit, G.; Leong-Sit, P.; Rinne, C.; Duray, G. Z.; Gold, M. R.; Hohnloser, S. H.; Kutyifa, V.; Benezet-Mazuecos, J.; Cosedis Nielsen, J.; Sticherling, C.; Benz, A. P.; Linde, C.; Kautzner, J.; Mabo, P.; Mairesse, G. H.; Connolly, S. J.; Healey, J. S.
abstract

Background: ARTESiA (Apixaban for the Reduction of Thrombo-Embolism in Patients With Device-Detected Sub-Clinical Atrial Fibrillation) demonstrated that apixaban, compared with aspirin, significantly reduced stroke and systemic embolism (SE) but increased major bleeding in patients with subclinical atrial fibrillation. Objectives: To help inform decision making, the authors evaluated the efficacy and safety of apixaban according to baseline CHA2DS2-VASc score. Methods: We performed a subgroup analysis according to baseline CHA2DS2-VASc score and assessed both the relative and absolute differences in stroke/SE and major bleeding. Results: Baseline CHA2DS2-VASc scores were <4 in 1,578 (39.4%) patients, 4 in 1,349 (33.6%), and >4 in 1,085 (27.0%). For patients with CHA2DS2-VASc >4, the rate of stroke was 0.98%/year with apixaban and 2.25%/year with aspirin; compared with aspirin, apixaban prevented 1.28 (95% CI: 0.43-2.12) strokes/SE per 100 patient-years and caused 0.68 (95% CI: −0.23 to 1.57) major bleeds. For CHA2DS2-VASc <4, the stroke/SE rate was 0.85%/year with apixaban and 0.97%/year with aspirin. Apixaban prevented 0.12 (95% CI: −0.38 to 0.62) strokes/SE per 100 patient-years and caused 0.33 (95% CI: −0.27 to 0.92) major bleeds. For patients with CHA2DS2-VASc =4, apixaban prevented 0.32 (95% CI: −0.16 to 0.79) strokes/SE per 100 patient-years and caused 0.28 (95% CI: −0.30 to 0.86) major bleeds. Conclusions: One in 4 patients in ARTESiA with subclinical atrial fibrillation had a CHA2DS2-VASc score >4 and a stroke/SE risk of 2.2% per year. For these patients, the benefits of treatment with apixaban in preventing stroke/SE are greater than the risks. The opposite is true for patients with CHA2DS2-VASc score <4. A substantial intermediate group (CHA2DS2-VASc =4) exists in which patient preferences will inform treatment decisions. (Apixaban for the Reduction of Thrombo-Embolism in Patients With Device-Detected Sub-Clinical Atrial Fibrillation; NCT01938248)

2024 - Assessment of Antitachycardia Pacing in Primary Prevention Patients: The APPRAISE ATP Randomized Clinical Trial [Articolo su rivista]
Schuger, C.; Joung, B.; Ando, K.; Mont, L.; Lambiase, P. D.; O'Hara, G. E.; Jennings, J. M.; Yung, D.; Boriani, G.; Piccini, J. P.; Wold, N.; Stein, K. M.; Daubert, J. P.
abstract

Importance: The emergence of novel programming guidelines that reduce premature and inappropriate therapies along with the availability of new implantable cardioverter-defibrillator (ICD) technologies lacking traditional endocardial antitachycardia pacing (ATP) capabilities requires the reevaluation of ATP as a first strategy in terminating fast ventricular tachycardias (VTs) in primary prevention ICD recipients. Objective: To assess the role of ATP in terminating fast VTs in primary prevention ICD recipients with contemporary programming. Design, Setting, and Participants: This global, prospective, double-blind, randomized clinical trial had an equivalence design with a relative margin of 35%. Superiority tests were performed at interim analyses and the final analysis if equivalence was not proven. Patients were enrolled between September 2016 and April 2021 at 134 sites in 8 countries, with the last date of follow-up on July 6, 2023. Patients were required to have an indication for a primary prevention ICD, including left ventricular ejection fraction less than or equal to 35%. Interventions: Patients were randomized in a 1:1 ratio to receive ATP plus shock vs shock only. Main Outcomes and Measures: The primary end point was time to first all-cause shock. Secondary end points included time to first appropriate shock, time to first inappropriate shock, all-cause mortality, and the composite of time to first all-cause shock plus all-cause mortality. Results: A total of 2595 patients were randomized (mean age, 63.9 years; 22.4% were females). At a mean follow-up of 38 months, first all-cause shock occurred in 129 participants in the ATP plus shock group and 178 participants in the shock only group. The hazard ratio (HR) for the primary end point was 0.72 (95.9% CI, 0.57-0.92), with P =.005 for superiority of the ATP plus shock group over the shock only group. During follow-up in an intention-to-treat analysis, the total shock burden per 100 patient-years was not statistically different, at 12.3 and 14.9, respectively (P =.70). Conclusions and Relevance: The use of a single burst of ATP prior to shock in primary prevention ICD recipients with modern ICD detection programming prolonged the time to first all-cause ICD shock. Trial Registration: ClinicalTrials.gov Identifier: NCT02923726.

2024 - Association between amount of biventricular pacing and heart failure status measured by a multisensor implantable defibrillator algorithm [Articolo su rivista]
Santini, L.; Calo, L.; D'Onofrio, A.; Manzo, M.; Dello Russo, A.; Savarese, G.; Pecora, D.; Amellone, C.; Santobuono, V. E.; Calvanese, R.; Viscusi, M.; Pisano, E.; Pangallo, A.; Rapacciuolo, A.; Bertini, M.; Lavalle, C.; Santoro, A.; Campari, M.; Valsecchi, S.; Boriani, G.
abstract

Background: Achieving a high biventricular pacing percentage (BiV%) is crucial for optimizing outcomes in cardiac resynchronization therapy (CRT). The HeartLogic index, a multiparametric heart failure (HF) risk score, incorporates implantable cardioverter-defibrillator (ICD)-measured variables and has demonstrated its predictive ability for impending HF decompensation. Objective: This study aimed to investigate the relationship between daily BiV% in CRT ICD patients and their HF status, assessed using the HeartLogic algorithm. Methods: The HeartLogic algorithm was activated in 306 patients across 26 centers, with a median follow-up of 26 months (25th–75th percentile: 15–37). Results: During the follow-up period, 619 HeartLogic alerts were recorded in 186 patients. Overall, daily values associated with the best clinical status (highest first heart sound, intrathoracic impedance, patient activity; lowest combined index, third heart sound, respiration rate, night heart rate) were associated with a BiV% exceeding 99%. We identified 455 instances of BiV% dropping below 98% after consistent pacing periods. Longer episodes of reduced BiV% (hazard ratio: 2.68; 95% CI: 1.02–9.72; P = .045) and lower BiV% (hazard ratio: 3.97; 95% CI: 1.74–9.06; P=.001) were linked to a higher risk of HeartLogic alerts. BiV% drops exceeding 7 days predicted alerts with 90% sensitivity (95% CI [74%–98%]) and 55% specificity (95% CI [51%–60%]), while BiV% ≤96% predicted alerts with 74% sensitivity (95% CI [55%–88%]) and 81% specificity (95% CI [77%–85%]). Conclusion: A clear correlation was observed between reduced daily BiV% and worsening clinical conditions, as indicated by the HeartLogic index. Importantly, even minor reductions in pacing percentage and duration were associated with an increased risk of HF alerts.

2024 - Asymptomatic vs. symptomatic atrial fibrillation: Clinical outcomes in heart failure patients [Articolo su rivista]
Boriani, G.; Bonini, N.; Vitolo, M.; Mei, D. A.; Imberti, J. F.; Gerra, L.; Romiti, G. F.; Corica, B.; Proietti, M.; Diemberger, I.; Dan, G. -A.; Potpara, T.; Lip, G. Y.
abstract

Background: The outcome implications of asymptomatic vs. symptomatic atrial fibrillation (AF) in specific groups of patients according to clinical heart failure (HF) and left ventricular ejection fraction (LVEF) need to be clarified. Methods: In a prospective observational study, patients were categorized according to overt HF with LVEF≤40 %, or with LVEF>40 %, or without overt HF with LVEF40 %≤ or > 40 %, as well as according to the presence of asymptomatic or symptomatic AF. Results: A total of 8096 patients, divided into 8 groups according to HF and LVEF, were included with similar proportions of asymptomatic AF (ranging from 43 to 48 %). After a median follow-up of 730 [699 -748] days, the composite outcome (all-cause death and MACE) was significantly worse for patients with asymptomatic AF associated with HF and reduced LVEF vs. symptomatic AF patients of the same group (p = 0.004). On adjusted Cox regression analysis, asymptomatic AF patients with HF and reduced LVEF were independently associated with a higher risk for the composite outcome (aHR 1.32, 95 % CI 1.04-1.69) and all-cause death (aHR 1.33, 95 % CI 1.02-1.73) compared to symptomatic AF patients with HF and reduced LVEF. Kaplan-Meier curves showed that HF-LVEF≤40 % asymptomatic patients had the highest cumulative incidence of all-cause death and MACE (p < 0.001 for both). Conclusions: In a large European cohort of AF patients, the risk of the composite outcome at 2 years was not different between asymptomatic and symptomatic AF in the whole cohort but adverse implications for poor outcomes were found for asymptomatic AF in HF with LVEF≤40 %.

2024 - Atrial Fibrillation and Other Cardiovascular Factors and the Risk of Dementia: An Italian Case–Control Study [Articolo su rivista]
Mazzoli, R.; Chiari, A.; Vitolo, M.; Garuti, C.; Adani, G.; Vinceti, G.; Zamboni, G.; Tondelli, M.; Galli, C.; Costa, M.; Salemme, S.; Boriani, G.; Vinceti, M.; Filippini, T.
abstract

: Dementia is a major neurologic syndrome characterized by severe cognitive decline, and it has a detrimental impact on overall physical health, leading to conditions such as frailty, changes in gait, and fall risk. Depending on whether symptoms occur before or after the age of 65, it can be classified as early-onset (EOD) or late-onset (LOD) dementia. The present study is aimed at investigating the role of cardiovascular factors on EOD and LOD risk in an Italian population. Using a case-control study design, EOD and LOD cases were recruited at the Modena Cognitive Neurology Centers in 2016-2019. Controls were recruited among caregivers of all the dementia cases. Information about their demographics, lifestyles, and medical history were collected through a tailored questionnaire. We used the odds ratio (OR) and 95% confidence interval (CI) to estimate the EOD and LOD risk associated with the investigated factors after adjusting for potential confounders. Of the final 146 participants, 58 were diagnosed with EOD, 34 with LOD, and 54 were controls. According to their medical history, atrial fibrillation was associated with increased disease risk (ORs 1.90; 95% CI 0.32-11.28, and 3.64; 95% CI 0.32-41.39 for EOD and LOD, respectively). Dyslipidemia and diabetes showed a positive association with EOD, while the association was negative for LOD. We could not evaluate the association between myocardial infarction and EOD, while increased risk was observed for LOD. No clear association emerged for carotid artery stenosis or valvular heart disease. In this study, despite the limited number of exposed subjects and the high imprecision of the estimates, we found positive associations between cardiovascular disease, particularly dyslipidemia, diabetes, and atrial fibrillation, and EOD.

2024 - Atrial High-Rate Episodes and Subclinical Atrial Fibrillation: State of the Art and Clinical Questions with Complex Solutions [Articolo su rivista]
Brookles, C. G.; De Ponti, R.; Russo, V.; Ziacchi, M.; Pelargonio, G.; Casella, M.; Lauretti, M.; Vilotta, M.; Themistoclakis, S.; D'Onofrio, A.; Boriani, G.; Anselmino, M.
abstract

Atrial high-rate episodes (AHREs) and subclinical atrial fibrillation (AF) are frequently registered in asymptomatic patients with cardiac implantable electronic devices (CIEDs) and insertable cardiac monitors (ICMs). While an increased risk of thromboembolic events (e.g., stroke) and benefits from anticoagulation have been widely assessed in the setting of clinical AF, concerns persist about optimal clinical management of subclinical AF/AHREs. As a matter of fact, an optimal threshold of subclinical episodes’ duration to predict stroke risk is still lacking and recently published randomized clinical trials assessing the impact of anticoagulation on thromboembolic events in this specific setting have shown contrasting results. The aim of this review is to summarize current evidence regarding classification and clinical impact of subclinical AF/AHREs and to discuss the latest evidence regarding the potential benefit of anticoagulation in this setting, highlighting which clinical questions are still unanswered.

2024 - Atrial fibrillation before and after transcatheter aortic valve implantation: short- and long-term clinical implications [Articolo su rivista]
Arrotti, Salvatore; Sgura, Fabio Alfredo; Leo, Giulio; Vitolo, Marco; Monopoli, Daniel; Forzati, Nicola; Siena, Valerio; Menozzi, Matteo; Cataldo, Paolo; Stuani, Marco; Morgante, Vernizia; Magnavacchi, Paolo; Gabbieri, Davide; Guiducci, Vincenzo; Benatti, Giorgio; Vignali, Luigi; Rossi, Rosario; Boriani, Giuseppe
abstract

BackgroundPatients with atrial fibrillation (AF) undergoing transcatheter aortic valve implantation (TAVI) have been associated with worse short-term outcomes compared with patients in sinus rhythm but data on long-term outcomes are limited. The aim of our study was to evaluate the association between AF and short- and long-term outcomes in patients undergoing TAVI.MethodsWe retrospectively evaluated patients undergoing TAVI between 2012 and 2022 in four tertiary centres. Two different analyses were conducted: (i) in-hospital and (ii) postdischarge analysis. First, we evaluated the association between preexisting AF and short-term outcomes according to VARC-3 criteria. Second, we analyzed the association between AF at discharge (defined as both preexisting and new-onset AF occurring after TAVI) and long-term outcomes at median follow-up of 3.2 years (i.e. all-cause death, hospitalization and major adverse cardiovascular events).ResultsA total of 759 patients were initially categorized according to the presence of preexisting AF (241 vs. 518 patients). The preexisting AF group had a higher occurrence of acute kidney injury [odds ratio (OR) 1.65; 95%confidence interval ( CI) 1.15-2.38] and major bleeding (OR 1.86, 95% CI 1.06-3.27). Subsequently, the population was categorized according to the presence of AF at discharge. At the adjusted Cox regression analysis, AF was independently associated with an increased risk of all-cause death and cardiovascular hospitalization [adjusted hazard ratio (aHR) 1.42, 95% CI 1.09-1.86], all-cause death and all-cause hospitalization (aHR 1.38, 95% CI 1.06-1.78) and all-cause hospitalization (aHR 1.59, 95% CI 1.14.2.22).ConclusionsIn a real-world cohort of patients undergoing TAVI, the presence of AF (preexisting and new-onset) was independently associated with both short- and long-term adverse outcomes.

2024 - Atrial fibrillation burden: Stepping beyond the categorical characterization [Articolo su rivista]
Doundoulakis, I.; Nedios, S.; Zafeiropoulos, S.; Vitolo, M.; Della Rocca, D. G.; Kordalis, A.; Shamloo, A. S.; Koliastasis, L.; Marcon, L.; Chiotis, S.; Sorgente, A.; Soulaidopoulos, S.; Imberti, J. F.; Botis, M.; Pannone, L.; Gatzoulis, K. A.; Sarkozy, A.; Stavrakis, S.; Boriani, G.; Boveda, S.; Tsiachris, D.; Chierchia, G. -B.; de Asmundis, C.
abstract

Traditional classifications categorize atrial fibrillation (AF) into paroxysmal, persistent, or permanent, but recent advancements in monitoring have revealed AF as a continuous variable, challenging existing paradigms. AF burden, defined basically as the amount of time spent in AF during a monitored period, has emerged as a crucial metric. This review assesses the evolving landscape of AF burden and its measurement methods, diagnostic modalities, and impact on outcomes. Guidelines suggest individualized approaches, combining AF burden with clinical scores (CHA2DS2-VASc), but studies have challenged this. Addressing the impact of AF burden on patients' quality of life before or after ablation is also crucial. Although continuous monitoring technologies offer promising avenues, the field faces challenges, such as defining clinically relevant thresholds. Future research should focus on refining these, designing trials centered around AF burden, and evaluating the efficacy of interventions in reducing AF burden, ultimately paving the way for personalized management strategies.

2024 - Atrial fibrillation, comorbidities, stroke, and mortality in real‑world clinical practice [Articolo su rivista]
Boriani, G.; Mei, D. A.; Imberti, J. F.
abstract

2024 - CHA2DS2-VA instead of CHA2DS2-VASc for stroke risk stratification in patients with atrial fibrillation: not just a matter of sex [Articolo su rivista]
Boriani, G.; Vitolo, M.; Mei, D. A.
abstract

2024 - Cardiac resynchronization therapy (CRT) nonresponders in the contemporary era: A state-of-the-art review [Articolo su rivista]
Gerra, L.; Bonini, N.; Mei, D. A.; Imberti, J. F.; Vitolo, M.; Bucci, T.; Boriani, G.; Lip, G. Y. H.
abstract

In the 2000s, cardiac resynchronization therapy (CRT) became a revolutionary treatment for heart failure with reduced left ventricular ejection fraction (HFrEF) and wide QRS. However, about one-third of CRT recipients do not show a favorable response. This review of the current literature aims to better define the concept of CRT response/nonresponse. The diagnosis of CRT nonresponder should be viewed as a continuum, and it cannot rely solely on a single parameter. Moreover, baseline features of some patients might predict an unfavorable response. A strong collaboration between heart failure specialists and electrophysiologists is key to overcoming this challenge with multiple strategies. In the contemporary era, new pacing modalities, such as His-bundle pacing and left bundle branch area pacing, represent a promising alternative to CRT. Observational studies have demonstrated their potential; however, several limitations should be addressed. Large randomized controlled trials are needed to prove their efficacy in HFrEF with electromechanical dyssynchrony.

2024 - Cardiovascular toxicities of radiotherapy: From practical issues to new perspectives [Articolo su rivista]
Aznar, M. C.; Bergler-Klein, J.; Boriani, G.; Cutter, D. J.; Hurkmans, C.; Levis, M.; Lopez-Fernandez, T.; Lyon, A. R.; Maraldo, M. V.
abstract

2024 - Challenging the status quo: a scoping review of value-based care models in cardiology and electrophysiology [Articolo su rivista]
Osoro, L.; Zylla, M. M.; Braunschweig, F.; Leyva, F.; Figueras, J.; Purerfellner, H.; Merino, J. L.; Casado-Arroyo, R.; Boriani, G.
abstract

Aims The accomplishment of value-based healthcare (VBHC) models could save up to $1 trillion per year for healthcare systems worldwide while improving patients’ wellbeing and experience. Nevertheless, its adoption and development are challenging. This review aims to provide an overview of current literature pertaining to the implementation of VBHC models used in cardiology, with a focus on cardiac electrophysiology Methods This scoping review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis andresults for Scoping Reviews. The records included in this publication were relevant documents published in PubMed, Mendeley, and ScienceDirect. The search criteria were publications about VBHC in the field of cardiology and electrophysiology published between 2006 and 2023. The implementation of VBHC models in cardiology and electrophysiology is still in its infant stages. There is a clear need to modify the current organizational structure in order to establish cross-functional teams with the patient at the centre of care. The adoption of new reimbursement schemes is crucial to moving this process forward. The implementation of technologies for data analysis and patient management, among others, poses challenges to the change processConclusion New VBHC models have the potential to improve the care process and patient experience while optimizing the costs. The implementation of this model has been insufficient mainly because it requires substantial changes in the existing infrastructures and local organization, the need to track adherence to guidelines, and the evaluation of the quality of life improvement and patient satisfaction, among others.

2024 - Clinical decisions for appropriate management of patients with atrial fibrillation [Articolo su rivista]
Boriani, G.; Bonini, N.; Imberti, J. F.; Vitolo, M.; Gerra, L.; Mantovani, M.; Serafini, K.; Birtolo, C.; Tartaglia, E.; Mei, D. A.
abstract

The management of patients with atrial fibrillation (AF) requires intricate clinical decision-making to optimize outcomes. In everyday clinical practice, physicians undergo difficult choices to better manage patients with AF. They need to balance thromboembolic and bleeding risk to focus on patients’ symptoms and to manage a variety of multiple comorbidities. In this review, we aimed to explore the multifaceted dimensions of clinical decision-making in AF patients, encompassing the definition and diagnosis of clinical AF, stroke risk stratification, oral anticoagulant therapy selection, consideration of bleeding risk, and the ongoing debate between rhythm and rate control strategies. We will also focus on possible grey zones for the management of AF patients. In navigating this intricate landscape, clinicians must reconcile the dynamic interplay of patient-specific factors, evolving guidelines, and emerging therapies. The review underscores the need for personalized, evidence-based clinical decision-making to tailor interventions for optimal outcomes according to specific AF patient profiles.

2024 - Clinical significance and prognostic value of right bundle branch block in permanent pacemaker patients [Articolo su rivista]
Mazza, A.; Bendini, M. G.; Leggio, M.; Imberti, J. F.; Valsecchi, S.; Boriani, G.
abstract

AIMS: In patients undergoing pacemaker implantation with no prior history of heart failure (HF), the presence of left bundle branch block (LBBB) has been identified as an independent predictor of HF-related death or hospitalization, while the prognostic significance of right bundle branch block (RBBB) remains uncertain. We aimed to assess the long-term risk of all-cause mortality in patients with a standard indication for permanent pacing and normal or moderately depressed left ventricular function when RBBB is detected at the time of implantation. METHODS: We retrospectively enrolled 1348 consecutive patients who had undergone single- or dual-chamber pacemaker implantation at the study center, from January 1990 to December 2022. Patients with a left ventricular ejection fraction ≤35% or a prior diagnosis of HF were excluded. RESULTS: The baseline 12-lead electrocardiogram revealed an RBBB in 241 (18%) and an LBBB in 98 (7%) patients. During a median follow-up of 65 [25th-75th percentile: 32-117] months, 704 (52%) patients died. The combined endpoint of cardiovascular death or HF hospitalization was reached by 173 (13%) patients. On multivariate analysis, RBBB was confirmed as an independent predictor of death [hazard ratio, 1.33; 95% confidence interval (CI), 1.09-1.63; P  = 0.005]. However, when considering the combined endpoint of cardiovascular death and HF hospitalization, this endpoint was independently associated with LBBB (hazard ratio, 2.13; 95% CI, 1.38-3.29; P  < 0.001), but not with RBBB. CONCLUSION: In patients with standard pacemaker indications and normal or moderately depressed left ventricular function, the presence of basal RBBB was an independent predictor of mortality. However, it was not associated with the combined endpoint of cardiovascular death and HF hospitalization.

2024 - Conduction system disease management in patients candidate and/or treated for the aortic valve disease: an Italian Survey promoted by Italian Association of Arrhythmology and Cardiac Pacing (AIAC) [Articolo su rivista]
Ziacchi, M.; Spadotto, A.; Palmisano, P.; Guerra, F.; De Ponti, R.; Zanotto, G.; Bertini, M.; Biffi, M.; Boriani, G.
abstract

Background: Conduction system disorders represent a frequent complication in patients undergoing surgical (surgical aortic valve replacement, SAVR) or percutaneous (transcatheter aortic valve implantation, TAVI) aortic valve replacement. The purpose of this survey was to evaluate experienced operators approach in this clinical condition. Methods: This survey was independently conducted by the Italian Association of Arrhythmology and Cardiac Pacing (AIAC) and it consisted of 24 questions regarding the respondents’ profile, the characteristics of participating centres, and conduction disease management in different scenarios. Results: Fifty-five physicians from 55 Italian arrhythmia centres took part in the survey. Prophylactic pacemaker implantation is rare. In case of persistent complete atrioventricular block (AVB), 49% and 73% respondents wait less than one week before implanting a definitive pacemaker after SAVR and TAVI, respectively. In case of second degree AVB, the respondents wait some days more for definitive implantation. Respondents consider bundle branch blocks, in particular pre-existing left bundle branch block (LBBB), the worst prognostic factors for pacemaker implantation after TAVI. The implanted valve type is considered a relevant element to evaluate. In patients with new-onset LBBB and severe/moderate left ventricular systolic dysfunction, respondents would implant a biventricular pacemaker in 100/55% of cases, respectively. Conclusions: Waiting time before a definitive pacemaker implantation after aortic valve replacement has reduced compared to the past, and it is anticipated in TAVI vs. SAVR. Bundle branch blocks are considered the worse prognostic factor for pacemaker implantation after TAVI. The type of pacemaker implanted in new-onset LBBB patients without severe left ventricular systolic dysfunction is heterogeneous.

2024 - Design and deployment of the STEEER-AF trial to evaluate and improve guideline adherence: a cluster-randomized trial by the European Society of Cardiology and European Heart Rhythm Association [Articolo su rivista]
Sterlinski, M.; Bunting, K. V.; Boriani, G.; Boveda, S.; Guasch, E.; Mont, L.; Rajappan, K.; Sommer, P.; Mehta, S.; Sun, Y.; Gale, C. P.; van Deutekom, C.; Van Gelder, I. C.; Kotecha, D.
abstract

Aims The aim is to describe the rationale, design, delivery, and baseline characteristics of the Stroke prevention and rhythm control Treatment: Evaluation of an Educational programme of the European society of cardiology in a cluster-Randomized trial in patients with Atrial Fibrillation (STEEER-AF) trial. Methods and results STEEER-AF is a pragmatic trial designed to objectively and robustly determine whether guidelines are adhered to in routine practice and evaluate a targeted educational programme for healthcare professionals. Seventy centres were randomized in six countries (France, Germany, Italy, Poland, Spain, and UK; 2022–23). The STEEER-AF centres recruited 1732 patients with a diagnosis of atrial fibrillation (AF), with a mean age of 68.9 years (SD 11.7), CHA2DS2-VASc score of 3.2 (SD 1.8), and 647 (37%) women. Eight hundred and forty-three patients (49%) were in AF at enrolment and 760 (44%) in sinus rhythm. Oral anticoagulant therapy was prescribed in 1543 patients (89%), with the majority receiving direct oral anticoagulants (1378; 89%). Previous cardioversion, antiarrhythmic drug therapy, or ablation was recorded in 836 patients (48.3%). Five hundred fifty-one patients (31.8%) were currently receiving an antiarrhythmic drug, and 446 (25.8%) were scheduled to receive a future cardioversion or ablation. The educational programme engaged 195 healthcare professionals across centres randomized to the intervention group, consisting of bespoke interactive online learning and reinforcement activities, supported by national expert trainers. Conclusion The STEEER-AF trial was successfully deployed across six European countries to investigate guideline adherence in real-world practice and evaluate if a structured educational programme for healthcare professionals can improve patient-level care.

2024 - Detection of subclinical atrial fibrillation with cardiac implanted electronic devices: What decision making on anticoagulation after the NOAH and ARTESiA trials? [Articolo su rivista]
Boriani, G.; Gerra, L.; Mei, D. A.; Bonini, N.; Vitolo, M.; Proietti, M.; Imberti, J. F.
abstract

Atrial fibrillation (AF) may be asymptomatic and the extensive monitoring capabilities of cardiac implantable electronic devices (CIEDs) revealed asymptomatic atrial tachi-arrhythmias of short duration (minutes-hours) occurring in patients with no prior history of AF and without AF detection at a conventional surface ECG. Both the terms “AHRE” (Atrial High-Rate Episodes) and subclinical AF were used in a series of prior studies, that evidenced the association with an increased risk of stroke. Two randomized controlled studies were planned in order to assess the risk-benefit profile of anticoagulation in patients with AHRE/subclinical AF: the NOAH and ARTESiA trials. The results of these two trials (6548 patients enrolled, overall) show that the risk of stroke/systemic embolism associated with AHRE/subclinical AF is in the range of 1–1.2 % per patient-year, but with an important proportion of severe/fatal strokes occurring in non-anticoagulated patients. The apparent discordance between ARTESiA and NOAH results may be approached by considering the related study-level meta-analysis, which highlights a consistent reduction of ischemic stroke with oral anticoagulants vs. aspirin/placebo (relative risk [RR] 0.68, 95 % CI 0.50–0.92). Oral anticoagulation was found to increase major bleeding (RR 1.62, 95 % CI 1.05–2.5), but no difference was found in fatal bleeding (RR 0.79, 95 % CI 0.37–1.69). Additionally, no difference was found in cardiovascular death or all-cause mortality. Taking into account these results, clinical decision-making for patients with AHRE/subclinical AF at risk of stroke, according to CHA2DS2-VASc, can now be evidence-based, considering the benefits and related risks of oral anticoagulants, to be shared with appropriately informed patients.

2024 - ECG/echo indexes in the diagnostic approach to amyloid cardiomyopathy: A head-to-head comparison from the AC-TIVE study [Articolo su rivista]
Pagura, L.; Porcari, A.; Cameli, M.; Biagini, E.; Canepa, M.; Crotti, L.; Imazio, M.; Forleo, C.; Pavasini, R.; Limongelli, G.; Perlini, S.; Metra, M.; Boriani, G.; Emdin, M.; Sinagra, G.; Merlo, M.; Longo, F.; Rossi, M.; Varra, G. G.; Saro, R.; Dore, F.; Girardi, F.; Vergaro, G.; Musumeci, B.; Autore, C.; Cappelli, F.; Perfetto, F.; Olivotto, I.; Favale, S.; Carella, M. C.; Guaricci, A. I.; Ciccone, M. M.; Di Bella, G.; Tomasoni, D.; Rella, V.; Branzi, G.; Badano, L.; Parati, G.; Palmiero, G.; Caiazza, M.; Caponetti, A. G.; Saturi, G.; Labate, M. E.; Andreis, A.; Paneva, E.; De Ferrari, G. M.; Di Ienno, L.; De Carli, G.; Giacomin, E.; Arzilli, C.
abstract

Background and aims: The discordance between QRS voltages on electrocardiogram (ECG) and left ventricle (LV) wall thickness (LVWT) on echocardiogram (echo) is a recognized red flag (RF) of amyloid cardiomyopathy (AC) and can be measured by specific indexes. No head-to-head comparison of different ECG/echo indexes among subjects with echocardiographic suspicion of AC has yet been undertaken. The study aimed at evaluating the performance and the incremental diagnostic value of different ECG/echo indexes in this subset of patients. Methods: Electrocardiograms of subjects with LV hypertrophy, preserved ejection fraction and ≥ 1 echocardiographic RF of AC participating in the AC-TIVE study, an Italian prospective multicenter study, were independently analyzed by two cardiologists. Low QRS voltages and 8 different ECG/echo indexes were evaluated. Cohort specific cut-offs were computed. Results: Among 170 patients, 55 (32 %) were diagnosed with AC. Combination of low QRS voltages with interventricular septum ≥ 1,6 cm was the most specific (specificity 100 %, positive predictive value 100 %) ECG/echo index, while the ratio between the sum of all QRS voltages and LVWT <7,8 was the most sensitive and accurate (sensitivity 94 %, negative predictive value 97 %, accuracy 82 %). When the latter index was added to a model using easily-accessible clinical variables, the diagnostic accuracy for AC greatly increased (AUC from 0,84 to 0,95; p = 0,007). Conclusions: Among patients with non-dilated hypertrophic ventricles with normal ejection fraction and echocardiographic RF of AC, easily-measurable ECG/echo indexes, mainly when added to few clinical variables, can help the physician orient second level investigations. External validation of the results is warranted.

2024 - Economic analyses in cardiac electrophysiology: from clinical efficacy to cost utility [Articolo su rivista]
Frausing, M. H. J. P.; Nielsen, J. C.; Westergaard, C. L.; Gerdes, C.; Kjellberg, J.; Boriani, G.; Kronborg, M. B.
abstract

Cardiac electrophysiology is an evolving field that relies heavily on costly device- and catheter-based technologies. An increasing number of patients with heart rhythm disorders are becoming eligible for cardiac interventions, not least due to the rising prevalence of atrial fibrillation and increased longevity in the population. Meanwhile, the expansive costs of healthcare face finite societal resources, and a cost-conscious approach to new technologies is critical. Cost-effectiveness analyses support rational decision-making in healthcare by evaluating the ratio of healthcare costs to health benefits for competing therapies. They may, however, be subject to significant uncertainty and bias. This paper aims to introduce the basic concepts, framework, and limitations of cost-effectiveness analyses to clinicians including recent examples from clinical electrophysiology and device therapy.

2024 - Efficacy and Safety of Non-Vitamin-K Antagonist Oral Anticoagulants Versus Warfarin Across the Spectrum of Body Mass Index and Body Weight: An Individual Patient Data Meta-Analysis of 4 Randomized Clinical Trials of Patients With Atrial Fibrillation [Articolo su rivista]
Patel, S. M.; Braunwald, E.; Steffel, J.; Boriani, G.; Palazzolo, M. G.; Antman, E. M.; Bohula, E. A.; Carnicelli, A. P.; Connolly, S. J.; Eikelboom, J. W.; Gencer, B.; Granger, C. B.; Morrow, D. A.; Patel, M. R.; Wallentin, L.; Ruff, C. T.; Giugliano, R. P.
abstract

BACKGROUND: The efficacy and safety of non-vitamin-K antagonist oral anticoagulants (NOACs) across the spectrum of body mass index (BMI) and body weight (BW) remain uncertain. METHODS: We analyzed data from COMBINE AF (A Collaboration Between Multiple Institutions to Better Investigate Non-Vitamin K Antagonist Oral Anticoagulant Use in Atrial Fibrillation), which pooled patient-level data from the 4 pivotal randomized trials of NOAC versus warfarin in patients with atrial fibrillation. The primary efficacy and safety outcomes were stroke or systemic embolic events (stroke/SEE) and major bleeding, respectively; secondary outcomes were ischemic stroke/SEE, intracranial hemorrhage, death, and the net clinical outcome (stroke/SEE, major bleeding, or death). Each outcome was examined across BMI and BW. Because few patients had a BMI <18.5 kg/m2 (n=598), the primary analyses were restricted to those with a BMI ≥18.5 kg/m2. RESULTS: Among 58 464 patients, the median BMI was 28.3 (interquartile range, 25.2-32.2) kg/m2, and the median BW was 81.0 (interquartile range, 70.0-94.3) kg. The event probability of stroke/SEE was lower at a higher BMI irrespective of treatment, whereas the probability of major bleeding was lower at a higher BMI with warfarin but relatively unchanged across BMI with NOACs. NOACs reduced stroke/SEE overall (adjusted hazard ratio [HRadj], 0.80 [95% CI, 0.73-0.88]; P<0.001), with a generally consistent effect across BMI (Ptrend across HRs, 0.48). NOACs also reduced major bleeding overall (HRadj, 0.88 [95% CI, 0.82-0.94]; P<0.001), but with attenuation of the benefit at a higher BMI (trend test across BMI [Ptrend], 0.003). The overall treatment effects of NOACs versus warfarin for secondary outcomes were consistent across BMI, with the exception of the net clinical outcome and death. While these outcomes were overall reduced with NOACs (net clinical outcome, HRadj, 0.91 [95% CI, 0.87-0.95]; P<0.001; death, HRadj, 0.91 [95% CI, 0.86-0.97]; P=0.003), these benefits were attenuated at higher BMI (Ptrend, 0.001 and 0.08, respectively). All findings were qualitatively similar when analyzed across BW. CONCLUSIONS: The treatment effect of NOACs versus warfarin in atrial fibrillation is generally consistent for stroke/SEE across the spectrum of BMI and BW, whereas the reduction in major bleeding is attenuated in those with higher BMI or BW. Death and the net clinical outcome are overall reduced with NOACs over warfarin, although there remain uncertainties for these outcomes at a very high BMI and BW.

2024 - European Society of Cardiology Core Curriculum for cardio-oncology [Articolo su rivista]
Lopez-Fernandez, T.; Farmakis, D.; Ameri, P.; Asteggiano, R.; de Azambuja, E.; Aznar, M.; Barac, A.; Bayes-Genis, A.; Bax, J. J.; Bergler-Klein, J.; Boriani, G.; Celutkiene, J.; Coats, A.; Cohen-Solal, A.; Cordoba, R.; Cosyns, B.; Filippatos, G.; Fox, K.; Gulati, G.; Inciardi, R. M.; Lee, G.; Mamas, M. A.; Novo, G.; Plummer, C.; Psyrri, A.; Rakisheva, A.; Suter, T.; Tini, G.; Tocchetti, C. G.; Toutouzas, K.; Wilhelm, M.; Metra, M.; Lyon, A. R.; Rosano, G. M. C.
abstract

Cardio-oncology is a rapidly growing field of cardiovascular (CV) medicine that has resulted from the continuously increasing clinical demand for specialized CV evaluation, prevention and management of patients suffering or surviving from malignant diseases. Dealing with CV disease in patients with cancer requires special knowledge beyond that included in the general core curriculum for cardiology. Therefore, the European Society of Cardiology (ESC) has developed a special core curriculum for cardio-oncology, a consensus document that defines the level of experience and knowledge required for cardiologists in this particular field. It is structured into 8 chapters, including (i) principles of cancer biology and therapy; (ii) forms and definitions of cancer therapy-related cardiovascular toxicity (CTR-CVT); (iii) risk stratification, prevention and monitoring protocols for CTR-CVT; (iv) diagnosis and management of CV disease in patients with cancer; (v) long-term survivorship programmes and cardio-oncology rehabilitation; (vi) multidisciplinary team management of special populations; (vii) organization of cardio-oncology services; (viii) research in cardio-oncology. The core curriculum aims at promoting standardization and harmonization of training and evaluation in cardio-oncology, while it further provides the ground for an ESC certification programme designed to recognize the competencies of certified specialists.

2024 - European Society of Cardiology: the 2023 Atlas of Cardiovascular Disease Statistics [Articolo su rivista]
Timmis, A.; Aboyans, V.; Vardas, P.; Townsend, N.; Torbica, A.; Kavousi, M.; Boriani, G.; Huculeci, R.; Kazakiewicz, D.; Scherr, D.; Karagiannidis, E.; Cvijic, M.; Kaplon-Cieslicka, A.; Ignatiuk, B.; Raatikainen, P.; De Smedt, D.; Wood, A.; Dudek, D.; Van Belle, E.; Weidinger, F.
abstract

This report from the European Society of Cardiology (ESC) Atlas Project updates and expands upon the 2021 report in presenting cardiovascular disease (CVD) statistics for the ESC member countries. This paper examines inequalities in cardiovascular healthcare and outcomes in ESC member countries utilizing mortality and risk factor data from the World Health Organization and the Global Burden of Disease study with additional economic data from the World Bank. Cardiovascular healthcare data were collected by questionnaire circulated to the national cardiac societies of ESC member countries. Statistics pertaining to 2022, or latest available year, are presented. New material in this report includes contemporary estimates of the economic burden of CVD and mortality statistics for a range of CVD phenotypes. CVD accounts for 11% of the EU’s total healthcare expenditure. It remains the most common cause of death in ESC member countries with over 3 million deaths per year. Proportionately more deaths from CVD occur in middle-income compared with high-income countries in both females (53% vs. 34%) and males (46% vs. 30%). Between 1990 and 2021, median age-standardized mortality rates (ASMRs) for CVD decreased by median >50% in high-income ESC member countries but in middle-income countries the median decrease was <12%. These inequalities between middle- and high-income ESC member countries likely reflect heterogeneous exposures to a range of environmental, socioeconomic, and clinical risk factors. The 2023 survey suggests that treatment factors may also contribute with middle-income countries reporting lower rates per million of percutaneous coronary intervention (1355 vs. 2330), transcatheter aortic valve implantation (4.0 vs. 153.4) and pacemaker implantation (147.0 vs. 831.9) compared with high-income countries. The ESC Atlas 2023 report shows continuing inequalities in the epidemiology and management of CVD between middle-income and high-income ESC member countries. These inequalities are exemplified by the changes in CVD ASMRs during the last 30 years. In the high-income ESC member countries, ASMRs have been in steep decline during this period but in the middle-income countries declines have been very small. There is now an important need for targeted action to reduce the burden of CVD, particularly in those countries where the burden is greatest.

2024 - Expert opinion on design and endpoints for studies on catheter ablation of atrial fibrillation [Articolo su rivista]
Lewalter, T.; Blomstrom-Lundqvist, C.; Lakkireddy, D.; Packer, D.; Meyer, R.; Kuniss, M.; Ladwig, K. -H.; Jilek, C.; Diener, H. -C.; Boriani, G.; Turakhia, M. P.; Schneider, S.; Svennberg, E.; Albers, B.; Andrade, J. G.; de Melis, M.; Brachmann, J.
abstract

Introduction: Catheter ablation of atrial fibrillation (AF) is frequently studied in randomized trials, observational and registry studies. The aim of this expert opinion is to provide guidance for clinicians and industry regarding the development of future clinical studies on catheter ablation of AF, implement lessons learned from previous studies, and promote a higher degree of consistency across studies. Background: Studies on catheter ablation of AF may benefit from well-described definitions of endpoints and consistent methodology and documentation of outcomes related to efficacy, safety and cost-effectiveness. The availably of new, innovative technologies warrants further consideration about their application and impact on study design and the choice of endpoints. Moreover, recent insights gained from AF ablation studies suggest a reconsideration of some methodological aspects. Methods: A panel of clinical experts on catheter ablation of AF and designing and conducting clinical studies developed an expert opinion on the design and endpoints for studies on catheter ablation of AF. Discussions within the expert panel with the aim to reach consensus on predefined topics were based on outcomes reported in the literature and experiences from recent clinical trials. Results: A comprehensive set of recommendations is presented. Key elements include the documentation of clinical AF, medication during the study, repeated ablations and their effect on endpoint assessments, postablation blanking and the choice of rhythm-related and other endpoints. Conclusion: This expert opinion provides guidance and promotes consistency regarding design of AF catheter ablation studies and identified aspects requiring further research to optimize study design and methodology. CONDENSED ABSTRACT: Recent insights from studies on catheter ablation of atrial fibrillation (AF) and the availability of new innovative technologies warrant reconsideration of methodological aspects related to study design and the choice and assessment of endpoints. This expert opinion, developed by clinical experts on catheter ablation of AF provides a comprehensive set of recommendations related to these methodological aspects. The aim of this expert opinion is to provide guidance for clinicians and industry regarding the development of clinical studies, implement lessons learned from previous studies, and promote a higher degree of consistency across studies.

2024 - External Validation of COOL-AF Scores in the Asian Pacific Heart Rhythm Society Atrial Fibrillation Registry [Articolo su rivista]
Bucci, T.; Shantsila, A.; Romiti, G. F.; Teo, W. -S.; Chao, T. -F.; Shimizu, W.; Boriani, G.; Tse, H. -F.; Krittayaphong, R.; Lip, G. Y. H.
abstract

Background: The COOL-AF (Cohort of Antithrombotic Use and Optimal International Normalized Ratio Levels in Patients with Atrial Fibrillation) risk scores for death, bleeding, and thromboembolic events (TEs) were derived from the COOL-AF cohort from Thailand and require external validation. Objectives: The authors sought to externally validate the COOL-AF scores in the APHRS (Asia-Pacific Heart Rhythm Society) registry and to compare their performance in the ESC-EHRA (European Society of Cardiology-European Heart Rhythm Association) EORP-AF (EURObservational Research Programme in Atrial Fibrillation) General Long-Term Registry. Methods: We studied 3,628 APHRS and 8,825 EORP-AF patients. Receiver operating characteristic (ROC) curves and Cox regression analyses were used to test the predictive value of COOL-AF scores and to compared them with the CHA2DS2-VASc and HAS-BLED scores. Results: Patients in the EORP-AF were older, had a higher prevalence of male sex, and were at higher thromboembolic and hemorrhagic risk than APHRS patients. After 1 year of follow-up in APHRS and EORP-AF, the following events were recorded: 87 (2.4%) and 435 (4.9%) death for any causes, 37 (1.0%) and 111 (1.3%) major bleeding, and 25 (0.7%) and 109 (1.2%) TEs, respectively. In APHRS, the COOL-AF scores showed moderate-to-good predictive value for all-cause mortality (area under the curve [AUC]: 0.77; 95% CI: 0.71-0.83), major bleeding (AUC: 0.68; 95% CI: 0.60-0.76), and TEs (AUC: 0.61; 95% CI: 0.51-0.71), and were similar to the CHA2DS2-VASc and HAS-BLED scores. In EORP-AF, the predictive value of COOL-AF for all-cause mortality (AUC: 0.68; 95% CI: 0.65-0.70) and major bleeding (AUC: 0.61; 95% CI: 0.60-0.62) was modest and lower than in APHRS. In EORP-AF, the COOL-AF score for TE was inferior to the CHA2DS2-VASc score. Conclusions: The COOL-AF risk scores may be an easy tool to identify Asian patients with AF at risk for death and major bleeding and performs better in Asian than in European patients with AF. (Clinical Survey on the Stroke Prevention in Atrial Fibrillation in Asia [AF-Registry]; NCT04807049)

2024 - Great debate: device-detected subclinical atrial fibrillation should be treated like clinical atrial fibrillation [Articolo su rivista]
Sanders, P.; Svennberg, E.; Diederichsen, S. Z.; Crijns, H. J. G. M.; Lambiase, P. D.; Boriani, G.; Van Gelder, I. C.
abstract

Summary of the factors representing the equipoise associated with device-detected subclinical atrial fibrillation to inform patient-specific treatment. AF, atrial fibrillation; CIED, cardiac implantable electronic device; OAC, oral anticoagulation; QoL, quality of life.

2024 - Heart Failure–Related Death in Subjects With Atrial Fibrillation in the United States, 1999 to 2020 [Articolo su rivista]
Zuin, M.; Bertini, M.; Vitali, F.; Turakhia, M.; Boriani, G.
abstract

BACKGROUND: Population-based data on heart failure (HF)-related death in patients with atrial fibrillation (AF) are lacking. We assessed HF-related death in people with AF in the United States over the past 21 years and examined differences by age, sex, race, ethnicity, urbanization, and census region. METHODS AND RESULTS: Data were extracted from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research to determine trends in age-adjusted mortality rates per 100 000 people, due to HF-related death among subjects with AF aged ≥15 years. To calculate nationwide annual trends, we assessed the average annual percent change (AAPC) and annual percent change with relative 95% CIs using joinpoint regression. Between 1999 and 2020, 916 685 HF-related deaths (396 205 men and 520 480 women) occurred among US adults having a concomitant AF. The overall ageadjusted mortality rates increased (AAPC: +4.1% [95% CI, 3.8–4.4]; P<0.001), especially after 2011 (annual percent change, +6.8% [95% CI, 6.2–7.4]; P<0.001) in men (AAPC, +4.8% [95% CI, 4.4–5.1]; P<0.001), in White subjects (AAPC: +4.2% [95% CI, 3.9 to 4.6]; P<0.001) and in subjects aged <65 years (AAPC: +7.5% [95% CI, 6.7–8.4]; P<0.001). The higher percentage of deaths were registered in the South (32.8%). During the first year of the COVID-19 pandemic, a significant excess in HF-related deaths among patients with AF aged >65 years was observed. CONCLUSIONS: A worrying increase in the HF-related mortality rate among patients with AF has been observed in the United States over the past 2 decades.

2024 - Identification of hemodynamically stable patients with acute pulmonary embolism at high risk for death: external validation of different models [Articolo su rivista]
Becattini, C.; Vedovati, M. C.; Colombo, S.; Vanni, S.; Abrignani, M. G.; Scardovi, A. B.; Marrazzo, A.; Borselli, M.; Barchetti, M.; Fabbri, A.; Dentali, F.; Maggioni, A. P.; Agnelli, G.; Gulizia, M. M.; Di Lenarda, A.; Enea, I.; Maggioni, A. P.; Pomero, F.; Ruggeri, M. P.; Lucci, D.; Duranti, M.; Guercini, F.; Groff, P.; Verso, M.; Fabbri, G.; Savoia, M.; Baldini, E.; Mecatti, B. B.; Bianchini, F.; Ceseri, M.; Gonzini, L.; Gorini, M.; Lorimer, A.; Orsini, G.; Tricoli, M.; Cimini, L. A.; Becattini, C.; Agnelli, G.; Cesarini, V.; Sanna, M.; Pepe, G.; Marchetti, C.; Roldan, M. O.; Lenzi, L.; Cozzio, S.; Tomio, P.; Diamanti, M.; Beltrame, A.; Glinski, L.; Treleani, M.; Coppa, A.; Vanni, S.; Bartalucci, P.; Taccone, A.; Costacurta, C.; Bortolotti, P.; Bortolussi, M.; De Vecchi, M.; Zanardi, F.; Greco, I.; Cosentini, R.; Gerloni, R.; Artusi, N.; Cominotto, F.; Sisto, U. G.; Picariello, C.; Roncon, L.; Maddalozzo, A.; Nitti, C.; Riccomi, F.; Buzzo, M.; Bassanelli, G.; Savonitto, S.; Bianchi, A.; Bilato, C.; Lobascio, I.; Dalla Valle, C.; Pomata, D. P.; Giostra, F.; Tinuper, A. L.; Zalunardo, B.; Visona, A.; Panzavolta, C.; Novelli, A.; Bertini, A.; Granai, C.; Colombo, S.; Periti, E.; Bonacchini, L.; Abrignani, M. G.; Casciolo, M. F.; D'Amato, A.; Scardovi, A. B.; Ricci, R.; Iosi, S.; Fontana, M. C.; Marrazzo, A.; Borselli, M.; Di Fusco, S. A.; Colivicchi, F.; Enea, I.; Triggiani, M.; Papa, I.; Pasini, G. F.; Fioravanti, C.; Panarello, S.; Raggi, F.; Marzolo, M.; Cuppini, S.; Milan, M.; Barchetti, M.; De Laura, D.; Caldarola, P.; Fiorini, R.; Rastelli, G.; Ameri, P.; La Malfa, G.; Cinelli, F.; Sganzerla, P. C.; Ubaldi, S.; Sanchez, F. A.; Forgione, C.; Cuccia, C.; Predieri, S.; Fusco, S.; Mumoli, N.; Porta, C.; Romei, M.; Lucidi, M.; Romaniello, A.; Volpe, M.; Mogni, P.; Pizzolato, E.; Martino, G. P.; Bitti, G.; Righini, G.; Bandiera, G.; Pennacchio, E.; Limauro, S.; Dachille, A.; Ignone, G.; Fuscaldo, G. F.; De Rosa, F. M.; Vazzana, N.; Chesi, G.; Di Filippo, F.; Pierpaoli, L.; Corapi, A.; Vatrano, M.; Angotti, C.; Baccetti, F.; Harari, S. A.; Luisi, F.; Daghini, E.; De Curtis, E.; Luca, F.; Ciancia, F.; Blandizzi, S.; Lettica, G. V.; D'Orazio, S.; Cosmi, F.; Zaccaroni, S.; Silingardi, M.; Valeriano, V.; Pugliese, F. R.; Murgia, A. P.; Parpaglia, P. P.; Martinelli, L.; Caponi, C.; Clemente, M. A.; Ciccarone, A.; Bongarzoni, A.; Garagiola, M.; Leone, M. C.; Veropalumbo, M. R.; Sacco, M.; Morella, P.; Dorigoni, S.; Peterlana, D.; Di Paola, R.; Felis, S.; Correale, M.; Brunetti, N. D.; Petrelli, G.; Feliziani, F. T.; Mastroiacovo, D.; Romualdi, R.; Pasin, F.; Bonardi, S.; Delfino, P.; Scifo, C.; Savioli, G.; Ceresa, I. F.; Galeotalanza, M.; Benazzi, B.; Porzio, M.; Rosini, F.; Ancona, C.; Verrelli, C.; Pasini, A. F.; Dalle Carbonare, L.; Bozza, N.; Nacci, F.; Scarabelli, M. A.; Amico, F.; Marchesi, C.; Mazzone, A.; Di Tommaso, R.; Cocco, F.; Pezzuto, G.; Luciani, A.; Zamboni, P.; Muriago, M.; Del Pesce, L.; Lucarini, A. R.; Guglielmelli, E.; Vannucchi, V.; Moroni, F.; Fichera, D.; Malatino, L.; Sgroi, C.; Morana, I. M.; Cicero, S.; La Rosa, D.; Mete, F.; Gino, M.; De Palma, A.; Alessandri, M.; Maestripieri, V.; Battocchio, M.; De Santis, M. T.; Saladini, F.; Corsi, D. C.; Macarone Palmieri, N.; Pierfranceschi, M. G.; Palmonari, V.; Fontanella, L.; Airoldi, L.; Bonocore, M.; Paliani, U.; Prat, L. I.; Chiecchi, L.; Cuonzo, M.; Paludo, A.; Padula, D.; Antonelli, A.; Bicchi, M.; Tota, G.; Ariello, M.; Sai, R.; Civita, M.; Tucci, M.; Barbati, G.; Conti, M.; Cettina, R.; Magnani, O.; Levato, M.; Gessi, V.; De Rui, M.; Bellizzi, A.; Farneti, L.; Salomone, P.; Mannarini, A.; Grifoni, E.; Del Ghianda, S.; Campodonico, J.; De Cesare, N.; Mutone, D.; Pasoli, P.; Meloni, S.; Frenda, A.; Viola, G.; Torromeo, C.; Campana, C.; Pistone, M. C.; Caravita, S.; La Creta, C. P.; Miscio, F.; Loreno, M.; Fenu, P.; Mazzetti, M.; Rossini, D.; Brunacci, M.; Capuano, A.; Tagliamonte, G.; Pinelli, M.; Ballocca, F.; Parca, G.; Pasini, S. M.; Maragno, M. G.; Vecc
abstract

Background: The optimal strategy for identification of hemodynamically stable patients with acute pulmonary embolism (PE) at risk for death and clinical deterioration remains undefined. Objectives: We aimed to assess the performances of currently available models/scores for identifying hemodynamically stable patients with acute, symptomatic PE at risk of death and clinical deterioration. Methods: This was a prospective multicenter cohort study including patients with acute PE (NCT03631810). Primary study outcome was in-hospital death within 30 days or clinical deterioration. Other outcomes were in-hospital death, death, and PE-related death, all at 30 days. We calculated positive and negative predictive values, c-statistics of European Society of Cardiology (ESC)-2014, ESC-2019, Pulmonary Embolism Thrombolysis (PEITHO), Bova, Thrombo-embolism lactate outcome study (TELOS), fatty acid binding protein, syncope and tachicardia (FAST), and National Early Warning Scale 2 (NEWS2) for the study outcomes. Results: In 5036 hemodynamically stable patients with acute PE, positive predictive values for the evaluated models/scores were all below 10%, except for TELOS and NEWS2; negative predictive values were above 98% for all the models/scores, except for FAST and NEWS2. ESC-2014 and TELOS had good performances for in-hospital death or clinical deterioration (c-statistic of 0.700 and 0.722, respectively), in-hospital death (c-statistic of 0.713 and 0.723, respectively), and PE-related death (c-statistic of 0.712 and 0.777, respectively); PEITHO, Bova, and NEWS2 also had good performances for PE-related death (c-statistic of 0.738, 0.741, and 0.742, respectively). Conclusion: In hemodynamically stable patients with acute PE, the accuracy for identification of hemodynamically stable patients at risk for death and clinical deterioration varies across the available models/scores; TELOS seems to have the best performance. These data can inform management studies and clinical practice.

2024 - Impact of chronic obstructive pulmonary disease in patients with atrial fibrillation: An analysis from the GLORIA-AF registry [Articolo su rivista]
Romiti, G. F.; Corica, B.; Mei, D. A.; Frost, F.; Bisson, A.; Boriani, G.; Bucci, T.; Olshansky, B.; Chao, T. -F.; Huisman, M. V.; Proietti, M.; Lip, G. Y. H.
abstract

Aims: Chronic obstructive pulmonary disease (COPD) may influence management and prognosis of atrial fibrillation (AF), but this relationship has been scarcely explored in contemporary global cohorts. We aimed to investigate the association between AF and COPD, in relation to treatment patterns and major outcomes. Methods and results: From the prospective, global GLORIA-AF registry, we analysed factors associated with COPD diagnosis, as well as treatment patterns and risk of major outcomes in relation to COPD. The primary outcome was the composite of all-cause death and major adverse cardiovascular events (MACEs). A total of 36 263 patients (mean age 70.1 ± 10.5 years, 45.2% females) were included; 2,261 (6.2%) had COPD. The prevalence of COPD was lower in Asia and higher in North America. Age, female sex, smoking, body mass index, and cardiovascular comorbidities were associated with the presence of COPD. Chronic obstructive pulmonary disease was associated with higher use of oral anticoagulant (OAC) [adjusted odds ratio (aOR) and 95% confidence interval (CI): 1.29 (1.13-1.47)] and higher OAC discontinuation [adjusted hazard ratio (aHR) and 95% CI: 1.12 (1.01-1.25)]. Chronic obstructive pulmonary disease was associated with less use of beta-blocker [aOR (95% CI): 0.79 (0.72-0.87)], amiodarone and propafenone, and higher use of digoxin and verapamil/diltiazem. Patients with COPD had a higher hazard of primary composite outcome [aHR (95% CI): 1.78 (1.58-2.00)]; no interaction was observed regarding beta-blocker use. Chronic obstructive pulmonary disease was also associated with all-cause death [aHR (95% CI): 2.01 (1.77-2.28)], MACEs [aHR (95% CI): 1.41 (1.18-1.68)], and major bleeding [aHR (95% CI): 1.48 (1.16-1.88)]. Conclusion: In AF patients, COPD was associated with differences in OAC treatment and use of other drugs; Patients with AF and COPD had worse outcomes, including higher mortality, MACE, and major bleeding.

2024 - Implications for clinical decision-making of the NOAH-AFNET 6 and ARTESiA studies: What risk-benefit ratio of anticoagulation in patients with subclinical atrial fibrillation? [Articolo su rivista]
Boriani, G.; Mantovani, M.; Birtolo, C.; Righelli, I.; Gerra, L.
abstract

2024 - Insights into Pathophysiology of Sickle-cell Disease Cardiomyopathy by 3D Echocardiography [Articolo su rivista]
Coppi, Francesca; Tampieri, Francesca; Palazzi, Giovanni; Boschini, Matteo; Pagnoni, Gianluca; Ferrara, Francesca; Manenti, Antonio; Mattioli, Anna Vittoria; Iughetti, Lorenzo; Boriani, Giuseppe
abstract

In sickle cell disease cardiomyopathy, 3D transthoracic Echocardiography (3D Echo) is an essential diagnostic tool for accurate diagnosis and further understanding of its pathophysiology. To this end, we performed a retrospective observational study in a cohort of 46 pediatric patients with homozygous or heterozygous sickle cell disease. In particular, we assessed that an increased right ventricular end-diastolic volume is the earliest sign of this disease progression, promoted by a high pulmonary artery systolic pressure and followed by uncoupling with the pulmonary artery. Over time, the dysfunction of the right ventricle also affects the left ventricle, leading to global heart failure, which can be considered "right ventricle-driven". In addition, 3D echocardiography is an essential tool in the followup of this disease and together with the reduced incidence of acute chest syndrome or peripheral vaso-occlusive events to choose the optimal medical treatment.

2024 - Longer and better lives for patients with atrial fibrillation: the 9th AFNET/EHRA consensus conference [Articolo su rivista]
Linz, D.; Andrade, J. G.; Arbelo, E.; Boriani, G.; Breithardt, G.; Camm, A. J.; Caso, V.; Nielsen, J. C.; De Melis, M.; De Potter, T.; Dichtl, W.; Diederichsen, S. Z.; Dobrev, D.; Doll, N.; Duncker, D.; Dworatzek, E.; Eckardt, L.; Eisert, C.; Fabritz, L.; Farkowski, M.; Filgueiras-Rama, D.; Goette, A.; Guasch, E.; Hack, G.; Hatem, S.; Haeusler, K. G.; Healey, J. S.; Heidbuechel, H.; Hijazi, Z.; Hofmeister, L. H.; Hove-Madsen, L.; Huebner, T.; Kaab, S.; Kotecha, D.; Malaczynska-Rajpold, K.; Merino, J. L.; Metzner, A.; Mont, L.; Andre Ng, G.; Oeff, M.; Parwani, A. S.; Puererfellner, H.; Ravens, U.; Rienstra, M.; Sanders, P.; Scherr, D.; Schnabel, R.; Schotten, U.; Sohns, C.; Steinbeck, G.; Steven, D.; Toennis, T.; Tzeis, S.; van Gelder, I. C.; van Leerdam, R. H.; Vernooy, K.; Wadhwa, M.; Wakili, R.; Willems, S.; Witt, H.; Zeemering, S.; Kirchho, P.
abstract

Aims Recent trial data demonstrate beneficial effects of active rhythm management in patients with atrial fibrillation (AF) and support the concept that a low arrhythmia burden is associated with a low risk of AF-related complications. The aim of this document is to summarize the key outcomes of the 9th AFNET/EHRA Consensus Conference of the Atrial Fibrillation NETwork (AFNET) and the European Heart Rhythm Association (EHRA) Methods Eighty-three international experts met in Münster for 2 days in September 2023. Key findings are as follows: (i) Active rhythm and results management should be part of the default initial treatment for all suitable patients with AF. (ii) Patients with device-detected AF have a low burden of AF and a low risk of stroke. Anticoagulation prevents some strokes and also increases major but non-lethal bleeding. (iii) More research is needed to improve stroke risk prediction in patients with AF, especially in those with a low AF burden. Biomolecules, genetics, and imaging can support this. (iv) The presence of AF should trigger systematic workup and comprehensive treatment of concomitant cardiovascular conditions. (v) Machine learning algorithms have been used to improve detection or likely development of AF. Cooperation between clinicians and data scientists is needed to leverage the potential of data science applications for patients with AF.Conclusions Patients with AF and a low arrhythmia burden have a lower risk of stroke and other cardiovascular events than those with a high arrhythmia burden. Combining active rhythm control, anticoagulation, rate control, and therapy of concomitant cardiovascular conditions can improve the lives of patients with AF.

2024 - Management and treatment of atrial fibrillation in cancer patients: An important decision-making hub in cardio-oncology [Articolo su rivista]
Boriani, G.; Mantovani, M.; Cherubini, B.; Tartaglia, E.; Bonini, N.
abstract

2024 - Managing Myotonic Dystrophy Type 1 Complicated by Metabolic Syndrome [Articolo su rivista]
Pagnoni, G.; Nassar, A.; Grossule, F.; Paolini, M.; Maini, A.; Mattioli, A. V.; Boriani, G.; Coppi, F.
abstract

Myotonic dystrophy type 1 (MD1) is the most common form of muscular dystrophy in adults. MD1 is caused by the expansion of CTG repeats in the DMPK gene and affects various organs beyond muscles. We present a case of a patient with MD1 exhibiting features of metabolic syndrome (MetS), including insulin resistance and dyslipidemia. The patient was treated with PCSK9 inhibitors, ezetimibe, and bempedoic acid because of intolerance. Metabolic syndrome is more prevalent in patients with muscle disorders like MD1, primarily caused by the sedentary lifestyle associated with muscle weakness. Although no specific studies on MetS frequency in MD1 exist, data on its components are available. This case highlights the management of MetS in MD1 with innovative therapies. Managing metabolic syndrome in MD1 patients requires personalized therapies. This case introduces a promising therapeutic approach for statin-intolerant patients.

2024 - Metabolically “extremely unhealthy” obese and non-obese people with diabetes and the risk of cardiovascular adverse events: the Silesia Diabetes - Heart Project [Articolo su rivista]
Janota, O.; Mantovani, M.; Kwiendacz, H.; Irlik, K.; Bucci, T.; Lam, S. H. M.; Huang, B.; Alam, U.; Boriani, G.; Hendel, M.; Piasnik, J.; Olejarz, A.; Wlosowicz, A.; Pabis, P.; Wojcik, W.; Gumprecht, J.; Lip, G. Y. H.; Nabrdalik, K.
abstract

Background: There is a growing burden of non-obese people with diabetes mellitus (DM). However, their cardiovascular risk (CV), especially in the presence of cardiovascular-kidney-metabolic (CKM) comorbidities is poorly characterised. The aim of this study was to analyse the risk of major CV adverse events in people with DM according to the presence of obesity and comorbidities (hypertension, chronic kidney disease, and dyslipidaemia). Methods: We analysed persons who were enrolled in the prospective Silesia Diabetes Heart Project (NCT05626413). Individuals were divided into 6 categories according to the presence of different clinical risk factors (obesity and CKM comorbidities): (i) Group 1: non-obese with 0 CKM comorbidities; (ii) Group 2: non-obese with 1–2 CKM comorbidities; (iii) Group 3: non-obese with 3 CKM comorbidities (non-obese “extremely unhealthy”); (iv) Group 4: obese with 0 CKM comorbidities; (v) Group 5: obese with 1–2 CKM comorbidities; and (vi) Group 6: obese with 3 CKM comorbidities (obese “extremely unhealthy”). The primary outcome was a composite of CV death, myocardial infarction (MI), new onset of heart failure (HF), and ischemic stroke. Results: 2105 people with DM were included [median age 60 (IQR 45–70), 48.8% females]. Both Group 1 and Group 6 were associated with a higher risk of events of the primary composite outcome (aHR 4.50, 95% CI 1.20-16.88; and aHR 3.78, 95% CI 1.06–13.47, respectively). On interaction analysis, in “extremely unhealthy” persons the impact of CKM comorbidities in determining the risk of adverse events was consistent in obese and non-obese ones (Pint=0.824), but more pronounced in individuals aged < 65 years compared to older adults (Pint= 0.028). Conclusion: Both non-obese and obese people with DM and 3 associated CKM comorbidities represent an “extremely unhealthy” phenotype which are at the highest risk of CV adverse events. These results highlight the importance of risk stratification of people with DM for risk factor management utilising an interdisciplinary approach.

2024 - Natural History of Coronary Atherosclerosis in Patients With Aortic Stenosis Undergoing Transcatheter Aortic Valve Replacement: The Role of Quantitative Flow Ratio [Articolo su rivista]
Colaiori, I.; Paolucci, L.; Mangiacapra, F.; Barbato, E.; Ussia, G. P.; Grigioni, F.; Demola, P.; Vitolo, M.; Benatti, G.; Vignali, L.; Gabbieri, D.; Magnavacchi, P.; Sgura, F. A.; Boriani, G.; Guiducci, V.
abstract

BACKGROUND: The prognostic impact of functionally significant coronary artery disease, as assessed with quantitative flow ratio (QFR), in patients with severe aortic stenosis treated with transcatheter aortic valve replacement is unknown. METHODS: This is a retrospective study with blind analysis of angiographic data, enrolling consecutive patients with severe aortic stenosis treated with transcatheter aortic valve replacement at 4 Italian centers. None of the patients enrolled received pre-transcatheter aortic valve replacement or concomitant coronary revascularization, either for the absence of significant coronary stenoses or by clinical decision. Visual estimation of diameter stenosis and QFR analysis were performed in all coronary arteries. The end point was all-cause mortality at a 3-year follow-up. RESULTS: A total of 318 patients were enrolled. At visual estimation, 140 patients (44%) presented a diameter stenosis ≥50% in at least 1 coronary artery, whereas 78 patients (24.5%) had at least 1 vessel with QFR <0.80 and, therefore, included in the positive QFR group. Overall, 69 (21.7%) patients died during the follow-up. In the Kaplan-Meier analysis, patients with positive QFR experienced significantly higher rates of death during follow-up compared with those without (51.1% versus 12.1%; P<0.001), whereas no significant difference was evident in terms of death between patients with or without significant coronary artery disease according to angiographic evaluation (24.3% versus 19.7%; P=0.244). In a multivariate regression model, positive QFR was an independent predictor of all-cause death during follow-up (hazard ratio, 5.31 [95% CI, 3.21-8.76]). CONCLUSIONS: Coronary QFR can predict mortality in patients with severe aortic stenosis treated with transcatheter aortic valve replacement without revascularization.

2024 - Optimizing the care management pathway of patients with ischemia and non-obstructive coronary arteries [Articolo su rivista]
Oliva, F.; Boriani, G.; Calabro, P.; Caldarola, P.; Carugo, S.; Castiglioni, B.; Celentani, D.; Comeglio, M.; De Luca, L.; De Maria, R.; Muro, M. D.; Ignone, G.; Leonardo, F.; Margonato, A.; Massari, F.; Murrone, A.; Nardi, F.; Patti, G.; Perna, G.; Pinna, P.; Poli, M.; Prati, F.; Raddino, R.; Pierdomenico, S. D.; Tammaro, P.; Porto, I.
abstract

Ischemia with non-obstructive coronary arteries (INOCA) is defined by the coexistence of anginal symptoms and demonstrable ischemia, with no evidence of obstructive coronary arteries. The underlying mechanism of INOCA is coronary microvascular dysfunction with or without associated vasospasm. INOCA patients have recurrent symptoms, functional limitations, repeated access to the emergency department, impaired quality of life and a higher incidence of cardiovascular events than the general population. Although well described in chronic coronary syndrome guidelines, INOCA remains underdiagnosed in clinical practice because of insufficient awareness, lack of accurate diagnostic tools, and poorly standardized and consistent definitions to diagnose, both invasively and non-invasively, coronary microvascular dysfunction. To disseminate current scientific evidence on INOCA as a distinct clinical entity, during 2022 we conducted at 30 cardiology units all over the country a clinical practice improvement initiative, with the aim of developing uniform and shared management pathways for INOCA patients across different operational settings. The present document highlights the outcomes of this multidisciplinary initiative.

2024 - Oral anticoagulants in patients with atrial fibrillation and end-stage renal disease: Walking the tightrope between thromboembolic and bleeding risk [Articolo su rivista]
Vitolo, M.; Gerra, L.; Boriani, G.
abstract

2024 - Oral anticoagulation for atrial fibrillation and high risk of bleeding in daily practice: What clinical considerations? [Articolo su rivista]
Boriani, G.; Tartaglia, E.; Imberti, J. F.
abstract

2024 - Patterns of comorbidities in patients with atrial fibrillation and impact on management and long-term prognosis: an analysis from the Prospective Global GLORIA-AF Registry [Articolo su rivista]
Romiti, G. F.; Corica, B.; Mei, D. A.; Bisson, A.; Boriani, G.; Olshansky, B.; Chao, T. -F.; Huisman, M. V.; Proietti, M.; Lip, G. Y. H.
abstract

Background Clinical complexity, as the interaction between ageing, frailty, multimorbidity and polypharmacy, is an increasing concern in patients with AF. There remains uncertainty regarding how combinations of comorbidities influence management and prognosis of patients with atrial fibrillation (AF). We aimed to identify phenotypes of AF patients according to comorbidities and to assess associations between comorbidity patterns, drug use and risk of major outcomes. Methods From the prospective GLORIA-AF Registry, we performed a latent class analysis based on 18 diseases, encompassing cardiovascular, metabolic, respiratory and other conditions; we then analysed the association between phenotypes of patients and (i) treatments received and (ii) the risk of major outcomes. Primary outcome was the composite of all-cause death and major adverse cardiovascular events (MACE). Secondary exploratory outcomes were also analysed. Results 32,560 AF patients (mean age 70.0 ± 10.5 years, 45.4% females) were included. We identified 6 phenotypes: (i) low complexity (39.2% of patients); (ii) cardiovascular (CV) risk factors (28.2%); (iii) atherosclerotic (10.2%); (iv) thromboembolic (8.1%); (v) cardiometabolic (7.6%) and (vi) high complexity (6.6%). Higher use of oral anticoagulants was found in more complex groups, with highest magnitude observed for the cardiometabolic and high complexity phenotypes (odds ratio and 95% confidence interval CI): 1.76 [1.49–2.09] and 1.57 [1.35–1.81], respectively); similar results were observed for beta-blockers and verapamil or diltiazem. We found higher risk of the primary outcome in all phenotypes, except the CV risk factor one, with highest risk observed for the cardiometabolic and high complexity groups (hazard ratio and 95%CI: 1.37 [1.13–1.67] and 1.47 [1.24–1.75], respectively). Conclusions Comorbidities influence management and long-term prognosis of patients with AF. Patients with complex phenotypes may require comprehensive and holistic approaches to improve their prognosis.

2024 - Performance of HAS-BLED and DOAC scores to predict major bleeding events in atrial fibrillation patients treated with direct oral anticoagulants: A report from a prospective European observational registry [Articolo su rivista]
Mei, D. A.; Imberti, J. F.; Bonini, N.; Romiti, G. F.; Corica, B.; Proietti, M.; Vitolo, M.; Lip, G. Y. H.; Boriani, G.
abstract

Background: The DOAC score has been recently proposed for bleeding risk stratification of patients with atrial fibrillation treated with direct oral anticoagulants (DOAC). Objective: To compare the performance of HAS-BLED and DOAC score in predicting major bleeding events in a contemporary cohort of European AF patients treated with DOAC. Methods: We included patients derived from a prospective observational registry of European AF patients. HAS-BLED and DOAC scores were calculated as per the original schemes. Our primary endpoint was major bleeding events. Receiver operating characteristic (ROC) curves were used to compare the predictive ability of the scores. Results: A total of 2834 AF patients (median age [IQR] 69 [62–77] years; 39.6 % female) treated with DOAC were included in the analysis. According to the HAS-BLED score, 577 patients (20.4 %) were categorized as very low risk of bleeding, as compared to 1276 (45.0 %) according to DOAC score. A total of 55 major bleeding events occurred with an overall incidence of 1.04 per 100 patient-years. Both scores showed only a modest ability for the prediction of bleeding events (HAS-BLED area under the curve [AUC], 0.65, 95 % confidence interval [CI] 0.55–0.70; DOAC score AUC 0.62, 95 % CI 0.59–0.71, p for difference = 0.332]. At calibration analysis, the DOAC score showed modest calibration, especially for patients at high risk, when compared to HAS-BLED. Conclusion: In a contemporary cohort of DOAC-treated AF patients, both HAS-BLED and DOAC scores only modestly predicted the occurrence of major bleeding events. Our results do not support the preferential use of DOAC score over HAS-BLED.

2024 - Practical guide on left atrial appendage closure for the non-implanting physician: an international consensus paper [Articolo su rivista]
Potpara, T.; Grygier, M.; Häusler, K. G.; Nielsen-Kudsk, J. E.; Berti, S.; Genovesi, S.; Marijon, E.; Boveda, S.; Tzikas, A.; Boriani, G.; Boersma, L. V. A.; Tondo, C.; De Potter, T.; Lip, G. Y. H.; Schnabel, R. B.; Bauersachs, R.; Senzolo, M.; Basile, C.; Bianchi, S.; Osmancik, P.; Schmidt, B.; Landmesser, U.; Döhner, W.; Hindricks, G.; Kovac, J.; Camm, A. J.
abstract

2024 - Provision of care in clinical cardiac electrophysiology during and after the COVID-19 pandemic: An open challenge for health care systems [Articolo su rivista]
Boriani, G.; Mei, D. A.; Imberti, J. F.
abstract

2024 - Risk of Stroke or Systemic Embolism According to Baseline Frequency and Duration of Subclinical Atrial Fibrillation: Insights From the ARTESiA Trial [Articolo su rivista]
Mcintyre, W. F.; Benz, A. P.; Healey, J. S.; Connolly, S. J.; Yang, M.; Lee, S. F.; Field, T. S.; Alings, M.; Benezet-Mazuecos, J.; Boriani, G.; Cosedis Nielsen, J.; Gold, M. R.; Pergolini, F.; Glotzer, T. V.; Granger, C. B.; Lopes, R. D.
abstract

BACKGROUND: In the ARTESiA trial (Apixaban for the Reduction of Thromboembolism in Patients With Device-Detected Subclinical Atrial Fibrillation), apixaban, compared with aspirin, reduced stroke or systemic embolism in patients with device-detected subclinical atrial fibrillation (SCAF). Clinical guidelines recommend considering SCAF episode duration when deciding whether to prescribe oral anticoagulation for this population. METHODS: We performed a retrospective cohort study in ARTESiA. Using Cox regression adjusted for CHA2DS2-VASc score and treatment allocation (apixaban or aspirin), we assessed frequency of SCAF episodes and duration of the longest SCAF episode in the 6 months before randomization as predictors of stroke risk and of apixaban treatment effect. RESULTS: Among 3986 patients with complete baseline SCAF data, 703 (17.6%) had no SCAF episode ≥6 minutes in the 6 months before enrollment. Among 3283 patients (82.4%) with ≥1 episode of SCAF ≥6 minutes in the 6 months before enrollment, 2542 (77.4%) had up to 5 episodes, and 741 (22.6%) had ≥6 episodes. The longest episode lasted <1 hour in 1030 patients (31.4%), 1 to <6 hours in 1421 patients (43.3%), and >6 hours in 832 patients (25.3%). Higher baseline SCAF frequency was not associated with increased risk of stroke or systemic embolism: 1.1% for 1 to 5 episodes versus 1.2%/patient-year for ≥6 episodes (adjusted hazard ratio, 0.89 [95% CI, 0.59–1.34]). In an exploratory analysis, patients with previous SCAF but no episode ≥6 minutes in the 6 months before enrollment had a lower risk of stroke or systemic embolism than patients with at least one episode during that period (0.5% versus 1.1%/patient-year; adjusted hazard ratio, 0.48 [95% CI, 0.27–0.85]). The frequency of SCAF did not modify the reduction in stroke or systemic embolism with apixaban (Pinteraction=0.1). The duration of the longest SCAF episode in the 6 months before enrollment was not associated with the risk of stroke or systemic embolism during follow-up (<1 hour: 1.0%/patient-year [reference]; 1–6 hours: 1.2%/patient-year [adjusted hazard ratio, 1.27 (95% CI, 0.85–1.90)]; >6 hours: 1.0%/patient-year [adjusted hazard ratio, 1.02 (95% CI, 0.63–1.66)]). SCAF duration did not modify the reduction in stroke or systemic embolism with apixaban (Ptrend=0.1). CONCLUSIONS: In ARTESiA, baseline SCAF frequency and longest episode duration were not associated with risk of stroke or systemic embolism and did not modify the effect of apixaban on reduction of stroke or systemic embolism.

2024 - Same-day discharge vs. overnight stay following catheter ablation for atrial fibrillation: a comprehensive review and meta-analysis by the European Heart Rhythm Association Health Economics Committee [Articolo su rivista]
Zylla, M. M.; Imberti, J. F.; Leyva, F.; Casado-Arroyo, R.; Braunschweig, F.; Purerfellner, H.; Merino, J. L.; Boriani, G.
abstract

Aims Same-day discharge (SDD) after catheter ablation of atrial fibrillation (AF) may address the growing socio-economic health burden of the increasing demand for interventional AF therapies. This systematic review and meta-analysis analyses the current evidence on clinical outcomes in SDD after AF ablation compared with overnight stay (ONS). Methods A systematic search of the PubMed database was performed. Pre-defined endpoints were complications at short-term and results (24–96 h) and 30-day post-discharge, re-hospitalization, and/or emergency room (ER) visits at 30-day post-discharge, and 30-day mortality. Twenty-four studies (154 716 patients) were included. Random-effects models were applied for meta-analyses of pooled endpoint prevalence in the SDD cohort and for comparison between SDD and ONS cohorts. Pooled estimates for complications after SDD were low both for short-term [2%; 95% confidence interval (CI): 1–5%; I2: 89%) and 30-day follow-up (2%; 95% CI: 1–4%; I2: 91%). There was no significant difference in complications rates between SDD and ONS [short-term: risk ratio (RR): 1.62; 95% CI: 0.52–5.01; I2: 37%; 30 days: RR: 0.65; 95% CI: 0.42–1.00; I2: 95%). Pooled rates of re-hospitalization/ER visits after SDD were 4% (95% CI: 1–10%; I2: 96%) with no statistically significant difference between SDD and ONS (RR: 0.86; 95% CI: 0.58–1.27; I2: 61%). Pooled 30-day mortality was low after SDD (0%; 95% CI: 0–1%; I2: 33%). All studies were subject to a relevant risk of bias, mainly due to study design. Conclusion In this meta-analysis including a large contemporary cohort, SDD after AF ablation was associated with low prevalence of post-discharge complications, re-hospitalizations/ER visits and mortality, and a similar risk compared with ONS. Due to limited quality of current evidence, further prospective, randomized trials are needed to confirm safety of SDD and define patient- and procedure-related prerequisites for successful and safe SDD strategies.

2024 - Selection of candidates for cardiac resynchronization therapy and implantation management: an Italian survey promoted by the Italian Association of Arrhythmology and Cardiac Pacing [Articolo su rivista]
Ziacchi, M.; Anselmino, M.; Palmisano, P.; Casella, M.; Pelargonio, G.; Russo, V.; D'Onofrio, A.; Massaro, G.; Vilotta, M.; Lauretti, M.; Themistoclakis, S.; Boriani, G.; De Ponti, R.
abstract

BackgroundCardiac resynchronization therapy (CRT) represents an effective heart failure treatment, associated with reduction in mortality and heart failure hospitalizations. This Italian survey aimed to address relevant CRT issues.MethodsAn online survey was administered to AIAC members.ResultsOne hundred and five electrophysiologists participated, with a median of 40 (23-70) CRT implantations/year (33% in high-volume centres). Forty-five percent of respondents (especially working in high-volume centres) reported an increase in CRT implantations in the last 2 years, in 16% a decrease, and in 38% CRT remained stable. Seventy-five percent of respondents implanted CRT only in patients with European Heart Rhythm Association (EHRA) class I indications. All operators collected ECG and echocardiography before implantation. Eighty-five percent of respondents selected coronary sinus target vein empirically, whereas 10% used mechanical and/or electrical delay techniques. Physicians working in high-volume centres reported a lower failure rate compared with others (16 vs. 34%; P=0.03). If the coronary sinus lead could not be positioned in the target branch, 80% placed it in another vein, whereas 16% opted for a surgical approach or for conduction system pacing (CSP). Eighty percent accomplished CRT optimization in all patients, 17% only in nonresponders. Regarding anticoagulation, high agreement with EHRA guidelines emerged.ConclusionCRT represents a valid therapeutic option in heart failure treatment. Nowadays, CRT implantations remain stable and are mainly performed in patients with class I indications. ECG remains the preferred tool for patient selection, whereas imaging is increasingly used to determine the left pacing target area. In most patients, the left ventricular lead can be successfully positioned in the target vein, but in some cases, the result can be unsatisfactory; however, the decision to explore alternative resynchronization approaches is rarely pursued.

2024 - Simple scores to predict 1-year mortality in atrial fibrillation [Articolo su rivista]
Cemin, R.; Maggioni, A. P.; Gonzini, L.; Di Pasquale, G.; Boriani, G.; Di Lenarda, A.; Nardi, F.; Gulizia, M. M.
abstract

BackgroundTraditional scores as CHADS2and CHA2DS2-Vasc are suitable for predicting stroke and systemic embolism in patients with atrial fibrillation (AF) and have shown to be also associated with mortality. Other more complex scores have been recommended for survival prediction. The purpose of our analysis was to test the performance of different clinical scores in predicting 1-year mortality in AF patients.Material and methodsCHADS2and CHA2DS2-Vasc scores were calculated for AF patients of the BLITZ-AF register and compared to R2-CHADS2, R2-CHA2DS2-Vasc and CHA2DS2VASc-RAF scores in predicting 1-year survival. Scores including renal function were calculated both with glomerular filtration rate (GFR) and creatinine clearance.ResultsOne-year vital status (1960 alive and 199 dead) was available in 2159 patients. Receiver-operating characteristic curves displayed an association of each score to all-cause mortality, with R2(ClCrea)-CHADS2being the best [area under the curve (AUC) 0.734]. Differences among the AUCs of the eight scores were not so evident, and a significant difference was found only between R2(ClCrea)-CHADS2and CHADS2, CHA2DS2VASc, (ClCrea)-CHA2DS2-VASC-RAF.All the scores showed a similar performance for cardiovascular (CV) mortality, with CHA2DS2VASc-RAF being the best (AUC 0.757), with a significant difference with respect to CHADS2, CHA2DS2VASc, and (ClCrea)CHA2DS2Vasc-RAF.ConclusionsMore complex scores, even if with better statistical performance, do not show a clinically relevant higher capability to discriminate alive or dead patients at 12 months. The classical and well known CHA2DS2VASc score, which is routinely used all around the world, has a high sensitivity in predicting all-cause mortality (AUC 0.695; Sensit. 80.4%) and CV mortality (AUC 0.691; Sensit. 80.0%).Graphical abstracthttp://links.lww.com/JCM/A632.

2024 - Standardized assessment of evidence supporting the adoption of mobile health solutions: A Clinical Consensus Statement of the ESC Regulatory Affairs Committee [Articolo su rivista]
Caiani, E. G.; Kemps, H.; Hoogendoorn, P.; Asteggiano, R.; Bohm, A.; Borregaard, B.; Boriani, G.; Brunner La Rocca, H. -P.; Casado-Arroyo, R.; Castelletti, S.; Christodorescu, R. M.; Cowie, M. R.; Dendale, P.; Dunn, F.; Fraser, A. G.; Lane, D. A.; Locati, E. T.; Malaczynska-Rajpold, K.; Mersa, C. O.; Neubeck, L.; Parati, G.; Plummer, C.; Rosano, G.; Scherrenberg, M.; Smirthwaite, A.; Szymanski, P.
abstract

Mobile health (mHealth) solutions have the potential to improve self-management and clinical care. For successful integration into routine clinical practice, healthcare professionals (HCPs) need accepted criteria helping the mHealth solutions' selection, while patients require transparency to trust their use. Information about their evidence, safety and security may be hard to obtain and consensus is lacking on the level of required evidence. The new Medical Device Regulation is more stringent than its predecessor, yet its scope does not span all intended uses and several difficulties remain. The European Society of Cardiology Regulatory Affairs Committee set up a Task Force to explore existing assessment frameworks and clinical and cost-effectiveness evidence. This knowledge was used to propose criteria with which HCPs could evaluate mHealth solutions spanning diagnostic support, therapeutics, remote follow-up and education, specifically for cardiac rhythm management, heart failure and preventive cardiology. While curated national libraries of health apps may be helpful, their requirements and rigour in initial and follow-up assessments may vary significantly. The recently developed CEN-ISO/TS 82304-2 health app quality assessment framework has the potential to address this issue and to become a widely used and efficient tool to help drive decision-making internationally. The Task Force would like to stress the importance of co-development of solutions with relevant stakeholders, and maintenance of health information in apps to ensure these remain evidence-based and consistent with best practice. Several general and domain-specific criteria are advised to assist HCPs in their assessment of clinical evidence to provide informed advice to patients about mHealth utilization.

2024 - Systematic review and meta-Analysis on the impact on outcomes of device algorithms for minimizing right ventricular pacing [Articolo su rivista]
Mei, D. A.; Imberti, J. F.; Vitolo, M.; Bonini, N.; Serafini, K.; Mantovani, M.; Tartaglia, E.; Birtolo, C.; Zuin, M.; Bertini, M.; Boriani, G.
abstract

Aims: Physiological activation of the heart using algorithms to minimize right ventricular pacing (RVPm) may be an effective strategy to reduce adverse events in patients requiring anti-bradycardia therapies. This systematic review and meta-Analysis aimed to evaluate current evidence on clinical outcomes for patients treated with RVPm algorithms compared to dual-chamber pacing (DDD). Methods and results: We conducted a systematic search of the PubMed database. The predefined endpoints were the occurrence of persistent/permanent atrial fibrillation (PerAF), cardiovascular (CV) hospitalization, all-cause death, and adverse symptoms. We also aimed to explore the differential effects of algorithms in studies enrolling a high percentage of atrioventricular block (AVB) patients. Eight studies (7229 patients) were included in the analysis. Compared to DDD pacing, patients using RVPm algorithms showed a lower risk of PerAF [odds ratio (OR) 0.74, 95% confidence interval (CI) 0.57-0.97] and CV hospitalization (OR 0.77, 95% CI 0.61-0.97). No significant difference was found for all-cause death (OR 1.01, 95% CI 0.78-1.30) or adverse symptoms (OR 1.03, 95% CI 0.81-1.29). No significant interaction was found between the use of the RVPm strategy and studies enrolling a high percentage of AVB patients. The pooled mean RVP percentage for RVPm algorithms was 7.96% (95% CI 3.13-20.25), as compared with 45.11% (95% CI 26.64-76.38) of DDD pacing. Conclusion: Algorithms for RVPm may be effective in reducing the risk of PerAF and CV hospitalization in patients requiring anti-bradycardia therapies, without an increased risk of adverse symptoms. These results are also consistent for studies enrolling a high percentage of AVB patients.

2024 - THE PREDICTIVE ROLE OF THE TAPSE/sPAP RATIO FOR CARDIOVASCULAR EVENTS AND MORTALITY IN SYSTEMIC SCLEROSIS COMPLICATED BY PULMONARY HYPERTENSION [Abstract in Rivista]
De Pinto, M.; Coppi, F.; Spinella, A.; Pagnoni, G.; Morgante, V.; Macripo’, P.; Guerra, A. F.; Secchi, O.; Orlandi, M.; Amati, G.; Lumetti F., F.; Sandri, G.; Rossi, R.; Boriani, G.; Mattioli, A. V.; Ferri, C.; Giuggioli., D.
abstract

2024 - Takotsubo Syndrome After Pacemaker Implantation: A Case Report and Literature Review [Articolo su rivista]
de Maria, E.; Borghi, A.; Cinelli, M. M.; Topazio, V.; Cappelli, S.; Galloni, J.; Boriani, G.
abstract

A 78-year-old male patient with complete atrioventricular block underwent an uncomplicated pacemaker implantation. After 24 h, he presented acute chest pain, dyspnea, ST-segment–elevation in the anterior leads, left ventricular apical ballooning, and an ejection fraction of 35%. His coronary angiogram was normal. Within 2 days, his symptoms and electrocardiogram (ECG) abnormalities disappeared, while wall motion abnormalities recovered after 6 weeks. A diagnosis of takotsubo syndrome (TTS) was made. Pacemaker implantation has been described as a potential trigger for TTS. The clinical picture exhibits some peculiarities, including a higher percentage of men and asymptomatic patients and challenging ST-segment interpretation of paced ECGs. It is unclear whether pathophysiologic mechanisms are different compared to other forms of TTS and whether the acute initiation of ventricular pacing plays a role.

2024 - Temporal implementation of a regional referral pathway in transthyretin cardiac amyloidosis: Emilia-Romagna experience [Articolo su rivista]
Longhi, S.; Biagini, E.; Guaraldi, P.; Carigi, S.; Dossi, M. C.; Bartolotti, M.; Gardini, E.; Merli, E.; Marzo, F.; Luisi, G. A.; Postiglione, E.; Serenelli, M.; Tugnoli, V.; De Gennaro, R.; Caponetti, A. G.; Gagliardi, C.; Saturi, G.; Ponziani, A.; Perugini, E.; Rinaldi, R.; Barbieri, A.; Bonatti, S.; Ariatti, A.; Leuzzi, C.; Codeluppi, L.; Serra, W.; Allegri, I.; Lanati, G.; Terracciano, C.; Cortelli, P.; Galie, N.; Boriani, G.
abstract

Aims Transthyretin cardiac amyloidosis (ATTR-CA) is a rare and progressive cardiomyopathy caused by amyloid fibril deposition in myocardial tissue. Diagnostic challenges have historically hampered timely detection. Recent advances in noninvasive diagnostic techniques have facilitated ATTR-CA diagnosis. We aimed to examine the development of a regional network for the diagnosis and management of ATTR-CA and describe a cohort of patients with ATTR-CA, investigate diagnostic pathways and assess clinical outcomes according to diagnosis periods. Methods We performed a survey study analyzing answers from 11 cardiology centers and we conducted a retrospective study including patients with ATTR-CA attending a referral center between 1 January 2012 and 31 December 2022, and categorized by the period of diagnosis (2012–2016 and 2017–2022). Results Over the years, a growing number of patients reached a diagnosis and were treated in the surveyed nonreferral centers of the region. The retrospective study showed a more significant diagnostic delay in the earlier period rather than the later one [13.4 (5–30.2) vs. 10.6 (5.0–17.9) months, P U 0.04]. Patients diagnosed after 2017 showed a greater survival rate than those diagnosed earlier (P U 0.02). In the multivariate analysis, the year of diagnosis from 2017 remained independently associated with mortality [hazard ratio (HR) 0.46, 95% confidence interval (CI) 0.28–0.79; P U 0.005]. Conclusion This study emphasized the shift toward noninvasive diagnostic criteria. It revealed a positive impact on patient survival and disease management with the use of disease-modifying therapies and diagnostic developments in more recent years. The findings underscore the importance of disease awareness and networking to reduce diagnostic delays and enhance patient journeys for ATTR-CA.

2024 - The budget impact of implementing atrial fibrillation-screening in European countries [Articolo su rivista]
Eklund, M.; Bernfort, L.; Appelberg, K.; Engler, D.; Schnabel, R. B.; Martinez, C.; Wallenhorst, C.; Boriani, G.; Buckley, C. M.; Diederichsen, S. Z.; Svendsen, J. H.; Montaner, J.; Potpara, T.; Levin, L. -A.; Lyth, J.
abstract

A budget impact analysis estimates the short-term difference between the cost of the current treatment strategy and a new treatment strategy, in this case to implement population screening for atrial fibrillation (AF). The aim of this study is to estimate the financial impact of implementing population-based AF-screening of 75-year-olds compared with the current setting of no screening from a healthcare payer perspective in eight European countries. The net budget impact of AF-screening was estimated in country-specific settings for Denmark, Germany, Ireland, Italy, Netherlands, Serbia, Spain, and Sweden. Country-specific parameters were used to allow for variations in healthcare systems and to reflect the healthcare sector in the country of interest. Similar results can be seen in all countries AF-screening incurs savings of stroke-related costs since AF treatment reduces the number of strokes. However, the increased number of detected AF and higher drug acquisition will increase the drug costs as well as the costs of physician- and control visits. The net budget impact per invited varied from €10 in Ireland to €122 in the Netherlands. The results showed the increased costs of implementing AF-screening were mainly driven by increased drug costs and screening costs. In conclusion, across Europe, though the initial cost of screening and more frequent use of oral anti-coagulants will increase the healthcare payers’ costs, introducing population screening for AF will result in savings of stroke-related costs.

2024 - The detrimental interplay between atrial fibrillation and COVID-19: new evidence and unsolved questions [Articolo su rivista]
Romiti, G. F.; Bonini, N.; Boriani, G.
abstract

2024 - The key role of public health in renovating Italian biomedical doctoral programs [Articolo su rivista]
Palandri, Lucia; Urbano, Teresa; Pezzuoli, Carla; Miselli, Francesca; Caraffi, Riccardo; Filippini, Tommaso; Bargellini, Annalisa; Righi, Elena; Mazzi, Davide; Vigezzi, Giacomo Pietro; Odone, Anna; Marmiroli, Sandra; Boriani, Giuseppe; Vinceti, Marco
abstract

Background: A key renovation of doctoral programs is currently ongoing in Italy. Public health and its competencies may play a pivotal role in high-level training to scientific research, including interdisciplinary and methodological abilities. Methods: As a case study, we used the ongoing renovation of the Clinical and Experimental Medicine doctoral program at the University of Modena and Reggio Emilia. We focused on how the program is designed to meet national requirements as well as students' needs, thus improving educational standards for scientific research in the biomedical field, and on the specific contribution of public health and epidemiology in such an effort. Results: The renovation process of doctoral programs in Italy, with specific reference to the biomedical field, focuses on epidemiologic-statistical methodology, ethics, language and communication skills, and open science from an interdisciplinary and international perspective. In the specific context of the doctoral program assessed in the study and from a broader perspective, public health appears to play a key role, taking advantage of most recent methodological advancements, and contributing to the renovation of the learning process and its systematic quality monitoring. Conclusions: From a comparative assessment of this case study and Italian legislation, the key role of public health has emerged in the renovation process of doctoral programs in the biomedical field.

2024 - The predictive role of the TAPSE/sPAP ratio for cardiovascular events and mortality in systemic sclerosis with pulmonary hypertension [Articolo su rivista]
DE PINTO, Marco; Coppi, Francesca; Spinella, Amelia; Pagnoni, Gianluca; Morgante, Vernizia; Macripò, Pierluca; Boschini, Matteo; Francesca Guerra, Anna; Tampieri, Francesca; Secchi, Ottavio; Orlandi, Martina; Amati, Gabriele; Lumetti, Federica; Sandri, Gilda; Rossi, Rosario; Boriani, Giuseppe; Mattioli, Anna Vittoria; Ferri, Clodoveo; Giuggioli, Dilia
abstract

Introduction: Reduced TAPSE/sPAP ratio has recently emerged as a predictive parameter risk factor for PH, however its role in SSc has been poorly investigated. The aim of the study was to investigate the prognostic value of the TAPSE/sPAP ratio for the prediction of mortality and cardiovascular events in patients with SSc complicated by PH. A comparison between SSc patients with PAH (SSc-PAH) and those with PH and significant ILD (SSc-PH) was also carried out. Materials and methods: A retrospective single-center study in which all patients having SSc—complicated by PH—referring to the Scleroderma-Unit of the AOU Policlinico of Modena, from October 2013 to October 2023 were evaluated. All SSc patients underwent recurrent clinical examination, routine blood chemistry analysis, functional, instrumental evaluation. Results: 61 SSc patients (F/M 52/9) were enrolled. During the follow-up, 60.1% of patients experienced at least one cardiovascular event and 62% died. The main causes of death were PH (39.4%) and other heart-related events (39.4%). The TAPSE/sPAP ratio was significantly lower in deceased patients compared to survivors (mm/mmHg 0.3 ± 0.12SD vs. 0.48 ± 0.17SD, p < 0.001). Compared to the SSc-PAH subgroup, the SSc-PH patients had lower survival rates (55.3 ± 31.2 SD months vs. 25 ± 19 SD, p = 0,05). At the multivariate analysis, TAPSE/sPAP ratio <0.32 mm/mmHg, male gender, and the presence of significant ILD were identified as independent predictors of mortality and cardiovascular events. Conclusion: Our work confirmed the predictive role of the TAPSE/sPAP ratio for mortality and cardiovascular events in patients with SSc complicated by PH.

2024 - Three-dimensional automated, machine-learning-based left heart chamber metrics: reference values and cut-offs derived from a group of healthy subjects [Articolo su rivista]
Barbieri, A.; Malaguti, M.; Boriani, G.
abstract

2024 - Trends in atrial fibrillation-related mortality in Europe, 2008–2019 [Articolo su rivista]
Zuin, M.; Malagu, M.; Vitali, F.; Balla, C.; De Raffele, M.; Ferrari, R.; Boriani, G.; Bertini, M.
abstract

Aims Update data regarding the atrial fibrillation (AF)-related mortality trend in Europe remain scant. We assess the age- and sex-specific trends in AF-related mortality in the European states between the years 2008 and 2019. Methods and Data on cause-specific deaths and population numbers by sex for European countries were retrieved through the publicly results available World Health Organization mortality dataset for the years 2008–2019. Atrial fibrillation-related deaths were ascertained when the International Classification of Diseases, 10th Revision code I48 was listed as the underlying cause of death in the medical death certificate. To calculate annual trends, we assessed the average annual % change (AAPC) with relative 95% confidence intervals (CIs) using Joinpoint regression. During the study period, 773 750 AF-related deaths (202 552 males and 571 198 females) occurred in Europe. The age-adjusted mortality rate (AAMR) linearly increased from 12.3 (95% CI: 11.2–12.9) per 100 000 population in 2008 to 15.3 (95% CI: 14.7–15.7) per 100 000 population in 2019 [AAPC: +2.0% (95% CI: 1.6–3.5), P < 0.001] with a more pronounced increase among men [AAPC: +2.7% (95% CI: 1.9–3.5), P < 0.001] compared with women [AAPC: +1.7% (95% CI: 1.1–2.3), P < 0.001] (P for parallelism 0.01). Higher AAMR increases were observed in some Eastern European countries such as Latvia, Lithuania, and Poland, while the lower increases were mainly clustered in Central Europe. Conclusion Over the last decade, the age-adjusted AF-related mortality has increased in Europe, especially among males. Disparities still exist between Western and Eastern European countries.

2024 - Validating the predictive ability of the 2MACE score for major adverse cardiovascular events in patients with atrial fibrillation: results from phase II/III of the GLORIA-AF registry [Articolo su rivista]
Ding, W. Y.; Fawzy, A. M.; Romiti, G. F.; Proietti, M.; Pastori, D.; Huisman, M. V.; Lip, G. Y. H.; Abban, D. W.; Abdul, N.; Abud, A. M.; Adams, F.; Addala, S.; Adragão, P.; Ageno, W.; Aggarwal, R.; Agosti, S.; Agostoni, P.; Aguilar, F.; Linares, J. A.; Aguinaga, L.; Ahmed, J.; Aiello, A.; Ainsworth, P.; Aiub, J. R.; Al-Dallow, R.; Alderson, L.; Velasco, J. A. A.; Alexopoulos, D.; Manterola, F. A.; Aliyar, P.; Alonso, D.; da Costa, F. A. A.; Amado, J.; Amara, W.; Amelot, M.; Amjadi, N.; Ammirati, F.; Andrade, M.; Andrawis, N.; Annoni, G.; Ansalone, G.; Ariani, M. K.; Arias, J. C.; Armero, S.; Arora, C.; Aslam, M. S.; Asselman, M.; Audouin, P.; Augenbraun, C.; Aydin, S.; Ayryanova, I.; Aziz, E.; Backes, L. M.; Badings, E.; Bagni, E.; Baker, S. H.; Bala, R.; Baldi, A.; Bando, S.; Banerjee, S.; Bank, A.; Esquivias, G. B.; Barr, C.; Bartlett, M.; Kes, V. B.; Baula, G.; Behrens, S.; Bell, A.; Benedetti, R.; Mazuecos, J. B.; Benhalima, B.; Bergler-Klein, J.; Berneau, J. B.; Berrospi, P.; Berti, S.; Berz, A.; Best, E.; Bettencourt, P.; Betzu, R.; Bhagwat, R.; Bhatta, L.; Biscione, F.; Bisignani, G.; Black, T.; Bloch, M. J.; Bloom, S.; Blumberg, E.; Bo, M.; Bøhmer, E.; Bollmann, A.; Bongiorni, M. G.; Boriani, G.; Boswijk, D. J.; Bott, J.; Bottacchi, E.; Kalan, M. B.; Bradman, D.; Brautigam, D.; Breton, N.; Brouwers, P. J. A. M.
abstract

The 2MACE score was specifically developed as a risk-stratification tool in atrial fibrillation (AF) to predict cardiovascular outcomes. We evaluated the predictive ability of the 2MACE score in the GLORIA-AF registry. All eligible patients from phase II/III of the prospective global GLORIA-AF registry were included. Major adverse cardiac events (MACEs) were defined as the composite outcome of stroke, myocardial infarction and cardiovascular death. Cox proportional hazards were used to examine the relationship between the 2MACE score and study outcomes. Predictive capability of the 2MACE score was investigated using receiver-operating characteristic curves. A total of 25,696 patients were included (mean age 71 years, female 44.9%). Over 3 years, 1583 MACEs were recorded. Patients who had MACE were older, with more cardiovascular risk factors and were less likely to be managed using a rhythm-control strategy. The median 2MACE score in the MACE and non-MACE groups were 2 (IQR 1-3) and 1 (IQR 0-2), respectively (p < 0.001). The 2MACE score was positively associated with an increase in the risk of MACE, with a score of & GE; 2 providing the best combination of sensitivity (69.6%) and specificity (51.6%), HR 2.47 (95% CI, 2.21-2.77). The 2MACE score had modest predictive performance for MACE in patients with AF (AUC 0.655 (95% CI, 0.641-0.669)). Our analysis in this prospective global registry demonstrates that the 2MACE score can adequately predict the risk of MACE (defined as myocardial infarction, CV death and stroke) in patients with AF. Clinical trial registration:. Unique identifiers: NCT01468701, NCT01671007 and NCT01937377

2023 - 2020 Catheter Ablation Registry of the Italian Association of Arrhythmology and Cardiac Pacing [Articolo su rivista]
Stabile, G.; Guerra, F.; Tola, G.; Vergara, P.; Accogli, M.; Bertini, M.; Bisignani, G.; Forleo, G. B.; Lavalle, C.; Notarstefano, P.; Zanotto, G.; Landolina, M.; Boriani, G.; Ricci, R. P.; D'Onofrio, A.; De Ponti, R.
abstract

Background. This report describes the findings of the 2020 Italian Catheter Ablation Registry of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC). Methods. Data collection was retrospective. A standardized questionnaire was completed by each of the participating centers. Results. A total of 10 378 ablation procedures were performed by 66 institutions. Most centers (70%) have an electrophysiology laboratory, and 23% a hybrid cardiac surgery laboratory. All centers have a 3D mapping system. The median number of electrophysiologists and nurses involved in the electrophysiology laboratory was 3.5 and 3, respectively. An electrophysiology technician was involved in 35% of all centers. In 88.2% of cases, catheter ablation was performed for supraventricular arrhythmias; the most frequently treated arrhythmia was atrial fibrillation (39.4%), followed by atrioventricular nodal reentrant tachycardia (18.6%), and common atrial flutter (10.6%). In 72.9% of patients, catheter ablation was performed using a 3D mapping system, with a “near-zero” fluoroscopic approach in 37.7% of all patients. Conclusions. The 2020 Italian Catheter Ablation Registry confirmed that the electrophysiology activity was markedly affected by the COVID-19 pandemic; atrial fibrillation is the most frequently treated arrhythmia with an increasing number of procedures performed with a 3D mapping system and a “near-zero” approach.

2023 - A systematic review and meta-analysis on oncological radiotherapy in patients with a cardiac implantable electronic device: Prevalence and predictors of device malfunction in 3121 patients [Articolo su rivista]
Malavasi, V. L.; Imberti, J. F.; Tosetti, A.; Romiti, G.; Vitolo, M.; Zecchin, M.; Mazzeo, E.; Giuseppina, D. M.; Lohr, F.; Lopez-Fernandez, T.; Boriani, G.
abstract

Background: The number of patients with cardiac implantable electronic devices (CIEDs) undergoing radiotherapy (RT) for cancer treatment is growing. At present, prevalence and predictors of RT-induced CIEDs malfunctions are not defined. Methods: Systematic review and meta-analysis conducted following the PRISMA recommendations. PubMed, Scopus and Google Scholar were searched from inception to 31/01/2022 for studies reporting RT-induced malfunctions in CIEDs patients. Aim was to assess the prevalence of RT-induced CIEDs malfunctions and identify potential predictors. Results: Thirty-two out of 3962 records matched the inclusion criteria and were included in the meta-analysis. A total of 135 CIEDs malfunctions were detected among 3121 patients (6.6%, 95% confidence interval [CI]: 5.1%–8.4%). The pooled prevalence increased moving from pacemaker (PM) to implantable cardioverter defibrillator (ICD), and cardiac resynchronization therapy and defibrillator (CRT-D) groups (4.1%, 95% CI: 2.9–5.8; 8.2% 95% CI: 5.9–11.3; and 19.8%, 95% CI: 11.4–32.2 respectively). A higher risk ratio (RR) of malfunctions was found when neutron-producing energies were used as compared to non-neutron-producing energies (RR 9.98, 95% CI: 5.09–19.60) and in patients with ICD/CRT-D as compared to patients with PM/CRT-P (RR 2.07, 95% CI: 1.40–3.06). On the contrary, no association was found between maximal radiation dose at CIED >2 Gy and CIEDs malfunctions (RR 0.93; 95% CI: 0.31–2.76). Conclusions: Radiotherapy related CIEDs malfunction had a prevalence ranging from 4% to 20%. The use of neutron-producing energies and more complex devices (ICD/CRT-D) were associated with higher risk of device malfunction, while the radiation dose at CIED did not significantly impact on the risk unless higher doses (>10 Gy) were used.

2023 - Adherence to the Atrial Fibrillation Better Care (ABC) pathway and the risk of major outcomes in patients with atrial fibrillation: A post-hoc analysis from the prospective GLORIA-AF Registry [Articolo su rivista]
Romiti, G. F.; Proietti, M.; Bonini, N.; Ding, W. Y.; Boriani, G.; Huisman, M. V.; Lip, G. Y. H.
abstract

Background: The ‘Atrial fibrillation Better Care’ (ABC) pathway has been proposed to streamline a more holistic or integrated care approach to atrial fibrillation (AF) management. We aimed to analyse the impact of adherence to the ABC pathway on the risk of major adverse outcomes in a contemporary prospective global cohort of patients with AF. Methods: Patients enrolled Phase II and III of the GLORIA-AF Registry with complete data on ABC pathway adherence and follow-up were included in this post-hoc analysis between November 2011 and December 2014 for Phase II, and between January 2014 and December 2016 for Phase III. The primary outcome was the composite of all-cause death and major adverse cardiovascular events (MACEs). Multivariable Cox-regression and delay of event (DoE) analyses were used to evaluate the association between adherence to the ABC pathway and the risk of outcomes. Findings: We included 24,608 patients in this analysis (mean age: 70.2 (10.3) years, 10,938 (44.4%) females). Adherence to the ABC pathway was associated with a significant risk reduction for the primary outcome, with greatest magnitude observed for full ABC pathway adherence (adjusted Hazard Ratio [aHR] 0.54, 95% Confidence Interval [CI]: 0.44–0.67, p < 0.0001). ABC pathway adherence was also associated with reduced risk of mortality (aHR: 0.89, 95% CI: 0.79–1.00, p = 0.048), thromboembolism (aHR: 0.78, 95% CI: 0.65–0.94, p = 0.0078), and MACE (aHR: 0.82, 95% CI: 0.71–0.95, p = 0.0071). An increasing number of ABC criteria attained was associated with longer event-free survival in the DoE analysis. Interpretation: Adherence to the ABC pathway in patients with AF was associated with a reduced risk of major adverse events, including mortality, thromboembolism and MACE. This underlines the importance of using the ABC pathway in the clinical care of patients with AF. Funding: This study was funded by Boehringer Ingelheim.

2023 - Alcohol Intake and Blood Pressure Levels: A Dose-Response Meta-Analysis of Nonexperimental Cohort Studies [Articolo su rivista]
Di Federico, Silvia; Filippini, Tommaso; Whelton, Paul K; Cecchini, Marta; Iamandii, Inga; Boriani, Giuseppe; Vinceti, Marco
abstract

Background: Alcohol consumption may increase blood pressure but the details of the relationship are incomplete, particularly for the association at low levels of alcohol consumption, and no meta-analyses are available for nonexperimental cohort studies. Methods: We performed a systematic search of longitudinal studies in healthy adults that reported on the association between alcohol intake and blood pressure. Our end points were the mean differences over time of systolic (SBP) and diastolic blood pressure (DBP), plotted according to baseline alcohol intake, by using a dose-response 1-stage meta-analytic methodology. Results: Seven studies, with 19 548 participants and a median follow-up of 5.3 years (range, 4-12 years), were included in the analysis. We observed a substantially linear positive association between baseline alcohol intake and changes over time in SBP and DBP, with no suggestion of an exposure-effect threshold. Overall, average SBP was 1.25 and 4.90 mm Hg higher for 12 or 48 grams of daily alcohol consumption, compared with no consumption. The corresponding differences for DBP were 1.14 and 3.10 mm Hg. Subgroup analyses by sex showed an almost linear association between baseline alcohol intake and SBP changes in both men and women, and for DBP in men while in women we identified an inverted U-shaped association. Alcohol consumption was positively associated with blood pressure changes in both Asians and North Americans, apart from DBP in the latter group. Conclusions: Our results suggest the association between alcohol consumption and SBP is direct and linear with no evidence of a threshold for the association, while for DBP the association is modified by sex and geographic location.

2023 - Atrial Fibrillation Ablation in Patients Recently Hospitalized for Worsening Heart Failure: Need for Individualized Decision-Making [Articolo su rivista]
Boriani, G.; Mei, D. A.; Imberti, J. F.
abstract

2023 - Atrial cardiomyopathy: An entity of emerging interest in the clinical setting [Articolo su rivista]
Boriani, G.; Gerra, L.; Mantovani, M.; Tartaglia, E.; Mei, D. A.; Imberti, J. F.; Vitolo, M.; Bonini, N.
abstract

Since 1995, the concept of atrial cardiomyopathy (ACM) has been associated with myocardial fibrosis. Despite a consensus document in 2016, ACM's definition primarily relies on histopathological findings. The focus on diagnostic criteria for ACM is driven by the potential link to thromboembolic events even independently on atrial fibrillation (AF). The complexity of the mutual relationships between ACM and AF makes difficult any assessment of the thromboembolic risk associated to ACM per se. ACM's thrombogenicity is a multifaceted clinical phenomenon involving electrical, functional, and structural modifications. Factors such as cardiovascular risk factors (e.g., hypertension), common cardiac comorbidities (e.g., heart failure), and extracardiac conditions (e.g., neuromuscular disorders) can promote atrial derangement, triggering atrial fibrillation (AF) and increasing the risk of thromboembolic events. Several diagnostic methods are available to detect the key features of ACM, including electrical changes assessed by surface and intracavitary ECG, and structural and functional alterations evaluated through echocardiography and cardiac magnetic resonance (CMR). These methods can be complemented by electro-anatomical mapping (EAM) to enhance the accuracy of myocardial tissue characterization and assessment of atrial fibrosis. Although certain clinical conditions (e.g., atrial high-rate episodes, AHREs; embolic stroke of undetermined source, ESUS) often exhibit atrial alterations in their thromboembolic presentations, recent randomized trials have failed to demonstrate the benefits of oral anticoagulation in patients with ACM without AF. However, ACM constitutes the substrate for the development of AF, as proposed in the AF European guidelines under the 4S-AF scheme. This review emphasizes the lack of a diagnostic gold standard and the need for clinical criteria for ACM, aiming to better understand the potential therapeutic implications of atrial structural and functional derangements, even in the absence of clinical evidence of AF.

2023 - Atrial fibrillation and HIV: a new association requiring pathophysiological and outcome studies [Articolo su rivista]
Imberti, Jacopo F; Vitolo, Marco; Boriani, Giuseppe
abstract

2023 - Atrial fibrillation and stroke prevention: 25 years of research at EP Europace journal [Articolo su rivista]
Lip, G. Y. H.; Proietti, M.; Potpara, T.; Mansour, M.; Savelieva, I.; Tse, H. F.; Goette, A.; Camm, A. J.; Blomstrom-Lundqvist, C.; Gupta, D.; Boriani, G.
abstract

Stroke prevention in patients with atrial fibrillation (AF) is one pillar of the management of this common arrhythmia. Substantial advances in the epidemiology and associated pathophysiology underlying AF-related stroke and thrombo-embolism are evident. Furthermore, the introduction of the non-vitamin K antagonist oral anticoagulants (also called direct oral anticoagulants) has clearly changed our approach to stroke prevention in AF, such that the default should be to offer oral anticoagulation for stroke prevention, unless the patient is at low risk. A strategy of early rhythm control is also beneficial in reducing strokes in selected patients with recent onset AF, when compared to rate control. Cardiovascular risk factor management, with optimization of comorbidities and attention to lifestyle factors, and the patient's psychological morbidity are also essential. Finally, in selected patients with absolute contraindications to long-term oral anticoagulation, left atrial appendage occlusion or exclusion may be considered. The aim of this state-of-the-art review article is to provide an overview of the current status of AF-related stroke and prevention strategies. A holistic or integrated care approach to AF management is recommended to minimize the risk of stroke in patients with AF, based on the evidence-based Atrial fibrillation Better Care (ABC) pathway, as follows: A: Avoid stroke with Anticoagulation; B: Better patient-centred, symptom-directed decisions on rate or rhythm control; C: Cardiovascular risk factor and comorbidity optimization, including lifestyle changes.

2023 - Atrial fibrillation in pneumonia: what clinical implications at long-term? [Articolo su rivista]
Vitolo, Marco; Bonini, Niccolò; Imberti, Jacopo F.; Boriani, Giuseppe
abstract

2023 - Atrial fibrillation in vascular surgery: a systematic review and meta-analysis on prevalence, incidence and outcome implications [Articolo su rivista]
Malavasi, V. L.; Muto, F.; Ceresoli, P. A. C. M.; Menozzi, M.; Righelli, I.; Gerra, L.; Vitolo, M.; Imberti, J. F.; Mei, D. A.; Bonini, N.; Gargiulo, M.; Boriani, G.
abstract

Aims: To know the prevalence of atrial fibrillation (AF), as well as the incidence of postoperative AF (POAF) in vascular surgery for arterial diseases and its outcome implications. Methods: We performed a systematic review and meta-analysis following the PRISMA statement. Results: After the selection process, we analyzed 44 records (30 for the prevalence of AF history and 14 for the incidence of POAF). The prevalence of history of AF was 11.5% [95% confidence interval (CI) 1-13.3] with high heterogeneity (I2 = 100%). Prevalence was higher in the case of endovascular procedures. History of AF was associated with a worse outcome in terms of in-hospital death [odds ratio (OR) 3.29; 95% CI 2.66-4.06; P < 0.0001; I2 94%] or stroke (OR 1.61; 95% CI 1.39-1.86; P < 0.0001; I2 91%). The pooled incidence of POAF was 3.6% (95% CI 2-6.4) with high heterogeneity (I2 = 100%). POAF risk was associated with older age (mean difference 4.67 years, 95% CI 2.38-6.96; P = 0.00007). The risk of POAF was lower in patients treated with endovascular procedures as compared with an open surgical procedure (OR 0.35; 95% CI 0.13-0.91; P = 0.03; I2 = 61%). Conclusions: In the setting of vascular surgery for arterial diseases a history of AF is found overall in 11.5% of patients, more frequently in the case of endovascular procedures, and is associated with worse outcomes in terms of short-term mortality and stroke. The incidence of POAF is overall 3.6%, and is lower in patients treated with an endovascular procedure as compared with open surgery procedures. The need for oral anticoagulants for preventing AF-related stroke should be evaluated with randomized clinical trials.

2023 - Atrial fibrillation screening: Great debate on which approach to apply, which tools to use and which population to target [Articolo su rivista]
Boriani, G.; Imberti, J. F.; Vitolo, M.
abstract

2023 - Avoiding unnecessary ventricular pacing is associated with reduced incidence of heart failure hospitalizations and persistent atrial fibrillation in pacemaker patients [Articolo su rivista]
Arnold, M.; Richards, M.; D'Onofrio, A.; Faulknier, B.; Gulizia, M.; Thakur, R.; Sakata, Y.; Lin, W.; Pollastrelli, A.; Grammatico, A.; Auricchio, A.; Boriani, G.
abstract

Aims In bradycardia patients treated with dual-chamber pacing, we aimed to evaluate whether pacing with atrioventricular (AV) delay management [AV hysteresis (AVH)], compared with standard pacing with fixed AV delays, reduces unnecessary ventricular pacing percentage (VPP) and is associated with better clinical outcomes. Main study endpoints were the incidence of heart failure hospitalizations (HFH), persistent atrial fibrillation (AF), and cardiac death. Methods Data from two identical prospective observational studies, BRADYCARE I in the USA and BRADYCARE II in Europe, Africa, and results and Asia, were pooled. Overall, 2592 patients (75 ± 10 years, 45.1% female, 50% with AVH) had complete clinical and device data at 1-year follow-up and were analysed. Primary pacing indication was sinus node disease (SND) in 1177 (45.4%), AV block (AVB) in 974 (37.6%), and other indications in 441 (17.0%) patients. Pacing with AVH, compared with standard pacing, was associated with a lower 1-year incidence of HFH [1.3% vs. 3.1%, relative risk reduction (RRR) 57.5%, P = 0.002] and of persistent AF (5.3% vs. 7.7%, RRR = 31.1%, P = 0.028). Cardiac mortality was not different between groups (1.0% vs. 1.4%, RRR = 27.8%, P = 0.366). Pacing with AVH, compared with standard pacing, was associated with a lower (P < 0.001) median VPP in all patients (7% vs. 75%), in SND (3% vs. 44%), in AVB (25% vs. 98%), and in patients with other pacing indications (3% vs. 47%).Conclusion Cardiac pacing with AV delay management via AVH is associated with reduced 1-year incidence of HFH and persistent AF, most likely due to a reduction in VPP compared to standard pacing.

2023 - Biventricular versus left ventricular only stimulation: an echocardiographic substudy of the B-LEFT HF trial [Articolo su rivista]
Ansalone, G.; Boriani, G.; Sassone, B.; Camastra, G.; Donal, E.; Calo, L.; Casella, M.; Delarche, N.; Lozano, I. F.; Biffi, M.; Boulogne, E.; Guidotto, T.; Leclercq, C.
abstract

BackgroundThe noninferiority of left ventricular pacing alone (LVp) compared with biventricular pacing (BIV) has not been yet definitely documented. In this study, we reviewed all the original echocardiographic measures of the Biventricular versus Left Univentricular Pacing with ICD Back-up in Heart Failure Patients (B-LEFT HF) trial in order to investigate mechanisms underlying LV remodelling with both pacing modalities.MethodsPatients with New York Heart Association functional class (NYHA) III or IV despite optimal medical therapy, LVEF 35% or less, left ventricular end-diastolic diameter (LVEDD) more than 55 mm, QRS duration at least 130 ms were randomized to BIV or LVp for 6 months. The primary end point was a composite of at least 1 point decrease in NYHA class and at least 5 mm decrease in left ventricular end-systolic diameter (LVESD). An additional end point was a LVp reverse remodelling defined as at least 10% decrease in LVESD. Mitral regurgitation and all echocardiographic measures were reassessed after 6-month follow-up.ResultsOne hundred and forty-three patients were enrolled. Seventy-six patients were in the BIV and 67 were in the LVp group. Left ventricular volumes decreased significantly without difference between groups (P = 0.8447). Similarly, left ventricular diameters decreased significantly in both groups with a significant decrease in LVESD with BIV (P < 0.0001), but not with LVp (P = 0.1383). LVEF improved in both groups without difference (P = 0.8072). Mitral regurgitation did not improve either with BIV, or with LVp.ConclusionThe echocardiographic sub-analysis of B-LEFT study showed the substantial equivalence of LVp in favouring left ventricular reverse remodelling as compared with BIV.

2023 - Cardiac Surgery in Jehovah's Witnesses Patients and Association With Peri-Operative Outcomes: A Systematic Review and Meta-Analysis [Articolo su rivista]
Vitolo, M.; Mei, D. A.; Cimato, P.; Bonini, N.; Imberti, J. F.; Cataldo, P.; Menozzi, M.; Filippini, T.; Vinceti, M.; Boriani, G.
abstract

Background: Strategies for blood conservation, coupled with a careful preoperative assessment, may be applied to Jehovah's Witnesses (JW) patients who are candidates for cardiac surgery interventions. There is a need to assess clinical outcomes and safety of bloodless surgery in JW patients undergoing cardiac surgery. Methods: We performed a systematic review and meta-analysis of studies comparing JW patients with controls undergoing cardiac surgery. The primary endpoint was short-term mortality (in-hospital or 30-day mortality). Peri-procedural myocardial infarction, re-exploration for bleeding, pre-and postoperative Hb levels and cardiopulmonary bypass (CPB) time were also analyzed. Results: A total of 10 studies including 2,302 patients were included. The pooled analysis showed no substantial differences in terms of short-term mortality among the two groups (OR 1.13, 95% CI 0.74-1.73, I2=0%). There were no differences in peri-operative outcomes among JW patients and controls (OR 0.97, 95% CI 0.39-2.41, I2=18% for myocardial infarction; OR 0.80, 95% CI 0.51-1.25, I2=0% for re-exploration for bleeding). JW patients had a higher level of preoperative Hb (Standardized Mean Difference [SMD] 0.32, 95% CI 0.06-0.57) and a trend toward a higher level of postoperative Hb (SMD 0.44, 95% CI -0.01-0.90). A slightly lower CPB time emerged in JWs compared with controls (SMD -0.11, 95% CI -0.30-0.07). Conclusions: JW patients undergoing cardiac surgery, with avoidance of blood transfusions, did not have substantially different peri-operative outcomes compared with controls, with specific reference to mortality, myocardial infarction, and re-exploration for bleeding. Our results support the safety and feasibility of bloodless cardiac surgery, applying patient blood management strategies.

2023 - Cardiology in a Digital Age: Opportunities and Challenges for e-Health: A Literature Review [Articolo su rivista]
Pegoraro, V.; Bidoli, C.; Dal Mas, F.; Bert, F.; Cobianchi, L.; Zantedeschi, M.; Campostrini, S.; Migliore, F.; Boriani, G.
abstract

To date, mortality rates associated with heart diseases are dangerously increasing, making them the leading cause of death globally. From this point of view, digital technologies can provide health systems with the necessary support to increase prevention and monitoring, and improve care delivery. The present study proposes a review of the literature to understand the state of the art and the outcomes of international experiences. A reference framework is defined to develop reflections to optimize the use of resources and technologies, favoring the development of new organizational models and intervention strategies. Findings highlight the potential significance of e-health and telemedicine in supporting novel solutions and organizational models for cardiac illnesses as a response to the requirements and restrictions of patients and health systems. While privacy concerns and technology-acceptance-related issues arise, new avenues for research and clinical practice emerge, with the need to study ad hoc managerial models according to the type of patient and disease.

2023 - Cardiovascular Reasons for Access to a Tertiary Oncological Emergency Service: The CARILLON Study [Articolo su rivista]
Imberti, J. F.; Maisano, A.; Rampini, F.; Minnocci, M.; Bertuglia, F.; Mantovani, M.; Cherubini, B.; Mei, D. A.; Ferrara, L.; Bonini, N.; Valenti, A. C.; Vitolo, M.; Longo, G.; Boriani, G.
abstract

Background: The prevalence of acute cardiovascular diseases (CVDs) in cancer patients is steadily increasing and represents a significant reason for admission to the emergency department (ED). Methods: We conducted a prospective observational study, enrolling consecutive patients with cancer presenting to a tertiary oncological ED and consequently admitted to the oncology ward. Two groups of patients were identified based on main symptoms that lead to ED presentation: symptoms potentially related to CVD vs. symptoms potentially not related to CVD. The aims of the study were to describe the prevalence of symptoms potentially related to CVD in this specific setting and to evaluate the prevalence of definite CV diagnoses at discharge. Secondary endpoints were new intercurrent in-hospital CV events occurrence, length of stay in the oncology ward, and mid-term mortality for all-cause. Results: A total of 469 patients (51.8% female, median age 68.0 [59.1–76.3]) were enrolled. One hundred and eighty-six out of 469 (39.7%) presented to the ED with symptoms potentially related to CVD. Baseline characteristics were substantially similar between the two study groups. A discharge diagnosis of CVD was confirmed in 24/186 (12.9%) patients presenting with symptoms potentially related to CVD and in no patients presenting without symptoms potentially related to CVD (p < 0.01). During a median follow-up of 3.4 (1.2–6.5) months, 204 (43.5%) patients died (incidence rate of 10.1 per 100 person/months). No differences were found between study groups in terms of all-cause mortality (hazard ratio [HR]: 0.85, 95% confidence interval [CI] 0.64–1.12), new in-hospital CV events (HR: 1.03, 95% CI 0.77–1.37), and length of stay (p = 0.57). Conclusions: In a contemporary cohort of cancer patients presenting to a tertiary oncological ED and admitted to an oncology ward, symptoms potentially related to CVD were present in around 40% of patients, but only a minority were actually diagnosed with an acute CVD.

2023 - Clinical Outcomes in Metabolically Healthy and Unhealthy Obese and Overweight Patients With Atrial Fibrillation: Findings From the GLORIA-AF Registry [Articolo su rivista]
Corica, Bernadette; Romiti, Giulio Francesco; Proietti, Marco; Mei, Davide Antonio; Boriani, Giuseppe; Chao, Tze-Fan; Olshansky, Brian; Huisman, Menno V; Lip, Gregory Y H
abstract

Objective: To explore the association between metabolic status, body mass index (BMI), and natural history of patients with atrial fibrillation (AF). Methods: The global, prospective GLORIA-AF Registry Phase II and III included patients with recent diagnosis of AF between November 2011 and December 2014 for Phase II and between January 2014 and December 2016 for Phase III. With this analysis, we categorized patients with AF according to BMI (normal weight [18.5 to 24.9 kg/m2], overweight [25.0 to 29.9 kg/m2], obese [30.0 to 60.0 kg/m2]) and metabolic status (presence of hypertension, diabetes, and hyperlipidemia). We analyzed risk of major outcomes using multivariable Cox regression analyses; the primary outcome was the composite of all-cause death and major adverse cardiovascular events. Results: There were 24,828 (mean age, 70.1±10.3 years; 44.6% female) patients with AF included. Higher BMI was associated with metabolically unhealthy status and higher odds of receiving oral anticoagulants and other treatments. Normal-weight unhealthy patients showed a higher risk of the primary composite outcome (adjusted hazard ratio [aHR], 1.20; 95% CI, 1.01 to 1.42) and thromboembolism, whereas a lower risk of cardiovascular death (aHR, 0.35; 95% CI, 0.14 to 0.88) and major adverse cardiovascular events (aHR, 0.56; 95% CI, 0.33 to 0.93) was observed in metabolically healthy obese individuals. Unhealthy metabolic groups were also associated with increased risk of major bleeding (aHR, 1.51 [95% CI, 1.04 to 2.20] and aHR, 1.96 [95% CI, 1.34 to 2.85] in overweight and obese groups, respectively). Conclusion: Increasing BMI was associated with poor metabolic status and with more intensive treatment. Prognosis was heterogeneous between BMI groups, with metabolically unhealthy patients showing higher risk of adverse events.

2023 - Combination of an implantable defibrillator multi-sensor heart failure index and an apnea index for the prediction of atrial high-rate events [Articolo su rivista]
Bertini, M.; Vitali, F.; D'Onofrio, A.; Vitulano, G.; Calo, L.; Savarese, G.; Santobuono, V. E.; Russo, A. D.; Mattera, A.; Santoro, A.; Calvanese, R.; Arena, G.; Amellone, C.; Ziacchi, M.; Palmisano, P.; Santini, L.; Mazza, A.; Campari, M.; Valsecchi, S.; Boriani, G.
abstract

Aims Patients with atrial fibrillation frequently experience sleep disorder breathing, and both conditions are highly prevalent in presence of heart failure (HF). We explored the association between the combination of an HF and a sleep apnoea (SA) index and the incidence of atrial high-rate events (AHRE) in patients with implantable defibrillators (ICDs). Methods and results Data were prospectively collected from 411 consecutive HF patients with ICD. The IN-alert HF state was measured by the multi-sensor HeartLogic Index (>16), and the ICD-measured Respiratory Disturbance Index (RDI) was computed to identify severe SA. The endpoints were as follows: daily AHRE burden of ≥5 min, ≥6 h, and ≥23 h. During a median follow-up of 26 months, the time IN-alert HF state was 13% of the total observation period. The RDI value was ≥30 episodes/h (severe SA) during 58% of the observation period. An AHRE burden of ≥5 min/day was documented in 139 (34%) patients, ≥6 h/ day in 89 (22%) patients, and ≥23 h/day in 68 (17%) patients. The IN-alert HF state was independently associated with AHRE regardless of the daily burden threshold: hazard ratios from 2.17 for ≥5 min/day to 3.43 for ≥23 h/day (P < 0.01). An RDI ≥ 30 episodes/h was associated only with AHRE burden ≥5 min/day [hazard ratio 1.55 (95% confidence interval: 1.11–2.16), P = 0.001]. The combination of IN-alert HF state and RDI ≥ 30 episodes/h accounted for only 6% of the follow-up period and was associated with high rates of AHRE occurrence (from 28 events/100 patient-years for AHRE burden ≥5 min/day to 22 events/100 patient-years for AHRE burden ≥23 h/day). Conclusions In HF patients, the occurrence of AHRE is independently associated with the ICD-measured IN-alert HF state and RDI ≥ 30 episodes/h. The coexistence of these two conditions occurs rarely but is associated with a very high rate of AHRE occurrence.

2023 - Comparative analysis of level of evidence and class of recommendation for 50 clinical practice guidelines released by the European Society of Cardiology from 2011 to 2022 [Articolo su rivista]
Boriani, G.; Venturelli, A.; Imberti, J. F.; Bonini, N.; Mei, D. A.; Vitolo, M.
abstract

Background: The European Society of Cardiology (ESC) clinical practice guidelines are essential tools for decision-making. Aim: To analyze the level of evidence (LOE) and the class of recommendations in the ESC guidelines released in the last 12 years. Methods: We evaluated 50 ESC guidelines released from 2011 to 2022, related to 27 topics and categorized them into seven macro-groups. We analyzed every recommendation in terms of LOE and class of recommendation, calculating their relative proportions and changes over time in consecutive editions of the same guideline. Results: A total of 6972 recommendations were found, with an increase in number per year over time. Among the 50 ESC guidelines, the proportional distribution of classes of recommendations was 49% for Class I, 29% for Class IIa, 15% for Class IIb, and 8% for Class III. Overall, 16% of the recommendations were classified as LOE A, 31% LOE B and 53% LOE C. The field of preventive cardiology had the largest proportion of LOE A, while the lowest was in the field of valvular, myocardial, pericardial and pulmonary diseases. The overall proportion of LOE A recommendations in the most recent guidelines compared to their prior versions increased from 17% to 20%. Conclusions: The recommendations included in the ESC guidelines widely differ in terms of quality of evidence, with only 16% supported by the highest quality of evidence. Although a slight global increase in LOE A recommendations was observed in recent years, further scientific research efforts are needed to increase the quality of evidence.

2023 - Contemporary management of atrial fibrillation and the predicted vs. absolute risk of ischaemic stroke despite treatment: a report from ESC-EHRA EORP-AF Long-Term General Registry [Articolo su rivista]
Ding, Wern Yew; Blomström-Lundqvist, Carina; Fauchier, Laurent; Marin, Francisco; Potpara, Tatjana S; Boriani, Giuseppe; Lip, Gregory Y H
abstract

Risk stratification in patients with atrial fibrillation (AF) is important to facilitate guideline-directed therapies. The Calculator of Absolute Stroke Risk (CARS) scheme enables an individualized estimation of 1-year absolute risk of stroke in AF. We aimed to investigate the predicted and absolute risks of ischaemic stroke, and evaluate whether CARS (and CHA2DS2-VASc score) may be useful for identifying high risk patients with AF despite contemporary treatment.

2023 - Drug management of atrial fibrillation in light of guidelines and current evidence: an Italian Survey on behalf of Italian Association of Arrhythmology and Cardiac Pacing [Articolo su rivista]
Diemberger, I.; Imberti, J. F.; Spagni, S.; Rapacciuolo, A.; Curcio, A.; Attena, E.; Amadori, M.; De Ponti, R.; D'Onofrio, A.; Boriani, G.
abstract

AimAtrial fibrillation is a multifaceted disease requiring personalized treatment, in accordance with current ESC guidelines. Despite a wide range of literature, we still have various aspects dividing the opinion of the experts in rate control, rhythm control and thromboembolic prophylaxis. The aim of this survey was to provide a country-wide picture of current practice regarding atrial fibrillation pharmacological management according to a patient's characteristics.MethodsData were collected using an in-person survey that was administered to members of the Italian Association of Arrhythmology and Cardiac Pacing.ResultsWe collected data from 106 physicians, working in 72 Italian hospitals from 15 of 21 regions. Our work evidenced a high inhomogeneity in atrial fibrillation management regarding rhythm control, rate control and thromboembolic prophylaxis in both acute and chronic patients. This element was more pronounced in settings in which literature shows a lack of evidence and, consequently, the indications provided by the guidelines are weak or absent.ConclusionThis National survey evidenced a high inhomogeneity in current approaches adopted for atrial fibrillation management by a sample of Italian cardiologist experts in arrhythmia management. Further studies are needed to explore if these divergences are associated with different long-term outcomes.

2023 - Dynamic changes in T-wave and QTc interval during tilt table testing: Innocent until proven otherwise [Articolo su rivista]
De Maria, E.; Borghi, A.; Mariani, C.; Serafini, K.; Cappelli, S.; Boriani, G.
abstract

A16-year-old female underwent tilt table testing, which resulted positive for reflex vasodepressive syncope. 12‑lead ECG during syncope showed T-wave inversion in infero-lateral leads, along with QTc interval increase >100 msec compared to baseline. These abnormalities rapidly disappeared in supine position with resumption of consciousness. Complete cardiac evaluation excluded heart disease. T-wave changes and moderate QTc prolongation are relatively common in young (mainly female) patients undergoing tilt table testing and they appear benign in nature. However, in a minority of cases, on the basis of the clinical context and after an accurate ECG analysis, further examinations may be warranted.

2023 - EHRA expert consensus document on the management of arrhythmias in frailty syndrome, endorsed by the Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), Latin America Heart Rhythm Society (LAHRS), and Cardiac Arrhythmia Society of Southern Africa (CASSA) [Articolo su rivista]
Savelieva, I.; Fumagalli, S.; Kenny, R. A.; Anker, S.; Benetos, A.; Boriani, G.; Bunch, J.; Dagres, N.; Dubner, S.; Fauchier, L.; Ferrucci, L.; Israel, C.; Kamel, H.; Lane, D. A.; Lip, G. Y. H.; Marchionni, N.; Obel, I.; Okumura, K.; Olshansky, B.; Potpara, T.; Stiles, M. K.; Tamargo, J.; Ungar, A.; Kosiuk, J.; Larsen, T. B.; Dinov, B.; Estner, H.; Garcia, R.; Costa, F. M. M.; Lampert, R.; Lin, Y. -J.; Chin, A.; Rodriguez, H. A.; Strandberg, T.; Grodzicki, T.
abstract

There is an increasing proportion of the general population surviving to old age with significant chronic disease, multimorbidity, and disability. The prevalence of pre-frail state and frailty syndrome increases exponentially with advancing age and is associated with greater morbidity, disability, hospitalization, institutionalization, mortality, and health care resource use. Frailty represents a global problem, making early identification, evaluation, and treatment to prevent the cascade of events leading from functional decline to disability and death, one of the challenges of geriatric and general medicine. Cardiac arrhythmias are common in advancing age, chronic illness, and frailty and include a broad spectrum of rhythm and conduction abnormalities. However, no systematic studies or recommendations on the management of arrhythmias are available specifically for the elderly and frail population, and the uptake of many effective antiarrhythmic therapies in these patients remains the slowest. This European Heart Rhythm Association (EHRA) consensus document focuses on the biology of frailty, common comorbidities, and methods of assessing frailty, in respect to a specific issue of arrhythmias and conduction disease, provide evidence base advice on the management of arrhythmias in patients with frailty syndrome, and identifies knowledge gaps and directions for future research.

2023 - Early diagnosis and better rhythm management to improve outcomes in patients with atrial fibrillation: the 8th AFNET/EHRA consensus conference [Articolo su rivista]
Schnabel, Renate B; Marinelli, Elena Andreassi; Arbelo, Elena; Boriani, Giuseppe; Boveda, Serge; Buckley, Claire M; Camm, A John; Casadei, Barbara; Chua, Winnie; Dagres, Nikolaos; de Melis, Mirko; Desteghe, Lien; Diederichsen, Søren Zöga; Duncker, David; Eckardt, Lars; Eisert, Christoph; Engler, Daniel; Fabritz, Larissa; Freedman, Ben; Gillet, Ludovic; Goette, Andreas; Guasch, Eduard; Svendsen, Jesper Hastrup; Hatem, Stéphane N; Haeusler, Karl Georg; Healey, Jeff S; Heidbuchel, Hein; Hindricks, Gerhard; Hobbs, F D Richard; Hübner, Thomas; Kotecha, Dipak; Krekler, Michael; Leclercq, Christophe; Lewalter, Thorsten; Lin, Honghuang; Linz, Dominik; Lip, Gregory Y H; Løchen, Maja Lisa; Lucassen, Wim; Malaczynska-Rajpold, Katarzyna; Massberg, Steffen; Merino, Jose L; Meyer, Ralf; Mont, Lluıs; Myers, Michael C; Neubeck, Lis; Niiranen, Teemu; Oeff, Michael; Oldgren, Jonas; Potpara, Tatjana S; Psaroudakis, George; Pürerfellner, Helmut; Ravens, Ursula; Rienstra, Michiel; Rivard, Lena; Scherr, Daniel; Schotten, Ulrich; Shah, Dipen; Sinner, Moritz F; Smolnik, Rüdiger; Steinbeck, Gerhard; Steven, Daniel; Svennberg, Emma; Thomas, Dierk; True Hills, Mellanie; van Gelder, Isabelle C; Vardar, Burcu; Palà, Elena; Wakili, Reza; Wegscheider, Karl; Wieloch, Mattias; Willems, Stephan; Witt, Henning; Ziegler, André; Daniel Zink, Matthias; Kirchhof, Paulus
abstract

Aims Despite marked progress in the management of atrial fibrillation (AF), detecting AF remains difficult and AF-related complications cause unacceptable morbidity and mortality even on optimal current therapy. Methods and results This document summarizes the key outcomes of the 8th AFNET/EHRA Consensus Conference of the Atrial Fibrillation NETwork (AFNET) and the European Heart Rhythm Association (EHRA). Eighty-three international experts met in Hamburg for 2 days in October 2021. Results of the interdisciplinary, hybrid discussions in breakout groups and the plenary based on recently published and unpublished observations are summarized in this consensus paper to support improved care for patients with AF by guiding prevention, individualized management, and research strategies. The main outcomes are (i) new evidence supports a simple, scalable, and pragmatic population-based AF screening pathway; (ii) rhythm management is evolving from therapy aimed at improving symptoms to an integrated domain in the prevention of AF-related outcomes, especially in patients with recently diagnosed AF; (iii) improved characterization of atrial cardiomyopathy may help to identify patients in need for therapy; (iv) standardized assessment of cognitive function in patients with AF could lead to improvement in patient outcomes; and (v) artificial intelligence (AI) can support all of the above aims, but requires advanced interdisciplinary knowledge and collaboration as well as a better medico-legal framework. Conclusions Implementation of new evidence-based approaches to AF screening and rhythm management can improve outcomes in patients with AF. Additional benefits are possible with further efforts to identify and target atrial cardiomyopathy and cognitive impairment, which can be facilitated by AI.

2023 - Economic analysis of remote monitoring in patients with implantable cardioverter defibrillators or cardiac resynchronization therapy defibrillators in the Trento area, Italy [Articolo su rivista]
Marini, M.; Videsott, L.; Dalle Fratte, C. F.; Francesconi, A.; Bonvicini, E.; Quintarelli, S.; Martin, M.; Guarracini, F.; Coser, A.; Benetollo, P. P.; Bonmassari, R.; Boriani, G.
abstract

Introduction: Remote monitoring (RM) technologies have the potential to improve patient care by increasing compliance, providing early indications of heart failure (HF), and potentially allowing for therapy optimization to prevent HF admissions. The aim of this retrospective study was to assess the clinical and economic consequences of RM vs. standard monitoring (SM) through in-office cardiology visits, in patients carrying a cardiac implantable electronic device (CIED). Methods: Clinical and resource consumption data were extracted from the Electrophysiology Registry of the Trento Cardiology Unit, which has been systemically collecting patient information from January 2011 to February 2022. From a clinical standpoint, survival analysis was conducted, and incidence of cardiovascular (CV) related hospitalizations was measured. From an economic standpoint, direct costs of RM and SM were collected to compare the cost per treated patient over a 2-year time horizon. Propensity score matching (PSM) was used to reduce the effect of confounding biases and the unbalance of patient characteristics at baseline. Results: In the enrollment period, N = 402 CIED patients met the inclusion criteria and were included in the analysis (N = 189 patients followed through SM; N = 213 patients followed through RM). After PSM, comparison was limited to N = 191 patients in each arm. After 2-years follow-up since CIED implantation, mortality rate for any cause was 1.6% in the RM group and 19.9% in the SM group (log-rank test, p < 0.0001). Also, a lower proportion of patients in the RM group (25.1%) were hospitalized for CV-related reasons, compared to the SM group (51.3%; p < 0.0001, two-sample test for proportions). Overall, the implementation of the RM program in the Trento territory was cost-saving in both payer and hospital perspectives. The investment required to fund RM (a fee for service in the payer perspective, and staffing costs for hospitals), was more than offset by the lower rate of hospitalizations for CV-related disease. RM adoption generated savings of −€4,771 and −€6,752 per patient in 2 years, in the payer and hospital perspective, respectively. Conclusion: RM of patients carrying CIED improves short-term (2-years) morbidity and mortality risks, compared to SM and reduces direct management costs for both hospitals and healthcare services.

2023 - Effects of Ivabradine on Right Ventricular Systolic Function in Patients With Chronic Obstructive Pulmonary Disease and Cor Pulmonale [Articolo su rivista]
Rossi, R.; Coppi, F.; Sgura, F. A.; Monopoli, D. E.; Arrotti, S.; Talarico, M.; Boriani, G.
abstract

Cor pulmonale is a clinical syndrome associated with pulmonary hypertension, frequently complicated by congestive heart failure, commonly caused by chronic obstructive pulmonary disease (COPD). Most patients with cor pulmonale have tachycardia. However, heart rate (HR) reduction represents a primary treatment goal to improve the survival and quality of life in these patients. Ivabradine can selectively slow HR at rest and during exercise. In this prospective study, we tested the hemodynamic effects, invasively determined using right-sided cardiac catheterization, of reducing HR with ivabradine. We selected 18 patients (13 men [72.2%], mean age 67 ± 10 years) with COPD and cor pulmonale, presenting with sinus tachycardia. All patients performed clinical evaluation, electrocardiogram, spirometry, echocardiogram, 6-minute walking distance, and right-sided cardiac catheterization within 1 month of enrollment. All tests were repeated after 6 months of ivabradine treatment (median assumed dose 11.9 mg/die). We noticed a significant decrease of HR (from 98 ± 7 to 77 ± 8 beats/min, p = 0.0001), with a concomitant reduction of the congestion index (from 25.9 ± 5.1 to 19.4 ± 5.7 mm Hg, p = 0.001), and the consequent improvement of the right ventricular systolic performance (right ventricular stroke volume augmented from 56.7 ± 7.9 to 75.2 ± 8.6 ml/beat, p = 0.0001). This allows an improvement in clinical status and exercise tolerance (Borg scale score decreased from 5.2 ± 1.4 to 4.1 ± 1.3, p = 0.01 and the 6-minute walking distance increased to 252 ± 65 to 377 ± 59 m, p = 0.001). In conclusion, HR reduction significantly improves hemodynamic and clinical status of patients with tachycardia affected by COPD and cor pulmonale.

2023 - Erratum: 2022 ESC Guidelines on cardio-oncology developed in collaboration with the European Hematology Association (EHA), the European Society for Therapeutic Radiology and Oncology (ESTRO) and the International Cardio-Oncology Society (IC-OS): Developed by the task force on cardio-oncology of the European Society of Cardiology (ESC) (European Heart Journal - Cardiovascular Imaging (2022) 23:3 (e333–e465) DOI: 10.1093/ehjci/jeac106) [Articolo su rivista]
Lyon, A. R.; Lopez-Fernandez, T.; Couch, L. S.; Asteggiano, R.; Aznar, M. C.; Bergler-Klein, J.; Boriani, G.; Cardinale, D.; Cordoba, R.; Cosyns, B.; Cutter, D. J.; de Azambuja, E.; de Boer, R. A.; Dent, S. F.; Farmakis, D.; Gevaert, S. A.; Gorog, D. A.; Herrmann, J.; Lenihan, D.; Moslehi, J.; Moura, B.; Salinger, S. S.; Stephens, R.; Suter, T. M.; Szmit, S.; Tamargo, J.; Thavendiranathan, P.; Tocchetti, C. G.; van der Meer, P.; van der Pal, H. J. H.
abstract

This is an erratum to: Alexander R Lyon, Teresa López-Fernández, Liam S Couch, Riccardo Asteggiano, Marianne C Aznar, Jutta Bergler-Klein, Giuseppe Boriani, Daniela Cardinale, Raul Cordoba, Bernard Cosyns, David J Cutter, Evandro de Azambuja, Rudolf A de Boer, Susan F Dent, Dimitrios Farmakis, Sofie A Gevaert, Diana A Gorog, Joerg Herrmann, Daniel Lenihan, Javid Moslehi, Brenda Moura, Sonja S Salinger, Richard Stephens, Thomas M Suter, Sebastian Szmit, Juan Tamargo, Paaladinesh Thavendiranathan, Carlo G Tocchetti, Peter van der Meer, Helena J H van der Pal, ESC Scientific Document Group, 2022 ESC Guidelines on cardio-oncology developed in collaboration with the European Hematology Association (EHA), the European Society for Therapeutic Radiology and Oncology (ESTRO) and the International Cardio-Oncology Society (IC-OS): Developed by the task force on cardio-oncology of the European Society of Cardiology (ESC), European Heart Journal - Cardiovascular Imaging, Volume 23, Issue 10, October 2022, Pages e333–e465, https://doi.org/10.1093/ehjci/jeac106 The following change has been made to the article: In Figure 7, the category ‘Very high risk’ has been corrected online to ‘High and very high risk’.

2023 - Erratum: How to use digital devices to detect and manage arrhythmias: an EHRA practical guide (EP Europace (2022) 24:6 (979-1005) DOI: 10.1093/europace/euac038) [Articolo su rivista]
Svennberg, E.; Tjong, F.; Goette, A.; Akoum, N.; Di Biase, L.; Bordachar, P.; Boriani, G.; Burri, H.; Conte, G.; Deharo, J. C.; Deneke, T.; Drossart, I.; Duncker, D.; Han, J. K.; Heidbuchel, H.; Jais, P.; de Oliveira Figueiredo, M. J.; Linz, D.; Lip, G. Y. H.; Malaczynska-Rajpold, K.; Marquez, M. F.; Ploem, C.; Soejima, K.; Stiles, M. K.; Wierda, E.; Vernooy, K.; Leclercq, C.; Meyer, C.; Pisani, C.; Pak, H. N.; Gupta, D.; Purerfellner, H.; Crijns, H. J. G. M.; Chavez, E. A.; Willems, S.; Waldmann, V.; Dekker, L.; Wan, E.; Kavoor, P.; Turagam, M. K.; Sinner, M.
abstract

In the originally published version of this manuscript, the names of authors Marcio Jansen de Oliveira Figueiredo and Manlio F. Márquez were incorrectly given. Both names have now been corrected online. In addition, the following affiliation was inadvertently omitted for author Manlio F. Márquez: Cardiology, Electrophysiology Service, American British Cowdray Medical Center, Mexico City, México This affiliation has now been added to the online version of the manuscript as affiliation 27 and all subsequent affiliations in this manuscript affected by this change have been updated accordingly.

2023 - Factors Associated with Progression of Atrial Fibrillation and Impact on All-Cause Mortality in a Cohort of European Patients [Articolo su rivista]
Vitolo, M.; Proietti, M.; Imberti, J. F.; Bonini, N.; Romiti, G. F.; Mei, D. A.; Malavasi, V. L.; Diemberger, I.; Fauchier, L.; Marin, F.; Nabauer, M.; Potpara, T. S.; Dan, G. -A.; Lip, G. Y. H.; Boriani, G.
abstract

Background: Paroxysmal atrial fibrillation (AF) may often progress towards more sustained forms of the arrhythmia, but further research is needed on the factors associated with this clinical course. Methods: We analyzed patients enrolled in a prospective cohort study of AF patients. Patients with paroxysmal AF at baseline or first-detected AF (with successful cardioversion) were included. According to rhythm status at 1 year, patients were stratified into: (i) No AF progression and (ii) AF progression. All-cause death was the primary outcome. Results: A total of 2688 patients were included (median age 67 years, interquartile range 60–75, females 44.7%). At 1-year of follow-up, 2094 (77.9%) patients showed no AF progression, while 594 (22.1%) developed persistent or permanent AF. On multivariable logistic regression analysis, no physical activity (odds ratio [OR] 1.35, 95% CI 1.02–1.78), valvular heart disease (OR 1.63, 95% CI 1.23–2.15), left atrial diameter (OR 1.03, 95% CI 1.01–1.05), or left ventricular ejection fraction (OR 0.98, 95% CI 0.97–1.00) were independently associated with AF progression at 1 year. After the assessment at 1 year, the patients were followed for an extended follow-up of 371 days, and those with AF progression were independently associated with a higher risk for all-cause death (adjusted hazard ratio 1.77, 95% CI 1.09–2.89) compared to no-AF-progression patients. Conclusions: In a contemporary cohort of AF patients, a substantial proportion of patients presenting with paroxysmal or first-detected AF showed progression of the AF pattern within 1 year, and clinical factors related to cardiac remodeling were associated with progression. AF progression was associated with an increased risk of all-cause mortality.

2023 - Features of Clinical Complexity in European Patients With Atrial Fibrillation: A Report From a European Observational Prospective AF Registry [Articolo su rivista]
Proietti, M.; Romiti, G. F.; Corica, B.; Mei, D. A.; Bonini, N.; Vitolo, M.; Imberti, J. F.; Boriani, G.; Lip, G. Y. H.
abstract

There is increasing concern regarding impact of clinical complexity in patients with atrial fibrillation (AF). We explored the impact of different clinical complexity features in AF patients. We analyzed patients from a prospective, observational, multicenter Europe-wide AF registry. Features of clinical complexity among patients with CHA2DS2-VASc ≥2 were: (1) history of bleeding; (2) frailty; (3) chronic kidney disease (CKD); (4) ≥2 features. A total of 10,169 patients were analyzed. Of these, 141 (1.4%) had history of bleeding, 954 (9.4%) were frail, 1767 (17.4%) had CKD and 1253 (12.3%) had ≥2 features. All features of clinical complexity were less treated with OAC. History of bleeding (HR 1.94, 95% CI 1.32-2.85), frailty (HR 1.38, 95% CI 1.11-1.71), CKD (HR 1.50, 95% 1.28-1.75) and ≥2 features (HR 2.08, 95% CI 1.73-2.51) were associated with outcomes. Presence of features of clinical complexity is associated with lower use of OAC and higher risk of outcomes.

2023 - Ibrutinib and Bruton's tyrosine kinase inhibitors in chronic lymphocytic leukemia: focus on atrial fibrillation and ventricular tachyarrhythmias/sudden cardiac death [Articolo su rivista]
Boriani, Giuseppe; Menna, Pierantonio; Morgagni, Riccardo; Minotti, Giorgio; Vitolo, Marco
abstract

Background: The natural history of chronic lymphocytic leukemia (CLL) was dramatically improved by the introduction of ibrutinib, a Bruton's kinase (BTK) inhibitor. In this review we aimed to summarize and critically evaluate the association between first and second generation BTK inhibitors and the risk of atrial fibrillation (AF) and ventricular arrhythmias (VA). Summary: Since the first clinical experience, the development of AF was observed as the result of off-target effects that likely combined with patient's predisposing risk factors and concomitant cardiac morbidities. More recently both ibrutinib dose reduction and arrhythmia management allowed long-term treatment, with positive effects on progression-free survival and reduced all-cause mortality as well. Second-generation BTK inhibitors, acalabrutinib and zanubrutinib have been tested and validated in CLL. A lower occurrence of AF as compared with ibrutinib has been found, although AF has always been a secondary endpoint of all studies that probed these agents. Key Messages: For this reason, caution should be exercised before concluding that second-generation BTK inhibitors are safer than ibrutinib. Recent data on the effectiveness of ibrutinib over a follow-up of 8 years show a remarkable benefit on all-cause mortality, which is of great value also for interpreting the clinical impact of the few cases of VA and sudden cardiac death (SCD) reported for ibrutinib, independently of QT lengthening. Since a risk of VA and SCD has been recently reported also during treatment with second-generation BTK inhibitors, it appears that this risk, usually reaching its maximum size effect at long-term follow-up, likely denotes a class effect of BTK-inhibitors.

2023 - Impact of ABC (Atrial Fibrillation Better Care) pathway adherence in high-risk subgroups with atrial fibrillation: A report from the ESC-EHRA EORP-AF long-term general registry [Articolo su rivista]
Ding, W. Y.; Proietti, M.; Romiti, G. F.; Vitolo, M.; Fawzy, A. M.; Boriani, G.; Marin, F.; Blomstrom-Lundqvist, C.; Potpara, T. S.; Fauchier, L.; H Lip, G. Y.
abstract

Background: Effects of Atrial Fibrillation Better Care (ABC) adherence among high-risk atrial fibrillation (AF) subgroups remains unknown. We aimed to evaluate the impact of ABC adherence on clinical outcomes in these high-risk patients. Methods: EORP-AF General Long-Term Registry is a prospective, observational registry from 250 centres across 27 European countries. High-risk patients were defined as those with either CKD (eGFR <60 mL/min/1.73m2), elderly patients (≥75 years) or prior thromboembolism. Primary outcome was a composite event of all-cause death, thromboembolism and acute coronary syndrome. Results: 6646 patients with AF were screened (median age was 70 [IQR 61 – 77] years; 40.2% females). There were 3304 (54.2%) patients with either CKD (n = 1750), older age (n = 2236) or prior thromboembolism (n = 728). Among these, 924 (28.0%) were managed as adherent to ABC. At 2-year follow-up, 966 (14.5%) patients reported the primary outcome. The incidence of the primary outcome was significantly lower in high-risk patients managed as adherent to ABC pathway (IRR 0.53 [95%CI, 0.43 – 0.64]). Consistent results were obtained in the individual subgroups. Using multivariable Cox proportional hazards analysis, ABC adherence in the high-risk cohort was independently associated with a lower risk of the primary outcome (aHR 0.64 [95%CI, 0.51 – 0.80]), as well as in the CKD (aHR 0.51 [95%CI, 0.37 – 0.70]) and elderly subgroups (aHR 0.69 [95%CI, 0.53 – 0.90]). Overall, there was greater reduction in the risk of primary outcome as more ABC criteria were fulfilled, both in the overall high-risk patients (aHR 0.39 [95%CI, 0.25 – 0.61]), as well as in the individual subgroups. Conclusion: In a large, contemporary cohort of patients with AF, we demonstrate that adherence to the ABC pathway was associated with a significant benefit among high-risk patients with either CKD, advanced age (≥75 years old) or prior thromboembolism.

2023 - Implications of Clinical Risk Phenotypes on the Management and Natural History of Atrial Fibrillation: A Report From the GLORIA-AF [Articolo su rivista]
Romiti, Giulio Francesco; Proietti, Marco; Corica, Bernadette; Bonini, Niccolò; Boriani, Giuseppe; Huisman, Menno V; Lip, Gregory Y H
abstract

: Background Clinical risk factors are common among patients with atrial fibrillation (AF), but there are still limited data on their association with oral anticoagulant (OAC) treatment patterns and major outcomes. We aim to analyze the association between clinical risk phenotypes on AF treatment patterns and the risk of major outcomes. Methods and Results The GLORIA-AF (Global Registry on Long-Term Oral Antithrombotic Treatment in Patients With Atrial Fibrillation) phase 2 and 3 registries enrolled patients with a recent diagnosis of AF between 2011 and 2016. We defined 4 features of clinical risk among patients with CHA2DS2-VASc ≥2: elderly individuals (aged ≥80 years), chronic kidney disease (estimated glomerular filtration rate <45 mL/min), history of stroke, and history of bleeding. We analyzed the odds of receiving OAC and the risk of OAC discontinuation and adverse events at follow-up according to specific combinations and cumulative burden of these features. Primary outcome was the composite of all-cause death, thromboembolism, and major bleeding. Among 28 891 (mean±SD age, 70.1±10.5 years; 45.5% women) patients included, 10 797 (37.3%) had at least 1 clinical risk feature. OAC use was lower among patients in the elderly group (odds ratio [OR], 0.85 [95% CI, 0.75-0.96]), those with history of both stroke and bleeding (OR, 0.45 [95% CI, 0.35-0.56]), and those with multiple features (OR, 0.71 [95% CI, 0.62-0.82]). Increasing burden of clinical risk features was associated with OAC discontinuation, with highest magnitude in those with ≥3 features (hazard ratio [HR], 1.68 [95% CI, 1.31-2.15]). Groups with increasingly complex clinical risk phenotypes were associated with the occurrence of the primary composite outcome, with the highest figures observed for groups with a history of both stroke and bleeding (adjusted HR, 2.36 [95% CI, 1.83-3.04]) and multiple features (adjusted HR, 2.86 [95% CI, 2.52-3.25]). Conclusions In patients with AF, clinical risk phenotypes are multifaceted and heterogenous, and they are associated with differences in stroke prevention and worse prognosis.

2023 - Improved prognosis after cardiac resynchronization therapy over a decade [Articolo su rivista]
Leyva, F.; Zegard, A.; Patel, P.; Stegemann, B.; Marshall, H.; Ludman, P.; de Bono, J.; Boriani, G.; Qiu, T.
abstract

Aims The past decade has seen an increased delivery of cardiac resynchronization therapy (CRT) for patients with heart failure (HF). We explored whether clinical outcomes after CRT have changed from the perspective of an entire public healthcare system. Methods and results A national database covering the population of England (56.3 million in 2019) was used to explore clinical outcomes after CRT from 2010 to 2019. A total of 64 698 consecutive patients (age 71.4 ± 11.7 years; 74.8% male) underwent CRT-defibrillation [n = 32 313 (49.7%)] or CRT-pacing [n = 32 655 (50.3%)] implantation. From 2010–2011 to 2018–2019, there was a 76% increase in CRT implantations. During the same period, the proportion of patients with hypertension (59.6–73.4%), diabetes (26.5–30.8%), and chronic kidney disease (8.62–22.5%) increased, as did the Charlson comorbidity index (CCI ≥ 3 from 20.0% to 25.1%) (all P < 0.001). Total mortality decreased at 30 days (1.43–1.09%) and 1 year (9.51–8.13%) after implantation (both P < 0.001). At 2 years, total mortality [hazard ratio (HR): 0.72; 95% confidence interval (CI) 0.69–0.76] and total mortality or HF hospitalization (HR: 0.59; 95% CI 0.57–0.62) decreased from 2010–2011 to 2018–2019, after correction for age, race, sex, device type (CRT-defibrillation or pacing), comorbidities (hypertension, diabetes, chronic kidney disease, and myocardial infarction), or the CCI (HR: 0.81; 95% CI 0.77–0.85). Conclusions From the perspective of an entire public health system, survival has improved and HF hospitalizations have decreased after CRT implantation over the past decade. This prognostic improvement has occurred despite an increasing comorbidity burden.

2023 - In memory of Francesco Furlanello: a great advocate for dedicated commitment to effective, up-to-date, and expert management of cardiac arrhythmias and sports cardiology [Articolo su rivista]
Boriani, G.; Camm, A. J.
abstract

2023 - Insertable cardiac monitoring results in higher rates of atrial fibrillation diagnosis and oral anticoagulation prescription after ischaemic stroke [Articolo su rivista]
Boriani, G.; Auricchio, A.; Botto, G. L.; Joseph, J. M.; Roberts, G. J.; Grammatico, A.; Nabutovsky, Y.; Piccini, J. P.
abstract

Aims: After an ischaemic stroke, atrial fibrillation (AF) detection allows for improved secondary prevention strategies. This study aimed to compare AF detection and oral anticoagulant (OAC) initiation in patients with an insertable cardiac monitor (ICM) vs. external cardiac monitor (ECM) after ischaemic stroke. Methods and results: Medicare Fee-for-Service (FFS) insurance claims and Abbott Labs device registration data were used to identify patients hospitalized with an ischaemic stroke in 2017-2019 who received an ICM or ECM within 3 months. Patients with continuous Medicare FFS insurance and prescription drug enrolment in the prior year were included. Patients with prior AF, atrial flutter, cardiac devices, or OAC were excluded. Insertable cardiac monitor and ECM patients were propensity score matched 1:4 on demographics, comorbidities, and stroke hospitalization characteristics. The outcomes of interest were AF detection and OAC initiation evaluated with Kaplan-Meier and Cox proportional hazard regression analyses. A total of 5702 Medicare beneficiaries (ICM, n = 444; ECM, n = 5258) met inclusion criteria. The matched cohort consisted of 2210 Medicare beneficiaries (ICM, n = 442; ECM, n = 1768) with 53% female, mean age 75 years, and mean CHA2DS2-VASc score 4.6 (1.6). Insertable cardiac monitor use was associated with a higher probability of AF detection [(hazard ratio (HR) 2.88, 95% confidence interval (CI) (2.31, 3.59)] and OAC initiation [HR 2.91, CI (2.28, 3.72)] compared to patients monitored only with ECM. Conclusion: Patients with an ischaemic stroke monitored with an ICM were almost three times more likely to be diagnosed with AF and to be prescribed OAC compared to patients who received ECM only.

2023 - Integration of a Smartphone HF-Dedicated App in the Remote Monitoring of Heart Failure Patients with Cardiac Implantable Electronic Devices: Patient Access, Acceptance, and Adherence to Use [Articolo su rivista]
Ziacchi, M.; Molon, G.; Giudici, V.; Botto, G. L.; Viscusi, M.; Brasca, F.; Santoro, A.; Curcio, A.; Manzo, M.; Mauro, E.; Biffi, M.; Costa, A.; Dell'Aquila, A.; Casale, M. C.; Boriani, G.
abstract

(200 w) Introduction. Remote monitoring (RM) of cardiac implantable electronic device (CIED) diagnostics helps to identify patients potentially at risk of worsening heart failure (HF). Additionally, knowledge of patient HF-related symptoms is crucial for decision making. Patient smartphone applications may represent an ideal option to remotely collect this information. Purpose. To assess real-world HF patient access, acceptance, and adherence to use of an HF-dedicated smartphone application (HF app). Methods. In this study, 10 Italian hospitals administered a survey on smartphone/app use to HF patients with CIED. The subgroup who accepted it downloaded the HF app. Mean 1-year adherence of the HF app use was evaluated. Results. A total of 495 patients (67 ± 13 years, 79% males, 26% NYHA III–IV) completed the survey, of which 84% had access to smartphones and 85% were willing to use the HF app. In total, 311/495 (63%) downloaded the HF app. Patients who downloaded the HF app were younger and had higher school qualification. Patients who were ≥60 years old had higher mean 1-year adherence (54.1%) than their younger counterparts (42.7%; p < 0.001). Hospitals with RM-dedicated staff had higher mean 1-year patient adherence (64.0% vs. 33.5%; p < 0.001). Adherence to HF app decreased from 63.3% (weeks_1–13) to 42.2% (weeks_40–52, p < 0.001). Conclusions. High access and acceptance of smartphones/apps by HF patients with CIED allow HF app use for RM of patient signs/symptoms. Younger patients with higher school qualifications are more likely to accept HF app; however, older patients have higher long-term adherence.

2023 - Interaction of heart failure and stroke: A clinical consensus statement of the ESC Council on Stroke, the Heart Failure Association (HFA) and the ESC Working Group on Thrombosis [Articolo su rivista]
Doehner, W.; Bohm, M.; Boriani, G.; Christersson, C.; Coats, A. J. S.; Haeusler, K. G.; Jones, I. D.; Lip, G. Y. H.; Metra, M.; Ntaios, G.; Savarese, G.; Shantsila, E.; Vilahur, G.; Rosano, G.
abstract

Heart failure (HF) is a major disease in our society that often presents with multiple comorbidities with mutual interaction and aggravation. The comorbidity of HF and stroke is a high risk condition that requires particular attention to ensure early detection of complications, efficient diagnostic workup, close monitoring, and consequent treatment of the patient. The bi-directional interaction between the heart and the brain is inherent in the pathophysiology of HF where HF may be causal for acute cerebral injury, and – in turn – acute cerebral injury may induce or aggravate HF via imbalanced neural and neurovegetative control of cardiovascular regulation. The present document represents the consensus view of the ESC Council on Stroke, the Heart Failure Association and the ESC Working Group on Thrombosis to summarize current insights on pathophysiological interactions of the heart and the brain in the comorbidity of HF and stroke. Principal aspects of diagnostic workup, pathophysiological mechanisms, complications, clinical management in acute conditions and in long-term care of patients with the comorbidity are presented and state-of-the-art clinical management and current evidence from clinical trials is discussed. Beside the physicians perspective, also the patients values and preferences are taken into account. Interdisciplinary cooperation of cardiologists, stroke specialists, other specialists and primary care physicians is pivotal to ensure optimal treatment in acute events and in continued long-term treatment of these patients. Key consensus statements are presented in a concise overview on mechanistic insights, diagnostic workup, prevention and treatment to inform clinical acute and continued care of patients with the comorbidity of HF and stroke.

2023 - Is there a reduced confidence towards direct oral anticoagulants compared to vitamin K antagonists in patients scheduled for an elective electrical cardioversion? The results of the BLITZ-AF study [Articolo su rivista]
Cemin, R.; Maggioni, A. P.; Boriani, G.; Di Pasquale, G.; Gonzini, L.; Lucci, D.; Colivicchi, F.; Gulizia, M. M.
abstract

Objective: To study the confidence of cardiologists in performing an electrical cardioversion in patients on oral anticoagulation (OA) with or without transoesophageal echocardiography (TOE). Methods: Data about atrial fibrillation (AF) patients admitted to cardiology wards for elective cardioversion (ECV) were extrapolated from the BLITZ-AF study. Percentage of vitamin K antagonists (VKAs), direct oral anticoagulants (DOAC) and heparin prescription were analysed in relation to the use of TOE before ECV. Results: Overall rate of TOE was 33.7% (240/713); it was used before ECV in 124/313 (39.6%) of DOACs patients and in 96/372 (25.8%) of the patients on VKAs, showing a significant reduced resort to TOE in VKAs patients (p = 0.0001). Among non-valvular patients TOE was more frequently performed in males, at younger ages and in patients on heparin when compared to patients treated with OA. TOE was also more frequently performed in tertiary hospitals and in hospitals with cardiology wards and electrophysiology labs, when compared to hospital provided only with cardiology wards. At multivariable analysis there was a significant less recourse to TOE in patients on VKAs (OR 0.47; 95% CI: 0.33–0.67) and higher recourse in the heparin group (OR: 3.85; 95% CI:1.59–9.28) with respect to patients on DOACs; a higher recourse to TOE was observed also in tertiary hospitals (OR 4.25; 95% CI 2.69–6.69) and in hospitals with cardiology wards and electrophysiology (EP) labs (OR 1.87; 95% CI 1.23–2.82). Conclusion: our study shows the reluctance in cardioverting patients on DOACs respect to VKAs without a previous TOE, despite adequate anticoagulant treatment.

2023 - Length of hospital stay for elective electrophysiological procedures: a survey from the European Heart Rhythm Association [Articolo su rivista]
Boriani, G.; Imberti, J. F.; Leyva, F.; Casado-Arroyo, R.; Chun, J.; Braunschweig, F.; Zylla, M. M.; Duncker, D.; Farkowski, M. M.; Purerfellner, H.; Merino, J. L.
abstract

AIMS: Electrophysiological (EP) operations that have traditionally involved long hospital lengths of stay (LOS) are now being undertaken as day case procedures. The coronavirus disease-19 pandemic served as an impetus for many centres to shorten LOS for EP procedures. This survey explores LOS for elective EP procedures in the modern era. METHODS AND RESULTS: An online survey consisting of 27 multiple-choice questions was completed by 245 respondents from 35 countries. With respect to de novo cardiac implantable electronic device (CIED) implantations, day case procedures were reported for 79.5% of implantable loop recorders, 13.3% of pacemakers (PMs), 10.4% of implantable cardioverter defibrillators (ICDs), and 10.2% of cardiac resynchronization therapy (CRT) devices. With respect to CIED generator replacements, day case procedures were reported for 61.7% of PMs, 49.2% of ICDs, and 48.2% of CRT devices. With regard to ablations, day case procedures were reported for 5.7% of atrial fibrillation (AF) ablations, 10.7% of left-sided ablations, and 17.5% of right-sided ablations. A LOS ≥ 2 days for CIED implantation was reported for 47.7% of PM, 54.5% of ICDs, and 56.9% of CRT devices and for 54.5% of AF ablations, 42.2% of right-sided ablations, and 46.1% of left-sided ablations. Reimbursement (43-56%) and bed availability (20-47%) were reported to have no consistent impact on the organization of elective procedures. CONCLUSION: There is a wide variation in the LOS for elective EP procedures. The LOS for some procedures appears disproportionate to their complexity. Neither reimbursement nor bed availability consistently influenced LOS.

2023 - Letter to the Editor, regarding Rakha S, Hammad A, Elmarsafawy H, Korkor MS, et al. (2023). A deeper look into the functions of right ventricle using three-dimensional echocardiography: the forgotten ventricle in children with systemic lupus erythematosus. Eur J Pediatr. 182:2807–2819 [Articolo su rivista]
Coppi, F.; Tampieri, F.; Palazzi, G.; Boschini, M.; Gianluca, P.; Leo, G.; Morgante, V.; Melegari, G.; Arrotti, S.; Manenti, A.; Mattioli, A. V.; Boriani, G.
abstract

2023 - Low Occurrence of Infections and Death in a Real-World Cohort of Patients with Cardiac Implantable Electronic Devices [Articolo su rivista]
Imberti, J. F.; Mei, D. A.; Fontanesi, R.; Gerra, L.; Bonini, N.; Vitolo, M.; Turco, V.; Casali, E.; Boriani, G.
abstract

Background. The incidence of infections and death in patients implanted with cardiac implantable electronic devices (CIEDs) is not fully known yet. Aim. To describe the incidence of CIED-related infection and death, and their potential predictors in a contemporary cohort of CIED patients. Methods. All consecutive patients implanted with a CIED at our institution were prospectively enrolled. Follow-up visits were performed 2 weeks after CIED implantation for all patients, and then every 6 months for implantable cardioverter defibrillator (ICD)/cardiac resynchronization therapy (CRT) patients and every 12 months for pacemaker (PM) patients. The adjudication of CIED-related infections was performed by two independent investigators and potential disagreement was resolved by a senior investigator. Results. Between September 2016 and August 2020, a total of 838 patients were enrolled (34.6% female; median age 77 (69.6–83.6); median PADIT score 2 (2–4)). PMs were implanted in 569 (68%) patients and ICD/CRT in 269 (32%) patients. All patients had pre-implant antibiotic prophylaxis and 5.5% had an antibiotic-eluting envelope. Follow-up data were available for 832 (99.2%) patients. After a median follow-up of 42.3 (30.2–56.4) months, five (0.6%) patients had a CIED-related infection and 212 (25.5%) patients died. Using multivariate Cox regression analysis, end-stage chronic kidney disease (CKD) requiring dialysis and therapy with corticosteroids was independently associated with a higher risk of infection (hazard ratio (HR): 14.20; 95% confidence interval (CI) 1.48–136.62 and HR: 14.71; 95% CI 1.53–141.53, respectively). Age (HR: 1.07; 95% CI 1.05–1.09), end-stage CKD requiring dialysis (HR: 6.13; 95% CI 3.38–11.13) and history of atrial fibrillation (HR: 1.47; 95% CI 1.12–1.94) were independently associated with all-cause death. Conclusions. In a contemporary cohort of CIED patients, mortality was substantially high and associated with clinical factors depicting a population at risk. On the other hand, the incidence of CIED-related infections was low.

2023 - Multimorbidity in atrial fibrillation: A call for integrated patient-centered care [Articolo su rivista]
Boriani, G.; Mei, D. A.; Imberti, J. F.
abstract

2023 - New Perspectives on Risk Stratification and Treatment in Patients with Atrial Fibrillation: An Analysis of Recent Contributions on the Journal of Cardiovascular Disease and Development [Articolo su rivista]
Boriani, G.; Bonini, N.; Imberti, J. F.; Vitolo, M.
abstract

: The medical approach to atrial fibrillation (AF) underwent a paradigm shift over time, evolving from considering AF as a simple arrhythmic phenomenon to a complex nosological entity [...].

2023 - Patterns of oral anticoagulant use and outcomes in Asian patients with atrial fibrillation: a post-hoc analysis from the GLORIA-AF Registry [Articolo su rivista]
Romiti, Giulio Francesco; Corica, Bernadette; Proietti, Marco; Mei, Davide Antonio; Frydenlund, Juliane; Bisson, Arnaud; Boriani, Giuseppe; Olshansky, Brian; Chan, Yi-Hsin; Huisman, Menno V; Chao, Tze-Fan; Lip, Gregory Y H
abstract

Background: Previous studies suggested potential ethnic differences in the management and outcomes of atrial fibrillation (AF). We aim to analyse oral anticoagulant (OAC) prescription, discontinuation, and risk of adverse outcomes in Asian patients with AF, using data from a global prospective cohort study. Methods: From the GLORIA-AF Registry Phase II-III (November 2011-December 2014 for Phase II, and January 2014-December 2016 for Phase III), we analysed patients according to their self-reported ethnicity (Asian vs. non-Asian), as well as according to Asian subgroups (Chinese, Japanese, Korean and other Asian). Logistic regression was used to analyse OAC prescription, while the risk of OAC discontinuation and adverse outcomes were analysed through Cox-regression model. Our primary outcome was the composite of all-cause death and major adverse cardiovascular events (MACE). The original studies were registered with ClinicalTrials.gov, NCT01468701, NCT01671007, and NCT01937377. Findings: 34,421 patients were included (70.0 ± 10.5 years, 45.1% females, 6900 (20.0%) Asian: 3829 (55.5%) Chinese, 814 (11.8%) Japanese, 1964 (28.5%) Korean and 293 (4.2%) other Asian). Most of the Asian patients were recruited in Asia (n = 6701, 97.1%), while non-Asian patients were mainly recruited in Europe (n = 15,449, 56.1%) and North America (n = 8378, 30.4%). Compared to non-Asian individuals, prescription of OAC and non-vitamin K antagonist oral anticoagulant (NOAC) was lower in Asian patients (Odds Ratio [OR] and 95% Confidence Intervals (CI): 0.23 [0.22-0.25] and 0.66 [0.61-0.71], respectively), but higher in the Japanese subgroup. Asian ethnicity was also associated with higher risk of OAC discontinuation (Hazard Ratio [HR] and [95% CI]: 1.79 [1.67-1.92]), and lower risk of the primary composite outcome (HR [95% CI]: 0.86 [0.76-0.96]). Among the exploratory secondary outcomes, Asian ethnicity was associated with higher risks of thromboembolism and intracranial haemorrhage, and lower risk of major bleeding. Interpretation: Our results showed that Asian patients with AF showed suboptimal thromboembolic risk management and a specific risk profile of adverse outcomes; these differences may also reflect differences in country-specific factors. Ensuring integrated and appropriate treatment of these patients is crucial to improve their prognosis. Funding: The GLORIA-AF Registry was funded by Boehringer Ingelheim GmbH.

2023 - Performance of a multi-sensor implantable defibrillator algorithm for heart failure monitoring in the presence of atrial fibrillation [Articolo su rivista]
Boriani, G.; Bertini, M.; Manzo, M.; Calo, L.; Santini, L.; Savarese, G.; Dello Russo, A.; Santobuono, V. E.; Lavalle, C.; Viscusi, M.; Amellone, C.; Calvanese, R.; Santoro, A.; Rapacciuolo, A.; Ziacchi, M.; Arena, G.; Imberti, J. F.; Campari, M.; Valsecchi, S.; D'Onofrio, A.
abstract

AIMS: The HeartLogic Index combines data from multiple implantable cardioverter defibrillators (ICDs) sensors and has been shown to accurately stratify patients at risk of heart failure (HF) events. We evaluated and compared the performance of this algorithm during sinus rhythm and during long-lasting atrial fibrillation (AF). METHODS AND RESULTS: HeartLogic was activated in 568 ICD patients from 26 centres. We found periods of ≥30 consecutive days with an atrial high-rate episode (AHRE) burden <1 h/day and periods with an AHRE burden ≥20 h/day. We then identified patients who met both criteria during the follow-up (AHRE group, n = 53), to allow pairwise comparison of periods. For control purposes, we identified patients with an AHRE burden <1 h throughout their follow-up and implemented 2:1 propensity score matching vs. the AHRE group (matched non-AHRE group, n = 106). In the AHRE group, the rate of alerts was 1.2 [95% confidence interval (CI): 1.0-1.5]/patient-year during periods with an AHRE burden <1 h/day and 2.0 (95% CI: 1.5-2.6)/patient-year during periods with an AHRE-burden ≥20 h/day (P = 0.004). The rate of HF hospitalizations was 0.34 (95% CI: 0.15-0.69)/patient-year during IN-alert periods and 0.06 (95% CI: 0.02-0.14)/patient-year during OUT-of-alert periods (P < 0.001). The IN/OUT-of-alert state incidence rate ratio of HF hospitalizations was 8.59 (95% CI: 1.67-55.31) during periods with an AHRE burden <1 h/day and 2.70 (95% CI: 1.01-28.33) during periods with an AHRE burden ≥20 h/day. In the matched non-AHRE group, the rate of HF hospitalizations was 0.29 (95% CI: 0.12-0.60)/patient-year during IN-alert periods and 0.04 (95% CI: 0.02-0.08)/patient-year during OUT-of-alert periods (P < 0.001). The incidence rate ratio was 7.11 (95% CI: 2.19-22.44). CONCLUSION: Patients received more alerts during periods of AF. The ability of the algorithm to identify increased risk of HF events was confirmed during AF, despite a lower IN/OUT-of-alert incidence rate ratio in comparison with non-AF periods and non-AF patients. CLINICAL TRIAL REGISTRATION: http://clinicaltrials.gov/Identifier: NCT02275637.

2023 - Predicting all-cause mortality by means of a multisensor implantable defibrillator algorithm for heart failure monitoring [Articolo su rivista]
D'Onofrio, A.; Vitulano, G.; Calo, L.; Bertini, M.; Santini, L.; Savarese, G.; Dello Russo, A.; Santobuono, V. E.; Lavalle, C.; Viscusi, M.; Amellone, C.; Calvanese, R.; Santoro, A.; Ziacchi, M.; Palmisano, P.; Pisano, E.; Bianchi, V.; Tavoletta, V.; Campari, M.; Valsecchi, S.; Boriani, G.
abstract

Background: The HeartLogic algorithm (Boston Scientific) has proved to be a sensitive and timely predictor of impending heart failure (HF) decompensation. Objective: The purpose of this study was to determine whether remotely monitored data from this algorithm could be used to identify patients at high risk for mortality. Methods: The algorithm combines implantable cardioverter-defibrillator (ICD)–measured accelerometer-based heart sounds, intrathoracic impedance, respiration rate, ratio of respiration rate to tidal volume, night heart rate, and patient activity into a single index. An alert is issued when the index crosses a programmable threshold. The feature was activated in 568 ICD patients from 26 centers. Results: During median follow-up of 26 months [25th–75th percentile 16–37], 1200 alerts were recorded in 370 patients (65%). Overall, the time IN-alert state was 13% of the total observation period (151/1159 years) and 20% of the follow-up period of the 370 patients with alerts. During follow-up, 55 patients died (46 in the group with alerts). The rate of death was 0.25 per patient-year (95% confidence interval [CI] 0.17–0.34) IN-alert state and 0.02 per patient-year (95% CI 0.01–0.03) OUT of the alert state, with an incidence rate ratio of 13.72 (95% CI 7.62–25.60; P <.001). After multivariate correction for baseline confounders (age, ischemic cardiomyopathy, kidney disease, atrial fibrillation), the IN-alert state remained significantly associated with the occurrence of death (hazard ratio 9.18; 95% CI 5.27–15.99; P <.001). Conclusion: The HeartLogic algorithm provides an index that can be used to identify patients at higher risk for all-cause mortality. The index state identifies periods of significantly increased risk of death.

2023 - Prepare our healthcare systems to manage complexity: the case of atrial fibrillation [Articolo su rivista]
Mei, D. A.; Romiti, G. F.; Boriani, G.
abstract

2023 - Prevention, diagnosis and treatment of cardiac implantable electronic device infections. Position paper of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC) [Articolo su rivista]
Pisano, E. C.; Mitacchione, G.; Pappalardo, A.; Di Grazia, A.; Solimene, F.; Boriani, G.; Migliore, F.; Curnis, A.
abstract

The number of cardiac implantable electronic device (CIED) implantations has increased over recent years as a result of population growth, increasing life expectancy, adoption of guidelines, and better access to healthcare. Device-related infection is, however, one of the most serious complications of CIED therapy associated with significant morbidity, mortality, and financial healthcare burden. Although many preventive strategies such as administration of intravenous antibiotic therapy before implantation are well recognized, uncertainties still exist about other regimens. Uncertainties have remained about the role of various preventive, diagnostic, and treatment measures such as skin antiseptics, pocket antibiotic solutions, anti-bacterial envelopes, prolonged antibiotics post-implantation, and others. The key aspect to successful treatment of definite CIED infections is complete removal of all parts of the system and transvenous hardware, including the device and all leads. Thus, transvenous lead extraction has been increasing. Expert consensus statements on how to prevent, diagnose, and treat CIED infections and on lead extraction have been published by the European Heart Rhythm Association in 2020 and 2018, respectively. The aim of this AIAC position paper is to describe the current knowledge on the risks for device-related infections and to assist healthcare professionals in their clinical decision making regarding its prevention, diagnosis, and management by providing the latest update of the most effective strategies.

2023 - Prevention, diagnosis and treatment of implantable electronic cardiac device infections. Position paper of the Italian Association of Arrhythmology and Cardiostimulation (AIAC) [Articolo su rivista]
Pisano, Ec; Mitacchione, G; Pappalardo, A; Di Grazia, A; Solimene, F; Boriani, G; Migliore, F; Curnis, A
abstract

The number of cardiac implantable electronic device (CIED) implantations has increased over recent years as a result of population growth, increasing life expectancy, adoption of guidelines, and better access to healthcare. Device-related infection is, however, one of the most serious complications of CIED therapy associated with significant morbidity, mortality, and financial healthcare burden. Although many preventive strategies such as administration of intravenous antibiotic therapy before implantation are well recognized, uncertainties still exist about other regimens. Uncertainties have remained about the role of various preventive, diagnostic, and treatment measures such as skin antiseptics, pocket antibiotic solutions, anti-bacterial envelopes, prolonged antibiotics post-implantation, and others. The key aspect to successful treatment of definite CIED infections is complete removal of all parts of the system and transvenous hardware, including the device and all leads. Thus, transvenous lead extraction has been increasing. Expert consensus statements on how to prevent, diagnose, and treat CIED infections and on lead extraction have been published by the European Heart Rhythm Association in 2020 and 2018, respectively. The aim of this AIAC position paper is to describe the current knowledge on the risks for device-related infections and to assist healthcare professionals in their clinical decision making regarding its prevention, diagnosis, and management by providing the latest update of the most effective strategies.

2023 - Progression of Atrial Fibrillation after Cryoablation [Articolo su rivista]
Boriani, G.; Imberti, J. F.; Vitolo, M.
abstract

To the Editor: Andrade et al. (Jan. 12 issue)(1) found that an initial strategy of catheter cryoballoon ablation in patients with paroxysmal atrial fibrillation was associated with a lower incidence of persistent atrial fibrillation, and a lower burden of arrhythmia than therapy with antiarrhythmic drugs during 3 years of follow-up. The article extends the initial findings of the Early Aggressive Invasive Intervention for Atrial Fibrillation (EARLY-AF) trial.(2) Given the number of participants (303 patients) and the relatively short follow-up, it would have been difficult to detect mortality benefits of cryoballoon ablation. Both the EARLY-AF and the STOP AF First(3) trials . . .

2023 - Quantification of Myocardial Contraction Fraction with Three-Dimensional Automated, Machine-Learning-Based Left-Heart-Chamber Metrics: Diagnostic Utility in Hypertrophic Phenotypes and Normal Ejection Fraction [Articolo su rivista]
Barbieri, A.; Imberti, J. F.; Bartolomei, M.; Bonini, N.; Laus, V.; Torlai Triglia, L.; Chiusolo, S.; Stuani, M.; Mari, C.; Muto, F.; Righelli, I.; Gerra, L.; Malaguti, M.; Mei, D. A.; Vitolo, M.; Boriani, G.
abstract

Aims: The differentiation of left ventricular (LV) hypertrophic phenotypes is challenging in patients with normal ejection fraction (EF). The myocardial contraction fraction (MCF) is a simple dimensionless index useful for specifically identifying cardiac amyloidosis (CA) and hypertrophic cardiomyopathy (HCM) when calculated by cardiac magnetic resonance. The purpose of this study was to evaluate the value of MCF measured by three-dimensional automated, machine-learning-based LV chamber metrics (dynamic heart model [DHM]) for the discrimination of different forms of hypertrophic phenotypes. Methods and Results: We analyzed the DHM LV metrics of patients with CA (n = 10), hypertrophic cardiomyopathy (HCM, n = 36), isolated hypertension (IH, n = 87), and 54 healthy controls. MCF was calculated by dividing LV stroke volume by LV myocardial volume. Compared with controls (median 61.95%, interquartile range 55.43–67.79%), mean values for MCF were significantly reduced in HCM—48.55% (43.46–54.86% p < 0.001)—and CA—40.92% (36.68–46.84% p < 0.002)—but not in IH—59.35% (53.22–64.93% p < 0.7). MCF showed a weak correlation with EF in the overall cohort (R2 = 0.136) and the four study subgroups (healthy adults, R2 = 0.039 IH, R2 = 0.089; HCM, R2 = 0.225; CA, R2 = 0.102). ROC analyses showed that MCF could differentiate between healthy adults and HCM (sensitivity 75.9%, specificity 77.8%, AUC 0.814) and between healthy adults and CA (sensitivity 87.0%, specificity 100%, AUC 0.959). The best cut-off values were 55.3% and 52.8%. Conclusions: The easily derived quantification of MCF by DHM can refine our echocardiographic discrimination capacity in patients with hypertrophic phenotype and normal EF. It should be added to the diagnostic workup of these patients.

2023 - Quantitative flow ratio-based outcomes in patients undergoing transcatheter aortic valve implantation quaestio study [Articolo su rivista]
Demola, P.; Colaiori, I.; Bosi, D.; Musto D'Amore, S.; Vitolo, M.; Benatti, G.; Vignali, L.; Tadonio, I.; Gabbieri, D.; Losi, L.; Magnavacchi, P.; Sgura, F. A.; Boriani, G.; Guiducci, V.
abstract

Background: Coronary artery disease (CAD) is common in patients with aortic valve stenosis (AS) ranging from 60% to 80%. The clinical and prognostic role of coronary artery lesions in patients undergoing Transcatheter Aortic Valve Implantation (TAVI) remains unclear. The aim of the present observational study was to estimate long-term clinical outcomes by Quantitative Flow Ratio (QFR) characterization of CAD in a well-represented cohort of patients affected by severe AS treated by TAVI. Methods: A total of 439 invasive coronary angiographies of patients deemed eligible for TAVI by local Heart Teams with symptomatic severe AS were retrospectively screened for QFR analysis. The primary endpoint of the study was all-cause mortality. The secondary endpoint was a composite of cardiovascular mortality, stroke/transient ischemic attack (TIA), acute myocardial infarction (AMI), and any hospitalization after TAVI. Results: After exclusion of patients with no follow-up data, coronary angiography not feasible for QFR analysis and previous surgical myocardial revascularization (CABG) 48/239 (20.1%) patients had a QFR value lower or equal to 0.80 (QFR + value), while the remaining 191/239 (79.9%) did not present any vessel with a QFR positive value. In the adjusted Cox regression analysis, patients with positive QFR were independently associated with an increased risk of all-casual mortality (Model 1, HR 3.47, 95% CI, 2.35−5.12; Model 2, HR 5.01, 95% CI, 3.17−7.90). In the adjusted covariate analysis, QFR+ involving LAD (37/48, 77,1%) was associated with the higher risk of the composite outcome compared to patients without any positive value of QFR or non-LAD QFR positive value (11/48, 22.9%). Conclusions: Pre-TAVI QFR analysis can be used for a safe, simple, wireless functional assessment of CAD. QFR permits to identify patients at high risk of cardiovascular mortality or MACE, and it could be considered by local Heart Teams.

2023 - REducing INFectiOns thRough Cardiac device Envelope: insight from real world data. The REINFORCE Project [Articolo su rivista]
Ziacchi, Matteo; Biffi, Mauro; Iacopino, Saverio; di Silvestro, Michele; Marchese, Procolo; Miscio, Francesca; Caccavo, Vincenzo Paolo; Zanotto, Gabriele; Tomasi, Luca; Dello Russo, Antonio; Donazzan, Luca; Boriani, Giuseppe
abstract

Background: Infections resulting from cardiac implantable electronic device (CIED) implantation are severely impacting on patients' and on health care systems. The use of TYRXTM absorbable antibiotic-eluting envelope has proven to decrease major CIED infections within 12 months of CIED surgery. Aims: to evaluate the impact of the envelope use on infection-related clinical events in a real-world contemporary patient population. Methods: Data on patients undergoing CIED surgery were collected prospectively by participating centers of the One Hospital ClinicalService project. Patients were divided into two groups according to whether TYRXTM absorbable antibiotic-eluting envelope was used or not. Results: Out of 1819 patients, 872 (47.9%) were implanted with an absorbable antibiotic-eluting envelope and included in the Envelope group and 947 (52.1%) patients who did not receive an envelope were included in the Control group. Compared to control, patients in the Envelope group had higher thrombo-embolic or hemorrhagic risk, higher BMI, lower LVEF and more comorbidities. During a mean follow-up of 1.4 years, the incidence of infection-related events was significantly higher in the control compared to the Envelope group (2.4% vs 0.8%, p = 0.007). The 5-year cumulative incidence of infection-related events was 8.1% in the control and 2.1% in the Envelope group (HR: 0.34, 95%CI: 0.14-0.80, p = 0.010). Conclusions: In our analysis, the use of an absorbable antibiotic-eluting envelope in the general CIED population was associated with a lower risk of systemic and pocket infection.

2023 - Radar-Based Monitoring of Vital Signs: A Tutorial Overview [Articolo su rivista]
Paterniani, G; Sgreccia, D; Davoli, A; Guerzoni, G; Di Viesti, P; Valenti, Ac; Vitolo, M; Vitetta, Gm; Boriani, G
abstract

In the last years, substantial attention has been paid to the use of radar systems in health monitoring, due to the availability of both low-cost radar devices and computationally efficient algorithms for processing their measurements. In this article, a tutorial overview of radar-based monitoring of vital signs is provided. More specifically, we first focus on the available radar technologies and the signal processing algorithms developed for the estimation of vital signs. Then, we provide some useful guidelines that should be followed in the selection of radar devices for vital sign monitoring and in their use. Finally, we illustrate various specific applications of radar systems to health monitoring and some relevant research trends in this field.

2023 - Real-world utilization of the pill-in-the-pocket method for terminating episodes of atrial fibrillation: data from the multinational Antiarrhythmic Interventions for Managing Atrial Fibrillation (AIM-AF) survey [Articolo su rivista]
Reiffel, J. A.; Blomstrom-Lundqvist, C.; Boriani, G.; Goette, A.; Kowey, P. R.; Merino, J. L.; Piccini, J. P.; Saksena, S.; Camm, A. J.
abstract

AIMS: Atrial fibrillation (AF) is the most common sustained arrhythmia encountered in clinical practice. Episodes may stop spontaneously (paroxysmal AF); may terminate only via intervention (persistent AF); or may persist indefinitely (permanent AF) (see European and American guidelines, referenced below, for more precise definitions). Recently, there has been renewed interest in an approach to terminate AF acutely referred to as 'pill-in-the-pocket' (PITP). The PITP is recognized in both the US and European guidelines as an effective option using an oral antiarrhythmic drug for acute conversion of acute/recent-onset AF. However, how PITP is currently used has not been systematically evaluated. METHODS AND RESULTS: The recently published Antiarrhythmic Interventions for Managing Atrial Fibrillation (AIM-AF) survey included questions regarding current PITP usage, stratified by US vs. European countries surveyed, by representative countries within Europe, and by cardiologists vs. electrophysiologists. This manuscript presents the data from this planned sub-study. Our survey revealed that clinicians in both the USA and Europe consider PITP in about a quarter of their patients, mostly for recent-onset AF with minimal or no structural heart disease (guideline appropriate). However, significant deviations exist. See the Graphical abstract for a summary of the data. CONCLUSION: Our findings highlight the frequent use of PITP and the need for further physician education about appropriate and optimal use of this strategy.

2023 - Remote monitoring of cardiac implantable electronic devices: from data to clinical actions [Articolo su rivista]
Imberti, Jacopo F; Vitolo, Marco; Boriani, Giuseppe
abstract

2023 - Remote multiparametric monitoring and management of heart failure patients through cardiac implantable electronic devices [Articolo su rivista]
Boriani, G.; Imberti, J. F.; Bonini, N.; Carriere, C.; Mei, D. A.; Zecchin, M.; Piccinin, F.; Vitolo, M.; Sinagra, G.
abstract

In this review we focus on heart failure (HF) which, as known, is associated with a substantial risk of hospitalizations and adverse cardiovascular outcomes, including death. In recent years, systems to monitor cardiac function and patient parameters have been developed with the aim to detect subclinical pathophysiological changes that precede worsening HF. Several patient-specific parameters can be remotely monitored through cardiac implantable electronic devices (CIED) and can be combined in multiparametric scores predicting patients’ risk of worsening HF with good sensitivity and moderate specificity. Early patient management at the time of pre-clinical alerts remotely transmitted by CIEDs to physicians might prevent hospitalizations. However, it is not clear yet which is the best diagnostic pathway for HF patients after a CIED alert, which kind of medications should be changed or escalated, and in which case in-hospital visits or in-hospital admissions are required. Finally, the specific role of healthcare professionals involved in HF patient management under remote monitoring is still matter of definition. We analyzed recent data on multiparametric monitoring of patients with HF through CIEDs. We provided practical insights on how to timely manage CIED alarms with the aim to prevent worsening HF. We also discussed the role of biomarkers and thoracic echo in this context, and potential organizational models including multidisciplinary teams for remote care of HF patients with CIEDs.

2023 - Run baby run … but not too fast! Rate control management in atrial fibrillation: a claim for personalization [Articolo su rivista]
Diemberger, I.; Boriani, G.
abstract

2023 - Screening for atrial fibrillation: different approaches targeted to reduce ischemic stroke [Articolo su rivista]
Boriani, Giuseppe; Imberti, Jacopo F; Vitolo, Marco
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2023 - Searching for atrial fibrillation: looking harder, looking longer, and in increasingly sophisticated ways. An EHRA position paper' [Articolo su rivista]
Kalarus, Zbigniew; Mairesse, Georges H; Sokal, Adam; Boriani, Giuseppe; Średniawa, Beata; Arroyo, Ruben Casado; Wachter, Rolf; Frommeyer, Gerrit; Traykov, Vassil; Dagres, Nikolaos; Lip, Gregory Y H; Boersma, Lucas; Peichl, Petr; Dobrev, Dobromir; Bulava, Alan; Blomström-Lundqvist, Carina; de Groot, Natasja M S; Schnabel, Renate; Heinzel, Frank; Van Gelder, Isabelle C; Carbuccichio, Corrado; Shah, Dipen; Eckardt, Lars
abstract

2023 - Short and long-term outcomes after cardiac surgery in Jehovah's Witnesses patients: a case-control study [Articolo su rivista]
Nanni, Giulia; Vitolo, Marco; Imberti, Jacopo F; Girolami, Denise; Bonini, Niccolò; Valenti, Anna Chiara; Cimato, Paolo; Boriani, Giuseppe
abstract

Cardiac surgery in Jehovah's Witnesses (JW) patients who refuse blood transfusion is challenging requiring dedicated strategies. We aimed to analyze non-selected JW patients undergoing cardiac surgery and to compare with matched controls both perioperative outcomes and long-term survival. We retrospectively analyzed JW patients undergoing cardiac surgery from January 2016 to March 2021 and compared them with matched controls. The primary outcome was a composite of in-hospital perioperative adverse events and in-hospital mortality. The secondary outcome was all-cause mortality at long-term follow-up. A total of 113 JW patients and 113 controls were included. Baseline clinical characteristics, including laboratory parameters were comparable. Overall, there were no statistical differences between JW vs controls in terms of in-hospital mortality (2.7% vs 1.8%, p = 1.00) but mortality was remarkably high (40%) in JW patients with post-op hemoglobin < 8 g/dl. Logistic regression analysis found that the JW group was not associated with a higher occurrence of the composite outcome (adjusted odds ratio 0.91, 95% confidence interval [CI] 0.54-1.57). After a median follow-up of 1397 [IQR 922.7-1723.5] days, JW patients were not associated with a significantly higher all-cause mortality (adjusted hazard ratio 0.77, 95% CI 0.24-2.42). Cardiac surgery can be safely performed in non-anemic JW patients despite the refusal of blood transfusions. Favorable clinical outcomes can be achieved by the use of specific perioperative strategies for bloodless surgery with no differences as compared to control patients except in JW patients with a very low level of post-operative hemoglobin not supported by immediate transfusions.

2023 - Single-lead VDD pacing: a literature review on short-term and long-term performance [Articolo su rivista]
Mei, Davide Antonio; Imberti, Jacopo Francesco; Vitolo, Marco; Bonini, Niccolò; Gerra, Luigi; Romiti, Giulio Francesco; Proietti, Marco; Lip, Gregory Y H; Boriani, Giuseppe
abstract

IntroductionVDD pacing system was introduced more than 30 years ago. Its use is considered by the 2021 European Society of Cardiology guidelines on cardiac pacing as a potential alternative to dual chambers system for patients with atrioventricular block and normal sinus node function.Areas coveredIn this article, we performed a narrative review of current literature in order to identify the strengths and weaknesses of this pacing system. VDD system allows the maintenance of AV synchronous pacing and its hemodynamic advantages. Some disadvantages may be related to the non-negligible incidence of atrial undersensing and the possible subsequent need for upgrade to DDD system. On the other hand, shorter implantation time and lower complications rate may be advantages.Expert opinionIn the modern pacing era, VDD pacing system struggles to find its own space. However, it may still be considered as a valuable alternative to a dual-chamber pacemaker for selected patients, in specific clinical scenarios.

2023 - Smartphone-based cardiac implantable electronic device remote monitoring: improved compliance and connectivity [Articolo su rivista]
Manyam, H.; Burri, H.; Casado-Arroyo, R.; Varma, N.; Lennerz, C.; Klug, D.; Carr-White, G.; Kolli, K.; Reyes, I.; Nabutovsky, Y.; Boriani, G.
abstract

Aims: Remote monitoring (RM) is the standard of care for follow up of patients with cardiac implantable electronic devices. The aim of this study was to compare smartphone-based RM (SM-RM) using patient applications (myMerlinPulse™ app) with traditional bedside monitor RM (BM-RM). Methods and results: The retrospective study included de-identified US patients who received either SM-RM or BM-RM capable of implantable cardioverter defibrillators or cardiac resynchronization therapy defibrillators (Abbott, USA). Patients in SM-RM and BM-RM groups were propensity-score matched on age and gender, device type, implant year, and month. Compliance with RM was quantified as the proportion of patients enrolling in the RM system (Merlin.net™) and transmitting data at least once. Connectivity was measured by the median number of days between consecutive transmissions per patient. Of the initial 9714 patients with SM-RM and 26 679 patients with BM-RM, 9397 patients from each group were matched. Remote monitoring compliance was higher in SM-RM; significantly more patients with SM-RM were enrolled in RM compared with BM-RM (94.4 vs. 85.0%, P < 0.001), similar number of patients in the SM-RM group paired their device (95.1 vs. 95.0%, P = 0.77), but more SM-RM patients transmitted at least once (98.1 vs. 94.3%, P < 0.001). Connectivity was significantly higher in the SM-RM, with patients transmitting data every 1.2 (1.1, 1.7) vs. every 1.7 (1.5, 2.0) days with BM-RM (P < 0.001) and remained better over time. Significantly more SM-RM patients utilized patient-initiated transmissions compared with BM-RM (55.6 vs. 28.1%, P < 0.001). Conclusion: In this large real-world study, patients with SM-RM demonstrated improved compliance and connectivity compared with BM-RM.

2023 - The Importance of Mehran Score to Predict Acute Kidney Injury in Patients with TAVI: A Large Multicenter Cohort Study [Articolo su rivista]
Arrotti, S.; Sgura, F. A.; Monopoli, D. E.; Siena, V.; Leo, G.; Morgante, V.; Cataldo, P.; Magnavacchi, P.; Gabbieri, D.; Guiducci, V.; Benatti, G.; Vignali, L.; Boriani, G.; Rossi, R.
abstract

Background: Transcatheter aortic valve implantation (TAVI) has developed as an alternative to surgery for symptomatic high-risk patients with aortic stenosis (AS). An important complication of TAVI is acute kidney injury. The purpose of the study was to investigate if the Mehran Score (MS) could be used to predict acute kidney injury (AKI) in TAVI patients. Methods: This is a multicenter, retrospective, observational study including 1180 patients with severe AS. The MS comprised eight clinical and procedural variables: hypotension, congestive heart failure class, glomerular filtration rate, diabetes, age >75 years, anemia, need for intra-aortic balloon pump, and contrast agent volume use. We assessed the sensitivity and specificity of the MS in predicting AKI following TAVI, as well as the predictive value of MS with each AKI-related characteristic. Results: Patients were categorized into four risk groups based on MS: low (≤5), moderate (6–10), high (11–15), and very high (≥16). Post-procedural AKI was observed in 139 patients (11.8%). MS classes had a higher risk of AKI in the multivariate analysis (HR 1.38, 95% CI, 1.43–1.63, p < 0.01). The best cutoff for MS to predict the onset of AKI was 13.0 (AUC, 0.62; 95% CI, 0.57–0.67), whereas the best cutoff for eGFR was 42.0 mL/min/1.73 m2 (AUC, 0.61; 95% CI, 0.56–0.67). Conclusions: MS was shown to be a predictor of AKI development in TAVI patients.

2023 - The burden of atrial fibrillation in patients with preserved or mildly reduced heart failure: a call to action for detecting atrial fibrillation and improving outcome [Articolo su rivista]
Boriani, G.; Imberti, J. F.; Vitolo, M.
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2023 - The epidemiology and mortality of patients with atrial fibrillation: a complex landscape [Articolo su rivista]
Boriani, Giuseppe; Bonini, Niccolò; Imberti, Jacopo Francesco
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2023 - Therapeutic effects of sodium–glucose cotransporter 2 inhibitors in patients with heart failure with preserved ejection fraction: From outcome improvement to potentially favourable influences on atrial fibrillation burden, atrial fibrillation progression and atrial cardiomyopathy [Articolo su rivista]
Boriani, G.; Mei, D. A.; Imberti, J. F.
abstract

2023 - Timing of cardiac resynchronization therapy implantation [Articolo su rivista]
Leyva, F.; Zegard, A.; Patel, P.; Stegemann, B.; Marshall, H.; Ludman, P.; Walton, J.; de Bono, J.; Boriani, G.; Qiu, T.
abstract

Aims The optimum timing of cardiac resynchronization therapy (CRT) implantation is unknown. We explored long-term outcomes after CRT in relation to the time interval from a first heart failure hospitalization (HFH) to device implantation. .Methods A database covering the population of England (56.3 million in 2019) was used to quantify clinical outcomes after CRT im- and results plantation in relation to first HFHs. From 2010 to 2019, 64 968 patients [age: 71.4 ± 11.7 years; 48 606 (74.8%) male] underwent CRT implantation, 57% in the absence of a previous HFH, 12.9% during the first HFH, and 30.1% after ≥1 HFH. Over 4.54 (2.80–6.71) years [median (interquartile range); 272 989 person-years], the time in years from the first HFH to CRT implantation was associated with a higher risk of total mortality [hazard ratio (HR); 95% confidence intervals (95% CI)] (1.15; 95% CI 1.14–1.16, HFH (HR: 1.26; 95% CI 1.24–1.28), and the combined endpoint of total mortality or HFH (HR: 1.19; 95% CI 1.27–1.20) than CRT in patients with no previous HFHs, after co-variate adjustment. Total mortality (HR: 1.67), HFH (HR: 2.63), and total mortality or HFH (HR: 1.92) (all P < 0.001) were highest in patients undergoing CRT ≥2 years after the first HFH. Conclusion In this study of a healthcare system covering an entire nation, delays from a first HFH to CRT implantation were associated with progressively worse long-term clinical outcomes. The best clinical outcomes were observed in patients with no previous HFH and in those undergoing CRT implantation during the first HFH. Condensed The optimum timing of CRT implantation is unknown. In this study of 64 968 consecutive patients, delays from a first heart abstract failure hospitalization (HFH) to CRT implantation were associated with progressively worse long-term clinical outcomes. Each year from a first HFH to CRT implantation was associated with a 21% higher risk of total mortality and a 34% higher risk of HFH. The best outcomes after CRT were observed in patients with no previous HFHs and in those undergoing implantation during their first HFH. The left upper panel shows the timing (y-axis) and numbers (x-axis) of cardiac resynchronization therapy (CRT) implantations in relation to the timing of first heart failure hospitalizations (HFHs); the right upper panel shows CRT implantations undertaken during a first HFH as a percentage of all implantations, according to year. Patients were regarded as not having had a HFH if this had not occurred within 5 years prior to CRT implantation. The left lower panel shows the Kaplan–Meier survival curve for total mortality. Event rates (per 100 person-years) for the three endpoints according to the timing of CRT implantation in relation to a first HFH are shown in the right lower panel.

2023 - Use of Diltiazem in Chronic Rate Control for Atrial Fibrillation: A Prospective Case-Control Study [Articolo su rivista]
Diemberger, I.; Spadotto, A.; Massaro, G.; Amadori, M.; Damaschin, L.; Martignani, C.; Ziacchi, M.; Biffi, M.; Galie, N.; Boriani, G.
abstract

Atrial fibrillation (AF) is a multifaceted disease requiring personalised treatment. The aim of our study was to explore the prognostic impact of a patient-specific therapy (PT) for rate control, including the use of non-dihydropyridine calcium channel blockers (NDDC) in patients with heart failure (HF) or in combination with beta-blockers (BB), compared to standard rate control therapy (ST), as defined by previous ESC guidelines. This is a single-centre prospective observational registry on AF patients who were followed by our University Hospital. We included 1112 patients on an exclusive rate control treatment. The PT group consisted of 125 (11.2%) patients, 93/125 (74.4%) of whom were prescribed BB + NDCC (±digoxin), while 85/125 (68.0%) were HF patients who were prescribed NDCC, which was diltiazem in all cases. The patients treated with a PT showed no difference in one-year overall survival compared to those with an ST. Notably, the patients with HF in ST had a worse prognosis (p < 0.001). To better define this finding, we performed three sensitivity analyses by matching each patient in the PT subgroups with three subjects from the ST cohort, showing an improved one-year survival of the HF patients treated with PT (p = 0.039). Our results suggest a potential outcome benefit of NDCC for rate control in AF patients, either alone or in combination with BB and in selected patients with HF.

2023 - Yield of diagnosis and risk of stroke with screening strategies for atrial fibrillation: a comprehensive review of current evidence [Articolo su rivista]
Corica, B.; Bonini, N.; Imberti, J. F.; Romiti, G. F.; Vitolo, M.; Attanasio, L.; Basili, S.; Freedman, B.; Potpara, T. S.; Boriani, G.; Lip, G. Y. H.; Proietti, M.
abstract

Atrial fibrillation (AF) is the most prevalent arrhythmia worldwide. The presence of AF is associated with increased risk of systemic thromboembolism, but with the uptake of oral anticoagulant (OAC) and implementation of a holistic and integrated care management, this risk is substantially reduced. The diagnosis of AF requires a 30-s-long electrocardiographic (ECG) trace, irrespective of the presence of symptoms, which may represent the main indication for an ECG tracing. However, almost half patients are asymptomatic at the time of incidental AF diagnosis, with similar risk of stroke of those with clinical AF. This has led to a crucial role of screening for AF, to increase the diagnosis of population at risk of clinical events. The aim of this review is to give a comprehensive overview about the epidemiology of asymptomatic AF, the different screening technologies, the yield of diagnosis in asymptomatic population, and the benefit derived from screening in terms of reduction of clinical adverse events, such as stroke, cardiovascular, and all-cause death. We aim to underline the importance of implementing AF screening programmes and reporting about the debate between scientific societies’ clinical guidelines recommendations and the concerns expressed by the regulatory authorities, which still do not recommend population-wide screening. This review summarizes data on the ongoing trials specifically designed to investigate the benefit of screening in terms of risk of adverse events which will further elucidate the importance of screening in reducing risk of outcomes and influence and inform clinical practice in the next future.

2022 - 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy Developed by the Task Force on cardiac pacing and cardiac resynchronization therapy of the European Society of Cardiology (ESC) With the special contribution of the European Heart Rhythm Association (EHRA) [Articolo su rivista]
Glikson, Michael; Nielsen, Jens Cosedis; Kronborg, Mads Brix; Michowitz, Yoav; Auricchio, Angelo; Barbash, Israel Moshe; Barrabés, José A; Boriani, Giuseppe; Braunschweig, Frieder; Brignole, Michele; Burri, Haran; Coats, Andrew J S; Deharo, Jean-Claude; Delgado, Victoria; Diller, Gerhard-Paul; Israel, Carsten W; Keren, Andre; Knops, Reinoud E; Kotecha, Dipak; Leclercq, Christophe; Merkely, Béla; Starck, Christoph; Thylén, Ingela; Tolosana, José Maria
abstract

2022 - 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy Developed by the Task Force on cardiac pacing and cardiac resynchronization therapy of the European Society of Cardiology (ESC) With the special contribution of the European Heart Rhythm Association (EHRA) [Articolo su rivista]
Glikson, M.; Nielsen, J. C.; Kronborg, M. B.; Michowitz, Y.; Auricchio, A.; Barbash, I. M.; Barrabes, J. A.; Boriani, G.; Braunschweig, F.; Brignole, M.; Burri, H.; Coats, A. J. S.; Deharo, J. -C.; Delgado, V.; Diller, G. -P.; Israel, C. W.; Keren, A.; Knops, R. E.; Kotecha, D.; Leclercq, C.; Merkely, B.; Starck, C.; Thylen, I.; Tolosana, J. M.
abstract

2022 - 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy: Developed by the Task Force on cardiac pacing and cardiac resynchronization therapy of the European Society of Cardiology (ESC) With the special contribution of the European Heart Rhythm Association (EHRA) [Articolo su rivista]
Glikson, M; Nielsen, Jc; Kronborg, Mb; Michowitz, Y; Auricchio, A; Barbash, Im; Barrabes, Ja; Boriani, G; Braunschweig, F; Brignole, M; Burri, H; Coats, Ajs; Deharo, Jc; Delgado, V; Diller, Gp; Israel, Cw; Keren, A; Knops, Re; Kotecha, D; Leclercq, C; Merkely, B; Starck, C; Thylen, I; Tolosana, Jm
abstract

2022 - 2022 ESC Guidelines for the management of ventricular arrhythmias and sudden cardiac death: an important focus on a multidisciplinary approach to a tailored diagnostic and therapeutic work-up|Linee guida europee 2022 su aritmie ventricolari e morte cardiaca improvvisa: un importante impulso a un impegno multidisciplinare in campo diagnostico e terapeutico per un’accurata personalizzazione dell’approccio clinico [Articolo su rivista]
Boriani, G.; Mei, D. A.; Vitolo, M.; Imberti, J. F.
abstract

2022 - 2022 ESC Guidelines on cardio-oncology developed in collaboration with the European Hematology Association (EHA), the European Society for Therapeutic Radiology and Oncology (ESTRO) and the International Cardio-Oncology Society (IC-OS) [Articolo su rivista]
Lyon, A. R.; Lopez-Fernandez, T.; Couch, L. S.; Asteggiano, R.; Aznar, M. C.; Bergler-Klein, J.; Boriani, G.; Cardinale, D.; Cordoba, R.; Cosyns, B.; Cutter, D. J.; de Azambuja, E.; de Boer, R. A.; Dent, S. F.; Farmakis, D.; Gevaert, S. A.; Gorog, D. A.; Herrmann, J.; Lenihan, D.; Moslehi, J.; Moura, B.; Salinger, S. S.; Stephens, R.; Suter, T. M.; Szmit, S.; Tamargo, J.; Thavendiranathan, P.; Tocchetti, C. G.; van der Meer, P.; van der Pal, H. J. H.; Lancellotti, P.; Thuny, F.; Abdelhamid, M.; Aboyans, V.; Aleman, B.; Alexandre, J.; Barac, A.; Borger, M. A.; Casado-Arroyo, R.; Cautela, J.; Celutkiene, J.; Cikes, M.; Cohen-Solal, A.; Dhiman, K.; Ederhy, S.; Edvardsen, T.; Fauchier, L.; Fradley, M.; Grapsa, J.; Halvorsen, S.; Heuser, M.; Humbert, M.; Jaarsma, T.; Kahan, T.; Konradi, A.; Koskinas, K. C.; Kotecha, D.; Ky, B.; Landmesser, U.; Lewis, B. S.; Linhart, A.; Lip, G. Y. H.; Lochen, M. -L.; Malaczynska-Rajpold, K.; Metra, M.; Mindham, R.; Moonen, M.; Neilan, T. G.; Nielsen, J. C.; Petronio, A. -S.; Prescott, E.; Rakisheva, A.; Salem, J. -E.; Savarese, G.; Sitges, M.; Ten Berg, J.; Touyz, R. M.; Tycinska, A.; Wilhelm, M.; Zamorano, J. L.
abstract

2022 - 2022 ESC Guidelines on cardio-oncology developed in collaboration with the European Hematology Association (EHA), the European Society for Therapeutic Radiology and Oncology (ESTRO) and the International Cardio-Oncology Society (IC-OS) [Articolo su rivista]
Lyon, Alexander R; López-Fernández, Teresa; Couch, Liam S; Asteggiano, Riccardo; Aznar, Marianne C; Bergler-Klein, Jutta; Boriani, Giuseppe; Cardinale, Daniela; Cordoba, Raul; Cosyns, Bernard; Cutter, David J; de Azambuja, Evandro; de Boer, Rudolf A; Dent, Susan F; Farmakis, Dimitrios; Gevaert, Sofie A; Gorog, Diana A; Herrmann, Joerg; Lenihan, Daniel; Moslehi, Javid; Moura, Brenda; Salinger, Sonja S; Stephens, Richard; Suter, Thomas M; Szmit, Sebastian; Tamargo, Juan; Thavendiranathan, Paaladinesh; Tocchetti, Carlo G; van der Meer, Peter; van der Pal, Helena J H
abstract

2022 - AIM-AF: A Physician Survey in the United States and Europe [Articolo su rivista]
Camm, A. J.; Blomstrom-Lundqvist, C.; Boriani, G.; Goette, A.; Kowey, P. R.; Merino, J. L.; Piccini, J. P.; Saksena, S.; Reiffel, J. A.
abstract

Background Guideline recommendations are the accepted reference for selection of therapies for rhythm control of atrial fibrillation (AF). This study was designed to understand physicians’ treatment practices and adherence to guidelines. Methods and Results The AIM-AF (Antiarrhythmic Medication for Atrial Fibrillation) study was an online survey of clinical cardiologists and electrophysiologists that was conducted in the United States and Europe (N=629). Respondents actively treated ≥30 patients with AF who received drug therapy, and had received or were referred for ablation every 3 months. The survey comprised 96 questions on physician demographics, AF types, and treatment practices. Overall, 54% of respondents considered guidelines to be the most important nonpatient factor influencing treatment choice. Across most queried comorbidities, amiodarone was selected by 60% to 80% of respondents. Other nonadherent usage included sotalol by 21% in patients with renal impairment; dofetilide initiation (16%, United States only) outside of hospital; class Ic agents by 6% in coronary artery disease; and dronedarone by 8% in patients with heart failure with reduced ejection fraction. Additionally, rhythm control strategies were frequently chosen in asymptomatic AF (antiarrhythmic drugs [AADs], 35%; ablation, 8%) and subclinical AF (AADs, 38%; ablation, 13%). Despite guideline algorithms emphasizing safety first, efficacy (48%) was selected as the most important consideration for AAD choice, followed by safety (34%). Conclusions Despite surveyed clinicians recognizing the importance of guidelines, nonadherence was frequently observed. While deviation may be reasonable in selected patients, in general, nonadherence has the potential to compromise patient safety. These findings highlight an underappreciation of the safe use of AADs, emphasizing the need for interventions to support optimal AAD selection.

2022 - Add-on Therapy With Sacubitril/Valsartan and Clinical Outcomes in CRT-D Nonresponder Patients [Articolo su rivista]
Russo, V.; Ammendola, E.; Gasperetti, A.; Bottino, R.; Schiavone, M.; Masarone, D.; Pacileo, G.; Nigro, G.; Golino, P.; Lip, G. Y. H.; D'andrea, A.; Boriani, G.; Proietti, R.
abstract

No data on the add-on sacubitril/valsartan (S/V) therapy among cardiac resynchronization therapy with a defibrillator (CRT-D) nonresponder patients are currently available in literature. We conducted a prospective observational study including 190 CRT-D nonresponder patients with symptomatic heart failure with reduced ejection fraction despite the optimal medical therapy from at least 1 year. The primary endpoint was the rate of additional responders (left ventricular end-systolic volume reduction >15%) at 12 months from the introduction of S/V therapy. At the end of the 12 months follow-up, 37 patients (19.5%) were deemed as "additional responders" to the combination use of CRT + S/V therapy. The only clinical predictor of additional response was a lower left ventricular ejection fraction [OR 0.881 (0.815-0.953), P = 0.002] at baseline. At 12 months follow-up, there were significant improvements in heart failure (HF) symptoms and functional status [New York Heart Association 2 (2-3) vs. 1 (1-2), P < 0.001; physical activity duration/day: 10 (8-12) vs. 13 (10-18) hours, P < 0.001]. Compared with the 12 months preceding S/V introduction, there were significant reductions in the rate of HF rehospitalization (35.5% vs. 19.5%, P < 0.001), in atrial tachycardia/atrial fibrillation burden [6.0 (5.0-8.0) % vs. 0 (0-2.0) %, P < 0.001] and in the proportions of patients experiencing ventricular arrhythmias (21.6% vs. 6.3%; P < 0.001). Our results indicate that S/V add-on therapy in CRT-D nonresponder patients is associated with 19.5% of additional responders, a reduction in HF symptoms and rehospitalizations, AF burden, and ventricular arrhythmias.

2022 - Adherence to the “Atrial fibrillation Better Care” (ABC) pathway in patients with atrial fibrillation and cancer: A report from the ESC-EHRA EURObservational Research Programme in atrial fibrillation (EORP-AF) General Long-Term Registry [Articolo su rivista]
Vitolo, M.; Proietti, M.; Malavasi, V. L.; Bonini, N.; Romiti, G. F.; Imberti, J. F.; Fauchier, L.; Marin, F.; Nabauer, M.; Potpara, T. S.; Dan, G. -A.; Kalarus, Z.; Maggioni, A. P.; Lane, D. A.; Lip, G. Y. H.; Boriani, G.; Boriani Chair, G.; Lip, G. Y. H.; Tavazzi, L.; Maggioni, A. P.; Dan, G. A.; Potpara, T.; Nabauer, M.; Marin, F.; Kalarus, Z.; Fauchier, L.; Goda, A.; Mairesse, G.; Shalganov, T.; Antoniades, L.; Taborsky, M.; Riahi, S.; Muda, P.; Bolao, I. G.; Piot, O.; Etsadashvili, K.; Simantirakis, E. N.; Haim, M.; Azhari, A.; Najafian, J.; Santini, M.; Mirrakhimov, E.; Kulzida, K.; Erglis, A.; Poposka, L.; Burg, M. R.; Crijns, H.; Erkuner, O.; Atar, D.; Lenarczyk, R.; Oliveira, M. M.; Shah, D.; Serdechnaya, E.; Dan, G. -A.; Diker, E.; Lane, D.
abstract

Background: Implementation of the Atrial fibrillation Better Care (ABC) pathway is recommended by guidelines on atrial fibrillation (AF), but the impact of adherence to ABC pathway in patients with cancer is unknown. Objectives: To investigate the adherence to ABC pathway and its impact on adverse outcomes in AF patients with cancer. Methods: Patients enrolled in the EORP-AF General Long-Term Registry were analyzed according to (i) No Cancer; and (ii) Prior or active cancer and stratified in relation to adherence to the ABC pathway. The composite Net Clinical Outcome (NCO) of all-cause death, major adverse cardiovascular events and major bleeding was the primary endpoint. Results: Among 6550 patients (median age 69 years, females 40.1%), 6005 (91.7%) had no cancer, while 545 (8.3%) had a diagnosis of active or prior cancer at baseline, with the proportions of full adherence to ABC pathway of 30.6% and 25.7%, respectively. Adherence to the ABC pathway was associated with a significantly lower occurrence of the primary outcome vs. non-adherence, both in ‘no cancer’ and ‘cancer’ patients [adjusted Hazard Ratio (aHR) 0.78, 95% confidence interval (CI): 0.66–0.92 and aHR 0.59, 95% CI 0.37–0.96, respectively]. Adherence to a higher number of ABC criteria was associated with a lower risk of the primary outcome, being lowest when 3 ABC criteria were fulfilled (no cancer: aHR 0.54, 95%CI: 0.36–0.81; with cancer: aHR 0.32, 95% CI 0.13–0.78). Conclusion: In AF patients with cancer enrolled in the EORP-AF General Long-Term Registry, adherence to ABC pathway was sub-optimal. Full adherence to ABC-pathway was associated with a lower risk of adverse events

2022 - Anthropometric parameters and radiation doses during percutaneous coronary procedures [Articolo su rivista]
Manicardi, Marcella; Nocetti, Luca; Brigidi, Alessio; Cadioli, Cecilia; Sgreccia, Daria; Valenti, Anna Chiara; Vitolo, Marco; Arrotti, Salvatore; Monopoli, Daniel Enrique; Sgura, Fabio; Rossi, Rosario; Guidi, Gabriele; Boriani, Giuseppe
abstract

Body size is a major determinant of patient's dose during percutaneous coronary interventions (PCI). Body mass index, body surface area (BSA), lean body mass and weight are commonly used estimates for body size. We aim to identify which of these measures and which procedural/clinical characteristics can better predict received dose.

2022 - Arrhythmias in COVID-19/SARS-CoV-2 Pneumonia Infection: Prevalence and Implication for Outcomes [Articolo su rivista]
Denegri, A.; Sola, M.; Morelli, M.; Farioli, F.; Alberto, T.; D'Arienzo, M.; Savorani, F.; Pezzuto, G. S.; Boriani, G.; Szarpak, L.; Magnani, G.
abstract

Arrhythmias (ARs) are potential cardiovascular complication of COVID-19 but may also have a prognostic role. The aim of this study was to explore the prevalence and impact of cardiac ARs in hospitalized COVID-19 patients. All-comer patients admitted to the emergency department of Modena University Hospital from 16 March to 31 December 2020 and diagnosed with COVID-19 pneumonia infection were included in the study. The primary endpoint was 30-day mortality. Out of 902 patients, 637 (70.6%) presented a baseline 12-lead ECG registration; of these, 122 (19.2%) were diagnosed with ARs. Atrial fibrillation (AF, 40.2%) was the most frequent AR detected. The primary endpoint (30-day mortality) occurred in 33.6% (p < 0.001). AR-patients presented an almost 3-fold risk of mortality compared to non-AR-patients at 30d (Adj. OR = 2.8, 95%CI: 1.8–4.3, p < 0.001). After adjustment for significant baseline characteristics selected by a stepwise backward selection, AR-patients remained at increased risk of mortality (Adj. HR = 2.0, 95%CI: 1.9–2.3, p < 0.001). Sub-group analysis revealed that among ARs patients, those with AF at admission presented the highest risk of 30-day mortality (Adj. HR = 3.1, 95%CI: 2.0–4.9, p < 0.001). In conclusion, ARs are a quite common manifestation in COVID-19 patients, who are burdened by even worse prognosis. AR patients with AF presented the highest risk of mortality; thus, these patients may benefit from a more aggressive secondary preventive therapy and a closer follow up.

2022 - Association Between Device-Detected Sleep-Disordered Breathing and Implantable Defibrillator Therapy in Patients With Heart Failure [Articolo su rivista]
Mazza, Andrea; Bendini, Maria Grazia; Bianchi, Valter; Esposito, Cristina; Calò, Leonardo; Andreoli, Chiara; Santobuono, Vincenzo Ezio; Dello Russo, Antonio; Viscusi, Miguel; La Greca, Carmelo; Baiocchi, Claudia; Talarico, Antonello; Albanese, Raimondo; Arena, Giuseppe; Giubilato, Giovanna; Ziacchi, Matteo; Rapacciuolo, Antonio; Campari, Monica; Valsecchi, Sergio; Boriani, Giuseppe
abstract

BACKGROUND Sleep-disordered breathing is highly prevalent in heart failure (HF) and has been suggested as a risk factor for malignant ventricular arrhythmias. The Respiratory Disturbance Index (RDI) computed by an implantable cardioverter-defibrillator (ICD) algorithm accurately identifies severe sleep apnea.OBJECTIVES In the present analysis, the authors evaluated the association between ICD-detected sleep apnea and the incidence of appropriate ICD therapies in patients with HF.METHODS We enrolled 411 HF patients who had received an ICD endowed with an algorithm that calculates the RDI each night. In this analysis, the weekly mean RDI value was considered. The endpoint was the first appropriate ICD shock.RESULTS The median follow-up was 26 months (25th to 75th percentile: 16-35 months). During follow-up, 1 or more ICD shocks were documented in 58 (14%) patients. Patients with shocks were younger (age 66 +/- 13 years vs 70 +/- 10 years; P = 0.038), and had more frequently undergone implantation for secondary prevention (21% vs 10%; P = 0.026). The maximum RDI value calculated during the entire follow-up period did not differ between patients with and without shocks (55 +/- 15 episodes/h vs 54 +/- 14 episodes/h; P = 0.539). However, the ICD-detected RDI showed considerable variability during follow-up. The overall median of the weekly RDI was 33 episodes/h (25th to 75th percentile: 24-45 episodes/h). A time-dependent Cox regression model revealed that a continuously measured weekly mean RDI of $45 episodes/h was independently associated with shock occurrence (HR: 4.63; 95% CI: 2.54-8.43; P < 0.001), after correction for baseline confounders (age, secondary prevention).CONCLUSIONS In HF patients, appropriate ICD shocks were more likely to be delivered during periods when patients exhibited more sleep-disordered breathing. (Arrhythmias Detection in a Real World Population [RHYTHM DETECT]; NCT02275637) (J Am Coll Cardiol EP 2022;8:1249-1256) (c) 2022 by the American College of Cardiology Foundation.

2022 - Association between implantable defibrillator-detected sleep apnea and atrial fibrillation: The DASAP-HF study [Articolo su rivista]
Boriani, G.; Diemberger, I.; Pisano, E. C. L.; Pieragnoli, P.; Locatelli, A.; Capucci, A.; Talarico, A.; Zecchin, M.; Rapacciuolo, A.; Piacenti, M.; Indolfi, C.; Arias, M. A.; Checchinato, C.; La Rovere, M. T.; Sinagra, G.; Emdin, M.; Ricci, R. P.; D'Onofrio, A.
abstract

Introduction: The Respiratory Disturbance Index (RDI) computed by an implantable cardioverter defibrillator (ICD) algorithm accurately identifies severe sleep apnea (SA). In the present analysis, we tested the hypothesis that RDI could also predict atrial fibrillation (AF) burden. Methods: Patients with ejection fraction ≤35% implanted with an ICD were enrolled and followed up for 24 months. One month after implantation, patients underwent a polysomnographic study. The weekly mean RDI value was considered, as calculated during the entire follow-up period and over a 1-week period preceding the sleep study. The endpoints were as follows: daily AF burden of ≥5 min, ≥6 h, ≥23 h. Results: Here, 164 patients had usable RDI values during the entire follow-up period. Severe SA (RDI ≥ 30 episodes/h) was diagnosed in 92 (56%) patients at the time of the sleep study. During follow-up, AF burden ≥ 5 min/day was documented in 70 (43%), ≥6 h/day in 48 (29%), and ≥23 h/day in 33 (20%) patients. Device-detected RDI ≥ 30 episodes/h at the time of the polygraphy, as well as the polygraphy-measured apnea hypopnea index ≥ 30 episodes/h, were not associated with the occurrence of the endpoints, using a Cox regression model. However, using a time-dependent model, continuously measured weekly mean RDI ≥ 30 episodes/h was independently associated with AF burden ≥ 5 min/day (hazard ratio [HR]: 2.13, 95% confidence interval [CI]: 1.24–3.65, p =.006), ≥6 h/day (HR: 2.75, 95% CI: 1.37–5.49, p =.004), and ≥23 h/day (HR: 2.26, 95% CI: 1.05–4.86, p =.037). Conclusions: In heart failure patients, ICD-diagnosed severe SA on follow-up data review identifies patients who are from two- to three-fold more likely to experience an AF episode, according to various thresholds of daily AF burden.

2022 - Atrial Fibrillation and Dementia: A Report From the AF-SCREEN International Collaboration [Articolo su rivista]
Rivard, L.; Friberg, L.; Conen, D.; Healey, J. S.; Berge, T.; Boriani, G.; Brandes, A.; Calkins, H.; Camm, A. J.; Yee Chen, L.; Lluis Clua Espuny, J.; Collins, R.; Connolly, S.; Dagres, N.; Elkind, M. S. V.; Engdahl, J.; Field, T. S.; Gersh, B. J.; Glotzer, T. V.; Hankey, G. J.; Harbison, J. A.; Georg Haeusler, K.; Hills, M. T.; Johnson, L. S. B.; Joung, B.; Khairy, P.; Kirchhof, P.; Krieger, D.; Lip, G. Y. H.; Lochen, M. -L.; Madhavan, M.; Mairesse, G. H.; Montaner, J.; Ntaios, G.; Quinn, T. J.; Rienstra, M.; Rosenqvist, M.; Sandhu, R. K.; Smyth, B.; Schnabel, R. B.; Stavrakis, S.; Themistoclakis, S.; Van Gelder, I. C.; Wang, J. -G.; Freedman, B.
abstract

Growing evidence suggests a consistent association between atrial fibrillation (AF) and cognitive impairment and dementia that is independent of clinical stroke. This report from the AF-SCREEN International Collaboration summarizes the evidence linking AF to cognitive impairment and dementia. It provides guidance on the investigation and management of dementia in patients with AF on the basis of best available evidence. The document also addresses suspected pathophysiologic mechanisms and identifies knowledge gaps for future research. Whereas AF and dementia share numerous risk factors, the association appears to be independent of these variables. Nevertheless, the evidence remains inconclusive regarding a direct causal effect. Several pathophysiologic mechanisms have been proposed, some of which are potentially amenable to early intervention, including cerebral microinfarction, AF-related cerebral hypoperfusion, inflammation, microhemorrhage, brain atrophy, and systemic atherosclerotic vascular disease. The mitigating role of oral anticoagulation in specific subgroups (eg, low stroke risk, short duration or silent AF, after successful AF ablation, or atrial cardiopathy) and the effect of rhythm versus rate control strategies remain unknown. Likewise, screening for AF (in cognitively normal or cognitively impaired patients) and screening for cognitive impairment in patients with AF are debated. The pathophysiology of dementia and therapeutic strategies to reduce cognitive impairment warrant further investigation in individuals with AF. Cognition should be evaluated in future AF studies and integrated with patient-specific outcome priorities and patient preferences. Further large-scale prospective studies and randomized trials are needed to establish whether AF is a risk factor for cognitive impairment, to investigate strategies to prevent dementia, and to determine whether screening for unknown AF followed by targeted therapy might prevent or reduce cognitive impairment and dementia.

2022 - Atrial Fibrillation and the Risk of Early‐Onset Dementia: A Systematic Review and Meta‐Analysis [Articolo su rivista]
Giannone, Maria Edvige; Filippini, Tommaso; Whelton, Paul K.; Chiari, Annalisa; Vitolo, Marco; Boriani, Giuseppe; Vinceti, Marco
abstract

BACKGROUNDRecent studies have identified an increased risk of dementia in patients with atrial fibrillation (AF). However, both AF and dementia usually manifest late in life. Few studies have investigated this association in adults with early‐onset dementia. The aim of this study was to investigate the relationship between AF and early‐onset dementia. METHODS AND RESULTSWe searched the PubMed/MEDLINE, Embase, and Scopus databases through April 15, 2022, for studies reporting on the association between AF and dementia in adults aged <70 years, without language restrictions. Two reviewers independently performed the study selection, assessed the risk of bias, and extracted the study data. We performed a meta‐analysis of early‐onset dementia risk according to occurrence of AF using a random‐effects model. We retrieved and screened 1006 potentially eligible studies. We examined the full text of 33 studies and selected the 6 studies that met our inclusion criteria. The pooled analysis of their results showed an increased risk of developing dementia in individuals with AF, with a summary relative risk of 1.50 (95% CI, 1.00–2.26) in patients aged <70 years, and 1.06 (95% CI, 0.55–2.06) in those aged <65 years. CONCLUSIONSIn this systematic review and meta‐analysis, AF was a risk factor for dementia in adults aged <70 years, with an indication of a slight and statistically imprecise excess risk already at ages <65 years. Further research is needed to assess which characteristics of the arrhythmia and which mechanisms play a role in this relationship.

2022 - Atrial Fibrillation in the Setting of Acute Pneumonia: Not a Secondary Arrhythmia [Articolo su rivista]
Maisano, A.; Vitolo, M.; Imberti, J. F.; Bonini, N.; Albini, A.; Valenti, A. C.; Sgreccia, D.; Mantovani, M.; Malavasi, V. L.; Boriani, G.
abstract

Atrial fibrillation (AF) is the most common arrhythmia in the setting of critically ill patients. Pneumonia, and in particular communityacquired pneumonia, is one of the most common causes of illness and hospital admission worldwide. This article aims to review the association between AF and acute diseases, with specific attention to pneumonia, from the pathophysiology to its clinical significance. Even though the relationship between pneumonia and AF has been known for years, it was once considered a transient bystander. In recent years there has been growing knowledge on the clinical significance of this arrhythmia in acute clinical settings, in which it holds a prognostic role which is not so different as compared to that of the so-called "primary"AF. AF is a distinct entity even in the setting of pneumonia, and acute critical illnesses in general, and it should therefore be managed with a guidelines-oriented approach, including prescription of anticoagulants in patients at thromboembolic risk, always considering patients' individuality. More data on the significance of the arrhythmia in this setting will help clinicians to give patients the best possible care.

2022 - Atrial High-Rate Episodes Detected by Cardiac Implantable Electronic Devices: Dynamic Changes in Episodes and Predictors of Incident Atrial Fibrillation [Articolo su rivista]
Imberti, J. F.; Bonini, N.; Tosetti, A.; Mei, D. A.; Gerra, L.; Malavasi, V. L.; Mazza, A.; Lip, G. Y. H.; Boriani, G.
abstract

Background. Atrial high rate episodes (AHRE) detected by cardiac implantable electronic devices (CIEDs) may be associated with a risk of progression towards long-lasting episodes (≥24 h) and clinical atrial fibrillation (AF). Methods. Consecutive CIED patients presenting AHRE (with confirmation of an arrhythmia lasting 5 min–23 h 59 min, atrial rate ≥175/min, with no AF at 12-lead ECG and no prior clinical AF) were retrospectively enrolled. The aims of this study were to describe patients’ characteristics and the incidence of adverse events, and second, to identify potential predictors of the composite outcome of clinical AF and/or AHRE episodes lasting ≥24 h. Results. 104/107 (97.2%) patients (median age 79.7 (74.0–84.2), 33.7% female) had available follow-up data. Over a median follow-up of 24.3 (10.6–40.3) months, 31/104 (29.8%) patients experienced the composite outcome of clinical AF or AHRE episodes lasting ≥24 h. Baseline CHA2DS2-VASc score and the longest AHRE episode at enrollment lasting 12 h–23 h 59 min were independently associated with the composite outcome (Hazard ratio (HR); 95% CI: 1.40; 1.07–1.83 and HR: 8.15; 95% CI 2.32–28.65, respectively). Baseline CHA2DS2-VASc score and the longest AHRE episode at enrollment lasting 12 h–23 h 59 min were the only independent predictors of incident clinical AF (HR: 1.45; 95% CI 1.06–2.00 and HR: 4.25; 95% CI 1.05–17.20, respectively). Conclusions. In patients with AHRE, the incidence of clinical AF or AHRE episodes lasting ≥24 h is high in a two-year follow-up. Baseline patients’ characteristics (CHA2DS2-VASc score) and AHRE duration may help to intensify monitoring and decision-making, being independently associated with clinical AF at follow-up.

2022 - Atrial cardiomyopathy: a derangement in atrial volumes, geometry, function, and pathology with important clinical implications [Articolo su rivista]
Boriani, G.; Vitolo, M.; Imberti, J. F.
abstract

2022 - Atrial fibrillation ablation in heart failure: Findings from the ESC-EHRA EORP Atrial Fibrillation Ablation long-term (AFA LT) registry [Articolo su rivista]
Temporelli, P. L.; Arbelo, E.; Laroche, C.; Blomstrom-Lundqvist, C.; Kirchhof, P.; Lip, G. Y. H.; Boriani, G.; Nakou, E.; Maggioni, A. P.; Tavazzi, L.
abstract

Background: The current practice of atrial fibrillation ablation (AFA) as a treatment option for atrial fibrillation (AF) in patients with heart failure (HF) across Europe, their clinical profiles and outcomes is still undefined. Methods: The European Society of Cardiology (ESC) led a prospective observational registry of consecutive patients undergoing AFA, in 27 member countries. The subgroup of patients with HF, followed-up for 1 year, was analyzed and the results are reported. Results: Of the 3582 AF patients in the Registry, 537 (14.9%) had HF. Diabetes, hypertension, hypercholesterolemia, CHA2DS2-VASc score ≥ 2, structural heart disease and persistent AF were more common in HF than non-HF patients (all p < 0.001). However the in-hospital complications were less frequent in HF patients (5.0% vs. 8.2% p = 0.01). Both in-hospital and 1-year outcomes, including 1-year AF recurrence (15.4%) and repeat ablations (9.5%), were similar in both groups. We subdivided HF patients according to their left ventricular ejection fraction (EF) at baseline into reduced (HFrEF, <40%), mid-range (HFmEF, 40–49%), or preserved EF (HFpEF, ≥ 50%). Most patients were HFpEF (n 375, 77%), 72 (15%) were HFmEF and 8% HFrEF. The most frequent underlying conditions in HFpEF were hypertension and ischemic heart disease, while those most common in HFmEF and HFrEF were valvular and dilated cardiomyopathy. Conclusion: In routine care in Europe, HF patients represent a minority of patients undergoing AFA, and most belong to the HFpEF phenotype. The limited clinical research on AFA HFpEF patients is reflected by the uncertainty expressed in the current AF Guidelines and Expert statements.

2022 - Atrial fibrillation post-coronary or cardiac surgery: A transient inflammation-related event or the expression of a pre-existing arrhythmogenic atrial substrate? [Articolo su rivista]
Boriani, Giuseppe; Vitolo, Marco; Imberti, Jacopo F
abstract

2022 - Atrial high rate episodes as a marker of atrial cardiomyopathy: In the quest of the Holy Grail. Author's reply [Articolo su rivista]
Vitolo, M.; Imberti, J. F.; Proietti, M.; Lip, G. Y. H.; Boriani, G.
abstract

2022 - Burden of disease and costs of infections associated with cardiac implantable electronic devices [Articolo su rivista]
Sgreccia, D.; Vitolo, M.; Valenti, A. C.; Manicardi, M.; Boriani, G.
abstract

Introduction: Infections are complications of Cardiac Implantable Electronic Device (CIED) procedures, associated with high mortality (20–25% at 1 year), long hospitalizations (23–30 days), and high costs for health-care systems (often higher than 30.000 €). The incidence rates are around 1–4%. Prevention strategies appear to be the best approach for minimizing the occurrence of CIED infections, but in real-world, the recommendations for the best practices are not always followed. Among the recommended preventive measures, the antibacterial envelope has proven to be effective in reducing CIED-related infections. Areas covered: Published studies investigate the role of antibacterial envelopes in infection prevention and the use of infection risk scores to select high-risk patients undergoing CIED implantation/replacement who can benefit from additional preventive measures. Expert opinion: A proficient selection of the best candidates for the antibacterial envelope can be the basis for reducing the healthcare system’s costs, in line with the principles of cost-effectiveness. Risk scores have been developed to select patients at high risk of CIED infections and their use appears simple and more complete than individual factors alone. Among them, the PADIT score seems to be effective in selecting patients eligible for antibacterial envelope insertion, with a good cost-effectiveness profile.

2022 - Cardiac troponins and adverse outcomes in European patients with atrial fibrillation: A report from the ESC-EHRA EORP atrial fibrillation general long-term registry [Articolo su rivista]
Vitolo, M.; Malavasi, V. L.; Proietti, M.; Diemberger, I.; Fauchier, L.; Marin, F.; Nabauer, M.; Potpara, T. S.; Dan, G. -A.; Kalarus, Z.; Tavazzi, L.; Maggioni, A. P.; Lane, D. A.; Lip, G. Y. H.; Boriani, G.
abstract

Background: Cardiac troponins (cTn) have been reported to be predictors for adverse outcomes in atrial fibrillation (AF), patients, but their actual use is still unclear. Aim: To assess the factors associated with cTn testing in routine practice and evaluate the association with outcomes. Methods: Patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry were stratified into 3 groups according to cTn levels as (i) cTn not tested, (ii) cTn in range (≤99th percentile), (iii) cTn elevated (>99th percentile). The composite outcome of any thromboembolism /any acute coronary syndrome/cardiovascular (CV) death, defined as Major Adverse Cardiovascular Events (MACE) and all-cause death were the main endpoints. Results: Among 10 445 AF patients (median age 71 years, 40.3% females) cTn were tested in 2834 (27.1%). cTn was elevated in 904/2834 (31.9%) and in-range in 1930/2834 (68.1%) patients. Female sex, in-hospital enrollment, first-detected AF, CV risk factors, history of coronary artery disease, and atypical AF symptoms were independently associated with cTn testing. Elevated cTn were independently associated with a higher risk for MACE (Model 1, hazard ratio [HR] 1.74, 95% confidence interval [CI] 1.40–2.16, Model 2, HR 1.62, 95% CI 1.28–2.05; Model 3 HR 1.76, 95% CI 1.37–2.26) and all-cause death (Model 1, HR 1.45, 95% CI 1.21–1.74; Model 2, HR 1.36, 95% CI 1.12–1.66; Model 3, HR 1.38, 95% CI 1.12–1.71). Conclusions: Elevated cTn levels were associated with an increased risk of all-cause mortality and adverse CV events. Clinical factors that might enhance the need to rule out CAD were associated with cTn testing.

2022 - Case Report: Free-Floating Intracoronary Thrombus: Who Is the Convict? [Articolo su rivista]
Mantovani, F.; Paolini, A.; Barbieri, A.; Boriani, G.
abstract

In young patients, especially with no traditional coronary risk factors, hypercoagulable states may always be considered as an alternative cause of acute coronary syndromes. The concomitant thrombotic and bleeding risk associated with myeloproliferative disorders complicates the decision-making, particularly regarding long-term dual antiplatelet therapy. The chosen therapy may need to be frequently revisited, depending on the patient’s bleeding complications. We reported the case of a 49-year-old woman with acute myocardial infarction with no traditional risk factors for coronary artery disease where a myeloproliferative neoplasm was diagnosed.

2022 - Chronic Kidney Disease with Mild and Mild to Moderate Reduction in Renal Function and Long-Term Recurrences of Atrial Fibrillation after Pulmonary Vein Cryoballoon Ablation [Articolo su rivista]
Boriani, G.; Iacopino, S.; Arena, G.; Pieragnoli, P.; Verlato, R.; Manfrin, M.; Molon, G.; Rovaris, G.; Curnis, A.; Perego, G. B.; Dello Russo, A.; Landolina, M.; Vitolo, M.; Tondo, C.
abstract

The aim of this research was to evaluate if patients with chronic kidney disease (CKD) and mild or mild to moderate depression of renal function have an increased risk of atrial fibrillation (AF) recurrences after cryoballoon (CB) ablation. We performed a retrospective analysis of AF patients undergoing pulmonary vein isolation (PVI) by CB. The cohort was divided according to the KDIGO CKD-EPI classification into a (1) normal, (2) mildly decreased, or (3) mild to moderate reduction in estimated glomerular filtration rate (eGFR). Freedom from AF recurrences was the primary endpoint. A total of 1971 patients were included (60 ± 10 years, 29.0% females, 73.6% paroxysmal AF) in the study. Acute success and complication rates were 99.2% and 3.7%, respectively, with no significant differences among the three groups. After a follow-up of 24 months, AF recurrences were higher in the mildly and mild to moderate CKD groups compared to the normal kidney function group (23.4% vs. 28.3% vs. 33.5%, p < 0.05). Mild to moderate CKD was an independent predictor of AF recurrences after the blanking period (hazard ratio:1.38, 95% CI 1.02–1.86, p = 0.037). In conclusion, a multicenter analysis of AF patients treated with cryoablation revealed mild to moderate reductions in renal functions were associated with a higher risk of AF recurrences. Conversely, the procedural success and complication rates were similar in patients with normal, mildly reduced, or mild to moderate reduction in eGFR.

2022 - Clinical Complexity Domains, Anticoagulation, and Outcomes in Patients with Atrial Fibrillation: A Report from the GLORIA-AF Registry Phase II and III [Articolo su rivista]
Romiti, G. F.; Proietti, M.; Bonini, N.; Ding, W. Y.; Boriani, G.; Huisman, M. V.; Lip, G. Y. H.
abstract

Background Clinical complexity is common in atrial fibrillation (AF) patients. We assessed the impact of clinical complexity on oral anticoagulant (OAC) treatment patterns and major adverse outcomes in a contemporary cohort of AF patients. Methods The GLORIA-AF Phase II and III Registry enrolled newly diagnosed AF patients with at least one stroke risk factor. Among patients with CHA2DS2-VASc score ≥2, we defined four domains of perceived clinical complexity: frail elderly (age ≥75 years and body mass index 23 kg/m2), chronic kidney disease (CKD, creatinine clearance 60 mL/min), history of bleeding, and those with ≥2 of the above conditions. We evaluated the associations between clinical complexity domains and antithrombotic treatment prescription, risk of OAC discontinuation, and major adverse outcomes. Results Among the 29,625 patients included (mean age 69.6 ± 10.7 years, 44.2% females), 9,504 (32.1%) presented with at least one complexity criterion. Clinical complexity was associated with lower OAC prescription, with stronger associations in frail elderly (odds ratio [OR]: 0.47, 95% confidence interval [CI]: 0.36-0.62) and those with ≥2 complexity domains (OR: 0.50, 95% CI: 0.44-0.57). Risk of OAC discontinuation was higher among frail elderly (hazard ratio [HR]: 1.30, 95% CI: 1.00-1.69), CKD (HR: 1.10, 95% CI: 1.02-1.20), and those with ≥ 2 complexity domains (HR: 1.39, 95% CI: 1.23-1.57). Clinical complexity was associated with higher risk of the primary outcome of all-cause death, thromboembolism, and major bleeding, with the highest magnitude in those with ≥ 2 criteria (HR: 1.63, 95% CI: 1.43-1.86). Conclusion In AF patients, clinical complexity influences OAC treatment management, and increases the risk of poor clinical outcomes. These patients require additional efforts, such as integrated care approach, to improve their management and prognosis.

2022 - Clinical Profile, Arrhythmias, and Adverse Cardiac Outcomes in Emery–Dreifuss Muscular Dystrophies: A Systematic Review of the Literature [Articolo su rivista]
Valenti, A. C.; Albini, A.; Imberti, J. F.; Vitolo, M.; Bonini, N.; Lattanzi, G.; Schnabel, R. B.; Boriani, G.
abstract

Cardiolaminopathies are a heterogeneous group of disorders which are due to mutations in the genes encoding for nuclear lamins or their binding proteins. The whole spectrum of cardiac manifestations encompasses atrial arrhythmias, conduction disturbances, progressive systolic dysfunction, and malignant ventricular arrhythmias. Despite the prognostic significance of cardiac involvement in this setting, the current recommendations lack strong evidence. The aim of our work was to systematically review the current data on the main cardiovascular outcomes in cardiolaminopathies. We searched PubMed/Embase for studies focusing on cardiovascular outcomes in LMNA mutation carriers (atrial arrhythmias, ventricular arrhythmias, sudden cardiac death, conduction disturbances, thromboembolic events, systolic dysfunction, heart transplantation, and all-cause and cardiovascular mortality). In total, 11 studies were included (1070 patients, mean age between 26–45 years, with follow-up periods ranging from 2.5 years up to 45 ± 12). When available, data on the EMD-mutated population were separately reported (40 patients). The incidence rates (IR) were individually assessed for the outcomes of interest. The IR for atrial fibrillation/atrial flutter/atrial tachycardia ranged between 6.1 and 13.9 events/100 pts–year. The IR of atrial standstill ranged between 0 and 2 events/100 pts-year. The IR for malignant ventricular arrhythmias reached 10.2 events/100 pts–year and 15.6 events/100 pts–year for appropriate implantable cardioverter–defibrillator (ICD) interventions. The IR for advanced conduction disturbances ranged between 3.2 and 7.7 events/100 pts–year. The IR of thromboembolic events reached up to 8.9 events/100 pts–year. Our results strengthen the need for periodic cardiological evaluation focusing on the early recognition of atrial arrhythmias, and possibly for the choice of preventive strategies for thromboembolic events. The frequent need for cardiac pacing due to advanced conduction disturbances should be counterbalanced with the high risk of malignant ventricular arrhythmias that would justify ICD over pacemaker implantation.

2022 - Clinical complexity and impact of the ABC (Atrial fibrillation Better Care) pathway in patients with atrial fibrillation: a report from the ESC-EHRA EURObservational Research Programme in AF General Long-Term Registry [Articolo su rivista]
Romiti, G. F.; Proietti, M.; Vitolo, M.; Bonini, N.; Fawzy, A. M.; Ding, W. Y.; Fauchier, L.; Marin, F.; Nabauer, M.; Dan, G. A.; Potpara, T. S.; Boriani, G.; Lip, G. Y. H.
abstract

BACKGROUND: Clinical complexity is increasingly prevalent among patients with atrial fibrillation (AF). The 'Atrial fibrillation Better Care' (ABC) pathway approach has been proposed to streamline a more holistic and integrated approach to AF care; however, there are limited data on its usefulness among clinically complex patients. We aim to determine the impact of ABC pathway in a contemporary cohort of clinically complex AF patients. METHODS: From the ESC-EHRA EORP-AF General Long-Term Registry, we analysed clinically complex AF patients, defined as the presence of frailty, multimorbidity and/or polypharmacy. A K-medoids cluster analysis was performed to identify different groups of clinical complexity. The impact of an ABC-adherent approach on major outcomes was analysed through Cox-regression analyses and delay of event (DoE) analyses. RESULTS: Among 9966 AF patients included, 8289 (83.1%) were clinically complex. Adherence to the ABC pathway in the clinically complex group reduced the risk of all-cause death (adjusted HR [aHR]: 0.72, 95%CI 0.58-0.91), major adverse cardiovascular events (MACEs; aHR: 0.68, 95%CI 0.52-0.87) and composite outcome (aHR: 0.70, 95%CI: 0.58-0.85). Adherence to the ABC pathway was associated with a significant reduction in the risk of death (aHR: 0.74, 95%CI 0.56-0.98) and composite outcome (aHR: 0.76, 95%CI 0.60-0.96) also in the high-complexity cluster; similar trends were observed for MACEs. In DoE analyses, an ABC-adherent approach resulted in significant gains in event-free survival for all the outcomes investigated in clinically complex patients. Based on absolute risk reduction at 1 year of follow-up, the number needed to treat for ABC pathway adherence was 24 for all-cause death, 31 for MACEs and 20 for the composite outcome. CONCLUSIONS: An ABC-adherent approach reduces the risk of major outcomes in clinically complex AF patients. Ensuring adherence to the ABC pathway is essential to improve clinical outcomes among clinically complex AF patients.

2022 - Clinical implications of assessing frailty in elderly patients treated with permanent cardiac pacing [Articolo su rivista]
Boriani, G.; Valenti, A. C.; Vitolo, M.
abstract

2022 - Clinical utility and prognostic implications of the novel 4S-AF scheme to characterize and evaluate patients with atrial fibrillation: a report from ESC-EHRA EORP-AF Long-Term General Registry [Articolo su rivista]
Ding, W. Y.; Proietti, M.; Boriani, G.; Fauchier, L.; Blomstrom-Lundqvist, C.; Marin, F.; Potpara, T. S.; Lip, G. Y. H.
abstract

AIMS: The 4S-AF classification scheme comprises of four domains: stroke risk (St), symptoms (Sy), severity of atrial fibrillation (AF) burden (Sb), and substrate (Su). We sought to examine the implementation of the 4S-AF scheme in the EORP-AF General Long-Term Registry and compare outcomes in AF patients according to the 4S-AF-led decision-making process. METHODS AND RESULTS : Atrial fibrillation patients from 250 centres across 27 European countries were included. A 4S-AF score was calculated as the sum of each domain with a maximum score of 9. Of 6321 patients, 8.4% had low (St), 47.5% EHRA I (Sy), 40.5% newly diagnosed or paroxysmal AF (Sb), and 5.1% no cardiovascular risk factors or left atrial enlargement (Su). Median follow-up was 24 months. Using multivariable Cox regression analysis, independent predictors of all-cause mortality were (St) [adjusted hazard ratio (aHR) 8.21, 95% confidence interval (CI): 2.60-25.9], (Sb) (aHR 1.21, 95% CI: 1.08-1.35), and (Su) (aHR 1.27, 95% CI: 1.14-1.41). For CV mortality and any thromboembolic event, only (Su) (aHR 1.73, 95% CI: 1.45-2.06) and (Sy) (aHR 1.29, 95% CI: 1.00-1.66) were statistically significant, respectively. None of the domains were independently linked to ischaemic stroke or major bleeding. Higher 4S-AF score was related to a significant increase in all-cause mortality, CV mortality, any thromboembolic event, and ischaemic stroke but not major bleeding. Treatment of all 4S-AF domains was associated with an independent decrease in all-cause mortality (aHR 0.71, 95% CI: 0.55-0.92). For each 4S-AF domain left untreated, the risk of all-cause mortality increased substantially (aHR 1.35, 95% CI: 1.16-1.56). CONCLUSION : Implementation of the novel 4S-AF scheme is feasible, and treatment decisions based on this scheme improve mortality rates in AF.

2022 - Comparative effectiveness and safety of non-vitamin K antagonists for atrial fibrillation in clinical practice: GLORIA-AF Registry [Articolo su rivista]
Lip, G. Y. H.; Kotalczyk, A.; Teutsch, C.; Diener, H. -C.; Dubner, S. J.; Halperin, J. L.; Ma, C. -S.; Rothman, K. J.; Marler, S.; Gurusamy, V. K.; Huisman, M. V.; Abban, D. W.; Aziz, E.; Kalan, M. B.; Abdul, N.; Backes, L. M.; Bradman, D.; Abud, A. M.; Badings, E.; Brautigam, D.; Adams, F.; Bagni, E.; Breton, N.; Addala, S.; Baker, S. H.; Brouwers, P. J. A. M.; Adragao, P.; Bala, R.; Browne, K.; Ageno, W.; Baldi, A.; Cortada, J. B.; Aggarwal, R.; Bando, S.; Bruni, A.; Agosti, S.; Banerjee, S.; Brunschwig, C.; Agostoni, P.; Bank, A.; Buathier, H.; Aguilar, F.; Esquivias, G. B.; Buhl, A.; Linares, J. A.; Barr, C.; Bullinga, J.; Aguinaga, L.; Bartlett, M.; Cabrera, J. W.; Ahmed, J.; Basic Kes, V.; Caccavo, A.; Aiello, A.; Baula, G.; Cai, S.; Ainsworth, P.; Behrens, S.; Caine, S.; Aiub, J. R.; Bell, A.; Calo, L.; Al-Dallow, R.; Benedetti, R.; Calvi, V.; Alderson, L.; Mazuecos, J. B.; Sanchez, M. C.; Velasco, J. A. A.; Benhalima, B.; Candeias, R.; Alexopoulos, D.; Bergler-Klein, J.; Capuano, V.; Manterola, F. A.; Berneau, J. -B.; Capucci, A.; Aliyar, P.; Bernstein, R. A.; Caputo, R.; Alonso, D.; Berrospi, P.; Rizo, T. C.; da Costa, F. A. A.; Berti, S.; Cardona, F.; Amado, J.; Berz, A.; da Costa Darrieux, F. C.; Amara, W.; Best, E.; Vera, Y. C. D.; Amelot, M.; Bettencourt, P.; Carolei, A.; Amjadi, N.; Betzu, R.; Carreno, S.; Ammirati, F.; Bhagwat, R.; Carvalho, P.; Andrade, M.; Bhatta, L.; Cary, S.; Andrawis, N.; Biscione, F.; Casu, G.; Annoni, G.; Bisignani, G.; Cavallini, C.; Ansalone, G.; Black, T.; Cayla, G.; Ariani, M. K.; Bloch, M. J.; Celentano, A.; Arias, J. C.; Bloom, S.; Cha, T. -J.; Armero, S.; Blumberg, E.; Cha, K. S.; Arora, C.; Bo, M.; Chae, J. K.; Aslam, M. S.; Bohmer, E.; Chalamidas, K.; Asselman, M.; Bollmann, A.; Challappa, K.; Audouin, P.; Bongiorni, M. G.; Chand, S. P.; Augenbraun, C.; Boriani, G.; Chandrashekar, H.; Aydin, S.; Boswijk, D. J.; Chartier, L.; Aydin, S.; Bott, J.; Chatterjee, K.; Ayryanova, I.; Bottacchi, E.; Ayala, C. A. C.; Cheema, A.; Davis, G.; Evonich, R.; Cheema, A.; Davy, J. -M.; Evseeva, O.; Chen, L.; Dayer, M.; Ezhov, A.; Chen, S. -A.; De Biasio, M.; Fahmy, R.; Chen, J. H.; De Bonis, S.; Fang, Q.; Chiang, F. -T.; De Caterina, R.; Farsad, R.; Chiarella, F.; De Franceschi, T.; Fauchier, L.; Chih-Chan, L.; de Groot, J. R.; Favale, S.; Cho, Y. K.; De Horta, J.; Fayard, M.; Choi, J. -I.; De La Briolle, A.; Fedele, J. L.; Choi, D. J.; de la Pena Topete, G.; Fedele, F.; Chouinard, G.; de Paola, A. A. V.; Fedorishina, O.; Chow, D. H. -F.; de Souza, W.; Fera, S. R.; Chrysos, D.; de Veer, A.; Ferreira, L. G. G.; Chumakova, G.; De Wolf, L.; Ferreira, J.; Valenzuela, E. J. J. R. C.; Decoulx, E.; Ferri, C.; Nica, N. C.; Deepak, S.; Ferrier, A.; Cislowski, D. J.; Defaye, P.; Ferro, H.; Clay, A.; Munoz, F. D. -C.; Finsen, A.; Clifford, P.; Brkljacic, D. D.; First, B.; Cohen, A.; Deumite, N. J.; Fischer, S.; Cohen, M.; Di Legge, S.; Fonseca, C.; Cohen, S.; Diemberger, I.; Almeida, L. F.; Colivicchi, F.; Dietz, D.; Forman, S.; Collins, R.; Dionisio, P.; Frandsen, B.; Colonna, P.; Dong, Q.; French, W.; Compton, S.; dos Santos, F. R.; Friedman, K.; Connolly, D.; Dotcheva, E.; Friese, A.; Conti, A.; Doukky, R.; Fruntelata, A. G.; Buenostro, G. C.; D'Souza, A.; Fujii, S.; Coodley, G.; Dubrey, S.; Fumagalli, S.; Cooper, M.; Ducrocq, X.; Fundamenski, M.; Coronel, J.; Dupljakov, D.; Furukawa, Y.; Corso, G.; Duque, M.; Gabelmann, M.; Sales, J. C.; Dutta, D.; Gabra, N.; Cottin, Y.; Duvilla, N.; Gadsboll, N.; Covalesky, J.; Duygun, A.; Galinier, M.; Cracan, A.; Dziewas, R.; Gammelgaard, A.; Crea, F.; Eaton, C. B.; Ganeshkumar, P.; Crean, P.; Eaves, W.; Gans, C.; Crenshaw, J.; Ebels-Tuinbeek, L. A.; Quintana, A. G.; Cullen, T.; Ehrlich, C.; Gartenlaub, O.; Darius, H.; Eichinger-Hasenauer, S.; Gaspardone, A.; Dary, P.; Eisenberg, S. J.; Genz, C.; Dascotte, O.; Jabali, A. E.; Georger, F.; Dauber, I.; Shahawy, M. E.; Georges, J. -L.; Davalos, V.; Hernandes, M. E.; Georgeson, S.; Davies, R.; Izal, A. E.; Giedrimas, E.; G
abstract

Background and purpose: Prospectively collected data comparing the safety and effectiveness of individual non-vitamin K antagonists (NOACs) are lacking. Our objective was to directly compare the effectiveness and safety of NOACs in patients with newly diagnosed atrial fibrillation (AF). Methods: In GLORIA-AF, a large, prospective, global registry program, consecutive patients with newly diagnosed AF were followed for 3 years. The comparative analyses for (1) dabigatran vs rivaroxaban or apixaban and (2) rivaroxaban vs apixaban were performed on propensity score (PS)-matched patient sets. Proportional hazards regression was used to estimate hazard ratios (HRs) for outcomes of interest. Results: The GLORIA-AF Phase III registry enrolled 21,300 patients between January 2014 and December 2016. Of these, 3839 were prescribed dabigatran, 4015 rivaroxaban and 4505 apixaban, with median ages of 71.0, 71.0, and 73.0 years, respectively. In the PS-matched set, the adjusted HRs and 95% confidence intervals (CIs) for dabigatran vs rivaroxaban were, for stroke: 1.27 (0.79–2.03), major bleeding 0.59 (0.40–0.88), myocardial infarction 0.68 (0.40–1.16), and all-cause death 0.86 (0.67–1.10). For the comparison of dabigatran vs apixaban, in the PS-matched set, the adjusted HRs were, for stroke 1.16 (0.76–1.78), myocardial infarction 0.84 (0.48–1.46), major bleeding 0.98 (0.63–1.52) and all-cause death 1.01 (0.79–1.29). For the comparison of rivaroxaban vs apixaban, in the PS-matched set, the adjusted HRs were, for stroke 0.78 (0.52–1.19), myocardial infarction 0.96 (0.63–1.45), major bleeding 1.54 (1.14–2.08), and all-cause death 0.97 (0.80–1.19). Conclusions: Patients treated with dabigatran had a 41% lower risk of major bleeding compared with rivaroxaban, but similar risks of stroke, MI, and death. Relative to apixaban, patients treated with dabigatran had similar risks of stroke, major bleeding, MI, and death. Rivaroxaban relative to apixaban had increased risk for major bleeding, but similar risks for stroke, MI, and death. Registration: URL: https://www.clinicaltrials.gov. Unique identifiers: NCT01468701, NCT01671007. Date of registration: September 2013. Graphical abstract: [Figure not available: see fulltext.]

2022 - Comparing atrial fibrillation guidelines: Focus on stroke prevention, bleeding risk assessment and oral anticoagulant recommendations [Articolo su rivista]
Imberti, J. F.; Mei, D. A.; Vitolo, M.; Bonini, N.; Proietti, M.; Potpara, T.; Lip, G. Y. H.; Boriani, G.
abstract

Clinical practice in atrial fibrillation (AF) patient management is constantly evolving. In the past 3 years, various new AF guidelines or focused updates have been published, given this rapidly evolving field. In 2019, the American College of Cardiology/American Heart Association published a focused update of the 2014 guidelines. In 2020, both the European Society of Cardiology and the Canadian Cardiovascular Society released their new guidelines. Finally, the most recent guidelines were those published in 2021 by the Asian Pacific Heart Rhythm Society, which updates their 2017 version and the 2021 National Institute for Health and Care Excellence (NICE) guidelines. In the present narrative review, we compare these guidelines, emphasizing similarities and differences in the following mainstay elements of patient care: thromboembolic risk assessment, oral anticoagulants (OACs) prescription, bleeding risk evaluation, and integrated patient management. A formal evaluation of baseline thromboembolic and bleeding risks and their reassessment during follow-up is evenly recommended, although some differences in using risk stratification scores. OACs prescription is highly encouraged where appropriate, and prescription algorithms are broadly similar. The importance of an integrated and multidisciplinary approach to patient care is emerging, aiming to address several different aspects of a multifaceted disease.

2022 - Consumer-Led Screening for Atrial Fibrillation: Frontier Review of the AF-SCREEN International Collaboration [Articolo su rivista]
Brandes, Axel; Stavrakis, Stavros; Freedman, Ben; Antoniou, Sotiris; Boriani, Giuseppe; Camm, A John; Chow, Clara K; Ding, Eric; Engdahl, Johan; Gibson, Michael M; Golovchiner, Gregory; Glotzer, Taya; Guo, Yutao; Healey, Jeff S; Hills, Mellanie T; Johnson, Linda; Lip, Gregory Y H; Lobban, Trudie; Macfarlane, Peter W; Marcus, Gregory M; Mcmanus, David D; Neubeck, Lis; Orchard, Jessica; Perez, Marco V; Schnabel, Renate B; Smyth, Breda; Steinhubl, Steven; Turakhia, Mintu P
abstract

The technological evolution and widespread availability of wearables and handheld ECG devices capable of screening for atrial fibrillation (AF), and their promotion directly to consumers, has focused attention of health care professionals and patient organizations on consumer-led AF screening. In this Frontiers review, members of the AF-SCREEN International Collaboration provide a critical appraisal of this rapidly evolving field to increase awareness of the complexities and uncertainties surrounding consumer-led AF screening. Although there are numerous commercially available devices directly marketed to consumers for AF monitoring and identification of unrecognized AF, health care professional-led randomized controlled studies using multiple ECG recordings or continuous ECG monitoring to detect AF have failed to demonstrate a significant reduction in stroke. Although it remains uncertain if consumer-led AF screening reduces stroke, it could increase early diagnosis of AF and facilitate an integrated approach, including appropriate anticoagulation, rate or rhythm management, and risk factor modification to reduce complications. Companies marketing AF screening devices should report the accuracy and performance of their products in high- and low-risk populations and avoid claims about clinical outcomes unless improvement is demonstrated in randomized clinical trials. Generally, the diagnostic yield of AF screening increases with the number, duration, and temporal dispersion of screening sessions, but the prognostic importance may be less than for AF detected by single-time point screening, which is largely permanent, persistent, or high-burden paroxysmal AF. Consumer-initiated ECG recordings suggesting possible AF always require confirmation by a health care professional experienced in ECG reading, whereas suspicion of AF on the basis of photoplethysmography must be confirmed with an ECG. Consumer-led AF screening is unlikely to be cost-effective for stroke prevention in the predominantly young, early adopters of this technology. Studies in older people at higher stroke risk are required to demonstrate both effectiveness and cost-effectiveness. The direct interaction between companies and consumers creates new regulatory gaps in relation to data privacy and the registration of consumer apps and devices. Although several barriers for optimal use of consumer-led screening exist, results of large, ongoing trials, powered to detect clinical outcomes, are required before health care professionals should support widespread adoption of consumer-led AF screening.

2022 - Correction to: Comparative effectiveness and safety of non-vitamin K antagonists for atrial fibrillation in clinical practice: GLORIA-AF Registry (Clinical Research in Cardiology, (2022), 111, 5, (560-573), 10.1007/s00392-022-01996-2) [Articolo su rivista]
Lip, G. Y. H.; Kotalczyk, A.; Teutsch, C.; Diener, H. -C.; Dubner, S. J.; Halperin, J. L.; Ma, C. -S.; Rothman, K. J.; Marler, S.; Gurusamy, V. K.; Huisman, M. V.; Abban, D. W.; Aziz, E.; Kalan, M. B.; Abdul, N.; Backes, L. M.; Bradman, D.; Abud, A. M.; Badings, E.; Brautigam, D.; Adams, F.; Bagni, E.; Breton, N.; Addala, S.; Baker, S. H.; Brouwers, P. J. A. M.; Adragao, P.; Bala, R.; Browne, K.; Ageno, W.; Baldi, A.; Cortada, J. B.; Aggarwal, R.; Bando, S.; Bruni, A.; Agosti, S.; Banerjee, S.; Brunschwig, C.; Agostoni, P.; Bank, A.; Buathier, H.; Aguilar, F.; Esquivias, G. B.; Buhl, A.; Linares, J. A.; Barr, C.; Bullinga, J.; Aguinaga, L.; Bartlett, M.; Cabrera, J. W.; Ahmed, J.; Basic Kes, V.; Caccavo, A.; Aiello, A.; Baula, G.; Cai, S.; Ainsworth, P.; Behrens, S.; Caine, S.; Aiub, J. R.; Bell, A.; Calo, L.; Al-Dallow, R.; Benedetti, R.; Calvi, V.; Alderson, L.; Mazuecos, J. B.; Sanchez, M. C.; Velasco, J. A. A.; Benhalima, B.; Candeias, R.; Alexopoulos, D.; Bergler-Klein, J.; Capuano, V.; Manterola, F. A.; Berneau, J. -B.; Capucci, A.; Aliyar, P.; Bernstein, R. A.; Caputo, R.; Alonso, D.; Berrospi, P.; Rizo, T. C.; da Costa, F. A. A.; Berti, S.; Cardona, F.; Amado, J.; Berz, A.; da Costa Darrieux, F. C.; Amara, W.; Best, E.; Vera, Y. C. D.; Amelot, M.; Bettencourt, P.; Carolei, A.; Amjadi, N.; Betzu, R.; Carreno, S.; Ammirati, F.; Bhagwat, R.; Carvalho, P.; Andrade, M.; Bhatta, L.; Cary, S.; Andrawis, N.; Biscione, F.; Casu, G.; Annoni, G.; Bisignani, G.; Cavallini, C.; Ansalone, G.; Black, T.; Cayla, G.; Ariani, M. K.; Bloch, M. J.; Celentano, A.; Arias, J. C.; Bloom, S.; Cha, T. -J.; Armero, S.; Blumberg, E.; Cha, K. S.; Arora, C.; Bo, M.; Chae, J. K.; Aslam, M. S.; Bohmer, E.; Chalamidas, K.; Asselman, M.; Bollmann, A.; Challappa, K.; Audouin, P.; Bongiorni, M. G.; Chand, S. P.; Augenbraun, C.; Boriani, G.; Chandrashekar, H.; Aydin, S.; Boswijk, D. J.; Chartier, L.; Aydin, S.; Bott, J.; Chatterjee, K.; Ayryanova, I.; Bottacchi, E.; Ayala, C. A. C.; Cheema, A.; Davis, G.; Evonich, R.; Cheema, A.; Davy, J. -M.; Evseeva, O.; Chen, L.; Dayer, M.; Ezhov, A.; Chen, S. -A.; De Biasio, M.; Fahmy, R.; Chen, J. H.; De Bonis, S.; Fang, Q.; Chiang, F. -T.; De Caterina, R.; Farsad, R.; Chiarella, F.; De Franceschi, T.; Fauchier, L.; Chih-Chan, L.; de Groot, J. R.; Favale, S.; Cho, Y. K.; De Horta, J.; Fayard, M.; Choi, J. -I.; De La Briolle, A.; Fedele, J. L.; Choi, D. J.; de la Pena Topete, G.; Fedele, F.; Chouinard, G.; de Paola, A. A. V.; Fedorishina, O.; Chow, D. H. -F.; de Souza, W.; Fera, S. R.; Chrysos, D.; de Veer, A.; Ferreira, L. G. G.; Chumakova, G.; De Wolf, L.; Ferreira, J.; Valenzuela, E. J. J. R. C.; Decoulx, E.; Ferri, C.; Nica, N. C.; Deepak, S.; Ferrier, A.; Cislowski, D. J.; Defaye, P.; Ferro, H.; Clay, A.; Munoz, F. D. -C.; Finsen, A.; Clifford, P.; Brkljacic, D. D.; First, B.; Cohen, A.; Deumite, N. J.; Fischer, S.; Cohen, M.; Di Legge, S.; Fonseca, C.; Cohen, S.; Diemberger, I.; Almeida, L. F.; Colivicchi, F.; Dietz, D.; Forman, S.; Collins, R.; Dionisio, P.; Frandsen, B.; Colonna, P.; Dong, Q.; French, W.; Compton, S.; dos Santos, F. R.; Friedman, K.; Connolly, D.; Dotcheva, E.; Friese, A.; Conti, A.; Doukky, R.; Fruntelata, A. G.; Buenostro, G. C.; D'Souza, A.; Fujii, S.; Coodley, G.; Dubrey, S.; Fumagalli, S.; Cooper, M.; Ducrocq, X.; Fundamenski, M.; Coronel, J.; Dupljakov, D.; Furukawa, Y.; Corso, G.; Duque, M.; Gabelmann, M.; Sales, J. C.; Dutta, D.; Gabra, N.; Cottin, Y.; Duvilla, N.; Gadsboll, N.; Covalesky, J.; Duygun, A.; Galinier, M.; Cracan, A.; Dziewas, R.; Gammelgaard, A.; Crea, F.; Eaton, C. B.; Ganeshkumar, P.; Crean, P.; Eaves, W.; Gans, C.; Crenshaw, J.; Ebels-Tuinbeek, L. A.; Quintana, A. G.; Cullen, T.; Ehrlich, C.; Gartenlaub, O.; Darius, H.; Eichinger-Hasenauer, S.; Gaspardone, A.; Dary, P.; Eisenberg, S. J.; Genz, C.; Dascotte, O.; Jabali, A. E.; Georger, F.; Dauber, I.; Shahawy, M. E.; Georges, J. -L.; Davalos, V.; Hernandes, M. E.; Georgeson, S.; Davies, R.; Izal, A. E.; Giedrimas, E.; G
abstract

In this article, the name of the GLORIA-AF investigator Anastasios Kollias was given incorrectly as Athanasios Kollias in the Acknowledgements. The original article has been corrected.

2022 - Current status of reimbursement practices for remote monitoring of cardiac implantable electrical devices across Europe [Articolo su rivista]
Boriani, Giuseppe; Burri, Haran; Svennberg, Emma; Imberti, Jacopo Francesco; Merino, Josè Luis; Leclercq, Christophe
abstract

Remote monitoring (RM) of cardiac implantable electrical devices (CIEDs) is currently proposed as a standard of care for CIEDs follow-up, as recommended by major cardiology societies worldwide. By detecting a series of relevant device and patient-related parameters, RM is a valuable option for early detection of CIEDs' technical issues, as well as changes in parameters related to cardio-respiratory functions. Moreover, RM may allow longer spacing between in-office follow-ups and better organization of in-hospital resources. Despite these potential advantages, resulting in improved patient safety, we are still far from a widespread diffusion of RM across Europe. Reimbursement policies across Europe still show an important heterogeneity and have been considered as an important barrier to full implementation of RM as a standard for the follow-up of all the patients with pacemakers, defibrillators, devices for cardiac resynchronization, or implantable loop recorders. Indeed, in many countries, there are still inertia and unresponsiveness to the request for widespread implementation of RM for CIEDs, although an improvement was found in some countries as compared to years ago, related to the provision of some form of reimbursement. As a matter of fact, the COVID-19 pandemic has promoted an increased use of digital health for connecting physicians to patients, even if digital literacy may be a limit for the widespread implementation of telemedicine. CIEDs have the advantage of making possible RM with an already defined organization and reliable systems for data transmissions that can be easily implemented as a standard of care for present and future cardiology practice.

2022 - DIGItal Health Literacy after COVID-19 Outbreak among Frail and Non-Frail Cardiology Patients: The DIGI-COVID Study [Articolo su rivista]
Vitolo, Marco; Ziveri, Valentina; Gozzi, Giacomo; Busi, Chiara; Imberti, Jacopo Francesco; Bonini, Niccolò; Muto, Federico; Mei, Davide Antonio; Menozzi, Matteo; Mantovani, Marta; Cherubini, Benedetta; Malavasi, Vincenzo Livio; Boriani, Giuseppe
abstract

Background: Telemedicine requires either the use of digital tools or a minimum technological knowledge of the patients. Digital health literacy may influence the use of telemedicine in most patients, particularly those with frailty. We aimed to explore the association between frailty, the use of digital tools, and patients' digital health literacy. Methods: We prospectively enrolled patients referred to arrhythmia outpatient clinics of our cardiology department from March to September 2022. Patients were divided according to frailty status as defined by the Edmonton Frail Scale (EFS) into robust, pre-frail, and frail. The degree of digital health literacy was assessed through the Digital Health Literacy Instrument (DHLI), which explores seven digital skill categories measured by 21 self-report questions. Results: A total of 300 patients were enrolled (36.3% females, median age 75 (66-84)) and stratified according to frailty status as robust (EFS ≤ 5; 70.7%), pre-frail (EFS 6-7; 15.7%), and frail (EFS ≥ 8; 13.7%). Frail and pre-frail patients used digital tools less frequently and accessed the Internet less frequently compared to robust patients. In the logistic regression analysis, frail patients were significantly associated with the non-use of the Internet (adjusted odds ratio 2.58, 95% CI 1.92-5.61) compared to robust and pre-frail patients. Digital health literacy decreased as the level of frailty increased in all the digital domains examined. Conclusions: Frail patients are characterized by lower use of digital tools compared to robust patients, even though these patients would benefit the most from telemedicine. Digital skills were strongly influenced by frailty.

2022 - Determinants of worse prognosis in patients with cardiac resynchronization therapy defibrillators. Are ventricular arrhythmias an adjunctive risk factor? [Articolo su rivista]
Landolina, Maurizio; Boriani, Giuseppe; Biffi, Mauro; Cattafi, Giuseppe; Capucci, Alessandro; Dello Russo, Antonio; Facchin, Domenico; Rordorf, Roberto; Sagone, Antonio; Del Greco, Maurizio; Morani, Giovanni; Nicolis, Daniele; Meloni, Sarah; Grammatico, Andrea; Gasparini, Maurizio
abstract

Cardiac resynchronization therapy (CRT) is indicated in patients with systolic heart failure (HF), severe left ventricle (LV) dysfunction and interventricular dyssynchrony.In prospective observational research, we aimed to evaluate whether CRT-induced LV reverse remodelling and occurrence of ventricular arrhythmias (VT/VF) independently contribute to prognosis in patients with CRT defibrillators (CRT-D).

2022 - Dronedarone for the treatment of atrial fibrillation with concomitant heart failure and preserved or mildly reduced ejection fraction: closer to Ithaca after a long odyssey? [Articolo su rivista]
Boriani, G.; Imberti, J. F.; Vitolo, M.
abstract

2022 - Effectiveness of atrial fibrillation ablation in heart failure across the entire spectrum of left ventricular ejection fraction [Articolo su rivista]
Boriani, Giuseppe; Marcovitolo, ; Imberti, Jacopof.
abstract

2022 - Epidemiology and impact of frailty in patients with atrial fibrillation in Europe [Articolo su rivista]
Proietti, M.; Romiti, G. F.; Vitolo, M.; Harrison, S. L.; Lane, D. A.; Fauchier, L.; Marin, F.; Nabauer, M.; Potpara, T. S.; Dan, G. -A.; Maggioni, A. P.; Cesari, M.; Boriani, G.; Lip, G. Y. H.
abstract

BACKGROUND: Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent. OBJECTIVES: We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients. METHODS: A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined. RESULTS: Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty. CONCLUSIONS: In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

2022 - Epidemiology of subclinical atrial fibrillation in patients with cardiac implantable electronic devices: A systematic review and meta-regression [Articolo su rivista]
Proietti, M.; Romiti, G. F.; Vitolo, M.; Borgi, M.; Rocco, A. D.; Farcomeni, A.; Miyazawa, K.; Healey, J. S.; Lane, D. A.; Boriani, G.; Basili, S.; Lip, G. Y. H.
abstract

Background: In recent years, attention to subclinical atrial fibrillation (SCAF), defined as the presence of atrial high-rate episodes (AHREs), in patients with cardiac implantable electronic devices (CIEDs), has gained much interest as a determinant of clinical AF and stroke risk. We aim to perform a systematic review and meta-regression of the available scientific evidence regarding the epidemiology of SCAF in patients receiving CIEDs. Methods: PubMed and EMBASE were searched for all studies documenting the prevalence of AHREs in patients (n=100 or more, <50% with history of AF) with CIEDs from inception to 20th August 2021, screened by two independent blind reviewers. This study was registered in PROSPERO: CRD42019106994. Results: Among the 2614 results initially retrieved, 54 studies were included, with a total of 72,784 patients. Meta-analysis of included studies showed a pooled prevalence of SCAF of 28.1% (95%CI: 24.3-32.1%), with high heterogeneity between studies (I2=98%). A multivariable meta-regression was able to explain significant proportion of heterogeneity (R2=61.9%, p<0.001), with age and follow-up time non-linearly, directly and independently associated with occurrence of SCAF. Older age, higher CHA2DS2-VASc score, history of AF, hypertension, CHF, and stroke/TIA were all associated with SCAF occurrence. Conclusions: In this systematic review and meta-regression analysis, SCAF was frequent among CIED recipients and was non-linearly associated with age and follow-up time. Older age, higher thromboembolic risk, and several cardiovascular comorbidities were associated with presence of SCAF.

2022 - Erratum: 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy: Developed by the Task Force on cardiac pacing and cardiac resynchronization therapy of the European Society of Cardiology (ESC): With the special contribution of the European Heart Rhythm Association (EHRA) (Europace (2022) 24 (71–164) DOI: 10.1093/europace/euab232) [Articolo su rivista]
Glikson, M.; Nielsen, J. C.; Kronborg, M. B.; Michowitz, Y.; Auricchio, A.; Barbash, I. M.; Barrabs, J. A.; Boriani, G.; Braunschweig, F.; Brignole, M.; Burri, H.; Coats, A. J. S.; Deharo, J. -C.; Delgado, V.; Diller, G. -P.; Israel, C. W.; Keren, A.; Knops, R. E.; Kotecha, D.; Leclercq, C.; Merkely, B.; Starck, C.; Thyln, I.; Tolosana, J. M.
abstract

In the originally published version of thismanuscript, there were several errors which are listed in this corrigendumas follows: In Table 4, The Level of Evidence for "For venous access, the cephalic or axillary vein should be considered as first choice" should read "B" instead of "C". In Table 10, the wording "TAVI in valve in valve vs. native valve procedure" should read "TAVI in native valve vs. valve-in-valve procedure". In the Supplementary Data, the wording in Table 14 should read "TAVI in native valve vs. valve-in-valve procedure" instead of "TAVI in valve in valve vs. native valve procedure". These errors have now been corrected.

2022 - Erratum: Publisher's note to: Optimizing indices of atrial fibrillation susceptibility and burden to evaluate atrial fibrillation severity, risk and outcomes (Cardiovascular Research (cvab147) DOI: 10.1093/cvr/cvab147) [Articolo su rivista]
Boriani, G.; Vitolo, M.; Diemberger, I.; Proietti, M.; Valenti, A. C.; Malavasi, V. L.; Lip, G. Y. H.
abstract

This article should have published into Issue 117-7 of Cardiovascular Research as online-only content. However, it was accidentally omitted. The article has been added to the issue retrospectively and we have published this notice to highlight the emendation.

2022 - European Society of Cardiology Quality Indicators for the care and outcomes of cardiac pacing: developed by the Working Group for Cardiac Pacing Quality Indicators in collaboration with the European Heart Rhythm Association of the European Society of Cardiology [Articolo su rivista]
Aktaa, Suleman; Abdin, Amr; Arbelo, Elena; Burri, Haran; Vernooy, Kevin; Blomström-Lundqvist, Carina; Boriani, Giuseppe; Defaye, Pascal; Deharo, Jean-Claude; Drossart, Inga; Foldager, Dan; Gold, Michael R; Johansen, Jens Brock; Leyva, Francisco; Linde, Cecilia; Michowitz, Yoav; Kronborg, Mads Brix; Slotwiner, David; Steen, Torkel; Tolosana, José Maria; Tzeis, Stylianos; Varma, Niraj; Glikson, Michael; Nielsen, Jens Cosedis; Gale, Chris P
abstract

Aims: To develop a suite of quality indicators (QIs) for the evaluation of the care and outcomes for adults undergoing cardiac pacing. Methods and results: Under the auspice of the Clinical Practice Guideline Quality Indicator Committee of the European Society of Cardiology (ESC), the Working Group for cardiac pacing QIs was formed. The Group comprised Task Force members of the 2021 ESC Clinical Practice Guidelines on Cardiac Pacing and Cardiac Resynchronization Therapy, members of the European Heart Rhythm Association, international cardiac device experts, and patient representatives. We followed the ESC methodology for QI development, which involved (i) the identification of the key domains of care by constructing a conceptual framework of the management of patients receiving cardiac pacing, (ii) the development of candidate QIs by conducting a systematic review of the literature, (iii) the selection of the final set of QIs using a modified-Delphi method, and (iv) the evaluation of the feasibility of the developed QIs. Four domains of care were identified: (i) structural framework, (ii) patient assessment, (iii) pacing strategy, and (iv) clinical outcomes. In total, seven main and four secondary QIs were selected across these domains and were embedded within the 2021 ESC Guidelines on Cardiac Pacing and Cardiac Resynchronization therapy. Conclusion: By way of a standardized process, 11 QIs for cardiac pacing were developed. These indicators may be used to quantify adherence to guideline-recommended clinical practice and have the potential to improve the care and outcomes of patients receiving cardiac pacemakers.

2022 - Evaluation and management of cancer patients presenting with acute cardiovascular disease: a Clinical Consensus Statement of the Acute CardioVascular Care Association (ACVC) and the ESC council of Cardio-Oncology-part 2: acute heart failure, acute myocardial diseases, acute venous thromboembolic diseases, and acute arrhythmias [Articolo su rivista]
Gevaert, Sofie A; Halvorsen, Sigrun; Sinnaeve, Peter R; Sambola, Antonia; Gulati, Geeta; Lancellotti, Patrizio; Van Der Meer, Peter; Lyon, Alexander R; Farmakis, Dimitrios; Lee, Geraldine; Boriani, Giuseppe; Wechalekar, Ashutosh; Okines, Alicia; Asteggiano, Riccardo; Combes, Alain; Pfister, Roman; Bergler-Klein, Jutta; Lettino, Maddalena
abstract

Advances in treatment, common cardiovascular (CV) risk factors and the ageing of the population have led to an increasing number of cancer patients presenting with acute CV diseases. These events may be related to cancer itself or cancer treatment. Acute cardiac care specialists must be aware of these acute CV complications and be able to manage them. This may require an individualized and multidisciplinary approach. The management of acute coronary syndromes and acute pericardial diseases in cancer patients was covered in part 1 of a clinical consensus document. This second part focusses on acute heart failure, acute myocardial diseases, venous thromboembolic diseases and acute arrhythmias.

2022 - Feasible approaches and implementation challenges to atrial fibrillation screening: A qualitative study of stakeholder views in 11 European countries [Articolo su rivista]
Engler, Daniel; L Hanson, Coral; Desteghe, Lien; Boriani, Giuseppe; Zöga Diederichsen, Søren; Freedman, Ben; Palà, Elena; S Potpara, Tatjana; Witt, Henning; Heidbuchel, Hein; Neubeck, Lis; B Schnabel, Renate
abstract

Objectives Atrial fibrillation (AF) screening may increase early detection and reduce complications of AF. European, Australian and World Heart Federation guidelines recommend opportunistic screening, despite a current lack of clear evidence supporting a net benefit for systematic screening. Where screening is implemented, the most appropriate approaches are unknown. We explored the views of European stakeholders about opportunities and challenges of implementing four AF screening scenarios. Design Telephone-based semi-structured interviews with results reported using Consolidated criteria for Reporting Qualitative research guidelines. Data were thematically analysed using the framework approach. Setting AF screening stakeholders in 11 European countries. Participants Healthcare professionals and regulators (n=24) potentially involved in AF screening implementation. Intervention Four AF screening scenarios: single time point opportunistic, opportunistic prolonged, systematic single time point/prolonged and patient-led screening. Primary outcome measures Stakeholder views about the challenges and feasibility of implementing the screening scenarios in the respective national/regional healthcare system. Results Three themes developed. (1) Current screening approaches: there are no national AF screening programmes, with most AF detected in symptomatic patients. Patient-led screening exists via personal devices, creating screening inequity. (2) Feasibility of screening: single time point opportunistic screening in primary care using single-lead ECG devices was considered the most feasible. Software algorithms may aid identification of suitable patients and telehealth services have potential to support diagnosis. (3) Implementation requirements: sufficient evidence of benefit is required. National screening processes are required due to different payment mechanisms and health service regulations. Concerns about data security, and inclusivity for those without primary care access or personal devices must be addressed. Conclusions There is an overall awareness of AF screening. Opportunistic screening appears the most feasible across Europe. Challenges are health inequalities, identification of best target groups for screening, streamlined processes, the need for evidence of benefit and a tailored approach adapted to national realities.

2022 - Frailty prevalence and impact on outcomes in patients with atrial fibrillation: A systematic review and meta-analysis of 1,187,000 patients [Articolo su rivista]
Proietti, Marco; Romiti, Giulio Francesco; Raparelli, Valeria; Diemberger, Igor; Boriani, Giuseppe; Vecchia, Laura Adelaide Dalla; Bellelli, Giuseppe; Marzetti, Emanuele; Lip, Gregory Yh; Cesari, Matteo
abstract

: Frailty is a clinical syndrome characterized by a reduced physiologic reserve, increased vulnerability to stressors and an increased risk of adverse outcomes. People with atrial fibrillation (AF) are often burdened by frailty due to biological, clinical, and social factors. The prevalence of frailty, its management and association with major outcomes in AF patients are still not well quantified. We systematically searched PubMed and EMBASE, from inception to September 13th, 2021, for studies reporting the prevalence of frailty in AF patients. The study was registered in PROSPERO (CRD42021235854). 33 studies were included in the systematic review (n = 1,187,651 patients). The frailty pooled prevalence was 39.7 % (95 %CI=29.9 %-50.5 %, I2 =100 %), while meta-regression analyses showed it is influenced by age, history of stroke, and geographical location. Meta-regression analyses showed that OAC prescription was influenced by study-level mean age, baseline thromboembolic risk, and study setting. Frail AF patients were associated with a higher risk of all-cause death (OR=5.56, 95 %CI=3.46-8.94), ischemic stroke (OR=1.59, 95 %CI=1.00-2.52), and bleeding (OR=1.64, 95 %CI=1.11-2.41), when compared to robust individuals. In this systematic review and meta-analysis, the prevalence of frailty was high in patients with AF. Frailty may influence the prognosis and management of AF patients, thus requiring person-tailored interventions in a holistic or integrated approach to AF care.

2022 - Guía ESC 2021 sobre estimulación cardiaca y terapia de resincronización [Articolo su rivista]
Glikson, M.; Nielsen, J. C.; Kronborg, M. B.; Michowitz, Y.; Auricchio, A.; Barbash, I. M.; Barrabes, J. A.; Boriani, G.; Braunschweig, F.; Brignole, M.; Burri, H.; Coats, A. J. S.; Deharo, J. -C.; Delgado, V.; Diller, G. -P.; Israel, C. W.; Keren, A.; Knops, R. E.; Kotecha, D.; Leclercq, C.; Merkely, B.; Starck, C.; Thylen, I.; Tolosana, J. M.
abstract

2022 - How to use digital devices to detect and manage arrhythmias: an EHRA practical guide [Articolo su rivista]
Svennberg, Emma; Tjong, Fleur; Goette, Andreas; Akoum, Nazem; Di Biase, Luigi; Bordachar, Pierre; Boriani, Giuseppe; Burri, Haran; Conte, Giulio; Deharo, Jean-Claude; Deneke, Thomas; Drossart, Inga; Duncker, David; Han, Janet K; Heidbuchel, Hein; Jais, Pierre; de Oliviera Figueiredo, Marcio Jansen; Linz, Dominik; Lip, Gregory Y H; Malaczynska-Rajpold, Katarzyna; Márquez, Manlio; Ploem, Corrette; Soejima, Kyoko; Stiles, Martin K; Wierda, Eric; Vernooy, Kevin; Leclercq, Christophe; Meyer, Christian; Pisani, Cristiano; Pak, Hui-Nam; Gupta, Dhiraj; Pürerfellner, Helmut; Crijns, H J G M; Chavez, Edgar Antezana; Willems, Stephan; Waldmann, Victor; Dekker, Lukas; Wan, Elaine; Kavoor, Pramesh; Turagam, Mohit K; Sinner, Moritz
abstract

2022 - Impact of COVID-19 in emergency medicine literature: a bibliometric analysis [Articolo su rivista]
Vitolo, M.; Venturelli, A.; Valenti, A. C.; Boriani, G.
abstract

2022 - Impact of anthropometric factors on outcomes in atrial fibrillation patients: analysis on 10 220 patients from the European Society of Cardiology (ESC)-European Heart Rhythm Association (EHRA) EurObservational Research Programme on Atrial Fibrillation (EORP-AF) general long-term registry [Articolo su rivista]
Boriani, Giuseppe; Vitolo, Marco; Malavasi, Vincenzo L; Proietti, Marco; Fantecchi, Elisa; Diemberger, Igor; Fauchier, Laurent; Marin, Francisco; Nabauer, Michael; Potpara, Tatjana S; Dan, Gheorghe-Andrei; Kalarus, Zbigniew; Tavazzi, Luigi; Maggioni, Aldo Pietro; Lane, Deirdre A; Lip, Gregory Y H
abstract

Aim: To investigate the association of anthropometric parameters [height, weight, body mass index (BMI), body surface area (BSA) and lean body mass (LBM)] with outcomes in atrial fibrillation (AF). Methods and results: 10220 patients were enrolled [40.3% females, median age 70 (62-77) years, followed for 728 (IQR 653-745) days]. Sex-specific tertiles were considered for the 5 anthropometric variables. At the end of follow-up survival free from all-cause death was worse in the lowest tertiles for all the anthropometric variables analyzed. On multivariable Cox regression analysis, an independent association with all-cause death was found for the lowest vs. middle tertile when body weight (hazard ratio [HR] 1.66, 95%CI 1.23-2.23), BMI (HR 1.65, 95%CI 1.23-2.21), BSA (HR 1.49, 95%CI 1.11-2.01) were analysed in female sex, as well as for body weight in male patients (HR 1.61, 95%CI 1.25-2 .07). Conversely, the risk of MACE was lower for the highest tertile (vs. middle tertile) of BSA and LBM in males and for the highest tertile of weight and BSA in female patients. A higher occurrence of hemorrhagic events was found for female patients in the lowest tertile of height [odds ratio (OR) 1.90, 95%CI 1.23-2.94] and LBM (OR 2.13, 95%CI 1.40-3.26).  . Conclusions: In AF patients height, weight, BMI, BSA and LBM were associated with clinical outcomes, with all-cause death being higher for patients presenting lower values of these variables, i.e in the lowest tertiles of distribution. The anthropometric variables independently associated with other outcomes were also different between male and female subjects.

2022 - Impact of body mass index on the outcome of elderly patients treated with transcatheter aortic valve implantation [Articolo su rivista]
Sgura, F. A.; Arrotti, S.; Monopoli, D.; Valenti, A. C.; Vitolo, M.; Magnavacchi, P.; Tondi, S.; Gabbieri, D.; Guiducci, V.; Benatti, G.; Vignali, L.; Rossi, R.; Boriani, G.
abstract

Underweight or overweight patients with cardiovascular diseases are associated with different outcomes. However, the data on the relation between body mass index (BMI) and outcomes after transcatheter aortic valve implantation (TAVI) are not homogeneous. The aim of this study was to assess the role of low BMI on short and long-term mortality in real-world patients undergoing TAVI. We retrospectively included patients undergoing TAVI for severe aortic valve stenosis. Patients were classified into three BMI categories: underweight (< 20 kg/m2), normal weight (20–24.9 kg/m2) and overweight/obese (≥ 25 kg/m2). Our primary endpoint was long-term all-cause mortality. The secondary endpoint was 30-day all-cause mortality. A total of 794 patients were included [mean age 82.3 ± 5.3, 53% females]. After a median follow-up of 2.2 years, all-cause mortality was 18.1%. Patients in the lowest BMI group showed a higher mortality rate as compared to those with higher BMI values. At the multivariate Cox regression analysis, as compared to the normal BMI group, BMI < 20 kg/m2 was associated with long-term mortality independently of baseline risk factors and postprocedural adverse events (hazard ratio [HR] 2.29, 95% confidence interval [CI] 1.30–4.03] and HR 2.61, 95% CI 1.48–4.60, respectively). The highest BMI values were found to be protective for both short- and long-term mortality as compared to lower BMI values even after applying the same adjustments. In our cohort, BMI values under 20 kg/m2 were independent predictors of increased long-term mortality. Conversely, the highest BMI values were associated with lower mortality rates both at short- and long-term follow-up.

2022 - Impact of diabetes on the management and outcomes in atrial fibrillation: an analysis from the ESC-EHRA EORP-AF Long-Term General Registry [Articolo su rivista]
Ding, W. Y.; Kotalczyk, A.; Boriani, G.; Marin, F.; Blomstrom-Lundqvist, C.; Potpara, T. S.; Fauchier, L.; Lip, G. Y. H.
abstract

Background: The prevalence of atrial fibrillation(AF) and diabetes mellitus is rising to epidemic proportions. We aimed to assess the impact of diabetes on the management and outcomes of patients with AF. Methods: The EORP-AF General Long-Term Registry is a prospective, observational registry from 250 centres across 27 European countries. Outcomes of interest were as follows: i)rhythm control interventions; ii)quality of life; iii)healthcare resource utilisation; and iv)major adverse events. Results: Of 11,028 patients with AF, the median age was 71 (63–77) years and 2537 (23.0%) had diabetes. Median follow-up was 24 months. Diabetes was related to increased use of anticoagulation but less rhythm control interventions. Using multivariable analysis, at 2-year follow-up, patients with diabetes were associated with greater levels of anxiety (p = 0.038) compared to those without diabetes. Overall, diabetes was associated with worse health during follow-up, as indicated by Health Utility Score and Visual Analogue Scale. Healthcare resource utilisation was greater with diabetes in terms of length of hospital stay (8.1 (±8.2) vs. 6.1 (±6.7) days); cardiology and internal medicine/general practitioner visits; and emergency room admissions. Diabetes was an independent risk factor of major adverse cardiovascular event (MACE; HR 1.26 [95% CI, 1.04–1.52]), all-cause mortality (HR 1.28 [95% CI, 1.08–1.52]), and cardiovascular mortality (HR 1.41 [95% CI, 1.09–1.83]). Conclusion: In this contemporary AF cohort, diabetes was present in 1 in 4 patients and it served as an independent risk factor for reduced quality of life, greater healthcare resource utilisation and excess MACE, all-cause mortality and cardiovascular mortality. There was increased use of anticoagulation therapy in diabetes but with less rhythm control interventions.

2022 - Impact of malignancy on outcomes in European patients with atrial fibrillation: A report from the ESC-EHRA EURObservational research programme in atrial fibrillation general long-term registry [Articolo su rivista]
Malavasi, Vincenzo L; Vitolo, Marco; Proietti, Marco; Diemberger, Igor; Fauchier, Laurent; Marin, Francisco; Nabauer, Michael; Potpara, Tatjana S; Dan, Gheorghe-Andrei; Kalarus, Zbigniew; Tavazzi, Luigi; Maggioni, Aldo Pietro; Lane, Deirdre A; Lip, Gregory Y H; Boriani, Giuseppe
abstract

Background: The management of patients with atrial fibrillation (AF) and malignancy is challenging given the paucity of evidence supporting their appropriate clinical management.Purpose: To evaluate the outcomes of patients with active or prior malignancy in a contemporary cohort of European AF patients.Methods: Patients enrolled in the EURObservational Research Programme in AF General Long-Term Registry were categorized into 3 categories: No Malignancy (NoMal), Prior Malignancy (PriorMal) and Active Malignancy (ActiveMal). The primary outcomes were all-cause death and the composite outcome MACE.Results: A total of 10 383 patients were analysed. Of these, 9597 (92.4%) were NoMal patients, 577 (5.6%) PriorMal and 209 (2%) ActiveMal. Lack of any antithrombotic treatment was more prevalent in ActiveMal patients (12.4%) as compared to other groups (5.0% vs 6.3% for PriorMal and NoMal, p <.001). After a median follow-up of 730 days, there were 982 (9.5%) deaths and 950 (9.7%) MACE events. ActiveMal was independently associated with a higher risk for all-cause death (HR 2.90, 95% CI 2.23-3.76) and MACE (HR 1.54, 95% CI 1.03-2.31), as well as any haemorrhagic events and major bleeding (OR 2.42, 95% CI 1.49-3.91 and OR 4.18, 95% CI 2.49-7.01, respectively). Use of oral anticoagulants was not significantly associated with a higher risk for all-cause death or bleeding in ActiveMal patients.Conclusions: In a large contemporary cohort of AF patients, active malignancy was independently associated with all-cause death, MACE and haemorrhagic events. Use of anticoagulants was not associated with a higher risk of all-cause death in patients with active malignancies.

2022 - Impact of renal impairment on atrial fibrillation: ESC-EHRA EORP-AF Long-Term General Registry [Articolo su rivista]
Ding, W. Y.; Potpara, T. S.; Blomstrom-Lundqvist, C.; Boriani, G.; Marin, F.; Fauchier, L.; Lip, G. Y. H.
abstract

BACKGROUND: Atrial fibrillation (AF) and renal impairment share a bidirectional relationship with important pathophysiological interactions. We evaluated the impact of renal impairment in a contemporary cohort of patients with AF. METHODS: We utilised the ESC-EHRA EORP-AF Long-Term General Registry. Outcomes were analysed according to renal function by CKD-EPI equation. The primary endpoint was a composite of thromboembolism, major bleeding, acute coronary syndrome and all-cause death. Secondary endpoints were each of these separately including ischaemic stroke, haemorrhagic event, intracranial haemorrhage, cardiovascular death and hospital admission. RESULTS: A total of 9306 patients were included. The distribution of patients with no, mild, moderate and severe renal impairment at baseline were 16.9%, 49.3%, 30% and 3.8%, respectively. AF patients with impaired renal function were older, more likely to be females, had worse cardiac imaging parameters and multiple comorbidities. Among patients with an indication for anticoagulation, prescription of these agents was reduced in those with severe renal impairment, p < .001. Over 24 months, impaired renal function was associated with significantly greater incidence of the primary composite outcome and all secondary outcomes. Multivariable Cox regression analysis demonstrated an inverse relationship between eGFR and the primary outcome (HR 1.07 [95% CI, 1.01-1.14] per 10 ml/min/1.73 m2 decrease), that was most notable in patients with eGFR <30 ml/min/1.73 m2 (HR 2.21 [95% CI, 1.23-3.99] compared to eGFR ≥90 ml/min/1.73 m2 ). CONCLUSION: A significant proportion of patients with AF suffer from concomitant renal impairment which impacts their overall management. Furthermore, renal impairment is an independent predictor of major adverse events including thromboembolism, major bleeding, acute coronary syndrome and all-cause death in patients with AF.

2022 - Implantable cardioverter defibrillators and devices for cardiac resynchronization therapy: what perspective for patients’ apps combined with remote monitoring? [Articolo su rivista]
Sgreccia, D.; Mauro, E.; Vitolo, M.; Manicardi, M.; Valenti, A. C.; Imberti, J. F.; Ziacchi, M.; Boriani, G.
abstract

Introduction: Remote monitoring (RM) of cardiac implantable electronic devices (CIED) allows rapid detection of clinical and electrical events. Recently, several smartphone applications have been developed with the aim of improving patient compliance and better interpreting and integrating data deriving from remote control for the management of heart failure (HF). Areas covered: Studies investigating the role of CIEDs’ RM in HF patients to predict and early treat acute decompensation. The importance of new technologies and applications developed to provide crucial information to clinicians, to better manage HF patients. Expert opinion: New medical technologies and smartphone applications for CIEDs’ RM were developed to help clinicians in the management of CIED carriers. Indeed, the accessibility of technological devices (e.g. smartphones) and the improvements in medical technology provide the opportunity to optimize HF patients’ monitoring by the transmission of device-related data, and with direct involvement of patients themselves. Thanks to these advancements, physicians have the possibility to recognize worsening signs of HF and promptly optimize treatments to potentially avoid hospitalization. The great value of this approach is its potential of reducing scheduled in-office visits or unnecessary medical contacts and optimizing healthcare resources management.

2022 - Implantable cardioverter-defibrillators for primary prevention of sudden cardiac death: what are the barriers to implementation in the ‘real world’? [Articolo su rivista]
Boriani, G.; Vitolo, M.; Leyva, F.
abstract

2022 - Incidence and Predictors of Infections and All-Cause Death in Patients with Cardiac Implantable Electronic Devices: The Italian Nationwide RI-AIAC Registry [Articolo su rivista]
Boriani, G.; Proietti, M.; Bertini, M.; Diemberger, I.; Palmisano, P.; Baccarini, S.; Biscione, F.; Bottoni, N.; Ciccaglioni, A.; Monte, A. D.; Ferrari, F. A.; Iacopino, S.; Piacenti, M.; Porcelli, D.; Sangiorgio, S.; Santini, L.; Malagu, M.; Stabile, G.; Imberti, J. F.; Caruso, D.; Zoni-Berisso, M.; De Ponti, R.; Ricci, R. P.
abstract

Background: The incidence of infections associated with cardiac implantable electronic devices (CIEDs) and patient outcomes are not fully known. Aim: To provide a contemporary assessment of the risk of CIEDs infection and associated clinical outcomes. Methods: In Italy, 18 centres enrolled all consecutive patients undergoing a CIED procedure and entered a 12-months follow-up. CIED infections, as well as a composite clinical event of infection or all-cause death were recorded. Results: A total of 2675 patients (64.3% male, age 78 (70–84)) were enrolled. During follow up 28 (1.1%) CIED infections and 132 (5%) deaths, with 152 (5.7%) composite clinical events were observed. At a multivariate analysis, the type of procedure (revision/upgrading/reimplantation) (OR: 4.08, 95% CI: 1.38–12.08) and diabetes (OR: 2.22, 95% CI: 1.02–4.84) were found as main clinical factors associated to CIED infection. Both the PADIT score and the RI-AIAC Infection score were significantly associated with CIED infections, with the RI-AIAC infection score showing the strongest association (OR: 2.38, 95% CI: 1.60–3.55 for each point), with a c-index = 0.64 (0.52–0.75), p = 0.015. Regarding the occurrence of composite clinical events, the Kolek score, the Shariff score and the RI-AIAC Event score all predicted the outcome, with an AUC for the RI-AIAC Event score equal to 0.67 (0.63−0.71) p < 0.001. Conclusions: In this Italian nationwide cohort of patients, while the incidence of CIED infections was substantially low, the rate of the composite clinical outcome of infection or all-cause death was quite high and associated with several clinical factors depicting a more impaired clinical status.

2022 - Integrated care for optimizing the management of stroke and associated heart disease: a position paper of the European Society of Cardiology Council on Stroke [Articolo su rivista]
Lip, Gregory Y H; Lane, Deirdre A; Lenarczyk, Radosław; Boriani, Giuseppe; Doehner, Wolfram; Benjamin, Laura A; Fisher, Marc; Lowe, Deborah; Sacco, Ralph L; Schnabel, Renate; Watkins, Caroline; Ntaios, George; Potpara, Tatjana
abstract

The management of patients with stroke is often multidisciplinary, involving various specialties and healthcare professionals. Given the common shared risk factors for stroke and cardiovascular disease, input may also be required from the cardiovascular teams, as well as patient caregivers and next-of-kin. Ultimately, the patient is central to all this, requiring a coordinated and uniform approach to the priorities of post-stroke management, which can be consistently implemented by different multidisciplinary healthcare professionals, as part of the patient 'journey' or 'patient pathway,' supported by appropriate education and tele-medicine approaches. All these aspects would ultimately aid delivery of care and improve patient (and caregiver) engagement and empowerment. Given the need to address the multidisciplinary approach to holistic or integrated care of patients with heart disease and stroke, the European Society of Cardiology Council on Stroke convened a Task Force, with the remit to propose a consensus on Integrated care management for optimizing the management of stroke and associated heart disease. The present position paper summarizes the available evidence and proposes consensus statements that may help to define evidence gaps and simple practical approaches to assist in everyday clinical practice. A post-stroke ABC pathway is proposed, as a more holistic approach to integrated stroke care, would include three pillars of management: center dot A: Appropriate Antithrombotic therapy. center dot B: Better functional and psychological status. center dot C: Cardiovascular risk factors and Comorbidity optimization (including lifestyle changes).

2022 - Kidney Function According to Different Equations in Patients Admitted to a Cardiology Unit and Impact on Outcome [Articolo su rivista]
Malavasi, V. L.; Valenti, A. C.; Ruggerini, S.; Manicardi, M.; Orlandi, C.; Sgreccia, D.; Vitolo, M.; Proietti, M.; Lip, G. Y. H.; Boriani, G.
abstract

Background: This paper aims to evaluate the concordance between the Chronic Kidney Disease Epidemiology Collaboration (CKD‐EPI) formula and alternative equations and to assess their predictive power for all‐cause mortality in unselected patients discharged alive from a cardiology ward. Methods: We retrospectively included patients admitted to our Cardiology Division independently of their diagnosis. The total population was classified according to Kidney Disease: Improving Global Outcomes (KDIGO) categories, as follows: G1 (estimated glomerular filtration rate (eGFR) ≥ 90 mL/min/1.73 m2); G2 (eGFR 89–60 mL/min/1.73 m2); G3a (eGFR 59–45 mL/min/1.73 m2); G3b (eGFR 44–30 mL/min/1.73 m2); G4 (eGFR 29–15 mL/min/1.73 m2); G5 (eGFR < 15 mL/min/1.73 m2). Cockcroft‐Gault (CG), CG adjusted for body surface area (CG‐BSA), Modification of Diet in Renal Disease (MDRD), Berlin Initiative Study (BIS‐1), and Full Age Spectrum (FAS) equations were also assessed. Results: A total of 806 patients were included. Good agreement was found between the CKD‐EPI formula and CG‐BSA, MDRD, BIS‐1, and FAS equations. In subjects younger than 65 years or aged ≥85 years, CKD‐EPI and MDRD showed the highest agreement (Cohen’s kappa (K) 0.881 and 0.588, respectively) while CG showed the lowest. After a median follow‐up of 407 days, overall mortality was 8.2%. The risk of death was higher in lower eGFR classes (G3b HR4.35; 95%CI 1.05–17.80; G4 HR7.13; 95%CI 1.63–31.23; G5 HR25.91; 95%CI 6.63–101.21). The discriminant capability of death prediction tested with ROC curves showed the best results for BIS‐1 and FAS equations. Conclusion: In our cohort, the concordance between CKD‐EPI and other equations decreased with age, with the MDRD formula showing the best agreement in both younger and older patients. Overall, mortality rates increased with the renal function decreasing. In patients aged ≥75 years, the best discriminant capability for death prediction was found for BIS‐1 and FAS equations.

2022 - Letter by Imberti et al Regarding Article, "DREAM-ICD-II Study" [Articolo su rivista]
Imberti, J. F.; Vitolo, M.; Boriani, G.
abstract

2022 - Low Levels of Vitamin D and Silent Myocardial Ischemia in Type 2 Diabetes: Clinical Correlations and Prognostic Significance [Articolo su rivista]
Rossi, R.; Talarico, M.; Pascale, A.; Pascale, V.; Minici, R.; Boriani, G.
abstract

Vitamin D deficiency has a pathogenetic and prognostic role in coronary artery disease and a key role in pain transmission. Diabetic patients have a higher risk of silent myocardial ischemia (SMI) due to diabetic neuropathy. We evaluated the correlation between SMI and Vitamin D serum levels in type 2 diabetic patients and assessed whether SMI patients had a worse survival rate than their symptomatic counterpart. We enrolled 253 patients admitted in our Cardiology Unit and compared them with 50 healthy volunteers. We created three sub-groups: symptomatic MI group (125, 32.4%); SMI group (78, 25.7%), and no-MI group (50, 41.9%). 25(OH)D levels (nmol/L) were lower in the SMI group (34.9 ± 5.8) compared to those in the symptomatic MI (49.6 ± 6.1; p = 0.01), no MI (53.1 ± 6.2; p = 0.001), and control groups (62.1 ± 6.7; p = 0.0001). 25(OH)D levels predicted SMI in diabetic patients, with an inverted odds ratio of 1.11 (p = 0.01). Symptomatic MI group survival was higher than the SMI one (6-year survival rate: 83 vs. 69%; p = 0.01). Diabetic patients with SMI had a higher mortality risk and showed lower 25(OH)D levels than the symptomatic group. This suggests the crucial role that vitamin D has in the pathogenesis of SMI.

2022 - Mobile health technology in atrial fibrillation [Articolo su rivista]
Bonini, Niccolò; Vitolo, Marco; Imberti, Jacopo Francesco; Proietti, Marco; Romiti, Giulio Francesco; Boriani, Giuseppe; Paaske Johnsen, Søren; Guo, Yutao; Lip, Gregory Y H
abstract

Introduction Mobile health (mHealth) solutions in atrial fibrillation (AF) are becoming widespread, thanks to everyday life devices, such as smartphones. Their use is validated both in monitoring and in screening scenarios. In the published literature, the diagnostic accuracy of mHealth solutions wide differs, and their current clinical use is not well established in principal guidelines. Areas covered mHealth solutions have progressively built an AF-detection chain to guide patients from the device's alert signal to the health-care practitioners' (HCPs) attention. This review aims to critically evaluate the latest evidence regarding mHealth devices and the future possible patient's uses in everyday life. Expert opinion The patients are the first to be informed of the rhythm anomaly, leading to the urgency of increasing the patients' AF self-management. Furthermore, HCPs need to update themselves about mHealth devices use in clinical practice. Nevertheless, these are promising instruments in specific populations, such as post-stroke patients, to promote an early arrhythmia diagnosis in the post-ablation/cardioversion period, allowing checks on the efficacy of the treatment or intervention.

2022 - Performance-based risk-sharing arrangements for devices and procedures in cardiac electrophysiology: an innovative perspective [Articolo su rivista]
Boriani, Giuseppe; Vitolo, Marco; Svennberg, Emma; Casado-Arroyo, Ruben; Merino, Josè L; Leclercq, Christophe
abstract

There is an increasing pressure on demonstrating the value of medical interventions and medical technologies resulting in the proposal of new approaches for implementation in the daily practice of innovative treatments that might carry a substantial cost. While originally mainly adopted by pharmaceutical companies, in recent years medical technology companies have initiated novel value-based arrangements for using medical devices, in the form of 'outcomes-based contracts', 'performance-based contracts', or 'risk-sharing agreements'. These are all characterized by linking coverage, reimbursement, or payment for the innovative treatment to the attainment of pre-specified clinical outcomes. Risk-sharing agreements have been promoted also in the field of electrophysiology and offer the possibility to demonstrate the value of specific innovative technologies proposed in this rapidly advancing field, while relieving hospitals from taking on the whole financial risk themselves. Physicians deeply involved in the field of devices and technologies for arrhythmia management and invasive electrophysiology need to be prepared for involvement as stakeholders. This may imply engagement in the evaluation of risk-sharing agreements and specifically, in the process of assessment of technology performances or patient outcomes. Scientific Associations may have an important role in promoting the basis for value-based assessments, in promoting educational initiatives to help assess the determinants of the learning curve for innovative treatments, and in promoting large-scale registries for a precise assessment of patient outcomes and of specific technologies' performance.

2022 - Personalizing configuration for atrial fibrillation external electrical cardioversion to improve first shock efficacy [Articolo su rivista]
Massaro, Giulia; Spagni, Stefano; Martignani, Cristian; Bettazzoni, Luca; Spadotto, Alberto; Ziacchi, Matteo; Biffi, Mauro; Galiè, Nazzareno; Boriani, Giuseppe; Frisoni, Jessica; Diemberger, Igor
abstract

Background Despite the common use of biphasic electrical cardioversion (ECV) to convert atrial fibrillation (AF), we lack definite recommendations on electrode configuration. Methods We adopted a quasi-experimental design enrolling all candidates to ECV for AF. In the first stage, two units were involved, one using antero-apical pads (AAP) and the second antero-posterior adhesive patches (APP). These data enabled the creation of a decision algorithm to personalize the ECV approach, which was subsequently validated during the second stage. Results A total of 492 patients were enrolled overall. In the first stage, APP and AAP presented similar conversion rates (87.4 vs. 86.9% at first attempt of a step-up protocol, P = 0.661). While body surface area (BSA) <= 2.12 m(2) was an independent predictor in the overall population, the two components (height and weight) acted differently in the two configurations: being height <= 1.73 m(2) a significant cut-off value in the AAP subgroup, and weight <83 kg in the APP subgroup. Considering these cut-offs, we developed a decision algorithm for electrode configuration. In the second stage, algorithm validation confirmed an improvement in the first shock efficacy with respect to the results of the first stage (93.2 vs. 87.2%, P = 0.025), with a significant reduction in shock impedance (70.8 +/- 15.3 vs. 81.8 +/- 15.6, P < 0.001). Conclusion Patients with high BSA require high energy shocks for sinus rhythm restoration with ECV. Weight seems to affect more APP configuration, while height seems to impact more for the AAP. These findings have the potential to optimize ECV in clinical practice.

2022 - Preoperative checklist to reduce the risk of cardiac implantable electronic device infections [Articolo su rivista]
Ziacchi, M.; Massaro, G.; Angeletti, A.; Statuto, G.; Diemberger, I.; Martignani, C.; Galie, N.; Biffi, M.; Boriani, G.
abstract

Cardiac implantable electronic device (CIED) infection represents a dramatic event with a high mortality rate (>3x) despite antibiotic therapy and device extraction; therefore, the real winning strategy in this situation could be represented by prevention. Antibiotic prophylaxis and antibiotic-releasing envelope are effective in improving patient outcome; however, healthcare costs related to CIED infections remain high over the years. In this review we would keep the attention on a pre-surgical checklist to reduce the risk of CIED infections. In fact, checklist is an effective instrument for medical care quality improvement mainly used in surgery, but not very commonly in cath-lab and electrophysiology procedures. All steps of this checklist are of proven effectiveness in reducing the risk of CIED infections but, up till now, they are not considered together in a pre-surgical approach.

2022 - Prognostic value of renal failure in patients undergoing transvenous lead extraction: single centre experience and systematic review of the literature [Articolo su rivista]
Massaro, G.; Spadotto, A.; Canovi, L.; Martignani, C.; Ziacchi, M.; Angeletti, A.; Galie, N.; Boriani, G.; Biffi, M.; Diemberger, I.
abstract

Introduction: Cardiac implantable electronic device infections (CIEDI) are challenging complications, associated with high mortality rate. Transvenous lead extraction (TLE) is the only curative treatment for CIEDI. Albeit continuous improvement in tools and techniques dramatically decreased TLE associated complications, survival after TLE for CIEDI is still poor. Renal failure (RF) is frequently reported in candidates to TLE, but due to variability in its definition, the real prevalence is not well defined. Objective: Considering the impact of RF on mortality among patients affected by cardiovascular diseases, we aimed our research at defining the role of RF as a predictor of post-TLE mortality. Method and Results: We will provide the results of a systematic revision of literature on the impact of RF on mortality at different time points after TLE, according to the various definitions adopted for RF. Considering the high variability of literature in this field, we will provide the results of an explorative analysis comparing the different definitions of RF on clinical outcomes in a cohort of candidates to TLE for CIEDI in a high-volume referral center. Conclusion: We discuss the possible reasons of the negative impact of RF after TLE, providing new perspectives for future research.

2022 - Pulmonary arterial hypertension and right ventricular systolic dysfunction in COVID-19 survivors [Articolo su rivista]
Rossi, R.; Coppi, F.; Monopoli, D. E.; Sgura, F. A.; Arrotti, S.; Boriani, G.
abstract

2022 - Real-world applicability and impact of early rhythm control for European patients with atrial fibrillation: a report from the ESC-EHRA EORP-AF Long-Term General Registry [Articolo su rivista]
Proietti, M.; Vitolo, M.; Harrison, S. L.; Lane, D. A.; Fauchier, L.; Marin, F.; Nabauer, M.; Potpara, T. S.; Dan, G. -A.; Boriani, G.; Lip, G. Y. H.
abstract

Background: Use of rate/rhythm control is essential to control symptoms in patients with atrial fibrillation (AF). Recently, the EAST-AFNET 4 trial described how early rhythm control strategy was associated with a lower risk of adverse clinical outcomes. Objectives: The aim was to evaluate the real-world applicability and impact of an early rhythm control strategy in patients with AF. Methods: Use of an early rhythm control strategy was assessed in a European cohort of AF patients derived from the EHRA-ESC EORP-AF General Long-Term Registry. Early rhythm control was defined as use of antiarrhythmic drugs or cardioversion/catheter ablation. The primary outcome included cardiovascular death, stroke, acute coronary syndrome, and worsening of heart failure. Quality of life and health-care resource usage were also assessed as outcomes. Results: Among the 10,707 patients evaluated for eligibility to EAST-AFNET 4, a total of 3774 (34.0%) were included. Early rhythm control was associated with better quality of life, but with greater use of health-care resources. During follow-up, the primary outcome occurred less often in early rhythm control patients than in those with no rhythm control (13.6% vs. 18.5%, p < 0.001). In the multivariate adjusted Cox regression model, no significant difference was found between no rhythm control and early rhythm control, for the primary outcome. No difference in the primary outcome between early rhythm control and ‘no rhythm control patients’ adherent to Atrial fibrillation Better Care (ABC) pathway’ was evident (p = 0.753) Conclusions: Use of an early rhythm control strategy was associated with a lower rate of major adverse events, but this difference was non-significant on multivariate analysis, being mediated by differences in baseline characteristics and clinical risk profile. Early rhythm control was associated with a higher use of health-care resources and risk of hospital admission, despite showing better quality of life. Graphic abstract: [Figure not available: see fulltext.]

2022 - Reimbursement practices for use of digital devices in atrial fibrillation and other arrhythmias: a European Heart Rhythm Association survey [Articolo su rivista]
Boriani, G.; Svennberg, E.; Guerra, F.; Linz, D.; Casado-Arroyo, R.; Malaczynska-Rajpold, K.; Duncker, D.; Boveda, S.; Merino, J. L.; Leclercq, C.
abstract

Since digital devices are increasingly used in cardiology for assessing cardiac rhythm and detecting arrhythmias, especially atrial fibrillation (AF), our aim was to evaluate the expectations and opinions of healthcare professionals in Europe on reimbursement policies for the use of digital devices (including wearables) in AF and other arrhythmias. An anonymous survey was proposed through announcements on the European Heart Rhythm Association website, social media channels, and mail newsletter. Two hundred and seventeen healthcare professionals participated in the survey: 32.7%, reported regular use of digital devices, 45.2% reported that they sometimes use these tools, 18.6% that they do not use but would like to. Only a minority (3.5%) reported a lack of trust in digital devices. The survey highlighted a general propensity to provide medical consultation for suspected AF or other arrhythmias detected by a consumer-initiated use of digital devices, even if time constraints and reimbursement availability emerged as important elements. More than 85% of respondents agreed that reimbursement should be applied for clinical use of digital devices, also in different settings such as post-stroke, post-cardioversion, post-ablation, and in patients with palpitations or syncope. Finally, 73.6% of respondents confirmed a lack of reimbursement fees in their country for physicians' consultations (tracings interpretation) related to digital devices. Digital devices, including wearables, are increasingly and widely used for assessing cardiac rhythm and detecting AF, but a definition of reimbursement policies for physicians' consultations is needed.

2022 - Rhythm- or rate-control strategies according to 4S-AF characterization scheme and long-term outcomes in atrial fibrillation patients: the FAMo (Fibrillazione Atriale in Modena) cohort [Articolo su rivista]
Malavasi, V. L.; Vitolo, M.; Colella, J.; Montagnolo, F.; Mantovani, M.; Proietti, M.; Potpara, T. S.; Lip, G. Y. H.; Boriani, G.
abstract

The 4S-AF scheme [Stroke risk, Symptom severity, Severity of atrial fibrillation (AF) burden, Substrate severity] was recently proposed to characterize AF patients. In this post hoc analysis we evaluated the agreement between the therapeutic strategy (rate or rhythm control, respectively), as suggested by the 4S-AF scheme, and the actual strategy followed in a patients cohort. Outcomes of interest were as follows: all-cause death, a composite of all-cause death/any thromboembolism/acute coronary syndrome, and a composite of all-cause death, any thrombotic/ischemic event, and major bleeding (net clinical outcome). We enrolled 615 patients: 60.5% male, median age 74 [interquartile range (IQR) 67–80] years; median CHA2DS2VASc 4 and median HAS-BLED 2. The 4S-AF score would have suggested a rhythm-control strategy in 351 (57.1%) patients while a rate control in 264 (42.9%). The strategy adopted was concordant with the 4S-AF suggestions in 342 (55.6%) cases, and non-concordant in 273 (44.4%). After a median follow-up of 941 days (IQR 365–1282), 113 (18.4%) patients died, 158 (25.7%) had an event of the composite endpoint. On adjusted Cox regression analysis, when 4S-AF score suggested rate control, disagreement with that suggestion was not associated with a worse outcome. When 4S-AF indicated rhythm control, disagreement was associated with a higher risk of all-cause death (HR 7.59; 95% CI 1.65–35.01), and of the composite outcome (HR 2.69; 95% CI 1.19–6.06). The 4S-AF scheme is a useful tool to comprehensively evaluate AF patients and aid the decision-making process. Disagreement with the rhythm control suggestion of the 4S-AF scheme was associated with adverse clinical outcomes.

2022 - Screening for Atrial Fibrillation in Relation to Stroke and Mortality Risk [Articolo su rivista]
Proietti, Marco; Boriani, Giuseppe
abstract

Not requested.

2022 - Screening for atrial fibrillation in the general population: experience from a cardiovascular risk campaign in the Emilia-Romagna Region|Screening della fibrillazione atriale nella popolazione generale: esperienza della campagna educazionale sul rischio cardiovascolare della Regione Emilia-Romagna [Articolo su rivista]
Di Pasquale, G.; Cardelli, L. S.; Canovi, L.; Dal Passo, B.; Frascaro, F.; Zanarelli, L.; Guardigli, G.; Campo, G.; Aschieri, D.; Vignali, L.; Navazio, A.; Rubboli, A.; Ortolani, P.; Galvani, M.; Ni, M.; Piovaccari, G.; Tortorici, G.; Urbinati, S.; Tondi, S.; Sassone, B.; Tortorella, G.; De Palma, R.; Casella, G.; Boriani, G.
abstract

Atrial fibrillation (AF) is a major cause of cerebral ischemia, and its early detection may impact on health. Both invasive and non-invasive devices can be used for the diagnosis of AF. The aim of our study was to estimate the prevalence of AF using a single-lead ECG device (MyDiagnostickTM) on an adult, asymptomatic population during a screening campaign.

2022 - Ten-year follow-up of cardiac resynchronization therapy patients with non-ischemic dilated cardiomyopathy assessed by radionuclide angiography: a single-center cohort study [Articolo su rivista]
Valzania, C.; Massaro, G.; Spadotto, A.; Muraglia, L.; Frisoni, J.; Martignani, C.; Ziacchi, M.; Diemberger, I.; Fanti, S.; Boriani, G.; Biffi, M.; Galie, N.
abstract

Purpose: Relatively few data are available on long-term survival and incidence of ventricular arrhythmias in cardiac resynchronization therapy (CRT) patients. We investigated long-term outcomes of CRT patients with non-ischemic dilated cardiomyopathy stratified as responders or non-responders according to radionuclide angiography. Methods: Fifty patients with non-ischemic dilated cardiomyopathy undergoing CRT were assessed by equilibrium Tc99 radionuclide angiography with bicycle exercise at baseline and after 3 months. Intra- and interventricular dyssynchrony were derived by Fourier phase analysis. Patient clinical outcome was assessed after 10 years. Results: At 3 months, 50% of patients were identified as CRT responders according to an increase in LV ejection fraction ≥ 5%. During a follow-up of 109 ± 48 months, 30% of patients died and 6% underwent heart transplantation. Age and history of paroxysmal atrial fibrillation were found to be predictors of all-cause mortality. CRT responders showed lower risk of death from cardiac causes than non-responders. At follow-up, 38% of patients presented at least one episode of sustained ventricular tachycardia, with a similar percentage between responders and non-responders. Conclusion: At long-term follow-up, non-ischemic CRT recipients identified as responders by radionuclide angiography were found to be at lower risk of worsening heart failure death than non-responders. Long-term risk for sustained ventricular arrhythmia was similar between CRT responders and non-responders.

2022 - The Interplay of PR Interval and AV Pacing Delays Used for Cardiac Resynchronization Therapy in Heart Failure Patients: Association with Clinical Response in a Retrospective Analysis of a Large Observational Study [Articolo su rivista]
Gasparini, Maurizio; Biffi, Mauro; Landolina, Maurizio; Cattafi, Giuseppe; Rordorf, Roberto; Botto, Giovanni Luca; Battista Forleo, Giovanni; Morani, Giovanni; Santini, Luca; Dello Russo, Antonio; Rossillo, Antonio; Meloni, Sarah; Grammatico, Andrea; Vitolo, Marco; Boriani, Giuseppe
abstract

Background. Cardiac resynchronization therapy (CRT) is a treatment for heart failure (HF) patients with prolonged QRS and impaired left ventricular (LV) systolic function. We aim to evaluate how the baseline PR interval is associated with outcomes (all-cause death or HF hospitalizations) and LV reverse remodeling (>15% relative reduction in LV end-systolic volume). Methods. Among 2224 patients with CRT defibrillators, 1718 (77.2%) had a device programmed at out-of-the-box settings (sensed AV delay: 100 ms and paced AV delay: 130 ms). Results. In this cohort of 1718 patients (78.7% men, mean age 66 years, 71.6% in NYHA class III/IV, LVEF = 27 +/- 6%), echocardiographic assessment at 6-month follow-up showed that LV reverse remodeling was not constant as a function of the PR interval; in detail, it occurred in 56.4% of all patients but was more frequent (76.6%) in patients with a PR interval of 160 ms. In a median follow-up of 20 months, the endpoint of death or HF hospitalizations occurred in 304/1718 (17.7%) patients; in the multivariable regression analysis it was significantly less frequent when the PR interval was between 150 and 170 ms (hazard ratio = 0.79, 95% confidence interval (CI): 0.63-0.99, p = 0.046). The same PR range was associated with higher probability of CRT response (odds ratio = 2.51, 95% CI: 1.41-4.47, p = 0.002). Conclusions. In a large population of CRT patients, with fixed AV pacing delays, specific PR intervals are associated with significant benefits in terms of LV reverse remodeling and lower morbidity. These observational data suggest the importance of optimizing pacing programming as a function of the PR interval to maximize CRT response and patient outcome.

2022 - The effect of cardiac resynchronization without a defibrillator on morbidity and mortality: insights from an individual patient data meta-analysis of COMPANION and CARE-HF [Articolo su rivista]
Leyva, F.; Boriani, G.
abstract

2022 - The impact of UEFA Euro 2020 football championship on Takotsubo Syndrome: Results of a multicenter national registry [Articolo su rivista]
Polimeni, A.; Spaccarotella, C.; Ielapi, J.; Esposito, G.; Ravera, A.; Martuscelli, E.; Ciconte, V.; Menichelli, M.; Varbella, F.; Imazio, M.; Navazio, A.; Sinagra, G.; Oberhollenzer, R.; Sibilio, G.; Cacciavillani, L.; Meloni, L.; Dominici, M.; Tomai, F.; Amico, F.; Corda, M.; Musumeci, G.; Lupi, A.; Zezza, L.; De Caterina, R.; Cernetti, C.; Metra, M.; Rossi, L.; Calabro, P.; Murrone, A.; Volpe, M.; Caldarola, P.; Carugo, S.; Cortese, B.; Valenti, R.; Boriani, G.; Fedele, F.; Ventura, G.; Manes, M. T.; Colavita, A. R.; Feola, M.; Versaci, F.; Assennato, P.; Arena, G.; Ceravolo, R.; Amodeo, V.; Tortorici, G.; Nassiacos, D.; Antonicelli, R.; Esposito, N.; Favale, S.; Licciardello, G.; Tedesco, L.; Indolfi, C.
abstract

Objectives: The UEFA 2020 European Football Championship held in multiple cities across Europe from June 11 to July 11, 2021, was won by Italy, providing an opportunity to examine the relationship between emotional stress and the incidence of acute cardiovascular events (ACE). Methods and results: Cardiovascular hospitalizations in the Cardiac Care Units of 49 hospital networks in Italy were assessed by emergency physicians during the UEFA Euro 2020 Football Championship. We compared the events that occurred during matches involving Italy with events that occurred during the remaining days of the championship as the control period. ACE was assessed in 1,235 patients. ACE during the UEFA Euro 2020 Football Championship semifinal and final, the most stressful matches ended with penalties and victory of the Italian team, were assessed. A significant increase in the incidence of Takotsubo Syndrome (TTS) by a factor of 11.41 (1.6–495.1, P < 0.003), as compared with the control period, was demonstrated during the semifinal and final, whereas no differences were found in the incidence of ACS [IRR 0.93(0.74–1.18), P = 0.57]. No differences in the incidence of ACS [IRR 0.98 (0.87–1.11; P = 0.80)] or TTS [IRR 1.66(0.80–3.4), P = 0.14] were found in the entire period including all matches of the UEFA Euro 2020 compared to the control period. Conclusions: The data of this national registry demonstrated an association between the semifinal and final of UEFA Euro 2020 and TTS suggesting that it can be triggered by also positive emotions such as the victory in the European Football Championship finals.

2022 - The search for a gold standard to clinically diagnose and monitor atrial cardiomyopathy [Articolo su rivista]
Boriani, G.; Vitolo, M.; Imberti, J. F.
abstract

Invited editorial commenting on:: Tufano A, Lancellotti P. "Atrial cardiomyopathy: Pathophysiology and clinical implications". Eur J Intern Med. 2022 Mar 11:S0953–6205(22)00097–8. doi: 10.1016/j.ejim.2022.03.007. Epub ahead of print. PMID: 35288030.

2022 - The value of wearable cardioverter defibrillator in adult patients with recent myocardial infarction: Economic and clinical implications from a health technology assessment perspective [Articolo su rivista]
Botto, G. L.; Mantovani, L. G.; Cortesi, P. A.; De Ponti, R.; D'Onofrio, A.; Biffi, M.; Capucci, A.; Casu, G.; Notarstefano, P.; Scaglione, M.; Zanotto, G.; Boriani, G.
abstract

Aims: Sudden cardiac death (SCD) causes high mortality and substantial societal burdens for healthcare systems (HSs). The risk of SCD is significantly increased in patients with reduced left ventricular ejection fraction after myocardial infarction (MI). Current guidelines recommend re-evaluation of cardioverter-defibrillator implantation 40 days post-MI, earliest. Medical therapy alone does not provide sufficient protection against SCD, especially in the first month post-MI, and needs time. Consequently, there is a gap in care of high-risk patients upon hospital discharge. The wearable cardioverter defibrillator (WCD) is a proven safe, effective therapy, which temporarily protects from SCD. Little information on WCD cost-effectiveness exists. We conducted this research to demonstrate the medical need of the device in the post-MI setting defining WCD cost-effectiveness. Methods & results: Based on a randomized clinical trials (RCTs) and Italian and international data, we developed a Markov-model comparing costs, patient survival, and quality-of-life, and calculated the Incremental Cost-Effectiveness Ratio (ICER) of a WCD vs. current standard of care in post-MI patients. The rather conservative base case analysis – based on the RCT intention-to-treat results - produced an ICER of €47,709 per Quality Adjusted Life Year (QALY) gained, which is far lower than the accepted threshold of €60,000 in the Italian National HS. The ICER per Life Year (LY) gained was €38,276. Conclusion: WCD utilization in post-MI patients is clinically beneficial and cost-effective. While improving guideline directed patient care, the WCD can also contribute to a more efficient use of resources in the Italian HS, and potentially other HSs as well.

2022 - Three-Dimensional Automated, Machine-Learning-Based Left Heart Chamber Metrics: Associations with Prevalent Vascular Risk Factors and Cardiovascular Diseases [Articolo su rivista]
Barbieri, A.; Albini, A.; Chiusolo, S.; Forzati, N.; Laus, V.; Maisano, A.; Muto, F.; Passiatore, M.; Stuani, M.; Torlai Triglia, L.; Vitolo, M.; Ziveri, V.; Boriani, G.
abstract

Background. Three-dimensional transthoracic echocardiography (3DE) powered by artificial intelligence provides accurate left chamber quantification in good accordance with cardiac magnetic resonance and has the potential to revolutionize our clinical practice. Aims. To evaluate the association and the independent value of dynamic heart model (DHM)-derived left atrial (LA) and left ventricular (LV) metrics with prevalent vascular risk factors (VRFs) and cardiovascular diseases (CVDs) in a large, unselected population. Materials and Methods. We estimated the association of DHM metrics with VRFs (hypertension, diabetes) and CVDs (atrial fibrillation, stroke, ischemic heart disease, cardiomyopathies, >moderate valvular heart disease/prosthesis), stratified by prevalent disease status: participants without VRFs or CVDs (healthy), with at least one VRFs but without CVDs, and with at least one CVDs. Results. We retrospectively included 1069 subjects (median age 62 [IQR 49–74]; 50.6% women). When comparing VRFs with the healthy, significant difference in maximum and minimum indexed atrial volume (LAVi max and LAVi min), left atrial ejection fraction (LAEF), left ventricular mass/left ventricular end-diastolic volume ratio, and left ventricular global function index (LVGFI) were recorded (p < 0.05). In the adjusted logistic regression, LAVi min, LAEF, LV ejection fraction, and LVGFI showed the most robust association (OR 3.03 [95% CI 2.48–3.70], 0.45 [95% CI 0.39–0.51], 0.28 [95% CI 0.22–0.35], and 0.22 [95% CI 0.16–0.28], respectively, with CVDs. Conclusions. The present data suggested that novel 3DE left heart chamber metrics by DHM such as LAEF, LAVi min, and LVGFI can refine our echocardiographic disease discrimination capacity.

2022 - Use of direct oral anticoagulants in patients with atrial fibrillation and obesity or low body weight: the additional contribution to knowledge provided by pharmacokinetic and pharmacodynamic studies [Articolo su rivista]
Boriani, G.
abstract

2022 - Vascular Accesses in Cardiac Stimulation and Electrophysiology: An Italian Survey Promoted by AIAC (Italian Association of Arrhythmias and Cardiac Pacing) [Articolo su rivista]
Ziacchi, M.; Placci, A.; Angeletti, D.; Quartieri, F.; Balla, C.; Virzi, S.; Bertini, M.; De Ponti, R.; Biffi, M.; Boriani, G.
abstract

Cardiac implantable electronic device (CIED) implants and electrophysiological procedures share a common step: Vascular access. On behalf of the AIAC Ricerca Investigators’ Network, we conducted a survey to outline Italian common practice regarding vascular access in EP-lab. All Italian physicians with experience in CIED implantation and electrophysiology were invited to answer an online questionnaire (from May 2020 to November 2020) featuring 20 questions. In total, 103 cardiologists (from 92 Italian hospitals) answered the survey. Vascular access during CIED implants was considered the most complex step following lead placement by 54 (52.4%) respondents and the most complex for 35 (33.9%). In total, 54 (52.4%) and 49 (47.6%) respondents considered the cephalic and subclavian vein the first option, respectively (intrathoracic and extrathoracic subclavian/axillary vein by 22 and 27, respectively). In total, 45 (43.7%) respondents performed close arterial femoral accesses manually; only 12 (11.7%) respondents made extensive use of vascular closure devices. A total of 46 out of 103 respondents had experience in ultrasound-guided vascular accesses, but only 10 (22%) used it for more than 50% of the accesses. In total, 81 (78.6%) respondents wanted to increase their ultrasound-guided vascular access skills. Reducing complications is a goal to reach in cardiac stimulation and electrophysiological procedures. Our survey shows the heterogeneity of the vascular approaches used in Italian centres. Some vascular accesses were proved to be superior to others in terms of complications, with ultrasound-guided puncture as an emerging technique. More effort to produce the standardization of vascular accesses could be made by scientific societies.

2022 - Ventricular and Atrial Remodeling after Transcatheter Edge-to-Edge Repair: A Pilot Study [Articolo su rivista]
Albini, Alessandro; Passiatore, Matteo; Imberti, Jacopo Francesco; Valenti, Anna Chiara; Leo, Giulio; Vitolo, Marco; Coppi, Francesca; Sgura, Fabio Alfredo; Boriani, Giuseppe
abstract

The aim of this study was to determine the impact of transcatheter edge-to-edge repair (TEER) on left and right ventricular (LV, RV) and left and right atrial (LA, RA) remodeling according to the mechanism of mitral regurgitation (MR) and history of atrial fibrillation (AF).

2021 - 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS) [Articolo su rivista]
Hindricks, Gerhard; Potpara, Tatjana; Dagres, Nikolaos; Arbelo, Elena; Bax, Jeroen J; Blomström-Lundqvist, Carina; Boriani, Giuseppe; Castella, Manuel; Dan, Gheorghe-Andrei; Dilaveris, Polychronis E; Fauchier, Laurent; Filippatos, Gerasimos; Kalman, Jonathan M; La Meir, Mark; Lane, Deirdre A; Lebeau, Jean-Pierre; Lettino, Maddalena; Lip, Gregory Y H; Pinto, Fausto J; Thomas, G Neil; Valgimigli, Marco; Van Gelder, Isabelle C; Van Putte, Bart P; Watkins, Caroline L; Kirchhof, Paulus; Kühne, Michael; Aboyans, Victor; Ahlsson, Anders; Balsam, Pawel; Bauersachs, Johann; Benussi, Stefano; Brandes, Axel; Braunschweig, Frieder; Camm, A John; Capodanno, Davide; Casadei, Barbara; Conen, David; Crijns, Harry J G M; Delgado, Victoria; Dobrev, Dobromir; Drexel, Heinz; Eckardt, Lars; Fitzsimons, Donna; Folliguet, Thierry; Gale, Chris P; Gorenek, Bulent; Haeusler, Karl Georg; Heidbuchel, Hein; Iung, Bernard; Katus, Hugo A; Kotecha, Dipak; Landmesser, Ulf; Leclercq, Christophe; Lewis, Basil S; Mascherbauer, Julia; Merino, Jose Luis; Merkely, Béla; Mont, Lluís; Mueller, Christian; Nagy, Klaudia V; Oldgren, Jonas; Pavlović, Nikola; Pedretti, Roberto F E; Petersen, Steffen E; Piccini, Jonathan P; Popescu, Bogdan A; Pürerfellner, Helmut; Richter, Dimitrios J; Roffi, Marco; Rubboli, Andrea; Scherr, Daniel; Schnabel, Renate B; Simpson, Iain A; Shlyakhto, Evgeny; Sinner, Moritz F; Steffel, Jan; Sousa-Uva, Miguel; Suwalski, Piotr; Svetlosak, Martin; Touyz, Rhian M; Dagres, Nikolaos; Arbelo, Elena; Bax, Jeroen J; Blomström-Lundqvist, Carina; Boriani, Giuseppe; Castella, Manuel; Dan, Gheorghe-Andrei; Dilaveris, Polychronis E; Fauchier, Laurent; Filippatos, Gerasimos; Kalman, Jonathan M; La Meir, Mark; Lane, Deirdre A; Lebeau, Jean-Pierre; Lettino, Maddalena; Lip, Gregory Y H; Pinto, Fausto J; Neil Thomas, G; Valgimigli, Marco; Van Gelder, Isabelle C; Watkins, Caroline L
abstract

2021 - 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS) [Articolo su rivista]
Hindricks, G.; Potpara, T.; Dagres, N.; Arbelo, E.; Bax, J. J.; Blomstrom-Lundqvist, C.; Boriani, G.; Castella, M.; Dan, G. -A.; Dilaveris, P. E.; Fauchier, L.; Filippatos, G.; Kalman, J. M.; La Meir, M.; Lane, D. A.; Lebeau, J. -P.; Lettino, M.; Lip, G. Y. H.; Pinto, F. J.; Neil Thomas, G.; Valgimigli, M.; Van Gelder, I. C.; Van Putte, B. P.; Watkins, C. L.
abstract

2021 - 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation, developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC), developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC [Articolo su rivista]
Hindricks, G.; Potpara, T.; Dagres, N.; Arbelo, E.; Bax, J. J.; Blomstrom-Lundqvist, C.; Boriani, G.; Castella, M.; Dan, G. -A.; Dilaveris, P. E.; Fauchier, L.; Filippatos, G.; Kalman, J. M.; Meir, M. L.; Lane, D. A.; Lebeau, J. -P.; Lettino, M.; Lip, G. Y. H.; Pinto, F. J.; Neil Thomas, G.; Valgimigli, M.; Van Gelder, I. C.; Van Putte, B. P.; Watkins, C. L.
abstract

2021 - 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy [Articolo su rivista]
Glikson, M.; Nielsen, J. C.; Kronborg, M. B.; Michowitz, Y.; Auricchio, A.; Barbash, I. M.; Barrabes, J. A.; Boriani, G.; Braunschweig, F.; Brignole, M.; Burri, H.; Coats, A. J. S.; Deharo, J. -C.; Delgado, V.; Diller, G. -P.; Israel, C. W.; Keren, A.; Knops, R. E.; Kotecha, D.; Leclercq, C.; Merkely, B.; Starck, C.; Thylen, I.; Tolosana, J. M.; Leyva, F.; Linde, C.; Abdelhamid, M.; Aboyans, V.; Arbelo, E.; Asteggiano, R.; Baron-Esquivias, G.; Bauersachs, J.; Biffi, M.; Birgersdotter-Green, U.; Bongiorni, M. G.; Borger, M. A.; Celutkiene, J.; Cikes, M.; Daubert, J. -C.; Drossart, I.; Ellenbogen, K.; Elliott, P. M.; Fabritz, L.; Falk, V.; Fauchier, L.; Fernandez-Aviles, F.; Foldager, D.; Gadler, F.; De Vinuesa, P. G. G.; Gorenek, B.; Guerra, J. M.; Hermann Haugaa, K.; Hendriks, J.; Kahan, T.; Katus, H. A.; Konradi, A.; Koskinas, K. C.; Law, H.; Lewis, B. S.; Linker, N. J.; Lochen, M. -L.; Lumens, J.; Mascherbauer, J.; Mullens, W.; Nagy, K. V.; Prescott, E.; Raatikainen, P.; Rakisheva, A.; Reichlin, T.; Ricci, R. P.; Shlyakhto, E.; Sitges, M.; Sousa-Uva, M.; Sutton, R.; Suwalski, P.; Svendsen, J. H.; Touyz, R. M.; Van Gelder, I. C.; Vernooy, K.; Waltenberger, J.; Whinnett, Z.; Witte, K. K.; Kronborg, M. B.; Michowitz, Y.; Auricchio, A.; Barbash, I. M.; Barrabes, J. A.; Qoriany, A.; Braunschweig, F.; Brignole, M.; Burri, H.; Coats, A. J. S.; Deharo, J. -C.; Delgado, V.; Diller, G. -P.; Israel, C. W.; Keren, A.; Knops, R. E.; Kotecha, D.; Leclercq, C.; Merkely, B.; Starck, C.; Thylen, I.; Tolosana, J. M.
abstract

2021 - 2021 European Heart Rhythm Association Practical Guide on the Use of Non-Vitamin K Antagonist Oral Anticoagulants in Patients with Atrial Fibrillation [Articolo su rivista]
Steffel, Jan; Collins, Ronan; Antz, Matthias; Cornu, Pieter; Desteghe, Lien; Haeusler, Karl Georg; Oldgren, Jonas; Reinecke, Holger; Roldan-Schilling, Vanessa; Rowell, Nigel; Sinnaeve, Peter; Vanassche, Thomas; Potpara, Tatjana; Camm, A John; Heidbüchel, Hein; Lip, Gregory Y H; Deneke, Thomas; Dagres, Nikolaos; Boriani, Giuseppe; Chao, Tze-Fan; Choi, Eue-Keun; Hills, Mellanie True; Santos, Itamar de Souza; Lane, Deirdre A; Atar, Dan; Joung, Boyoung; Cole, Oana Maria; Field, Mark
abstract

2021 - Anticoagulant selection in relation to the SAMe-TT2R2 score in patients with atrial fibrillation: The GLORIA-AF registry [Articolo su rivista]
Ntaios, G.; Huisman, M. V.; Diener, H. -C.; Halperin, J. L.; Teutsch, C.; Marler, S.; Gurusamy, V. K.; Thompson, M.; Lip, G. Y. H.; Olshansky, B.; Abban, D. W.; Abdul, N.; Abud, A. M.; Adams, F.; Addala, S.; Adragao, P.; Ageno, W.; Aggarwal, R.; Agosti, S.; Agostoni, P.; Aguilar, F.; Linares, J. A.; Aguinaga, L.; Ahmed, J.; Aiello, A.; Ainsworth, P.; Aiub, J. R.; Al-Dallow, R.; Alderson, L.; Aldrete Velasco, J. A.; Alexopoulos, D.; Manterola, F. A.; Aliyar, P.; Alonso, D.; Alves da Costa, F. A.; Amado, J.; Amara, W.; Amelot, M.; Amjadi, N.; Ammirati, F.; Andrade, M.; Andrawis, N.; Annoni, G.; Ansalone, G.; Ariani, M. K.; Arias, J. C.; Armero, S.; Arora, C.; Aslam, M. S.; Asselman, M.; Audouin, P.; Augenbraun, C.; Aydin, S.; Ayryanova, I.; Aziz, E.; Backes, L. M.; Badings, E.; Bagni, E.; Baker, S. H.; Bala, R.; Baldi, A.; Bando, S.; Banerjee, S.; Bank, A.; Esquivias, G. B.; Barr, C.; Bartlett, M.; Kes, V. B.; Baula, G.; Behrens, S.; Bell, A.; Benedetti, R.; Mazuecos, J. B.; Benhalima, B.; Bergler-Klein, J.; Berneau, J. -B.; Bernstein, R. A.; Berrospi, P.; Berti, S.; Berz, A.; Best, E.; Bettencourt, P.; Betzu, R.; Bhagwat, R.; Bhatta, L.; Biscione, F.; Bisignani, G.; Black, T.; Bloch, M. J.; Bloom, S.; Blumberg, E.; Bo, M.; Bohmer, E.; Bollmann, A.; Bongiorni, M. G.; Boriani, G.; Boswijk, D. J.; Bott, J.; Bottacchi, E.; Kalan, M. B.; Bradman, D.; Brautigam, D.; Breton, N.; Brouwers, P. J. A. M.; Browne, K.; Cortada, J. B.; Bruni, A.; Brunschwig, C.; Buathier, H.; Buhl, A.; Bullinga, J.; Cabrera, J. W.; Caccavo, A.; Cai, S.; Caine, S.; Calo, L.; Calvi, V.; Sanchez, M. C.; Candeias, R.; Capuano, V.; Capucci, A.; Caputo, R.; Rizo, T. C.; Cardona, F.; Carlos da Costa Darrieux, F.; Duarte Vera, Y. C.; Carolei, A.; Carreno, S.; Carvalho, P.; Cary, S.; Casu, G.; Cavallini, C.; Cayla, G.; Celentano, A.; Cha, T. -J.; Cha, K. S.; Chae, J. K.; Chalamidas, K.; Challappa, K.; Chand, S. P.; Chandrashekar, H.; Chartier, L.; Chatterjee, K.; Chavez Ayala, C. A.; Cheema, A.; Cheema, A.; Chen, L.; Chen, S. -A.; Chen, J. H.; Chiang, F. -T.; Chiarella, F.; Chih-Chan, L.; Cho, Y. K.; Choi, J. -I.; Choi, D. J.; Chouinard, G.; Hoi-Fan Chow, D.; Chrysos, D.; Chumakova, G.; Jose Roberto Chuquiure Valenzuela, E. J.; Nica, N. C.; Cislowski, D. J.; Clay, A.; Clifford, P.; Cohen, A.; Cohen, M.; Cohen, S.; Colivicchi, F.; Collins, R.; Colonna, P.; Compton, S.; Connolly, D.; Conti, A.; Buenostro, G. C.; Coodley, G.; Cooper, M.; Coronel, J.; Corso, G.; Sales, J. C.; Cottin, Y.; Covalesky, J.; Cracan, A.; Crea, F.; Crean, P.; Crenshaw, J.; Cullen, T.; Darius, H.; Dary, P.; Dascotte, O.; Dauber, I.; Davalos, V.; Davies, R.; Davis, G.; Davy, J. -M.; Dayer, M.; De Biasio, M.; De Bonis, S.; De Caterina, R.; De Franceschi, T.; de Groot, J. R.; De Horta, J.; De La Briolle, A.; Topete, G. D. L. P.; Vicenzo de Paola, A. A.; de Souza, W.; de Veer, A.; De Wolf, L.; Decoulx, E.; Deepak, S.; Defaye, P.; Del-Carpio Munoz, F.; Brkljacic, D. D.; Deumite, N. J.; Di Legge, S.; Diemberger, I.; Dietz, D.; Dionisio, P.; Dong, Q.; Rossi dos Santos, F.; Dotcheva, E.; Doukky, R.; D'Souza, A.; Dubrey, S.; Ducrocq, X.; Dupljakov, D.; Duque, M.; Dutta, D.; Duvilla, N.; Duygun, A.; Dziewas, R.; Eaton, C. B.; Eaves, W.; Ebels-Tuinbeek, L. A.; Ehrlich, C.; Eichinger-Hasenauer, S.; Eisenberg, S. J.; El Jabali, A.; El Shahawy, M.; Hernandes, M. E.; Izal, A. E.; Evonich, R.; Evseeva, O.; Ezhov, A.; Fahmy, R.; Fang, Q.; Farsad, R.; Fauchier, L.; Favale, S.; Fayard, M.; Fedele, J. L.; Fedele, F.; Fedorishina, O.; Fera, S. R.; Gomes Ferreira, L. G.; Ferreira, J.; Ferri, C.; Ferrier, A.; Ferro, H.; Finsen, A.; First, B.; Fischer, S.; Fonseca, C.; Almeida, L. F.; Forman, S.; Frandsen, B.; French, W.; Friedman, K.; Friese, A.; Fruntelata, A. G.; Fujii, S.; Fumagalli, S.; Fundamenski, M.; Furukawa, Y.; Gabelmann, M.; Gabra, N.; Gadsboll, N.; Galinier, M.; Gammelgaard, A.; Ganeshkumar, P.; Gans, C.; Quintana, A. G.; Gartenlaub, O.; Gaspardone, A.; Genz, C.; Georger, F.; Georges, J. -L.; Georgeson, S.;
abstract

Aim: The SAMe-TT2R2 score helps identify patients with atrial fibrillation (AF) likely to have poor anticoagulation control during anticoagulation with vitamin K antagonists (VKA) and those with scores >2 might be better managed with a target-specific oral anticoagulant (NOAC). We hypothesized that in clinical practice, VKAs may be prescribed less frequently to patients with AF and SAMe-TT2R2 scores >2 than to patients with lower scores. Methods and results: We analyzed the Phase III dataset of the Global Registry on Long-Term Oral Antithrombotic Treatment in Patients with Atrial Fibrillation (GLORIA-AF), a large, global, prospective global registry of patients with newly diagnosed AF and ≥1 stroke risk factor. We compared baseline clinical characteristics and antithrombotic prescriptions to determine the probability of the VKA prescription among anticoagulated patients with the baseline SAMe-TT2R2 score >2 and ≤ 2. Among 17,465 anticoagulated patients with AF, 4,828 (27.6%) patients were prescribed VKA and 12,637 (72.4%) patients an NOAC: 11,884 (68.0%) patients had SAMe-TT2R2 scores 0-2 and 5,581 (32.0%) patients had scores >2. The proportion of patients prescribed VKA was 28.0% among patients with SAMe-TT2R2 scores >2 and 27.5% in those with scores ≤2. Conclusions: The lack of a clear association between the SAMe-TT2R2 score and anticoagulant selection may be attributed to the relative efficacy and safety profiles between NOACs and VKAs as well as to the absence of trial evidence that an SAMe-TT2R2-guided strategy for the selection of the type of anticoagulation in NVAF patients has an impact on clinical outcomes of efficacy and safety. The latter hypothesis is currently being tested in a randomized controlled trial. Clinical trial registration: URL: https://www.clinicaltrials.gov//Unique identifier: NCT01937377, NCT01468701, and NCT01671007.

2021 - Anticoagulation in patients with atrial fibrillation and active cancer: an international survey on patient management [Articolo su rivista]
Boriani, G.; Lee, G.; Parrini, I.; Lopez-Fernandez, T.; Lyon, A. R.; Suter, T.; Van der Meer, P.; Cardinale, D.; Lancellotti, P.; Zamorano, J. L.; Bax, J. J.; Asteggiano, R.
abstract

BACKGROUND: In patients with active cancer and atrial fibrillation (AF) anticoagulation, thrombotic and bleeding risk still entail uncertainty. AIM: We explored the results of an international survey examining the knowledge and behaviours of a large group of physicians. METHODS AND RESULTS: A web-based survey was completed by 960 physicians (82.4% cardiologists, 75.5% from Europe). Among the currently available anticoagulants for stroke prevention in patients with active cancer, direct oral anticoagulants (DOACs) were preferred by 62.6%, with lower values for low molecular weight heparin (LMWH) (24.1%) and for warfarin (only 7.3%). About 46% of respondents considered that DOACs should be used in all types of cancers except in non-operable gastrointestinal cancers. The lack of controlled studies on bleeding risk (33.5% of respondents) and the risk of drug interactions (31.5%) were perceived as problematic issues associated with use of anticoagulants in cancer. The decision on anticoagulation involved a cardiologist in 27.8% of cases, a cardiologist and an oncologist in 41.1%, and a team approach in 21.6%. The patient also was involved in decision-making, according to ∼60% of the respondents. For risk stratification, use of CHA2DS2-VASc and HAS-BLED scores was considered appropriate, although not specifically validated in cancer patients, by 66.7% and 56.4%, respectively. CONCLUSION: This survey highlights that management of anticoagulation in patients with AF and active cancer is challenging, with substantial heterogeneity in therapeutic choices. Direct oral anticoagulants seems having an emerging role but still the use of LMWH remains substantial, despite the absence of long-term data on thromboprophylaxis in AF.

2021 - Atrial fibrillation in dilated cardiomyopathy: Outcome prediction from an observational registry [Articolo su rivista]
Nuzzi, V.; Cannata, A.; Manca, P.; Castrichini, M.; Barbati, G.; Aleksova, A.; Fabris, E.; Zecchin, M.; Merlo, M.; Boriani, G.; Sinagra, G.
abstract

Background: Little is known about the role of different types of atrial fibrillation (AF) in dilated cardiomyopathy (DCM). We investigated the epidemiological and prognostic impact of different types of AF in DCM during long-term follow-up. Method: We evaluated consecutive DCM patients enrolled in the Trieste Muscle Heart Disease Registry. Uni- and multivariable, extended Kaplan-Meier and propensity score-matching analyses were performed for a composite outcome including death/heart transplantation/ventricular-assist device implantation. Results: Out of 1181 DCM patients (71% males, age 49 ± 15 years, left ventricular ejection fraction 33 ± 11%), 46 (3.9%) had baseline permanent AF (permAF), while 66 (5.6%) had a history of paroxysmal/persistent AF. Compared with sinus rhythm (SR) patients, permAF patients were older (48 ± 15 vs. 61 ± 11 respectively, p = 0.001), were more frequently in NYHA class III-IV (18% vs. 30%, p = 0.002) and had larger left atrium diameter (40 ± 8 vs. 50 ± 10 mm, respectively). Paroxysmal/persistent AF patients had intermediate characteristics between permAF and SR. During a median follow-up of 135 (75–210) months, 63 patients developed permAF (0.45 new cases/100patients/year). At multivariable analysis, permAF as a time-dependent variable was an independent outcome predictor (HR 2.45; 95% C.I. 2.61–3.63, p < 0.001), together with creatinine, NYHA class, restrictive filling pattern and moderate-severe mitral regurgitation, while paroxysmal/persistent AF was neutral. Propensity score-matching analysis confirmed the higher rate of primary outcome events in patients with baseline or incident permAF versus patients without permAF during a very long-term follow-up (70% vs. 20%, p < 0.001). Conclusions: PermAF in a large DCM cohort had low prevalence and incidence but had a relevant. prognostic role on hard outcomes.

2021 - Atrial fibrillation is related to higher mortality in COVID-19/SARS-CoV-2 pneumonia infection [Articolo su rivista]
Denegri, Andrea; Morelli, Marianna; Pezzuto, Giuseppe; Malavasi, Vincenzo Livio; Boriani, Giuseppe
abstract

2021 - Atrial fibrillation pattern and factors affecting the progression to permanent atrial fibrillation [Articolo su rivista]
Malavasi, V. L.; Fantecchi, E.; Tordoni, V.; Melara, L.; Barbieri, A.; Vitolo, M.; Lip, G. Y. H.; Boriani, G.
abstract

Atrial fibrillation (AF) may progress from a non-permanent to a permanent form, and improvement in prediction may help in decision-making. In- and outpatients with non-permanent AF were enrolled in a prospective study and followed every 6 months. At baseline, 314 out of 523 patients (60%) had non-permanent AF (25.5% paroxysmal AF, 52.5% persistent, 2% first diagnosed AF). They were mostly males (188, 59.9%), median age 71 years [interquartile range (IQ) 62–77], median CHA2DS2VASc 3 (IQ 1–4), median HATCH score 1 (IQ 1–2). During a follow-up of 701 (IQ 437–902) days, 66 patients (21%) developed permanent AF. CHA2DS2VASc and HATCH scores were incrementally associated with AF progression (p for trend CHA2DS2VASc < 0.001, HATCH p = 0.001). Cox multivariable proportional hazard regression analysis showed that age [hazard ratio (HR) 1.042; 95%CI 1.005–1.080; p = 0.025], moderate–severe left atrial (LA) enlargement at echo (HR 2.072, 95%CI, 1.121–3.831; p = 0.020), antiarrhythmics drugs (HR 0.087, 95%CI 0.011–0.659, p = 0.018), EHRA score > 2 (HR 0.358, 95%CI 0.162–0.791, p = 0.011) and valvular disease (HR 2.196, 95%CI 1.072–4.499, p = 0.032) were significantly associated with AF progression. Adding “moderate–severe LA dilation” to clinical scores, eg. HATCH score (HATCH-LA) with 2 points (Cox multivariable regression analysis) improved prediction of AF progression vs. HATCH score (p = 0.0225). In patients without permanent AF, progression of AF was independently associated with age, LA dilation, AF symptoms severity, antiarrhythmic drugs and valvular disease. Adding LA dilation (moderate–severe volume increase) to clinical scores improved prediction of progression to permanent AF.

2021 - Beyond the 2020 guidelines on atrial fibrillation of the European society of cardiology [Articolo su rivista]
Boriani, G.; Vitolo, M.; Lane, D. A.; Potpara, T. S.; Lip, G. Y.
abstract

The most recent atrial fibrillation (AF) guidelines delivered by European Society of Cardiology (ESC) offer an updated approach to AF management, with the perspective of improved characterization of the arrhythmia, the cardiac substrate and the patients profile in terms of associated risk factors and comorbidities. Recommendations were based on careful scrutiny and assessment of all available evidence with the final aim to offer to practitioners a lower level of uncertainty in the complex process of decision making for patients with AF. The 2020 ESC guidelines on AF propose a paradigm shift in the clinical approach to AF patients, moving from a single-domain AF classification to comprehensive characterization of AF patients. Given the complex nature of AF, an integrated holistic management of AF patients is suggested by the guidelines for improving patients outcomes through the formal introduction of the CC (Confirm AF and Characterize AF) to ABC (Atrial fibrillation Better Care) pathway. In line with this concept, these new guidelines underline the importance of a more comprehensive management of AF patients which should not be limited to simply prescribe oral anticoagulation or decide between a rhythm or rate control strategy. Indeed, each step of the ABC pathway represents one of the pivotal pillars in the management of AF and only a holistic approach has the potential to improve patients’ outcomes. In this review we will discuss the background that supports some of the new recommendations of 2020 ESC guidelines, with important implications for daily management of AF patients.

2021 - Biomarkers in atrial fibrillation: A constant search for simplicity, practicality, and cost-effectiveness [Articolo su rivista]
Boriani, G.; Valenti, A. C.; Vitolo, M.
abstract

2021 - COVID-19 pandemic: complex interactions with the arrhythmic profile and the clinical course of patients with cardiovascular disease [Articolo su rivista]
Boriani, Giuseppe; Vitolo, Marco
abstract

2021 - Cardiac resynchronization therapy: variations across Europe in implant rates and types of implanted devices [Articolo su rivista]
Boriani, G.; Imberti, J. F.; Bonini, N.; Vitolo, M.
abstract

2021 - Catheter ablation as first-line treatment for paroxysmal atrial fibrillation: A systematic review and meta-analysis [Articolo su rivista]
Imberti, J. F.; Ding, W. Y.; Kotalczyk, A.; Zhang, J.; Boriani, G.; Lip, G.; Andrade, J.; Gupta, D.
abstract

Objective: To assess the efficacy and safety of catheter ablation (CA) compared with antiarrhythmic drugs (AADs) as first-line treatment for symptomatic paroxysmal atrial fibrillation (AF). Methods: Systematic review and meta-analysis of randomised controlled trials identified using MEDLINE, Cochrane Library and Embase published between 01/01/2000 and 19/03/2021. The primary efficacy endpoint was the first documented recurrence of atrial arrhythmias following the blanking period. The primary safety endpoint was a composite of all serious adverse events (SAEs). Results: From 441 records, 6 studies met the inclusion criteria. 609 patients received CA, while 603 received AAD therapy. 212/609 patients in the CA group had a recurrence of atrial arrhythmias as compared with 318/603 in the AADs group resulting in a 36% relative risk reduction (risk ratio: 0.64, 95% CI 0.51 to 0.80, p<0.01). The risk of all SAEs was not statistically different between CA and AAD (0.87, 0.58 to 1.30, p=0.49); 107/609 SAE in the CA group vs 126/603 in the AAD group. Both recurrence of symptomatic atrial arrhythmias (109/505 vs 186/504) and healthcare utilisation (126/397 vs 185/394) were significantly lower in the CA group (0.53, 0.35 to 0.79 and 0.65, 0.48 to 0.89, respectively). There was a 79% reduction in the crossover rate during follow-up among patients randomised to CA compared with AAD (0.21, 0.13 to 0.32, p<0.01). Conclusions: First-line treatment with CA is superior to AAD therapy in patients with symptomatic paroxysmal AF, as it significantly reduces the recurrence of any atrial arrhythmias and symptomatic atrial arrhythmias, and healthcare resource utilisation with comparable safety profile.

2021 - Characterization of atrial fibrillation in real-world patients: testing the 4S-AF scheme in the Spanish and French cohorts of the EORP-AF Long-Term General Registry [Articolo su rivista]
Rivera-Caravaca, José Miguel; Piot, Olivier; Roldán-Rabadán, Inmaculada; Denis, Arnaud; Anguita, Manuel; Mansourati, Jacques; Pérez-Cabeza, Alejandro; Marijon, Eloi; García-Seara, Javier; Leclercq, Christophe; García-Bolao, Ignacio; Lellouche, Nicolas; Potpara, Tatjana; Boriani, Giuseppe; Fauchier, Laurent; Lip, Gregory Y H; Marín, Francisco
abstract

The 4S-AF scheme [Stroke risk, Symptom severity, Severity of atrial fibrillation (AF) burden, Substrate severity] has recently been described as a novel approach to in-depth characterization of AF. We aim to determine if the 4S-AF scheme would be useful for AF characterization and provides prognostic information in real-world AF patients.

2021 - Clinical Factors Associated with Atrial Fibrillation Detection on Single-Time Point Screening Using a Hand-Held Single-Lead ECG Device [Articolo su rivista]
Boriani, Giuseppe; Palmisano, Pietro; Malavasi, Vincenzo Livio; Fantecchi, Elisa; Vitolo, Marco; Bonini, Niccolo’; Imberti, Jacopo F.; Valenti, Anna Chiara; Schnabel, Renate B.; Freedman, Ben
abstract

Our aim was to assess the prevalence of unknown atrial fibrillation (AF) among adults during single-time point rhythm screening performed during meetings or social recreational activities organized by patient groups or volunteers. A total of 2814 subjects (median age 68 years) underwent AF screening by a handheld single-lead ECG device (MyDiagnostick). Overall, 56 subjects (2.0%) were diagnosed with AF, as a result of 12-lead ECG following a positive/suspected recording. Screening identified AF in 2.9% of the subjects >= 65 years. None of the 265 subjects aged below 50 years was found positive at AF screening. Risk stratification for unknown AF based on a CHA(2)DS(2)VASc > 0 in males and >1 in females (or CHA(2)DS(2)VA > 0) had a high sensitivity (98.2%) and a high negative predictive value (99.8%) for AF detection. A slightly lower sensitivity (96.4%) was achieved by using age >= 65 years as a risk stratifier. Conversely, raising the threshold at >= 75 years showed a low sensitivity. Within the subset of subjects aged >= 65 a CHA(2)DS(2)VASc > 1 in males and >2 in females, or a CHA(2)DS(2)VA > 1 had a high sensitivity (94.4%) and negative predictive value (99.3%), while age >= 75 was associated with a marked drop in sensitivity for AF detection.

2021 - Clinical Value of Complex Echocardiographic Left Ventricular Hypertrophy Classification Based on Concentricity, Mass, and Volume Quantification [Articolo su rivista]
Barbieri, Andrea; Albini, Alessandro; Maisano, Anna; De Mitri, Gerardo; Camaioni, Giovanni; Bonini, Niccolò; Mantovani, Francesca; Boriani, Giuseppe
abstract

Echocardiography is the most validated, non-invasive and used approach to assess left ventricular hypertrophy (LVH). Alternative methods, specifically magnetic resonance imaging, provide high cost and practical challenges in large scale clinical application. To include a wide range of physiological and pathological conditions, LVH should be considered in conjunction with the LV remodeling assessment. The universally known 2-group classification of LVH only considers the estimation of LV mass and relative wall thickness (RWT) to be classifying variables. However, knowledge of the 2-group patterns provides particularly limited incremental prognostic information beyond LVH. Conversely, LV enlargement conveys independent prognostic utility beyond LV mass for incident heart failure. Therefore, a 4-group LVH subdivision based on LV mass, LV volume, and RWT has been recently suggested. This novel LVH classification is characterized by distinct differences in cardiac function, allowing clinicians to distinguish between different LV hemodynamic stress adaptations in various cardiovascular diseases. The new 4-group LVH classification has the advantage of optimizing the LVH diagnostic approach and the potential to improve the identification of maladaptive responses that warrant targeted therapy. In this review, we summarize the current knowledge on clinical value of this refinement of the LVH classification, emphasizing the role of echocardiography in applying contemporary proposed indexation methods and partition values.

2021 - Clinical and electrocardiographic characteristics at admission of COVID-19/SARS-CoV2 pneumonia infection [Articolo su rivista]
Denegri, A.; Pezzuto, G.; D'Arienzo, M.; Morelli, M.; Savorani, F.; Cappello, C. G.; Luciani, A.; Boriani, G.
abstract

Background: The aim of the present study was to compare clinical and electrocardiographic characteristics of patients with COVID-19 pneumonia in Modena, Emilia Romagna, Italy. Methods: Patients admitted to the emergency department for suspected COVID-19 pneumonia from March the 16th to April the 15th were enrolled in the study. COVID-19 pneumonia was confirmed by positive nasopharyngeal swab. Primary endpoint was 30-day mortality. Results: 201 patients were diagnosed with COVID-19 pneumonia. Compared to survivors, patients who died were older (79.7 ± 10.8 vs 65.6 ± 14.1, p < 0.001), with a more complex cardiovascular history, including coronary artery disease (CAD, 33.3% vs 13.3%, p = 0.004), atrial fibrillation (23.8 vs 8.8, p = 0.011) and chronic kidney disease (CKD 35.7% vs 7.0%, p < 0.001). 30-day mortality was 20,9% in these patients; atrial fibrillation (OR 12.74, 95% CI 3.65–44.48, p < 0.001), ST-segment depression (OR 5.30, 95% CI 1.50–18.81, p = 0.010) and QTc-interval prolongation (OR 3.17, 95% CI 1.24–8.10, p = 0.016) at ECG admission were associated to an increased mortality risk. On the contrary, sinus rhythm (OR 0.08, 95% CI 0.02–0.27, p < 0.001) and low-molecular weight heparin (LMWH) administration (OR 0.08, 95% CI 0.02–0.29, p < 0.001) were related to reduced mortality. At multivariate analysis, after adjustment for age, sex, diabetes, CAD, and MCA admission, sinus rhythm (HR 2.7, CI 95% 1.1–7.0, p = 0.038) and LMWH (HR 8.5, 95% CI 2.0–36.6, p = 0.004) were confirmed to be independent predictors of increased survival. Conclusion: Sinus rhythm at ECG admission in COVID-19 pneumonia patients was associated with greater survival as well as LMWH administration, which conferred an overall better outcome.

2021 - Clinical management of electrical storm: a current overview [Articolo su rivista]
Guarracini, Fabrizio; Casella, Michela; Muser, Daniele; Barbato, Gaetano; Notarstefano, Pasquale; Sgarito, Giuseppe; Marini, Massimiliano; Grandinetti, Giuseppe; Mariani, Marco V.; Boriani, Giuseppe; Ricci, Renato P.; De Ponti, Roberto; Lavalle, Carlo
abstract

The number of patients affected by electrical storm has been continuously increasing in emergency departments. Patients are often affected by multiple comorbidities requiring multidisciplinary interventions to achieve a clinical stability. Careful reprogramming of cardiac devices, correction of electrolyte imbalance, knowledge of underlying heart disease and antiarrhythmic drugs in the acute phase play a crucial role. The aim of this review is to provide a comprehensive overview of pharmacological treatment, latest transcatheter ablation techniques and advanced management of patients with electrical storm.

2021 - Clinical phenotype classification of atrial fibrillation patients using cluster analysis and associations with trial-adjudicated outcomes [Articolo su rivista]
Vitolo, M.; Proietti, M.; Shantsila, A.; Boriani, G.; Lip, G. Y. H.
abstract

Background and purpose: Given the great clinical heterogeneity of atrial fibrillation (AF) patients, conventional classification only based on disease subtype or arrhythmia patterns may not adequately characterize this population. We aimed to identify different groups of AF patients who shared common clinical phenotypes using cluster analysis and evaluate the association between identified clusters and clinical outcomes. Methods: We performed a hierarchical cluster analysis in AF patients from AMADEUS and BOREALIS trials. The primary outcome was a composite of stroke/thromboembolism (TE), cardiovascular (CV) death, myocardial infarction, and/or all-cause death. Individual components of the primary outcome and major bleeding were also assessed. Results: We included 3980 AF patients treated with the Vitamin-K Antagonist from the AMADEUS and BOREALIS studies. The analysis identified four clusters in which patients varied significantly among clinical characteristics. Cluster 1 was characterized by patients with low rates of CV risk factors and comorbidities; Cluster 2 was characterized by patients with a high burden of CV risk factors; Cluster 3 consisted of patients with a high burden of CV comorbidities; Cluster 4 was characterized by the highest rates of non-CV comorbidities. After a mean follow-up of 365 (standard deviation 187) days, Cluster 4 had the highest cumulative risk of outcomes. Compared with Cluster 1, Cluster 4 was independently associated with an increased risk for the composite outcome (hazard ratio (HR) 2.43, 95% confidence interval (CI) 1.70–3.46), all-cause death (HR 2.35, 95% CI 1.58–3.49) and major bleeding (HR 2.18, 95% CI 1.19–3.96). Conclusions: Cluster analysis identified four different clinically relevant phenotypes of AF patients that had unique clinical characteristics and different outcomes. Cluster analysis highlights the high degree of heterogeneity in patients with AF, suggesting the need for a phenotype-driven approach to comorbidities, which could provide a more holistic approach to management aimed to improve patients’ outcomes.

2021 - Cognitive impairment in patients with atrial fibrillation: Implications for outcome in a cohort study [Articolo su rivista]
Malavasi, Vincenzo Livio; Zoccali, Cristina; Brandi, Maria Chiara; Micali, Giulia; Vitolo, Marco; Imberti, Jacopo Francesco; Mussi, Chiara; Schnabel, Renate B; Freedman, Ben; Boriani, Giuseppe
abstract

The impact of cognitive status on outcomes of patients with atrial fibrillation (AF) is not well defined.

2021 - Cohort profile The ESC EURObservational Research Programme Atrial Fibrillation III (AF III) Registry [Articolo su rivista]
Potpara, Tatjana S; Lip, Gregory Y H; Dagres, Nikolaos; Crijns, Harry J M G; Boriani, Giuseppe; Kirchhof, Paulus; Arbelo, Elena; Savelieva, Irina; Lenarczyk, Radoslaw; Fauchier, Laurent; Maggioni, Aldo P; Gale, Chris P
abstract

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP)-Atrial Fibrillation (AF) III Registry aims to identify contemporary patterns in AF management in clinical practice, assess their compliance with the 2016 ESC AF Guidelines, identify major gaps in guideline implementation, characterize the clinical practice settings associated with good versus poor guideline implementation and assess and compare the 1-year outcome of guideline-adherent versus guideline non-adherent management strategies.

2021 - Comparing outcomes in asymptomatic and symptomatic atrial fibrillation: A systematic review and meta-analysis of 81,462 patients [Articolo su rivista]
Sgreccia, D.; Manicardi, M.; Malavasi, V. L.; Vitolo, M.; Valenti, A. C.; Proietti, M.; Lip, G. Y. H.; Boriani, G.
abstract

Background: In atrial fibrillation (AF) patients, the presence of symptoms can guide the decision between rate or rhythm control therapy, but it is still unclear if AF-related outcomes are determined by symptomatic status of their clinical presentation. Methods: We performed a systematic review and metanalysis following the PRISMA recommendations on available studies that compared asymptomatic to symptomatic AF reporting data on all-cause mortality, cardiovascular death, and thromboembolic events (TEs). We included studies with a total number of patients enrolled equal to or greater than 200, with a minimum follow-up period of six months. Results: From the initial 5476 results retrieved after duplicates’ removal, a total of 10 studies were selected. Overall, 81,462 patients were included, of which 21,007 (26%) were asymptomatic, while 60,455 (74%) were symptomatic. No differences were found between symptomatic and asymptomatic patients regarding the risks of all-cause death (odds ratio (OR) 1.03, 95% confidence interval (CI) 0.81–1.32), and cardiovascular death (OR 0.87, 95% CI 0.54–1.39). No differences between symptomatic and asymptomatic groups were evident for stroke (OR 1.22, 95% CI 0.77–1.93) and stroke/TE (OR 1.06, 95% CI 0.86–1.31) risks. Conclusions: Mortality and stroke/TE events in AF patients were unrelated to symptomatic status of their clinical presentation. Adoption of management strategies in AF patients should not be based on symptomatic clinical status.

2021 - Comparison of HAS-BLED and ORBIT Bleeding Risk Scores in AF Patients treated with NOACs: A Report from the ESC-EHRA EORP-AF General Long-Term Registry [Articolo su rivista]
Proietti, Marco; Romiti, Giulio Francesco; Vitolo, Marco; Potpara, Tatjana S; Boriani, Giuseppe; Lip, Gregory Y H
abstract

Introduction: Bleeding risk assessment is recommended in guidelines for the management of atrial fibrillation (AF). HAS-BLED score was proposed prior to non-vitamin K antagonist oral anticoagulants (NOACs) and has been suggested that the ORBIT score may be superior in predicting bleeds in NOAC users. We aimed to compare the HAS-BLED and ORBIT scores in contemporary AF patients treated with NOACs. Methods and results: We analyzed patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. HAS-BLED and ORBIT scores were computed based on original schemes. The primary outcome was the occurrence of Major Bleeding (MB). A total of 3018 patients (median age 70; 39.6% females) were included: median [IQR] HAS-BLED and ORBIT scores were 1 [1-2] and 1 [0-2], respectively; 356 (11.8%) patients were at high risk for MB using HAS-BLED (≥3) and 123 (4.1%) using ORBIT (≥4). Overall, 60 (2.0%) MB events were recorded, with an incidence of 1.1 per 100 patient-years.Both HAS-BLED and ORBIT were associated with outcome, modestly predicting MB (AUC 0.653, 95% CI 0.593-0.714 and AUC 0.601, 95% CI 0.526-0.677, respectively). Calibration plots showed that both scores were poorly calibrated, particularly the ORBIT score, which showed consistent poorer calibration. Time-dependent reclassification analysis showed a trend towards incorrect lower risk reclassification using ORBIT compared to HAS-BLED. Conclusion: In this real-life contemporary cohort of AF patients treated with NOACs, the ORBIT score did not provide reclassification improvement, showing even poorer calibration compared to HAS-BLED. Our findings do not support the preferential use of ORBIT in NOAC-treated AF patients.

2021 - Contemporary management of patients with atrial fibrillation in the Netherlands and Belgium: a report from the EORP-AF long-term general registry [Articolo su rivista]
Erkuner, O.; van Eck, M.; Xhaet, O.; Verheij, H.; Neefs, J.; Duygun, A.; Nijmeijer, R.; Said, S. A. M.; Uiterwaal, H.; Hagens, V.; Bhagwandien, R.; Szili-Torok, T.; Bijsterveld, N.; Tjeerdsma, G.; Vijgen, J.; Friart, A.; Hoffer, E.; Evrard, P.; Srynger, M.; Meeder, J.; de Groot, J. R.; van Opstal, J.; Gevers, R.; Lip, G. Y. H.; Boriani, G.; Crijns, H. J. G. M.; Luermans, J. G. L. M.; Mairesse, G. H.
abstract

Background: Contemporary data regarding the characteristics, treatment and outcomes of patients with atrial fibrillation (AF) are needed. We aimed to assess these data and guideline adherence in the EURObservational Research Programme on Atrial Fibrillation (EORP-AF) long-term general registry. Methods: We analysed 967 patients from the EORP-AF long-term general registry included in the Netherlands and Belgium from 2013 to 2016. Baseline and 1‑year follow-up data were gathered. Results: At baseline, 887 patients (92%) received anticoagulant treatment. In 88 (10%) of these patients, no indication for chronic anticoagulant treatment was present. A rhythm intervention was performed or planned in 52 of these patients, meaning that the remaining 36 (41%) were anticoagulated without indication. Forty patients were not anticoagulated, even though they had an indication for chronic anticoagulation. Additionally, 63 of the 371 patients (17%) treated with a non-vitamin K antagonist oral anticoagulant (NOAC) were incorrectly dosed. In total, 50 patients (5%) were overtreated and 89 patients (9%) were undertreated. However, the occurrence of major adverse cardiac and cerebrovascular events (MACCE) was still low with 4.2% (37 patients). Conclusions: Overtreatment and undertreatment with anticoagulants are still observable in 14% of this contemporary, West-European AF population. Still, MACCE occurred in only 4% of the patients after 1 year of follow-up.

2021 - Corrigendum to: 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC (Eur Heart J (2021) 42 (373–498) DOI: 10.1093/eurheartj/ehaa612) [Articolo su rivista]
Hindricks, G.; Potpara, T.; Dagres, N.; Arbelo, E.; Bax, J. J.; Blomstrom-Lundqvist, C.; Boriani, G.; Castella, M.; Dan, G. -A.; Dilaveris, P. E.; Fauchier, L.; Filippatos, G.; Kalman, J. M.; La Meir, M.; Lane, D. A.; Lebeau, J. -P.; Lettino, M.; Lip, G. Y. H.; Pinto, F. J.; Thomas, G. N.; Valgimigli, M.; Van Gelder, I. C.; Van Putte, B. P.; Watkins, C. L.
abstract

Supplementary Table 9, column 'Edoxaban', row 'eGFR category', '95 mL/min' (page 15). The cell should be coloured green instead of yellow. It should also read "60 mg"instead of "60 mg (use with caution in 'supranormal' renal function)."In the above-indicated cell, a footnote has also been added to state: "Edoxaban should be used in patients with high creatinine clearance only after a careful evaluation of the individual thromboembolic and bleeding risk."Supplementary Table 9, column 'Edoxaban', row 'Dose reduction in selected patients' (page 16). The cell should read "Edoxaban 60 mg reduced to 30 mg once daily if any of the following: creatinine clearance 15-50 mL/min, body weight <60 kg, concomitant use of dronedarone, erythromycin, ciclosporine or ketokonazole"instead of "Edoxaban 60 mg reduced to 30 mg once daily, and edoxaban 30 mg reduced to 15mg once daily, if any of the following: creatinine clearance of 30-50 mL/min, body weight <60 kg, concomitant us of verapamil or quinidine or dronedarone."

2021 - Cost-Effectiveness Analyses of an Absorbable Antibacterial Envelope for Use in Patients at Increased Risk of Cardiac Implantable Electronic Device Infection in Germany, Italy, and England [Articolo su rivista]
Boriani, G.; Kennergren, C.; Tarakji, K. G.; Wright, D. J.; Ahmed, F. Z.; Mccomb, J. M.; Goette, A.; Blum, T.; Biffi, M.; Green, M.; Shore, J.; Carion, P. L.; Wilkoff, B. L.
abstract

Objectives: To model the cost-effectiveness of the TYRX Absorbable Antibacterial Envelope when used in patients at increased risk of cardiac implantable electronic device (CIED) infection in the context of 3 European healthcare systems: Germany, Italy, and England. Methods: A decision tree model with a lifetime horizon was populated using data from the Worldwide Randomized Antibiotic Envelope Infection Prevention Trial, a large multicenter randomized controlled trial. Use of the antibacterial envelope adjunctive to standard of care was compared to standard of care infection prevention alone. Patients in the model were divided into subgroups based on presence of factors known to increase infection risk. Results: The antibacterial envelope had the most favorable cost-effectiveness profile when patients had previously experienced CIED infection, had a history of immunosuppressive therapy, or had a Prevention of Arrhythmia Device Infection Trial (PADIT) score indicating high risk of infection (scores ≥6) at cost-effectiveness thresholds of €50 000 in Germany (assumed in the absence of an official threshold), €40 000 in Italy, and £30 000 in England. Probabilistic sensitivity analysis indicated that the antibacterial envelope was likely to be cost-effective in patients with other risk factors (including replacement of high power CIEDs, generator replacement with lead modification, and PADIT scores indicating intermediate risk of infection) when used with some device types and in some countries. Conclusions: The absorbable antibacterial envelope was associated with cost-effectiveness ratios below European benchmarks in selected patients at increased risk of infection, suggesting the envelope provides value for European healthcare systems by reducing CIED infections.

2021 - Cost-minimization analysis of a wearable cardioverter defibrillator in adult patients undergoing ICD explant procedures: Clinical and economic implications [Articolo su rivista]
Boriani, G.; Mantovani, L. G.; Cortesi, P. A.; De Ponti, R.; D'Onofrio, A.; Arena, G.; Curnis, A.; Forleo, G.; Guerra, F.; Porcu, M.; Sgarito, G.; Botto, G. L.
abstract

Aims: Patients with permanently increased risk of sudden cardiac death (SCD) can be protected by implantable cardioverter defibrillators (ICD). If an ICD must be removed due to infection, for example, immediate reimplantation might not be possible or indicated. The wearable cardioverter defibrillator (WCD) is an established, safe and effective solution to protect patients from SCD during this high-risk bridging period. Very few economic evaluations on WCD use are currently available. Methods: We conducted a systematic review to evaluate the available evidence of WCD in patients undergoing ICD explant/lead extraction. Additionally, a decision model was developed to compare use and costs of the WCD with standard therapy (in-hospital stay). For this purpose, a cost-minimization analysis was conducted, and complemented by a one-way sensitivity analysis. Results: In the base case scenario, the WCD was less expensive compared to standard therapy. The cost-minimization analysis showed a cost reduction of €1782 per patient using the WCD. If costs of standard care were changed, cost savings associated with the WCD varied from €3500 to €0, assuming costs for standard care of €6800 to €3600. Conclusion: After ICD explantation, patients can be safely and effectively protected from SCD after hospital discharge through WCD utilization. Furthermore, the use of a WCD for this patient group is cost saving when compared to standard therapy.

2021 - Device-detected atrial high rate episodes and the risk of stroke/thrombo-embolism and atrial fibrillation incidence: a systematic review and meta-analysis [Articolo su rivista]
Vitolo, M.; Imberti, J. F.; Maisano, A.; Albini, A.; Bonini, N.; Valenti, A. C.; Malavasi, V. L.; Proietti, M.; Healey, J. S.; Lip, G. Y.; Boriani, G.
abstract

Background: Atrial High Rate Episodes (AHRE) are asymptomatic atrial tachy-arrhythmias detected through continuous monitoring with a cardiac implantable electronic device. The risks of stroke/Thromboembolic (TE) events and incident clinical Atrial Fibrillation (AF) associated with AHRE varies markedly. Objectives: To assess the relationship between AHRE and TE events, and between AHRE and incident clinical AF. Methods: This systematic review and meta-analysis was conducted following the PRISMA recommendations. PubMed, Scopus, and Google Scholar were searched from inception to 18/02/2021 for studies reporting TE events and incident clinical AF in patients with AHRE, as compared with patients without. Results: Ten out of 8081 records fulfilled the inclusion criteria, for a total of 37 266 patients. Seven out of ten studies excluded patients with prior history of clinical AF (4961 patients), embracing the most recent definition of AHRE. The risk ratio (RR) for TE events in AHRE patients was 2.13 (95% CI: 1.53–2.95, I2: 0%). The incidence of clinical AF was reported in four studies excluding patients with a history of clinical AF (3574 patients). The RR for incident clinical AF was 3.34 (95%CI: 1.89–5.90, I2: 73%). Conclusions: AHRE are significantly associated with systemic thromboembolism and incident clinical AF. Further studies are needed to improve patients' risk stratification and management.

2021 - Digital literacy as a potential barrier to implementation of cardiology tele-visits after COVID-19 pandemic: The INFO-COVID survey [Articolo su rivista]
Boriani, G.; Maisano, A.; Bonini, N.; Albini, A.; Imberti, J. F.; Venturelli, A.; Menozzi, M.; Ziveri, V.; Morgante, V.; Camaioni, G.; Passiatore, M.; de Mitri, G.; Nanni, G.; Girolami, D.; Fontanesi, R.; Siena, V.; Sgreccia, D.; Malavasi, V. L.; Valenti, A. C.; Vitolo, M.
abstract

BACKGROUND During the COVID-19 pandemic, the implementation of telemedicine has represented a new potential option for outpatient care. The aim of our study was to evaluate digital literacy among cardiology outpatients. METHODS From March to June 2020, a survey on telehealth among cardiology outpatients was performed. Digital literacy was investigated through six main domains: age; sex; educational level; internet access; availability of internet sources; knowledge and use of teleconference software programs. RESULTS The study included 1 067 patients, median age 70 years, 41.3% females. The majority of the patients (58.0%) had a secondary school degree, but among patients aged ≥ 75 years old the most represented educational level was primary school or none. Overall, for internet access, there was a splitting between “never” (42.1%) and “every day” (41.0%), while only 2.7% answered “at least 1/month” and 14.2% “at least 1/week”. In the total population, the most used devices for internet access were smartphones (59.0%), and WhatsApp represented the most used app (57.3%). Internet users were younger compared to non-internet users (63 vs. 78 years old, respectively) and with a higher educational level. Age and educational level were associated with non-use of internet (age-per 10-year increase odds ratio (OR) = 3.07, 95% CI: 2.54−3.71, secondary school OR = 0.18, 95% CI: 0.12−0.26, university OR = 0.05, 95% CI: 0.02−0.10). CONCLUSIONS Telemedicine represents an appealing option to implement medical practice, and for its development it is important to address the gaps in patients’ digital skills, with age and educational level being key factors in this setting.

2021 - Echocardiographic Left Ventricular Mass Assessment: Correlation between 2D-Derived Linear Dimensions and 3-Dimensional Automated, Machine Learning-Based Methods in Unselected Patients [Articolo su rivista]
Barbieri, Andrea; Bursi, Francesca; Camaioni, Giovanni; Maisano, Anna; Imberti, Jacopo Francesco; Albini, Alessandro; De Mitri, Gerardo; Mantovani, Francesca; Boriani, Giuseppe
abstract

A recently developed algorithm for 3D analysis based on machine learning (ML) principles detects left ventricular (LV) mass without any human interaction. We retrospectively studied the correlation between 2D-derived linear dimensions using the ASE/EACVI-recommended formula and 3D automated, ML-based methods (Philips HeartModel) regarding LV mass quantification in unselected patients undergoing echocardiography. We included 130 patients (mean age 60 +/- 18 years; 45% women). There was only discrete agreement between 2D and 3D measurements of LV mass (r = 0.662, r(2) = 0.348, p < 0.001). The automated algorithm yielded an overestimation of LV mass compared to the linear method (Bland-Altman positive bias of 13.1 g with 95% limits of the agreement at 4.5 to 21.6 g, p = 0.003, ICC 0.78 (95%CI 0.68-8.4). There was a significant proportional bias (Beta -0.22, t = -2.9) p = 0.005, the variance of the difference varied across the range of LV mass. When the published cut-offs for LV mass abnormality were used, the observed proportion of overall agreement was 77% (kappa = 0.32, p < 0.001). In consecutive patients undergoing echocardiography for any indications, LV mass assessment by 3D analysis using a novel ML-based algorithm showed systematic differences and wide limits of agreements compared with quantification by ASE/EACVI- recommended formula when the current cut-offs and partition values were applied.

2021 - Edoxaban versus Warfarin in Patients with Atrial Fibrillation at the Extremes of Body Weight: An Analysis from the ENGAGE AF-TIMI 48 Trial [Articolo su rivista]
Boriani, G.; Ruff, C. T.; Kuder, J. F.; Shi, M.; Lanz, H. J.; Antman, E. M.; Braunwald, E.; Giugliano, R. P.
abstract

Background The effects of anticoagulants at extremes of body weight (BW) are not well described. The aim of this study was to analyze the pharmacokinetics/pharmacodynamics and clinical outcomes in patients randomized to warfarin, higher dose edoxaban (HDER), and lower dose edoxaban (LDER) regimens at extremes of BW in ENGAGE AF-TIMI 48. Methods and Results We analyzed three BW groups: low BW (LBW: <5th percentile, ≤55 kg, N = 1,082), middle BW (MBW: 45th-55th percentile, 79.8-84 kg, N = 2,153), and high BW (HBW: >95th percentile, ≥120 kg, N = 1,093). In the warfarin arm, LBW patients had higher rates of stroke/systemic embolism (SSE: 6.5 vs. 4.7 in MBW vs. 1.6% in HBW, P trend < 0.001), major bleeding (MB: 9.3 vs. 7.7 vs. 6.5%, P trend = 0.08), and worse net clinical outcome of systemic embolic event, MB, or death (31.5 vs. 19.1 vs. 16.0%, P trend < 0.0001). The time-in-therapeutic range with warfarin was lowest in LBW patients (63.0 vs. 69.3 vs. 70.1% patients, P trend < 0.001). The pharmacokinetic/pharmacodynamic profile of edoxaban was consistent across BW groups. The risk of SSE was similar between HDER and warfarin for each of the three weight groups (P int = 0.52, P int-trend = 0.86). MB was reduced by LDER versus warfarin (P int = 0.061, P int-trend = 0.023), especially in LBW patients. Net clinical outcomes were improved by HDER versus warfarin (P int = 0.087, P int-trend = 0.027), especially in LBW patients. Conclusion Patients with LBW in ENGAGE AF-TIMI 48 had in general a more fragile clinical status and poorer international normalized ratio control. The pharmacokinetic/pharmacodynamic profile of edoxaban was consistent across extremes of BW, resulting in similar efficacy compared with warfarin, while major or clinically relevant non-MB and net outcomes were most favorable with edoxaban as compared to warfarin in LBW patients.

2021 - Effects of sildenafil on right ventricle remodelling in Portopulmonary hypertension [Articolo su rivista]
Rossi, R.; Talarico, M.; Schepis, F.; Coppi, F.; Sgura, F. A.; Monopoli, D. E.; Minici, R.; Boriani, G.
abstract

Portopulmonary hypertension (PoPH) is a clinical condition associated with end‐stage liver disease, described by the coexistence of pulmonary arterial hypertension (PAH) and portal hypertension. In PoPH patients, there is a right ventricle (RV) remodeling to compensate for the increased resistance in the lung circulation. There are no studies on the effects of the PAH-targeted pharmacological treatment on the RV dimension and function. The present study summarizes our experience in patients with PoPH treated with sildenafil in a period of 6 years (from 2013 to 2019). We enrolled 64 consecutive patients identified as PoPH, all treated with sildenafil (57.6% in monotherapy; in the other cases in association with macitentan; in 19.0% with initial combination therapy). A hemodynamic invasive cardiopulmonary study was performed at baseline and after 6 months of sildenafil treatment. In our population we showed a significative improvement in RV performance, with a significant increase in RV stroke volume (+33%), RV ejection fraction (+31%) and RV stroke work index (+17.5%). We registered the reduction of the RV cavity dimension over time in all patients treated with sildenafil (RV end diastolic diameter decreased by 15% after 6 months of follow-up). Regarding diastolic function, we highlighted a very significant reduction in RV end-diastolic pressure (−50% concerning baseline). Sildenafil was effective both when used as monotherapy and in combination with macitentan. In conclusion, Sildenafil had a positive impact on RV systolic and diastolic function in patients with PoPH and was able to conditionate the reverse remodeling of the RV.

2021 - Estimate and reporting of longevity for cardiac implantable electronic devices: a proposal for standardized criteria [Articolo su rivista]
Censi, F.; Calcagnini, G.; Mattei, E.; Ricci, R. P.; Zoni Berisso, M.; Landolina, M.; Boriani, G.
abstract

Background: Cardiac implantable electronic devices (CIEDs) are widely used according to consensus guidelines in various patient categories. The longevity of CIED is a major determinant of the frequency with which patients require device replacement. Given the mismatch between the useful life of the devices and patient survival, device replacement is often needed. There is a great variability in the criteria used by manufacturers to determine the longevity of pacemakers (PM), implantable defibrillators (ICDs), and devices for cardiac resynchronization therapy (CRT). Thus, a fair comparison and an effective device evaluation is often difficult. Methods: The objective of this paper is to provide standardized criteria based on typical clinical settings for estimating the longevity of single and dual chamber ICDs, cardiac resynchronization defibrillators (CRT-D), single and dual chamber PMs, and cardiac resynchronization PMs (CRT- P) to be used in health technology assessment for an appropriate comparison among different devices. Results: The proposed parameters, if applied to the current marketed devices, provide longevity values in the range 5–17.2 years. Conclusion: The values of longevity with the non-standardized criteria used by the manufacturers result in higher maximum values respect to the proposed standardized criteria for CRT-D, CRTD-MPP, CRT-P, and Dual-chamber PM.

2021 - Evaluation and management of cancer patients presenting with acute cardiovascular disease: a Consensus Document of the Acute CardioVascular Care (ACVC) association and the ESC council of Cardio-Oncology-Part 1: acute coronary syndromes and acute pericardial diseases [Articolo su rivista]
Gevaert, Sofie A; Halvorsen, Sigrun; Sinnaeve, Peter R; Sambola, Antonia; Gulati, Geeta; Lancellotti, Patrizio; Van Der Meer, Peter; Lyon, Alexander R; Farmakis, Dimitrios; Lee, Geraldine; Boriani, Giuseppe; Wechalekar, Ashutosh; Okines, Alicia; Asteggiano, Riccardo
abstract

Advances in treatment, common cardiovascular (CV) risk factors and the ageing of the population have led to an increasing number of cancer patients presenting with acute CV diseases. These events may be related to the cancer itself or the cancer treatment. Acute cardiac care specialists must be aware of these acute CV complications and be able to manage them. This may require an individualized and multidisciplinary approach. We summarize the most common acute CV complications of cytotoxic, targeted, and immune-based therapies. This is followed by a proposal for a multidisciplinary approach where acute cardiologists work close together with the treating oncologists, haematologists, and radiation specialists, especially in situations where immediate therapeutic decisions are needed. In this first part, we further focus on the management of acute coronary syndromes and acute pericardial diseases in patients with cancer.

2021 - Grey zones in the practice of permanent cardiac pacing: The case of preventive pacing for improving rhythm control in atrial fibrillation [Articolo su rivista]
Boriani, G.; Vitolo, M.
abstract

2021 - Grupul de lucru pentru diagnosticul şi tratamentul fi brilaţiei atriale al societăţii europene de cardiologie (Esc) [Articolo su rivista]
Hindricks, G.; Potpara, T.; Dagres, N.; Arbelo, E.; Bax, J. J.; Blomstrom-Lundqvist, C.; Boriani, G.; Castella, M.; Dan, G. -A.; Dilaveris, P. E.; Fauchier, L.; Filippatos, G.; Kalman, J. M.; La Meir, M.; Lane, D. A.; Lebeau, J. -P.; Lettino, M.; Lip, G. Y. H.; Pinto, F. J.; Neil Thomas, G.; Valgimigli, M.; Van Gelder, I. C.; Van Putte, B. P.; Watkins, C. L.
abstract

2021 - High sensitivity C-reactive protein (hsCRP) and its implications in cardiovascular outcomes [Articolo su rivista]
Denegri, Andrea; Boriani, Giuseppe
abstract

Atherosclerosis and its fearsome complications represent the first cause of morbidity and mortality worldwide. Over the last two decades, several evidences have been accumulated, suggesting a central role for inflammation in atheroma development. High sensitivity C-reactive protein (hsCRP) is a well-established marker of cardiovascular (CV) disease; high levels of hsCRP have been associated with adverse CV outcome after acute coronary syndrome (ACS) and, despite some controversy, an active role for hsCRP in initiation and development of the atherosclerotic plaque has been also proposed. Randomized clinical trials focusing on hsCRP have been crucial in elucidating the anti-inflammatory effects of statin therapy. Thus, hsCRP has been progressively considered a real CV risk factor likewise to low-density lipoprotein cholesterol (LDL-C), rising the concept of residual CV inflammatory risk. Subsequent research has been designed to investigate potential new targets of atherothrombotic protection. Despite clinical usefulness of hsCRP is widely recognized, hsCRP may not represent the ideal target of specific anti-inflammatory therapies. Clinical investigations, therefore, have focused also on other inflammatory mediators, restricting hsCRP to an indicator rather than a therapeutic target. The aim of the present review is to provide an illustrative overview on the current knowledge of atherosclerosis and inflammation, highlighting the most representative clinical studies of lipid lowering- and antiinflammatory therapies focused on hsCRP in CV diseases.

2021 - How did COVID-19 affect medical and cardiology journals? A pandemic in literature [Articolo su rivista]
Venturelli, A.; Vitolo, M.; Albini, A.; Boriani, G.
abstract

BACKGROUND AND AIMS: The spreading speed of the COVID-19 pandemic forced the medical community to produce efforts in updating and sharing the evidence about this new disease, trying to preserve the accuracy of the data but at the same time avoiding the potentially harmful delay from discovery to implementation. The aim of our analysis was to assess the impact of the COVID-19 pandemic on medical literature in terms of proportion of COVID-19-related published papers and temporal patterns of publications within a sample of general/internal medicine and cardiology journals. METHODS: We searched through PubMed scientific papers published from 1 January 2020 to 31 January 2021 about COVID-19 in ten major medical journals, of which five were in general/internal medicine and five in the cardiology field. We analyzed the proportion of COVID-19-related papers, and we examined temporal trends in the number of published papers. RESULTS: Overall, the proportion of COVID-19-related papers was 18.5% (1986/10 756). This proportion was higher among the five selected general/internal medicine journals, compared with cardiology journals (23.8% vs 9.5%). The vast majority of papers were not original articles; in particular, in cardiology journals, there were 28% 'original articles', 17% 'review articles' and 55.1% 'miscellaneous', compared with 20.2%, 5.1% and 74.7% in general/internal medicine journals, respectively. CONCLUSIONS: Our analysis highlights the big impact of the COVID-19 pandemic on international scientific literature. General and internal medicine journals were mainly involved, with cardiology journals only at a later time.

2021 - Impact of Weight on Clinical Outcomes of Edoxaban Therapy in Atrial Fibrillation Patients Included in the ETNA-AF-Europe Registry [Articolo su rivista]
Boriani, Giuseppe; De Caterina, Raffaele; Manu, Marius Constantin; Souza, José; Pecen, Ladislav; Kirchhof, Paulus
abstract

Background: Extremes of body weight may alter exposure to non-vitamin K antagonist oral anticoagulants and thereby impact clinical outcomes. This ETNA-AF-Europe sub-analysis assessed 1-year outcomes in routine care patients with atrial fibrillation across a range of body weight groups treated with edoxaban. Methods: ETNA-AF-Europe is a multinational, multicentre, observational study conducted in 825 sites in 10 European countries. Overall, 1310, 5565, 4346 and 1446 enrolled patients were categorised into <= 60 kg, >60-<= 80 kg (reference weight group), >80-<= 100 kg and >100 kg groups. Results: Patients weighing <= 60 kg were older, more frail and had a higher CHA(2)DS(2)-VASc score vs. the other weight groups. The rates of stroke/systemic embolism, major bleeding and ICH were low at 1 year (0.82, 1.05 and 0.24%/year), with no significant differences among weight groups. The annualised event rates of all-cause death were 3.50%/year in the overall population. After adjustment for eGFR and CHA(2)DS(2)-VASc score, the risk of all-cause death was significantly higher in extreme weight groups vs. the reference group. Conclusions: Low rates of stroke and bleeding were reported with edoxaban, independent of weight. The risk of all-cause death was higher in extremes of weight vs. the reference group after adjustment for important risk modifiers, thus no obesity paradox was observed.

2021 - Impact of clinical phenotypes on management and outcomes in European atrial fibrillation patients: a report from the ESC-EHRA EURObservational Research Programme in AF (EORP-AF) General Long-Term Registry [Articolo su rivista]
Proietti, M.; Vitolo, M.; Harrison, S. L.; Lane, D. A.; Fauchier, L.; Marin, F.; Nabauer, M.; Potpara, T. S.; Dan, G. -A.; Boriani, G.; Lip, G. Y. H.; Boriani (Chair), G.; Lip, G. Y. H.; Tavazzi, L.; Maggioni, A. P.; Dan, G. -A.; Potpara, T.; Nabauer, M.; Marin, F.; Kalarus, Z.; Fauchier, L.; Ferrari, R.; Shantsila, A.; Goda, A.; Mairesse, G.; Shalganov, T.; Antoniades, L.; Taborsky, M.; Riahi, S.; Muda, P.; Garcia Bolao, I.; Piot, O.; Nabauer, M.; Etsadashvili, K.; Simantirakis, E. N.; Haim, M.; Azhari, A.; Najafian, J.; Santini, M.; Mirrakhimov, E.; Kulzida, K.; Erglis, A.; Poposka, L.; Burg, M. R.; Crijns, H.; Erkuner, O.; Atar, D.; Lenarczyk, R.; Martins Oliveira, M.; Shah, D.; Dan, G. -A.; Serdechnaya, E.; Potpara, T.; Diker, E.; Lip, G. Y. H.; Lane, D.; Zera, E.; Ekmekciu, U.; Paparisto, V.; Tase, M.; Gjergo, H.; Dragoti, J.; Goda, A.; Ciutea, M.; Ahadi, N.; el Husseini, Z.; Raepers, M.; Leroy, J.; Haushan, P.; Jourdan, A.; Lepiece, C.; Desteghe, L.; Vijgen, J.; Koopman, P.; Van Genechten, G.; Heidbuchel, H.; Boussy, T.; De Coninck, M.; Van Eeckhoutte, H.; Bouckaert, N.; Friart, A.; Boreux, J.; Arend, C.; Evrard, P.; Stefan, L.; Hoffer, E.; Herzet, J.; Massoz, M.; Celentano, C.; Sprynger, M.; Pierard, L.; Melon, P.; Van Hauwaert, B.; Kuppens, C.; Faes, D.; Van Lier, D.; Van Dorpe, A.; Gerardy, A.; Deceuninck, O.; Xhaet, O.; Dormal, F.; Ballant, E.; Blommaert, D.; Yakova, D.; Hristov, M.; Yncheva, T.; Stancheva, N.; Tisheva, S.; Tokmakova, M.; Nikolov, F.; Gencheva, D.; Shalganov, T.; Kunev, B.; Stoyanov, M.; Marchov, D.; Gelev, V.; Traykov, V.; Kisheva, A.; Tsvyatkov, H.; Shtereva, R.; Bakalska-Georgieva, S.; Slavcheva, S.; Yotov, Y.; Kubickova, M.; Marni Joensen, A.; Gammelmark, A.; Hvilsted Rasmussen, L.; Dinesen, P.; Riahi, S.; Krogh Veno, S.; Sorensen, B.; Korsgaard, A.; Andersen, K.; Fragtrup Hellum, C.; Svenningsen, A.; Nyvad, O.; Wiggers, P.; May, O.; Aarup, A.; Graversen, B.; Jensen, L.; Andersen, M.; Svejgaard, M.; Vester, S.; Hansen, S.; Lynggaard, V.; Ciudad, M.; Vettus, R.; Muda, P.; Maestre, A.; Castano, S.; Cheggour, S.; Poulard, J.; Mouquet, V.; Leparree, S.; Bouet, J.; Taieb, J.; Doucy, A.; Duquenne, H.; Furber, A.; Dupuis, J.; Rautureau, J.; Font, M.; Damiano, P.; Lacrimini, M.; Abalea, J.; Boismal, S.; Menez, T.; Mansourati, J.; Range, G.; Gorka, H.; Laure, C.; Vassaliere, C.; Elbaz, N.; Lellouche, N.; Djouadi, K.; Roubille, F.; Dietz, D.; Davy, J.; Granier, M.; Winum, P.; Leperchois-Jacquey, C.; Kassim, H.; Marijon, E.; Le Heuzey, J.; Fedida, J.; Maupain, C.; Himbert, C.; Gandjbakhch, E.; Hidden-Lucet, F.; Duthoit, G.; Badenco, N.; Chastre, T.; Waintraub, X.; Oudihat, M.; Lacoste, J.; Stephan, C.; Bader, H.; Delarche, N.; Giry, L.; Arnaud, D.; Lopez, C.; Boury, F.; Brunello, I.; Lefevre, M.; Mingam, R.; Haissaguerre, M.; Le Bidan, M.; Pavin, D.; Le Moal, V.; Leclercq, C.; Piot, O.; Beitar, T.; Martel, I.; Schmid, A.; Sadki, N.; Romeyer-Bouchard, C.; Da Costa, A.; Arnault, I.; Boyer, M.; Piat, C.; Fauchier, L.; Lozance, N.; Nastevska, S.; Doneva, A.; Fortomaroska Milevska, B.; Sheshoski, B.; Petroska, K.; Taneska, N.; Bakrecheski, N.; Lazarovska, K.; Jovevska, S.; Ristovski, V.; Antovski, A.; Lazarova, E.; Kotlar, I.; Taleski, J.; Poposka, L.; Kedev, S.; Zlatanovik, N.; Jordanova, S.; Bajraktarova Proseva, T.; Doncovska, S.; Maisuradze, D.; Esakia, A.; Sagirashvili, E.; Lartsuliani, K.; Natelashvili, N.; Gumberidze, N.; Gvenetadze, R.; Etsadashvili, K.; Gotonelia, N.; Kuridze, N.; Papiashvili, G.; Menabde, I.; Gloggler, S.; Napp, A.; Lebherz, C.; Romero, H.; Schmitz, K.; Berger, M.; Zink, M.; Koster, S.; Sachse, J.; Vonderhagen, E.; Soiron, G.; Mischke, K.; Reith, R.; Schneider, M.; Rieker, W.; Boscher, D.; Taschareck, A.; Beer, A.; Oster, D.; Ritter, O.; Adamczewski, J.; Walter, S.; Frommhold, A.; Luckner, E.; Richter, J.; Schellner, M.; Landgraf, S.; Bartholome, S.; Naumann, R.; Schoeler, J.; Westermeier, D.; William, F.; Wilhelm, K.; Maerkl, M.; Oekinghaus, R.; Denart, M.; Kriete, M.; Tebbe, U.; Sche
abstract

Background: Epidemiological studies in atrial fibrillation (AF) illustrate that clinical complexity increase the risk of major adverse outcomes. We aimed to describe European AF patients’ clinical phenotypes and analyse the differential clinical course. Methods: We performed a hierarchical cluster analysis based on Ward’s Method and Squared Euclidean Distance using 22 clinical binary variables, identifying the optimal number of clusters. We investigated differences in clinical management, use of healthcare resources and outcomes in a cohort of European AF patients from a Europe-wide observational registry. Results: A total of 9363 were available for this analysis. We identified three clusters: Cluster 1 (n = 3634; 38.8%) characterized by older patients and prevalent non-cardiac comorbidities; Cluster 2 (n = 2774; 29.6%) characterized by younger patients with low prevalence of comorbidities; Cluster 3 (n = 2955;31.6%) characterized by patients’ prevalent cardiovascular risk factors/comorbidities. Over a mean follow-up of 22.5 months, Cluster 3 had the highest rate of cardiovascular events, all-cause death, and the composite outcome (combining the previous two) compared to Cluster 1 and Cluster 2 (all P <.001). An adjusted Cox regression showed that compared to Cluster 2, Cluster 3 (hazard ratio (HR) 2.87, 95% confidence interval (CI) 2.27–3.62; HR 3.42, 95%CI 2.72–4.31; HR 2.79, 95%CI 2.32–3.35), and Cluster 1 (HR 1.88, 95%CI 1.48–2.38; HR 2.50, 95%CI 1.98–3.15; HR 2.09, 95%CI 1.74–2.51) reported a higher risk for the three outcomes respectively. Conclusions: In European AF patients, three main clusters were identified, differentiated by differential presence of comorbidities. Both non-cardiac and cardiac comorbidities clusters were found to be associated with an increased risk of major adverse outcomes.

2021 - Impact of covid-19 pandemic on remote monitoring of cardiac implantable electronic devices in italy: Results of a survey promoted by aiac (italian association of arrhythmology and cardiac pacing) [Articolo su rivista]
Maines, M.; Palmisano, P.; Del Greco, M.; Melissano, D.; De Bonis, S.; Baccillieri, S.; Zanotto, G.; D'onofrio, A.; Ricci, R. P.; De Ponti, R.; Boriani, G.
abstract

The COVID-19 pandemic has had a profound impact on the organisation of health care in Italy, with an acceleration in the development of telemedicine. To assess the impact of the COVID-19 pandemic on the spread of remote monitoring (RM) of cardiac implantable electronic devices (CIEDs) in Italy, a survey addressed to cardiologists operating in all Italian CIED-implanting centres was launched. A total of 127 cardiologists from 116 Italian arrhythmia centres took part in the survey, 41.0% of all 283 CIED-implanting centres operating in Italy in 2019. All participating centres declared to use RM of CIEDs. COVID-19 pandemic resulted in an increase in the use of RM in 83 (71.6%) participating centres. In a temporal perspective, an increase in the median number of patients per centre followed up by RM was found from 2012 to 2017, followed by an exponential increase from 2017 to 2020. In 36 participating centres (31.0%) a telehealth visits service was activated as a replacement for in-person outpatient visits (in patients with or without CIED) during the COVID-19 pandemic. COVID-19 pandemic has caused an acceleration in the use of RM of CIEDs and in the use of telemedicine in the clinical practice of cardiology.

2021 - Implantation of cardiac electronic devices in active COVID-19 patients: Results from an international survey [Articolo su rivista]
Tovia-Brodie, Oholi; Acha, Moshe Rav; Belhassen, Bernard; Gasperetti, Alessio; Schiavone, Marco; Forleo, Giovanni Battista; Guevara-Valdivia, Milton E; Ruiz, David Valdeolivar; Lellouche, Nicolas; Hamon, David; Castagno, Davide; Bellettini, Matteo; De Ferrari, Gaetano M; Laredo, Mikael; Carvès, Jean-Baptiste; Ignatiuk, Barbara; Pasquetto, Giampaolo; De Filippo, Paolo; Malanchini, Giovanni; Pavri, Behzad B; Raphael, Craig; Rivetti, Luigi; Mantovan, Roberto; Chinitz, Jason; Harding, Melissa; Boriani, Giuseppe; Casali, Edoardo; Wan, Elaine Y; Biviano, Angelo; Macias, Carlos; Havranek, Stepan; Lazzerini, Pietro Enea; Canu, Antonio M; Zardini, Marco; Conte, Giulio; Cano, Óscar; Casella, Michela; Rudic, Boris; Omelchenko, Alexander; Mathuria, Nilesh; Upadhyay, Gaurav A; Danon, Asaf; Schwartz, Arie Lorin; Maury, Philippe; Nakahara, Shiro; Goldenberg, Gustavo; Schaerli, Nicolas; Bereza, Sergiy; Auricchio, Angelo; Glikson, Michael; Michowitz, Yoav
abstract

Background: Cardiac implantable electronic device (CIED) implantation rates as well as the clinical and procedural characteristics and outcomes in patients with known active coronavirus disease 2019 (COVID-19) are unknown. Objective: The purpose of this study was to gather information regarding CIED procedures during active COVID-19, performed with personal protective equipment, based on an international survey. Methods: Fifty-three centers from 13 countries across 4 continents provided information on 166 patients with known active COVID-19 who underwent a CIED procedure. Results: The CIED procedure rate in 133,655 hospitalized COVID-19 patients ranged from 0 to 16.2 per 1000 patients (P <.001). Most devices were implanted due to high-degree/complete atrioventricular block (112 [67.5%]) or sick sinus syndrome (31 [18.7%]). Of the 166 patients in the study survey, the 30-day complication rate was 13.9% and the 180-day mortality rate was 9.6%. One patient had a fatal outcome as a direct result of the procedure. Differences in patient and procedural characteristics and outcomes were found between Europe and North America. An older population (76.6 vs 66 years; P <.001) with a nonsignificant higher complication rate (16.5% vs 7.7%; P = .2) was observed in Europe vs North America, whereas higher rates of critically ill patients (33.3% vs 3.3%; P <.001) and mortality (26.9% vs 5%; P = .002) were observed in North America vs Europe. Conclusion: CIED procedure rates during known active COVID-19 disease varied greatly, from 0 to 16.2 per 1000 hospitalized COVID-19 patients worldwide. Patients with active COVID-19 infection who underwent CIED implantation had high complication and mortality rates. Operators should take these risks into consideration before proceeding with CIED implantation in active COVID-19 patients.

2021 - In- and out-of-hospital mortality for myocardial infarction during the first wave of the COVID-19 pandemic in Emilia-Romagna, Italy: A population-based observational study [Articolo su rivista]
Campo, G.; Fortuna, D.; Berti, E.; De Palma, R.; Pasquale, G. D.; Galvani, M.; Navazio, A.; Piovaccari, G.; Rubboli, A.; Guardigli, G.; Galie, N.; Boriani, G.; Tondi, S.; Ardissino, D.; Piepoli, M.; Banchelli, F.; Santarelli, A.; Casella, G.
abstract

Background: The COVID-19 pandemic has put several healthcare systems under severe pressure. The present analysis investigates how the first wave of the COVID-19 pandemic affected the myocardial infarction (MI) network of Emilia-Romagna (Italy). Methods: Based on Emilia-Romagna mortality registry and administrative data from all the hospitals from January 2017 to June 2020, we analysed: i) temporal trend in MI hospital admissions; ii) characteristics, management, and 30-day mortality of MI patients; iii) out-of-hospital mortality for cardiac cause. Findings: Admissions for MI declined on February 22, 2020 (IRR -19.5%, 95%CI from -8.4% to -29.3%, p = 0.001), and further on March 5, 2020 (IRR -21.6%, 95%CI from -9.0% to -32.5%, p = 0.001). The return to pre-COVID-19 MI-related admission levels was observed from May 13, 2020 (IRR 34.3%, 95%CI 20.0%-50.2%, p<0.001). As compared to those before the pandemic, MI patients admitted during and after the first wave were younger and with fewer risk factors. The 30-day mortality remained in line with that expected based on previous years (ratio observed/expected was 0.96, 95%CI 0.84–1.08). MI patients positive for SARS-CoV-2 were few (1.5%) but showed poor prognosis (around 5-fold increase in 30-day mortality). In 2020, the number of out-of-hospital cardiac deaths was significantly higher (ratio observed/expected 1.17, 95%CI 1.08–1.27). The peak was reached in April. Interpretation: In Emilia-Romagna, MI hospitalizations significantly decreased during the first wave of the COVID-19 pandemic. Management and outcomes of hospitalized MI patients remained unchanged, except for those with SARS-CoV-2 infection. A concomitant increase in the out-of-hospital cardiac mortality was observed. Funding: None.

2021 - Infections associated with cardiac electronic implantable devices: economic perspectives and impact of the TYRX™ antibacterial envelope [Articolo su rivista]
Boriani, G.; Vitolo, M.; Wright, D. J.; Biffi, M.; Brown, B.; Tarakji, K. G.; Wilkoff, B. L.
abstract

The occurrence of cardiac implantable electronic devices (CIED) infections and related adverse outcomes have an important financial impact on the healthcare system, with hospitalization length of stay (2-3 weeks on average) being the largest cost driver, including the cost of device system extraction and device replacement accounting for more than half of total costs. In the recent literature, the economic profile of the TYRX™ absorbable antibacterial envelope was analysed taking into account both randomized and non-randomized trial data. Economic analysis found that the envelope is associated with cost-effectiveness ratios below USA and European benchmarks in selected patients at increased risk of infection. Therefore, the TYRX™ envelope, by effectively reducing CIED infections, provides value according to the criteria of affordability currently adopted by USA and European healthcare systems.

2021 - Infective endocarditis with perivalvular abscess complicated by septic embolization with acute ST-segment elevation myocardial infarction and peripheral ischemia [Articolo su rivista]
Denegri, A.; Venturelli, A.; Boriani, G.
abstract

2021 - Inhibition of lysyl oxidase stimulates TGF-β signaling and metalloproteinases-2 and -9 expression and contributes to the disruption of ascending aorta in rats: protection by propylthiouracil [Articolo su rivista]
Merico, V.; Imberti, J. F.; Zanoni, M.; Boriani, G.; Garagna, S.; Imberti, R.
abstract

Mutations in lysyl oxidase (LOX) genes cause severe vascular anomalies in mice and humans. LOX activity can be irreversibly inhibited by the administration of β-aminoproprionitrile (BAPN). We investigated the mechanisms underlying the damage to the ascending thoracic aorta induced by LOX deficiency and evaluated whether 6-propylthiouracil (PTU) can afford protection in rats. BAPN administration caused disruption of the ascending aortic wall, increased the number of apoptotic cells, stimulated TGF-β signaling (increase of nuclear p-SMAD2 staining), and up-regulated the expression of metalloproteinases-2 and -9. In BAPN-treated animals, PTU reduced apoptosis, p-SMAD2 staining, MMP-2, and -9 expression, and markedly decreased the damage to the aortic wall. Our results suggest that, as in some heritable vascular diseases, enhanced TGF-β signaling and upregulation of MMP-2 and -9 can contribute to the pathogenesis of ascending aorta damage caused by LOX deficiency. We have also shown that PTU, a drug already in clinical use, protects against the effects of LOX inhibition. MMP-2 and -9 might be potential targets of new therapeutic strategies for the treatment of vascular diseases caused by LOX deficiency.

2021 - Long-term outcomes of postoperative atrial fibrillation following non cardiac surgery: A systematic review and metanalysis [Articolo su rivista]
Albini, A.; Malavasi, V. L.; Vitolo, M.; Imberti, J. F.; Marietta, M.; Lip, G. Y. H.; Boriani, G.
abstract

Background: New-onset atrial fibrillation (AF) in non-cardiac postoperative setting is common and is associated with a high risk of in-hospital mortality and morbidity. The long-term risks of stroke, mortality and AF recurrence rate in patients with postoperative AF (POAF) are unclear. Methods: We performed a systematic literature review in electronic databases from inception to March 5th, 2020 of studies reporting the incidence of stroke, mortality and AF recurrence in patients with POAF. We confined our analysis to studies with a cohort of at least 150 patients with POAF and with a median follow-up of 12 months as a minimum. Odds Ratios (OR) were pooled using a random-effects model. Results: Qualitative analysis included 8 studies (7 observational cohort studies and 1 randomized controlled trial) enrolling 3,718,587 patients. Six studies underwent metanalysis comprising 17,684 postoperative patients with POAF and 2,169,248 postoperative patients without POAF. The development of POAF conferred a four-fold increased risk of stroke in the long-term [OR 4.05; 95% confidence interval (CI) 2.91–5.62]. Mortality in the two studies reporting long-term data was higher in patients with POAF compared to those without POAF (OR 3.59; CI 95% 2.84–4.53). Data about recurrence were too heterogeneous to undergo metanalysis. Conclusions: POAF is associated with a greater risk of stroke and mortality over the long-term period. Studies focusing on AF recurrence are needed to address the perception of POAF as a benign transient entity. The increased mortality risk following POAF should encourage systematic detection and prevention of this arrhythmia.

2021 - Medical therapies for prevention of cardiovascular and renal events in patients with atrial fibrillation and diabetes mellitus [Articolo su rivista]
Fauchier, Laurent; Boriani, Giuseppe; de Groot, Joris R; Kreutz, Reinhold; Rossing, Peter; Camm, A John
abstract

2021 - Optimized implementation of cardiac resynchronization therapy: a call for action for referral and optimization of care: A joint position statement from the Heart Failure Association (HFA), European Heart Rhythm Association (EHRA), and European Association of Cardiovascular Imaging (EACVI) of the European Society of Cardiology [Articolo su rivista]
Mullens, Wilfried; Auricchio, Angelo; Martens, Pieter; Witte, Klaus; Cowie, Martin R; Delgado, Victoria; Dickstein, Kenneth; Linde, Cecilia; Vernooy, Kevin; Leyva, Francisco; Bauersachs, Johann; Israel, Carsten W; Lund, Lars H; Donal, Erwan; Boriani, Giuseppe; Jaarsma, Tiny; Berruezo, Antonio; Traykov, Vassil; Yousef, Zaheer; Kalarus, Zbigniew; Nielsen, Jens Cosedis; Steffel, Jan; Vardas, Panos; Coats, Andrew; Seferovic, Petar; Edvardsen, Thor; Heidbuchel, Hein; Ruschitzka, Frank; Leclercq, Christophe
abstract

: Cardiac resynchronization therapy (CRT) is one of the most effective therapies for heart failure with reduced ejection fraction and leads to improved quality of life, reductions in heartfailure hospitalization rates and reduces all-cause mortality. Nevertheless, up to two-thirds ofeligible patients are not referred for CRT. Furthermore, post implantation follow-up is oftenfragmented and suboptimal, hampering the potential maximal treatment effect. This jointposition statement from three ESC Associations, HFA, EHRA and EACVI focuses onoptimized implementation of CRT. We offer theoretical and practical strategies to achievemore comprehensive CRT referral and post-procedural care by focusing on four actionabledomains; (I) overcoming CRT under-utilization, (II) better understanding of pre-implantcharacteristics, (III) abandoning the term 'non-response' and replacing this by the concept ofdisease modification, and (IV) implementing a dedicated post-implant CRT care pathway.

2021 - Optimizing indices of atrial fibrillation susceptibility and burden to evaluate atrial fibrillation severity, risk and outcomes [Articolo su rivista]
Boriani, Giuseppe; Vitolo, Marco; Diemberger, Igor; Proietti, Marco; Valenti, Anna Chiara; Malavasi, Vincenzo Livio; Lip, Gregory Y H
abstract

2021 - Organization and procedures in contemporary catheter ablation centres: data from the 2018 Italian Catheter Ablation Registry [Articolo su rivista]
Stabile, G.; Bertaglia, E.; Guerra, F.; Palmisano, P.; Zoni Berisso, M.; Soldati, E.; Bisignani, G.; Forleo, G. B.; Zanotto, G.; Landolina, M.; Boriani, G.; D'Onofrio, A.; De Ponti, R.; Ricci, R. P.
abstract

AIMS: This report describes the findings of the 2018 Italian Catheter Ablation Registry of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC). METHODS: The Italian Catheter Ablation Registry systematically collects data on the ablation procedures performed in Italy. Data collection was retrospective. A standardized questionnaire was completed by participating centres. RESULTS: We collected data on 15 714 catheter ablation procedures performed in Italy during 2018 in 94 electrophysiology centres. In most centres (75/94, 80%), a single electrophysiology laboratory was available, and a hybrid electrophysiology laboratory was available in 15% (14/94) of centres. In most (93%) centres, at least two electrophysiologists were involved in the catheter ablation procedures. In only 13 out of 94 (14%) electrophysiology laboratories, an anaesthesiologist assists every electrophysiology procedure; in most cases (74/94, 79%), an on-demand anaesthesiology service was available. On-site cardiothoracic surgery was reported in 43 out of 94 (46%) centres.Nonfluoroscopic navigation systems were available in most centres (88/94, 93%). Intracardiac echocardiography was used in 59 out of 94 (63%) electrophysiology laboratories. Atrial fibrillation (31%) was the most frequently treated ablation target, followed by atrioventricular nodal re-entrant tachycardia (20%) and cavo-tricuspid isthmus (15%). In 61.7% of all procedures, a 3D mapping system was used. In about one-third of procedures, a near-zero approach was performed. CONCLUSION: In most Italian electrophysiology centres, a single electrophysiology laboratory was available and at least two electrophysiologists were involved in the ablation procedures. An increasing number of procedures were performed by means of a nonfluoroscopic mapping system with a near-zero approach.

2021 - Outcomes of digoxin vs. beta-blocker in AF: report from ESC-EHRA EORP-AF Long-Term General Registry [Articolo su rivista]
Ding, Wern Yew; Boriani, Giuseppe; Marin, Francisco; Blomström-Lundqvist, Carina; Potpara, Tatjana S; Fauchier, Laurent; Lip, Gregory Y H
abstract

Background: The safety of digoxin therapy in atrial fibrillation (AF) remains ill-defined. We aimed to evaluate the effects of digoxin over beta-blocker therapy in AF. Methods: Patients with AF who were treated with either digoxin or beta-blocker from the ESC-EHRA EORP-AF General Long-Term Registry were included. Outcomes of interest were all-cause mortality, cardiovascular (CV) mortality, non-CV mortality, quality of life and number of patients with unplanned hospitalisations. Results: Of 6377 patients, 549(8.6%) were treated with digoxin. Over 24 months, there were 550(8.6%) all-cause mortality events and 1304(23.6%) patients with unplanned emergency hospitalisations. Compared to beta-blocker, digoxin therapy was associated with increased all-cause mortality (HR 1.90 [95%CI,1.48-2.44], CV mortality (HR 2.18 [95%CI,1.47-3.21] and non-CV mortality (HR 1.68 [95%CI,1.02-2.75] with reduced quality of life (Health Utility Score 0.555[±0.406] vs. 0.705[±0.346], P<0.001) but no differences in emergency hospitalisations (HR 1.00 [95%CI,0.56-1.80]) or AF-related hospitalisations (HR 0.95 [95%CI,0.60-1.52]).On multivariable analysis, there were no differences in any of the outcomes between both groups, after accounting for potential confounders. Similar results were obtained in the subgroups of patients with permanent AF and coexisting heart failure. There was no differences in outcomes between AF patients receiving digoxin with and without chronic kidney disease. Conclusion: Poor outcomes related to the use of digoxin over beta-blocker therapy in terms of excess mortality and reduced quality of life are associated with the presence of other risk factors rather than digoxin per se. The choice of digoxin or beta-blocker therapy had no influence on the incidence of unplanned hospitalisations.

2021 - Percorso clinico decisionale nel paziente anziano fragile con fibrillazione atriale: La proposta di un gruppo di lavoro multidisciplinare [Clinical management of older, frail patients with atrial fibrillation. The proposal of a multidisciplinary working group] [Articolo su rivista]
Marchionni, N; Fumagalli, S; Bo, M; Boccanelli, A; Boriani, G; Rubboli, A; Violi, F; Di Pasquale, G
abstract

Atrial fibrillation (AF) is the most common arrhythmia in elderly people. Older patients with AF have several comorbidities and should be treated with complex therapeutic schemes. Arrhythmia complications are also common at an advanced age. Accordingly, AF can be considered a marker of frailty. Few indications can be found concerning the management of frail older subjects in current guidelines. The Frailty in Atrial Fibrillation Survey Study (FAST) was designed to overcome the gap of knowledge about this extremely vulnerable subset of patients. A multidisciplinary team composed by cardiologists, geriatricians and internists participated in the project. In a first phase, a survey was conducted aiming at clarifying specialty-related differences in definition and oral anticoagulant therapy (OAT) management of frail individuals. In the second phase, specific chapters were prepared about AF and frailty epidemiology, the network for the management of the arrhythmia, the diagnostic strategies for AF (including a minimum data set of tools derived from the geriatric multidimensional assessment), OAT and the choice between a rate or a rhythm control strategy. For each chapter, up-to-date evidence and current guideline recommendations were presented and discussed among the 47 Italian centers participating in the project. In the last phase of FAST, the results of the survey and the final draft of the chapters were merged into the present document. A lack of homogeneity in frailty definition existed. The integration among cardiologists, geriatricians and internists can represent the most effective tool to get through these differences improving the management of frail older patients.

2021 - Percutaneous pericardiocentesis for pericardial effusion: predictors of mortality and outcomes [Articolo su rivista]
Pennacchioni, A.; Nanni, G.; Sgura, F. A.; Imberti, J. F.; Monopoli, D. E.; Rossi, R.; Longo, G.; Arrotti, S.; Vitolo, M.; Boriani, G.
abstract

Pericardial effusion can dangerously precipitate patient’s hemodynamic stability and requires prompt intervention in case of tamponade. We investigated potential predictors of in-hospital mortality, a composite outcome of in-hospital mortality, pericardiocentesis-related complications, and the need for emergency cardiac surgery and all-cause mortality in patients undergoing percutaneous pericardiocentesis. This is an observational, retrospective, single-center study on patients undergoing percutaneous pericardiocentesis (2010–2019). We enrolled 81 consecutive patients. Median age was 71.4 years (interquartile range [IQR] 58.1–78.1 years) and 51 (63%) were male. Most of the pericardiocentesis were performed in an urgency setting (76.5%) for cardiac tamponade (77.8%). The most common etiology was idiopathic (33.3%) followed by neoplastic (22.2%). In-hospital mortality was 14.8% while mortality during follow-up (mean 17.1 months) was 44.4%. Only hemodynamic instability (i.e., cardiogenic shock, hypotension refractory to fluid challenge therapy and inotropes) was associated with in-hospital mortality at the univariate analysis (odds ratio [OR] 7.2; 95% confidence interval [CI] 1.76–29.4). Non-neoplastic/non-idiopathic etiology and hemodynamic instability were associated with the composite outcome of in-hospital mortality, need for emergency cardiac surgery, or pericardiocentesis-related complications (OR 5.75, 95% CI 1.65–20.01, and OR 5.81, 95% CI 2.11–15.97, respectively). Multivariate Cox regression analysis adjusted for possible confounding variables (age, coronary artery disease, and hemodynamic instability) showed that neoplastic etiology was independently associated with medium-term mortality (hazard ratio [HR] 4.05, 95% CI 1.45–11.36). In a real-world population treated with pericardiocentesis for pericardial effusion, in-hospital adverse outcomes and medium-term mortality are consistent, in particular for patients presenting with hemodynamic instability or neoplastic pericardial effusion.

2021 - Permanent Atrial Fibrillation as the Terminal Stage of a Chronic Disease: Palliative Care Needs to be Considered in Selected Patients with Markedly Impaired Quality of Life [Articolo su rivista]
Boriani, G.; Valenti, A. C.; Vitolo, M.
abstract

2021 - Prevalence, management and impact of chronic obstructive pulmonary disease in atrial fibrillation: a systematic review and meta-analysis of 4,200,000 patients [Articolo su rivista]
Romiti, Giulio Francesco; Corica, Bernadette; Pipitone, Eugenia; Vitolo, Marco; Raparelli, Valeria; Basili, Stefania; Boriani, Giuseppe; Harari, Sergio; Lip, Gregory Y H; Proietti, Marco
abstract

Prevalence of chronic obstructive pulmonary disease (COPD) in atrial fibrillation (AF) patients is unclear, and its association with adverse outcomes is often overlooked. Our aim was to estimate the prevalence of COPD, its impact on clinical management and outcomes in patients with AF, and the impact of beta-blockers (BBs) on outcomes in patients with COPD.

2021 - Prevention of long-lasting atrial fibrillation through antitachycardia pacing in DDDR pacemakers [Articolo su rivista]
Boriani, G.; Sakamoto, Y.; Botto, G.; Komura, S.; Pieragnoli, P.; Minamiguchi, H.; Iacopino, S.; Noma, T.; Infusino, T.; Takahashi, Y.; Facchin, D.; De Rosa, F.; Pisano, E.; Meloni, S.; Biffi, M.
abstract

Objective: The MINERVA trial showed that in pacemaker patients with atrial fibrillation (AF) history, DDDRP pacing combining three algorithms – (a) atrial antitachycardia pacing with Reactive ATP enabled, (b) atrial preventive pacing and (c) managed ventricular pacing (MVP)—may effectively delay progression to persistent/permanent AF compared with standard DDDR pacing. We performed a comparative non-randomised evaluation to evaluate if Reactive ATP can be the main driver of persistent/permanent AF reduction independently on preventive pacing. Methods: Thirty-one centres included consecutive dual-chamber pacemaker patients with AF history. Reactive ATP was programmed in all patients while preventive atrial pacing was not enabled. These patients were compared with the three groups of MINERVA randomised trial (Control DDDR, MVP, and DDDRP). The main endpoint was the incidence of AF longer than 7 consecutive days. Results: A total of 146 patients (73 years old, 54% male) were included and followed for a median observation period of 31 months. The 2-year incidence of AF > 7 days was 12% in the Reactive ATP group, very similar to that found in the DDDRP arm of the MINERVA trial (13.8%, P =.732) and significantly lower than AF incidence found in the MINERVA Control DDDR arm (25.8%, P =.012) and in the MINERVA MVP arm (25.9%, P =.025). Conclusions: In a real-world population of dual-chamber pacemaker patients with AF history, the use of Reactive ATP is associated with a low incidence of persistent AF, highlighting that the positive results of the MINERVA trial were related to the effectiveness of Reactive ATP rather than to preventive pacing.

2021 - Procedural complications in patients undergoing catheter ablation for atrial fibrillation: Let's talk about sex [Articolo su rivista]
Imberti, Jacopo Francesco; Boriani, Giuseppe; Gupta, Dhiraj; Lip, Gregory Y H
abstract

2021 - Prognostic value of implantable defibrillator-computed respiratory disturbance index: The DASAP-HF study [Articolo su rivista]
Boriani, Giuseppe; Pisanò, Ennio C L; Pieragnoli, Paolo; Locatelli, Alessandro; Capucci, Alessandro; Talarico, Antonello; Zecchin, Massimo; Rapacciuolo, Antonio; Piacenti, Marcello; Indolfi, Ciro; Arias, Miguel Angel; Diemberger, Igor; Checchinato, Catia; La Rovere, Maria Teresa; Sinagra, Gianfranco; Emdin, Michele; Ricci, Renato Pietro; D'Onofrio, Antonio
abstract

Sleep apnea, as measured by polysomnography, is associated with adverse outcomes in heart failure. The DASAP-HF (Diagnosis and Treatment of Sleep Apnea in Patient With Heart Failure) study previously demonstrated that the respiratory disturbance index (RDI) computed by the ApneaScan algorithm (Boston Scientific) accurately identifies severe sleep apnea in implantable cardioverter-defibrillator (ICD) patients.

2021 - Red blood cell distribution width in patients undergoing transcatheter aortic valve implantation: Implications for outcomes [Articolo su rivista]
Valenti, A. C.; Vitolo, M.; Manicardi, M.; Arrotti, S.; Magnavacchi, P.; Gabbieri, D.; Tondi, S.; Guiducci, V.; Losi, L.; Vignali, L.; Sgura, F. A.; Boriani, G.
abstract

Background: Red cell distribution width (RDW) is recently emerging as a prognostic indicator in many cardiovascular diseases. However, less is known about its predictive role in patients undergoing transcatheter aortic valve implantation (TAVI). Methods: We retrospectively included very high-risk patients with severe aortic valve stenosis undergoing TAVI between February 2012 and December 2019. Patients were classified according to RDW tertiles. Our primary endpoint was long-term all-cause mortality. The secondary endpoint was a composite of in-hospital major adverse events as defined by the Valve Academic Research Consortium 2 criteria and/or long-term all-cause mortality. Results: A total of 424 patients [median age 83.5 years, 52.6% females] were analysed. After a median follow-up of 1.55 years, all-cause mortality was 25.5%. At the multivariate-adjusted Cox regression analysis, patients in the highest RDW tertile were associated with a higher risk for all-cause mortality [hazard ratio [HR] 1.73, 95%confidence interval [CI] 1.02-2.95] compared with the lowest tertile. When considering RDW as a continuous variable, we found an 11% increased risk in overall mortality [HR 1.11, 95% CI 1.00-1.24] for each increased point in RDW. The highest RDW tertile was also independently associated with the occurrence of the composite endpoint [odds ratio [OR] 2.10, 95% CI 1.17-3.76] compared with lower tertiles. Conclusions: In our cohort, elevated basal RDW values were independent predictors of increased long-term mortality and higher rate of in-hospital adverse events. The inclusion of a routinely available biomarker as RDW, may help the pre-operative risk assessment in potential TAVI candidates and optimise their management.

2021 - Red cell distribution width and patient outcome in cardiovascular disease: A ‘’real-world” analysis [Articolo su rivista]
Talarico, M.; Manicardi, M.; Vitolo, M.; Malavasi, V. L.; Valenti, A. C.; Sgreccia, D.; Rossi, R.; Boriani, G.
abstract

Red cell distribution width (RDW) has been shown to predict adverse outcomes in specific scenarios. We aimed to assess the association between RDW and all-cause death and a clinically relevant composite endpoint in a population with various clinical manifestations of cardiovascular diseases. We retrospectively analyzed 700 patients (median age 72.7 years [interquartile range, IQR, 62.6–80]) admitted to the Cardiology ward between January and November 2016. Patients were divided into tertiles according to baseline RDW values. After a median follow-up of 3.78 years (IQR 3.38–4.03), 153 (21.9%) patients died and 247 (35.3%) developed a composite endpoint (all-cause death, acute coronary syndromes, transient ischemic attack/stroke, and/or thromboembolic events). With multivariate Cox regression analysis, the highest RDW tertile was independently associated with an increased risk of all-cause death (adjusted hazard ratio [HR] 2.73, 95% confidence interval [CI] 1.63–4.56) and of the composite endpoint (adjusted HR 2.23, 95% CI 1.53–3.24). RDW showed a good predictive ability for all-cause death (C-statistics: 0.741, 95% CI 0.694–0.788). In a real-world cohort of patients, we found that higher RDW values were independently associated with an increased risk of all-cause death and clinical adverse cardiovascular events thus proposing RDW as a prognostic marker in cardiovascular patients.

2021 - Red cell distribution width: a routinely available biomarker with important clinical implications in patients with atrial fibrillation [Articolo su rivista]
Valenti, Anna Chiara; Vitolo, Marco; Imberti, Jacopo Francesco; Malavasi, Vincenzo Livio; Boriani, Giuseppe
abstract

2021 - Registro Italiano Ablazioni 2019. Associazione Italiana di Aritmologia e Cardiostimolazione [Articolo su rivista]
Stabile, Giuseppe; Guerra, Federico; Tola, Gianfranco; Bertaglia, Emanuele; Palmisano, Pietro; Berisso, Massimo Zoni; Soldati, Ezio; Bisignani, Giovanni; Forleo, Giovanni Battista; Zanotto, Gabriele; Landolina, Maurizio; Boriani, Giuseppe; D'Onofrio, Antonio; De Ponti, Roberto; Ricci, Renato Pietro
abstract

Background: This report describes the findings of the 2019 Italian Catheter Ablation Registry of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC). Methods: Data collection was retrospective. A standardized questionnaire was completed by each of the participating centers. Results: A total of 15 201 ablation procedures were performed by 91 institutions. Most (78%) of the centers has one electrophysiology laboratory, and 17% of them has a hybrid cardiac surgery laboratory. Almost all (98%) centers have a 3D mapping system. The median number of electrophysiologists and nurses involved in the electrophysiology laboratory was 3 and an electrophysiology technician was involved in 30% of all centers. In 88.4% of cases, ablations were performed for supraventricular arrhythmias, and among these the most frequently treated arrhythmia was atrial fibrillation (32.9%), followed by atrioventricular nodal reentrant tachycardia (23.9%), and common atrial flutter (11.7%). In 10 256 (67.4%) patients catheter ablation was performed by means of a 3D mapping system, with a "near-zero" fluoroscopic approach in 4626 (30.4%) of all patients. Conclusions: The 2019 Italian Catheter Ablation Registry confirmed that atrial fibrillation is the most commonly treated arrhythmia in the ablation centers with an increasing number of procedures performed with a 3D mapping system and a "near-zero" approach.

2021 - Relation of outcomes to ABC (Atrial Fibrillation Better Care) pathway adherent care in European patients with atrial fibrillation: an analysis from the ESC-EHRA EORP Atrial Fibrillation General Long-Term (AFGen LT) Registry [Articolo su rivista]
Proietti, Marco; Lip, Gregory Y H; Laroche, Cécile; Fauchier, Laurent; Marin, Francisco; Nabauer, Michael; Potpara, Tatjana; Dan, Gheorghe-Andrei; Kalarus, Zbigniew; Tavazzi, Luigi; Maggioni, Aldo Pietro; Boriani, Giuseppe
abstract

There has been an increasing focus on integrated, multidisciplinary, and holistic care in the treatment of atrial fibrillation (AF). The 'Atrial Fibrillation Better Care' (ABC) pathway has been proposed to streamline integrated care in AF. We evaluated the impact on outcomes of an ABC adherent management in a contemporary real-life European-wide AF cohort.

2021 - Remote monitoring and telemedicine in heart failure: implementation and benefits [Articolo su rivista]
Imberti, J. F.; Tosetti, A.; Mei, D. A.; Maisano, A.; Boriani, G.
abstract

Purpose of review: Remote monitoring (RM) of cardiac implantable electronic devices (CIEDs) is recommended as part of the individualized multidisciplinary follow-up of heart failure (HF) patients. Aim of this article is to critically review recent findings on RM, highlighting potential benefits and barriers to its implementation. Recent findings: Device-based RM is useful in the early detection of CIEDs technical issues and cardiac arrhythmias. Moreover, RM allows the continuous monitoring of several patients' clinical parameters associated with impending HF decompensation, but there is still uncertainty regarding its effectiveness in reducing mortality and hospitalizations. Summary: Implementation of RM strategies, together with a proactive physicians' attitude towards clinical actions in response to RM data reception, will make RM a more valuable tool, potentially leading to better outcomes.

2021 - Reshaping of italian echocardiographic laboratories activities during the second wave of covid-19 pandemic and expectations for the post-pandemic era [Articolo su rivista]
Ciampi, Q.; Antonini-Canterin, F.; Barbieri, A.; Barchitta, A.; Benedetto, F.; Cresti, A.; Miceli, S.; Monte, I.; Petrella, L.; Trocino, G.; Aquila, I.; Barbati, G.; Barletta, V.; Barone, D.; Beraldi, M.; Bergandi, G.; Bilardo, G.; Boriani, G.; Bossone, E.; Bongarzoni, A.; Bovolato, F. E.; Bursi, F.; Cammalleri, V.; Carbonella, M.; Casavecchia, G.; Cicco, S.; Cioffi, G.; Cocchia, R.; Colonna, P.; Cortigiani, L.; Cucchini, U.; D'Alfonso, M. G.; D'Andrea, A.; Dell'Angela, L.; Dentamaro, I.; De Paolis, M.; De Stefanis, P.; Deste, W.; Di Fulvio, M.; Di Giannuario, G.; Di Lisi, D.; Di Nora, C.; Fabiani, I.; Esposito, R.; Fazzari, F.; Ferrara, L.; Filice, G.; Forno, D.; Giorgi, M.; Giustiniano, E.; Greco, C. A.; Iannuzzi, G. L.; Izzo, A.; Lanzone, A. M.; Malagoli, A.; Mantovani, F.; Manuppelli, V.; Mega, S.; Merli, E.; Ministeri, M.; Morrone, D.; Napoletano, C.; Nunziata, L.; Pastorini, G.; Pedone, C.; Petruccelli, E.; Polito, M. V.; Polizzi, V.; Prota, C.; Rigo, F.; Rivaben, D. E.; Saponara, S.; Sciacqua, A.; Sartori, C.; Scarabeo, V.; Serra, W.; Severino, S.; Spinelli, L.; Tamborini, G.; Tota, A.; Villari, B.; Carerj, S.; Picano, E.; Pepi, M.
abstract

Background: Cardiology divisions reshaped their activities during the coronavirus disease 2019 (COVID-19) pandemic. This study aimed to analyze the organization of echocardiographic laboratories and echocardiography practice during the second wave of the COVID-19 pandemic in Italy, and the expectations for the post-COVID era. Methods: We analyzed two different time periods: the month of November during the second wave of the COVID-19 pandemic (2020) and the identical month during 2019 (November 2019). Results: During the second wave of the COVID-19 pandemic, the hospital activity was partially reduced in 42 (60%) and wholly interrupted in 3 (4%) echocardiographic laboratories, whereas outpatient echocardiographic activity was partially reduced in 41 (59%) and completely interrupted in 7 (10%) laboratories. We observed an important change in the organization of activities in the echocardiography laboratory which reduced the operator-risk and improved self-protection of operators by using appropriate personal protection equipment. Operators wore FFP2 in 58 centers (83%) during trans-thoracic echocardiography (TTE), in 65 centers (93%) during transesophageal echocardiography (TEE) and 63 centers (90%) during stress echocardiography. The second wave caused a significant reduction in number of echocardiographic exams, compared to November 2019 (from 513 ± 539 to 341 ± 299 exams per center, −34%, p < 0.001). On average, there was a significant increase in the outpatient waiting list for elective echocardiographic exams (from 32.0 ± 28.1 to 45.5 ± 44.9 days, +41%, p < 0.001), with a reduction of in-hospital waiting list (2.9 ± 2.4 to 2.4 ± 2.0 days, −17%, p < 0.001). We observed a large diffusion of point-of-care cardiac ultrasound (88%), with a significant increase of lung ultrasound usage in 30 centers (43%) during 2019, extended to all centers in 2020. Carbon dioxide production by examination is an indicator of the environmental impact of technology (100-fold less with echocardiography compared to other cardiac imaging techniques). It was ignored in 2019 by 100% of centers, and currently it is considered potentially crucial for decision-making in cardiac imaging by 65 centers (93%). Conclusions: In one year, major changes occurred in echocardiography practice and culture. The examination structure changed with extensive usage of point-of-care cardiac ultrasound and with lung ultrasound embedded by default in the TTE examination, as well as the COVID-19 testing.

2021 - Role of cardiac imaging in patients undergoing catheter ablation of ventricular tachycardia [Articolo su rivista]
Muser, Daniele; Lavalle, Carlo; Guarracini, Fabrizio; Sassone, Biagio; Conte, Edoardo; Magnani, Silavia; Notarstefano, Pasquale; Barbato, Gaetano; Sgarito, Giuseppe; Grandinetti, Giuseppe; Nucifora, Gaetano; Ricci, Renato P; Boriani, Giuseppe; De Ponti, Roberto; Casella, Michela
abstract

: Ventricular tachycardia is a major health issue in patients with structural heart disease (SHD). Implantable cardioverter defibrillator (ICD) therapy has significantly reduced the risk of sudden cardiac death (SCD) in such patients, but on the other hand, it has led to frequent ICD shocks as an emerging problem, being associated with poor quality of life, frequent hospitalizations and increased mortality. Myocardial scar plays a central role in the genesis and maintenance of re-entrant arrhythmias, as the coexistence of surviving myocardial fibres within fibrotic tissue leads to the formation of slow conduction pathways and to a dispersion of activation and refractoriness that constitutes the milieu for ventricular tachycardia circuits. Catheter ablation has repeatedly proven to be well tolerated and highly effective in treating VT and in the last two decades has benefited from continuous efforts to determine ventricular tachycardia mechanisms by integration with a wide range of invasive and noninvasive imaging techniques such as intracardiac echocardiography, cardiac magnetic resonance, multidetector computed tomography and nuclear imaging. Cardiovascular imaging has become a fundamental aid in planning and guiding catheter ablation procedures by integrating structural and electrophysiological information, enabling the ventricular tachycardia arrhythmogenic substrate to be characterized and effective ablation targets to be identified with increasing precision, and allowing the development of new ablation strategies with improved outcomes. In this review, we provide an overview of the role of cardiac imaging in patients undergoing catheter ablation of ventricular tachycardia.

2021 - Screening for Atrial Fibrillation in Relation to Stroke and Mortality Risk [Articolo su rivista]
Proietti, M.; Boriani, G.
abstract

2021 - Seventeen-year trend (2001–2017) in pacemaker and implantable cardioverter-defibrillator utilization based on hospital discharge database data: An analysis by age groups [Articolo su rivista]
Zecchin, M.; Torre, M.; Carrani, E.; Sampaolo, L.; Ciminello, E.; Ortis, B.; Ricci, R.; Proclemer, A.; Sinagra, G.; Boriani, G.
abstract

Aims: To analyze temporal trends (2001 -2017) of Pacemakers (PM) and Implantable Cardioverter-Defibrillators (ICD) procedures in Italy, according to the national Hospital Discharge Database (HDD). Methods: Frequency and implant rate (IR) in the Italian population were analyzed by age groups (<50, 50–79, ≥80 years). Results: From 2001 (2009 for Cardiac Resynchronization Therapy-Defibrillator – CRT-D) to 2017, first PM implants (1stPM) increased from 36,823 (637/million inhabitants) to 49,716 (820/million), ICD implants from 3,141 (54/million) to 24,255 (400/million) and CRT-D from 2,915 (49/million, 16.5% of ICD) to 8,595 (142/million, 35.4% of ICD). ICD implants due to ventricular tachycardia or ventricular fibrillation decreased from 55.6% to 13.5% and from 15.9% to 4.5% respectively, while the proportion increased among patients with heart failure (from 22.9% to 46.8%), hypertension (from 11.1% to 15.0%), diabetes (from 6.5% to 10.9%), and renal insufficiency (from 4.4% to 7.6%). Both PM and ICD procedures markedly increased in patients ≥80 years old. However, while IR for ICDs increased from 82/million to 1,038/million inhabitants, IR of 1stPM only changed from 6,111/million to 6,212/million as the population in this age group nearly doubled in Italy. Conclusion: Since 2001, the increase of 1stPM in Italy was mainly due to the ultra-octogenarian population growth. No differences were observed for IR in each PM age group, while the absolute number and IR increased in all groups (especially ≥80 years old) for ICDs and CRT-Ds. An increase in comorbidities and a reduction in implants for secondary prevention were observed in the ICD population.

2021 - Sinergy between drugs and devices in the fight against sudden cardiac death and heart failure [Articolo su rivista]
Boriani, G.; De Ponti, R.; Guerra, F.; Palmisano, P.; Zanotto, G.; D'Onofrio, A.; Ricci, R. P.
abstract

The impact of sudden cardiac death (SCD) in heart failure (HF) patients is important and prevention of SCD is a reasonable and clinically justified endpoint if associated with a reduction in all-cause mortality. According to literature, in HF with reduced ejection fraction, only three classes of agents were found effective in reducing SCD and all-cause mortality: beta-blockers, mineralcorticoid receptor antagonists and, more recently, angiotensin-receptor neprilysin-inhibitors. In the PARADIGM trial that tested sacubitril/valsartan vs. enalapril, the 20% relative risk reduction in cardiovascular deaths obtained with sacubitril/valsartan was attributable to reductions in the incidence of both SCD and death due to HF worsening and this effect can be added to the known positive effect of implantable cardioverter-defibrillators in appropriately selected patients. In order to maximize the implementation of all the available treatments, patients with HF should be included in virtuous networks with a dialogue between all the physician involved, with commitment by all these physicians for appropriate decision-making on application of pharmacological and device treatments according to available evidence, as well as commitment for drug titration before and after device implant, taking advantage from remote monitoring, and with the safety of back up device therapy when indicated. There are potential synergistic effects of drug therapy, with all the therapies acting on neuro-hormonal and sympathetic activation, but specifically with sacubitril/valsartan, and device therapy, in particular cardiac resynchronization therapy, with added incremental benefits on positive cardiac remodelling, prevention of HF progression, and prevention of ventricular tachyarrhythmias.

2021 - Sudden cardiac death in dialysis patients: different causes and management strategies [Articolo su rivista]
Genovesi, Simonetta; Boriani, Giuseppe; Covic, Adrian; Vernooij, Robin W M; Combe, Christian; Burlacu, Alexandru; Davenport, Andrew; Kanbay, Mehmet; Kirmizis, Dimitrios; Schneditz, Daniel; van der Sande, Frank; Basile, Carlo
abstract

Sudden cardiac death (SCD) represents a major cause of death in end-stage kidney disease (ESKD). The precise estimate of its incidence is difficult to establish because studies on the incidence of SCD in ESKD are often combined with those related to sudden cardiac arrest (SCA) occurring during a haemodialysis (HD) session. The aim of the European Dialysis Working Group of ERA-EDTA was to critically review the current literature examining the causes of extradialysis SCD and intradialysis SCA in ESKD patients and potential management strategies to reduce the incidence of such events. Extradialysis SCD and intradialysis SCA represent different clinical situations and should be kept distinct. Regarding the problem, numerically less relevant, of patients affected by intradialysis SCA, some modifiable risk factors have been identified, such as a low concentration of potassium and calcium in the dialysate, and some advantages linked to the presence of automated external defibrillators in dialysis units have been documented. The problem of extra-dialysis SCD is more complex. A reduced left ventricular ejection fraction associated with SCD is present only in a minority of cases occurring in HD patients. This is the proof that SCD occurring in ESKD has different characteristics compared with SCD occurring in patients with ischaemic heart disease and/or heart failure and not affected by ESKD. Recent evidence suggests that the fatal arrhythmia in this population may be due more frequently to bradyarrhythmias than to tachyarrhythmias. This fact may partly explain why several studies could not demonstrate an advantage of implantable cardioverter defibrillators in preventing SCD in ESKD patients. Electrolyte imbalances, frequently present in HD patients, could explain part of the arrhythmic phenomena, as suggested by the relationship between SCD and timing of the HD session. However, the high incidence of SCD in patients on peritoneal dialysis suggests that other risk factors due to cardiac comorbidities and uraemia per se may contribute to sudden mortality in ESKD patients.

2021 - The 4S-AF scheme (Stroke Risk; Symptoms; Severity of Burden; Substrate): A novel approach to in-depth characterization (rather than classification) of atrial fibrillation [Articolo su rivista]
Potpara, T. S.; Lip, G. Y. H.; Blomstrom-Lundqvist, C.; Boriani, G.; Van Gelder, I. C.; Heidbuchel, H.; Hindricks, G.; Camm, A. J.
abstract

Atrial fibrillation (AF) is a complex condition requiring holistic management with multiple treatment decisions about optimal thromboprophylaxis, symptom control (and prevention of AF progression), and identification and management of concomitant cardiovascular risk factors and comorbidity. Sometimes the information needed for treatment decisions is incomplete, as available classifications of AF mostly address a single domain of AF (or patient)-related characteristics. The most widely used classification of AF based on AF episode duration and temporal patterns (that is, the classification to first-diagnosed, paroxysmal, persistent/long-standing persistent, and permanent AF) has contributed to a better understanding of AF prevention and treatment but its limitations and the need for a multidimensional AF classification have been recognized as more complex treatment options became available. We propose a paradigm shift from classification toward a structured characterization of AF, addressing specific domains having treatment and prognostic implications to become a standard in clinical practice, thus aiming to streamline the assessment of AF patients at all health care levels facilitating communication among physicians, treatment decision-making, and optimal risk evaluation and management of AF patients. Specifically, we propose the 4S-AF structured pathophysiology-based characterization (rather than classification) scheme that includes four AF- and patient-related domains-Stroke risk, Symptoms, Severity of AF burden, and Substrate severity-and provide a hypothetical model for the use of 4S-AF characterization scheme to aid treatment decision making concerning the management of patients with AF in clinical practice.

2021 - The challenge to improve knowledge on the interplay between subclinical atrial fibrillation, atrial cardiomyopathy, and atrial remodeling [Articolo su rivista]
Boriani, G.; Imberti, J. F.; Vitolo, M.
abstract

2021 - The impact of covid-19 pandemic and lockdown restrictions on cardiac implantable device recipients with remote monitoring [Articolo su rivista]
Diemberger, I.; Vicentini, A.; Cattafi, G.; Ziacchi, M.; Iacopino, S.; Morani, G.; Pisano, E.; Molon, G.; Giovannini, T.; Russo, A. D.; Boriani, G.; Bertaglia, E.; Biffi, M.; Bongiorni, M. G.; Rordorf, R.; Zucchelli, G.
abstract

From 2020, many countries have adopted several restrictions to limit the COVID-19 pandemic. The forced containment impacted on healthcare organizations and the everyday life of patients with heart disease. We prospectively analyzed data recorded from implantable defibrillators and/or cardiac resynchronization devices of Italian patients during the lockdown (LDP), post-lockdown period (PLDP) and a control period (CP) of the previous year. We analyzed device data of the period 9 March 2019–31 May 2020 of remotely monitored patients from 34 Italian centers. Patients were also categorized according to areas with high/low infection prevalence. Among 696 patients, we observed a significant drop in median activity in LDP as compared to CP that significantly increased in the PLDP, but well below CP (all p < 0.0001). The median day heart rate and heart rate variability showed a similar trend. This behavior was associated during LDP with a significant increase in the burden of atrial arrhythmias (p = 0.0150 versus CP) and of ventricular arrhythmias [6.6 vs. 1.5 per 100 patient-weeks in CP; p = 0.0026]; the latter decreased in PLDP [0.3 per 100 patient-weeks; p = 0.0035 vs. LDP]. No modifications were recorded in thoracic fluid levels. The high/low prevalence of COVID-19 infection had no significant impact. We found an increase in the arrhythmic burden in LDP coupled with a decrease in physical activity and heart rate variability, without significant modifications of transthoracic impedance, independent from COVID-19 infection prevalence. These findings suggest a negative impact of the COVID-19 pandemic, probably related to lockdown restrictions.

2021 - The importance of adherence and persistence with oral anticoagulation treatment in patients with atrial fibrillation [Articolo su rivista]
Lip, Gregory Y H; Boriani, Giuseppe; Lane, Deirdre A; Vitolo, Marco
abstract

2021 - The practice of deep sedation in electrophysiology and cardiac pacing laboratories: Results of an italian survey promoted by the aiac (italian association of arrhythmology and cardiac pacing) [Articolo su rivista]
Palmisano, P.; Ziacchi, M.; Angeletti, A.; Guerra, F.; Forleo, G. B.; Bertini, M.; Notarstefano, P.; Accogli, M.; Lavalle, C.; Bisignani, G.; Landolina, M.; Zanotto, G.; D'Onofrio, A.; Ricci, R. P.; De Ponti, R.; Boriani, G.
abstract

The aim of this survey, which was open to all Italian cardiologists involved in arrhythmia, was to assess common practice regarding sedation and analgesia in interventional electrophysiology procedures in Italy. The survey consisted of 28 questions regarding the approach to sedation used for elective direct-current cardioversion (DCC), subcutaneous implantable cardioverter-defibrillator (S-ICD) implantation, atrial fibrillation (AF) ablation, ventricular tachycardia (VT) ablation, and transvenous lead extraction procedures. A total of 105 cardiologists from 92 Italian centres took part in the survey. The rate of centres where DCC, S-ICD implantation, AF ablation, VT ablation and lead extraction procedures were performed without anaesthesiologic assistance was 60.9%, 23.6%, 51.2%, 37.3%, and 66.7%, respectively. When these procedures were performed without anaesthesiologic assistance, the drugs (in addition to local anaesthetics) commonly administered were benzodiazepines (from 64.3% to 79.6%), opioids (from 74.4% to 88.1%), and general anaesthetics (from 7.1% to 30.4%). Twenty-three (21.9%) of the 105 cardiologists declared that they routinely administered propofol, without the supervision of an anaesthesiologist, in at least one of the above-mentioned procedures. In current Italian clinical practice, there is a lack of uniformity in the sedation/analgesia approach used in interventional electrophysiology procedures.

2021 - Trans-catheter valve implantation and patient outcomes: Focus on the kidney [Articolo su rivista]
Boriani, G.; Arrotti, S.; Gabbieri, D.; Magnavacchi, P.; Sgura, F. A.
abstract

2021 - Updating a simple clinical score predicting incident atrial fibrillation: The C2HEST score or more (mC2HEST)? [Articolo su rivista]
Imberti, J. F.; Boriani, G.; Lip, G. Y. H.
abstract

2021 - Worldwide Survey of COVID-19 Associated Arrhythmias [Articolo su rivista]
Coromilas, Ellie J; Kochav, Stephanie; Goldenthal, Isaac; Biviano, Angelo; Garan, Hasan; Goldbarg, Seth; Kim, Joon-Hyuk; Yeo, Ilhwan; Tracy, Cynthia; Ayanian, Shant; Akar, Joseph; Singh, Avinainder; Jain, Shashank; Zimerman, Leandro; Pimentel, Maurício; Osswald, Stefan; Twerenbold, Raphael; Schaerli, Nicolas; Crotti, Lia; Fabbri, Daniele; Parati, Gianfranco; Li, Yi; Atienza, Felipe; Zatarain, Eduardo; Tse, Gary; Leung, Keith Sai Kit; Guevara-Valdivia, Milton E; Rivera-Santiago, Carlos A; Soejima, Kyoko; De Filippo, Paolo; Ferrari, Paola; Malanchini, Giovanni; Kanagaratnam, Prapa; Khawaja, Saud; Mikhail, Ghada W; Scanavacca, Mauricio; Hajjar, Ludhmila Abrahão; Rizerio Gomes, Brenno; Sacilotto, Luciana; Mollazadeh, Reza; Eslami, Masoud; Laleh Far, Vahideh; Mattioli, Anna Vittoria; Boriani, Giuseppe; Migliore, Federico; Cipriani, Alberto; Donato, Filippo; Compagnucci, Paolo; Casella, Michela; Dello Russo, Antonio; Coromilas, James; Aboyme, Andrew; O'Brien, Connor Galen; Rodriguez, Fatima; Wang, Paul J; Naniwadekar, Aditi; Moey, Melissa; Know, Chia Siang; Cheah, Wee Kooi; Auricchio, Angelo; Conte, Giulio; Hwang, Jongmin; Han, Seongwook; Lazzerini, Pietro Enea; Franchi, Federico; Santoro, Amato; Capecchi, Pier Leopoldo; Joglar, Jose A; Rosenblatt, Anna G; Zardini, Marco; Bricoli, Serena; Bonura, Rosario; Echarte-Morales, Julio; Benito-González, Tomás; Minguito-Carazo, Carlos; Fernández-Vázquez, Felipe; Wan, Elaine Y
abstract

Background - COVID-19 has led to over 1 million deaths worldwide and has been associated with cardiac complications including cardiac arrhythmias. The incidence and pathophysiology of these manifestations remain elusive. In this worldwide survey of patients hospitalized with COVID-19 who developed cardiac arrhythmias, we describe clinical characteristics associated with various arrhythmias, as well as global differences in modulations of routine electrophysiology practice during the pandemic. Methods - We conducted a retrospective analysis of patients hospitalized with COVID-19 infection worldwide with and without incident cardiac arrhythmias. Patients with documented atrial fibrillation (AF), atrial flutter (AFL), supraventricular tachycardia (SVT), non-sustained or sustained ventricular tachycardia (VT), ventricular fibrillation (VF), atrioventricular block (AVB), or marked sinus bradycardia (HR<40bpm) were classified as having arrhythmia. De-identified data was provided by each institution and analyzed. Results - Data was collected for 4,526 patients across 4 continents and 12 countries, 827 of whom had an arrhythmia. Cardiac comorbidities were common in patients with arrhythmia: 69% had hypertension, 42% diabetes mellitus, 30% had heart failure and 24% coronary artery disease. Most had no prior history of arrhythmia. Of those who did develop an arrhythmia, the majority (81.8%) developed atrial arrhythmias, 20.7% developed ventricular arrhythmias, and 22.6% had bradyarrhythmia. Regional differences suggested a lower incidence of AF in Asia compared to other continents (34% vs. 63%). Most patients in in North America and Europe received hydroxychloroquine, though the frequency of hydroxychloroquine therapy was constant across arrhythmia types. Forty-three percent of patients who developed arrhythmia were mechanically ventilated and 51% survived to hospital discharge. Many institutions reported drastic decreases in electrophysiology procedures performed. Conclusions - Cardiac arrhythmias are common and associated with high morbidity and mortality among patients hospitalized with COVID-19 infection. There were significant regional variations in the types of arrhythmias and treatment approaches.

2020 - A giant right coronary artero-venous fistula revealed by an integrated multimodality imaging approach [Articolo su rivista]
Denegri, A.; Albini, A.; Barbieri, A.; Boriani, G.
abstract

2020 - AB0611 STRAIN ANALYSIS OF THE RIGHT VENTRICLE USING 2D-SPECKLE TRACKING ECHOCARDIOGRAPHY IN A COHORT OF PATIENTS WITH SYSTEMIC SCLEROSIS [Abstract in Rivista]
Spinella, A; Macripo, P; Cocchiara, E; Galli, E; Lumetti, F; Magnani, L; Coppi, F; Mattioli, Av; Rossi, R; Boriani, G; Salvarani, C; Giuggioli, D
abstract

Background: Systemic Sclerosis (SSc) is a rare and life-threatening connective tissue disease with multiple organ impairment. Cardio-pulmonary involvement is common: pulmonary fibrosis, pulmonary hypertension (PH), and electrical disorders are the most serious complications and causes of increased mortality. Objectives: We evaluated features related with the onset and development of PH in a cohort of SSc patients. We further studied ecocardiographic abnormalities, by means of 2D-speckle tracking echocardiography (STE) with specific reference to the right ventricular strain measure (RV-strain). Methods: We analyzed data from 50 SSc patients (pts) referred to our University-based Rheumatology Centre and SSc Unit from January 2007 to June 2019 (F/M 45/5; lc/dcSSc 45/5; mean age 59.20±14.357 years; mean disease duration 12.08±8.75 years). All pts underwent general and cardio-pulmonary …

2020 - Anticoagulation to prevent ischemic stroke in patients with atrial fibrillation: a complex scenario including underdiagnosis, undertreatment or underdosing of oral anticoagulants [Articolo su rivista]
Boriani, Giuseppe; Imberti, Jacopo F; Vitolo, Marco
abstract

2020 - Antithrombotic treatment in atrial fibrillation patients undergoing percutaneous coronary interventions: focus on stent thrombosis [Articolo su rivista]
Vitolo, Marco; Javed, Saad; Capodanno, Davide; Rubboli, Andrea; Boriani, Giuseppe; Lip, Gregory Y H
abstract

Coronary artery disease (CAD) commonly coexists with atrial fibrillation (AF), requiring oral anticoagulation (OAC) in a significant subset of patients. These patients also often require revascularization with percutaneous coronary intervention (PCI), which traditionally is supported with dual antiplatelet therapy (DAPT) to prevent complications including stent thrombosis (ST). Recent clinical studies have demonstrated that dual therapy (DAT, i.e. OAC plus single P2Y12 inhibitor) has a more favorable safety profile than triple antithrombotic therapy (TAT). As none of these trials were sufficiently powered for evaluating ischemic outcomes, some concerns remain regarding ischemic complications, in particular ST, a catastrophic complication of PCI.

2020 - Are atrial high rate episodes (AHREs) a precursor to atrial fibrillation? [Articolo su rivista]
Khan, A. A.; Boriani, G.; Lip, G. Y. H.
abstract

Abstract: Atrial high rate episodes (AHREs), also termed, subclinical atrial tachyarrhythmias or subclinical atrial fibrillation (AF) are an important cardiovascular condition. Advancement in implantable cardiac devices such as pacemakers or internal cardiac defibrillators has enabled the continuous assessment of atrial tachyarrhythmias in patients with an atrial lead. Patients with device-detected AHREs are at an elevated risk of stroke and may have unmet anticoagulation needs. While the benefits of oral anticoagulation for stroke prevention in patients with clinical AF are well recognised, it is not known whether the same risk–benefit ratio exists for anticoagulation therapy in patients with AHREs. The occurrence and significance of AHRE are increasingly acknowledged but these events are still not often acted upon in patients presenting with stroke and TIA. Additionally, patients with AHRE show a significant risk for major adverse cardiovascular events (MACE) including acute heart failure, myocardial infarction, cardiovascular hospitalisation, ventricular tachycardia/fibrillation, which is dependent on AHRE burden. In this review, we present an overview of this relatively new entity, its associated thromboembolic risk and its management implications. Graphic abstract: [Figure not available: see fulltext.]

2020 - Association between clinical risk scores and mortality in atrial fibrillation: Systematic review and network meta-regression of 669,000 patients [Articolo su rivista]
Proietti, M.; Farcomeni, A.; Romiti, G. F.; Di Rocco, A.; Placentino, F.; Diemberger, I.; Lip, G. Y. H.; Boriani, G.
abstract

Aims: Many clinical scores for risk stratification in patients with atrial fibrillation have been proposed, and some have been useful in predicting all-cause mortality. We aim to analyse the relationship between clinical risk score and all-cause death occurrence in atrial fibrillation patients. Methods: We performed a systematic search in PubMed and Scopus from inception to 22 July 2017. We considered the following scores: ATRIA-Stroke, ATRIA-Bleeding, CHADS2, CHA2DS2-VASc, HAS-BLED, HATCH and ORBIT. Papers reporting data about scores and all-cause death rates were considered. Results: Fifty studies and 71 scores groups were included in the analysis, with 669,217 patients. Data on ATRIA-Bleeding, CHADS2, CHA2DS2-VASc and HAS-BLED were available. All the scores were significantly associated with an increased risk for all-cause death. All the scores showed modest predictive ability at five years (c-indexes (95% confidence interval) CHADS2: 0.64 (0.63–0.65), CHA2DS2-VASc: 0.62 (0.61–0.64), HAS-BLED: 0.62 (0.58–0.66)). Network meta-regression found no significant differences in predictive ability. CHA2DS2-VASc score had consistently high negative predictive value (≥94%) at one, three and five years of follow-up; conversely it showed the highest probability of being the best performing score (63% at one year, 60% at three years, 68% at five years). Conclusion: In atrial fibrillation patients, contemporary clinical risk scores are associated with an increased risk of all-cause death. Use of these scores for death prediction in atrial fibrillation patients could be considered as part of holistic clinical assessment. The CHA2DS2-VASc score had consistently high negative predictive value during follow-up and the highest probability of being the best performing clinical score.

2020 - Atrial fibrillation and remote monitoring through cardiac implantable electronic devices in heart failure patients [Articolo su rivista]
Boriani, G.; Imberti, J. F.; Vitolo, M.
abstract

2020 - Atrial high-rate episodes: clinical significance, prognostic impact and clinical management [Articolo su rivista]
Boriani, G.; Imberti, J. F.; Bonini, N.; Albini, A.; Autieri, A.; Vitolo, M.
abstract

The rapid increase in cardiac implantable electronic device (CIED) implants and their ability to monitor atrial activity significantly contributed to a parallel increase in the occasional detection of atrial tachyarrhythmias, termed as atrial high-rate episodes (AHREs). These episodes of atrial tachyarrhythmia are usually asymptomatic and they are often diagnosed incidentally during the regular follow-up of patients with CIEDs or during the diagnostic work-up for patients affected by cryptogenic stroke. Over the past 20 years, numerous studies attempted to demonstrate the clinical significance and prognostic impact of these episodes, but their clinical management remains unclear. However, AHREs are not only significantly associated with a greater risk of developing clinical atrial fibrillation over time, but are also associated with an increased risk of cerebral and/or systemic thromboembolic events. Therefore, if deemed favorable, the use of oral anticoagulant therapy may be reasonable. The purpose of this review is to perform a state of the art analysis focusing on the clinical management of AHREs, their prognostic impact, the risks and benefits of anticoagulation and the critical issues that have emerged in the last years of studies.

2020 - COVID-19 pandemic: usefulness of telemedicine in management of arrhythmias in elderly people [Articolo su rivista]
Mattioli, Anna Vittoria; Cossarizza, Andrea; Boriani, Giuseppe
abstract

In March 2020, the WHO defined the diffusion of novel coronavirus, Severe Acute Respiratory Syndrome-Coronavirus- 2 (SARS-CoV-2) as pandemic.[13] As a consequence, the Italian Government among others has enforced quarantine on the population to contain the diffusion of the infection.

2020 - Cardiac arrest: The need for integrated multi-disciplinary actions for a continuum of care both in acute and at long-term [Articolo su rivista]
Boriani, G.
abstract

2020 - Cardiac electronic devices: Future directions and challenges [Articolo su rivista]
Kotalczyk, A.; Kalarus, Z.; Wright, D. J.; Boriani, G.; Lip, G. Y. H.
abstract

Cardiovascular implantable electronic devices (CIEDs) are essential management options for patients with brady-and tachyarrhythmias or heart failure with concomitant optimal pharmacotherapy. Despite increasing technological advances, there are still gaps in the management of CIED patients, eg, the growing number of lead-and pocket-related longterm complications, including cardiac device–related infective endocarditis, requires the greatest care. Likewise, patients with CIEDs should be monitored remotely as a part of a comprehensive, holistic management approach. In addition, novel technologies used in smartwatches may be a convenient tool for long-term atrial fibrillation (AF) screening, especially in high-risk populations. Early detection of AF may reduce the risk of stroke and other AF-related complications. The objective of this review article was to provide an overview of novel technologies in cardiac rhythm–management devices and future challenges related to CIEDs.

2020 - Cardiac implantable electrical devices in patients with hypertrophic cardiomyopathy: single center implant data extracted from the Swedish pacemaker and ICD registry [Articolo su rivista]
Valzania, C.; Gadler, F.; Boriani, G.; Rapezzi, C.; Eriksson, M. J.
abstract

Objectives: To investigate cardiac implantable electrical device (CIED) first implants in patients with hypertrophic cardiomyopathy (HCM) in a Swedish tertiary university hospital. Design: Clinical and technical data on pacemaker, implantable cardioverter defibrillator (ICD), and cardiac resynchronization therapy (CRT) first implants performed in HCM patients at the Karolinska University Hospital from 2005 to 2016 were extracted from the Swedish Pacemaker and ICD Registry. Echocardiographic data were obtained by review of hospital recordings. Results: The number of first pacemaker implants in HCM patients was 70 (1.5% of total pacemaker implants). The mean age of HCM pacemaker patients was 71 ± 10 years. Pacemaker implants were almost uniformly distributed between genders. Dual-chamber pacemakers with or without CRT properties were prevalent (6 and 93%, respectively). The number of first ICD implants in HCM patients was 99 (5.1% of total ICD implants). HCM patients receiving an ICD were 53 ± 15 years and prevalently men (70%). Sixty-five (66%) patients were implanted for primary prevention. Dual-chamber ICDs with or without CRT were 21 and 65%, respectively. Obstructive HCM was present in 47% pacemaker patients and 25% ICD patients with available pre-implant echo. Conclusions: This retrospective registry-based study provides a picture of CIED first implants in HCM patients in a Swedish tertiary university hospital. ICDs were the most commonly implanted devices, covering 59% of CIED implants. HCM patients receiving a pacemaker or an ICD had different epidemiological and clinical profiles.

2020 - Cardioversion of recent-onset atrial fibrillation: current evidence, practical considerations, and controversies in a complex clinical scenario [Articolo su rivista]
Boriani, G.; Bonini, N.; Albini, A.; Venturelli, A.; Imberti, J. F.; Vitolo, M.
abstract

Atrial fibrillation (AF) represents the most common arrhythmia and is associated with increased morbidity and mortality generating high social costs. Due to its high prevalence, AF is usually managed not only by cardiologists but also by general practitioners or clinicians in emergency departments. The conventional classification of AF includes "recent‑onset AF" defined as an arrhythmia episode shorter than 48 hours. In patients with a definite duration of AF of less than 24 hours and a very low-risk profile (CHA2DS2VASc of 0 in men and 1 in women), the thromboembolic risk seems to be low, and the standard 4‑week anticoagulation therapy is now regarded as optional treatment. Cardioversion (electrical or pharmacological) in recent‑onset AF represents a valid rhythm control strategy. Electrical cardioversion is usually reserved for hemodynamically unstable patients and performed with biphasic waveform shocks. On the other hand, pharmacological cardioversion is preferred in hemodynamically stable patients. Several antiarrhythmic drugs have been studied so far, but some questions still remain unresolved mainly due to lack of randomized clinical trials and prospective studies. The current guidelines do not uniformly agree on which drug to use for pharmacological cardioversion, and drug preference varies widely in clinical practice. The aim of this narrative review is to sum up and critically evaluate novel evidence regarding recent‑onset AF as well as to provide some practical considerations particularly focused on rhythm control with pharmacological cardioversion.

2020 - Complicated myocardial infarction in a 99-year-old lady in the era of COVID-19 pandemic: from the need to rule out coronavirus infection to emergency percutaneous coronary angioplasty [Articolo su rivista]
Sgura, F. A.; Arrotti, S.; Cappello, C. G.; Boriani, G.
abstract

2020 - Consumer-led screening for atrial fibrillation using consumer-facing wearables, devices and apps: A survey of health care professionals by AF-SCREEN international collaboration [Articolo su rivista]
Boriani, G.; Schnabel, R. B.; Healey, J. S.; Lopes, R. D.; Verbiest-van Gurp, N.; Lobban, T.; Camm, J. A.; Freedman, B.
abstract

Aim: A variety of consumer-facing wearables, devices and apps are marketed directly to consumers to detect atrial fibrillation (AF). However, their management is not defined. Our aim was to explore their role for AF screening via a survey. Methods and Results: An anonymous web-based survey was undertaken by 588 health care professionals (HCPs) (response rate 23.7%). Overall, 57% HCPs currently advise wearables/apps for AF detection in their patients: this was much higher for electrophysiologists and nurses/allied health professionals (74–75%) than cardiologists (57%) or other physicians (34–38%). Approximately 46% recommended handheld (portable) single-lead dedicated ECG devices, or, less frequently, wristband ECG monitors with similar differentials between HCPs. Only 10–15% HCPs advised photoplethysmographic wristband monitors or smartphone apps. In over half of the HCP consultations for AF detected by wearables/apps, the decision to screen was entirely the patient's. About 45% of HCPs perceive a potential role for AF screening in people aged >65 years or in those with risk factors. Almost 70% of HCPs believed we are not yet ready for mass consumer-initiated screening for AF using wearable devices/apps, with patient anxiety, risk of false positives and negatives, and risk of anticoagulant-related bleeding perceived as potential disadvantages, and perceived need for appropriate management pathways. Conclusions: There is a great potential for appropriate use of consumer-facing wearables/apps for AF screening. However, it appears that there is a need to better define suitable individuals for screening and an appropriate mechanism for managing positive results before they can be recommended by HCPs.

2020 - Continuous monitoring of sleep-disordered breathing with pacemakers: Indexes for risk stratification of atrial fibrillation and risk of stroke [Articolo su rivista]
Mazza, A.; Bendini, M. G.; Leggio, M.; De Cristofaro, R.; Valsecchi, S.; Boriani, G.
abstract

Background: Sleep apnea (SA) is a risk factor for atrial fibrillation (AF). Advanced pacemakers are now able to calculate indexes of SA severity. Hypothesis: We investigated the changes in pacemaker-measured indexes of SA, we assessed their predictive value for AF occurrence and the associated risk of stroke and death at long-term. Methods: We enrolled 439 recipients of a pacemaker endowed with an algorithm for the calculation of a Respiratory Disturbance Index (RDI). The RDI variability was measured over the first 12 months after implantation, as well as its potential association with the occurrence of AF, defined as device-detected cumulative AF burden ≥6 hoursours in a day. Results: The individual RDI mean was 30 ± 18 episodes/h, and the RDI maximum was 59 ± 21 episodes/h. RDI ≥30 episodes/h was detected in 351 (80%) patients during at least one night. The proportion of nights with RDI ≥30 episodes/h was 14% (2%-36%). AF ≥6 hours was detected in 129 (29%) patients during the first 12 months. The risk of AF was higher in patients with RDI maximum ≥63 episodes/h (HR:1.74; 95%CI: 1.22-2.48; P =.001) and with RDI mean ≥ 46 episodes/h (HR:1.63; 95%CI: 1.03-2.57; P =.014). The risk of all-cause death or stroke was higher in patients with AF burden ≥6 hours (HR:1.75; 95%CI: 1.06-2.86; P =.016). Moreover, among patients with no previous history of AF the risk was higher in those with RDI maximum ≥63 episodes/h (HR:1.96; 95%CI: 1.06-3.63; P =.031). Conclusions: Pacemaker-detected SA showed a considerable variability during follow-up. We confirmed the association between RDI and higher risk of AF, and we observed an association between higher RDI maximum and all-cause death or stroke among patients with no previous history of AF.

2020 - Cost-effectiveness of an antibacterial envelope for cardiac implantable electronic device infection prevention in the US healthcare system from the WRAP-IT Trial [Articolo su rivista]
Wilkoff, B. L.; Boriani, G.; Mittal, S.; Poole, J. E.; Kennergren, C.; Corey, G. R.; Krahn, A. D.; Schloss, E. J.; Gallastegui, J. L.; Pickett, R. A.; Evonich, R. F.; Roark, S. F.; Sorrentino, D. M.; Sholevar, D. P.; Cronin, E. M.; Berman, B. J.; Riggio, D. W.; Khan, H. H.; Silver, M. T.; Collier, J.; Eldadah, Z.; Holbrook, R.; Lande, J. D.; Lexcen, D. R.; Seshadri, S.; Tarakji, K. G.
abstract

Background: In the WRAP-IT trial (Worldwide Randomized Antibiotic Envelope Infection Prevention), adjunctive use of an absorbable antibacterial envelope resulted in a 40% reduction of major cardiac implantable electronic device infection without increased risk of complication in 6983 patients undergoing cardiac implantable electronic device revision, replacement, upgrade, or initial cardiac resynchronization therapy defibrillator implant. There is limited information on the cost-effectiveness of this strategy. As a prespecified objective, we evaluated antibacterial envelope cost-effectiveness compared with standard-of-care infection prevention strategies in the US healthcare system. Methods: A decision tree model was used to compare costs and outcomes of antibacterial envelope (TYRX) use adjunctive to standard-of-care infection prevention versus standard-of-care alone over a lifelong time horizon. The analysis was performed from an integrated payer-provider network perspective. Infection rates, antibacterial envelope effectiveness, infection treatment costs and patterns, infection-related mortality, and utility estimates were obtained from the WRAP-IT trial. Life expectancy and long-term costs associated with device replacement, follow-up, and healthcare utilization were sourced from the literature. Costs and quality-adjusted life years were discounted at 3%. An upper willingness-to-pay threshold of $150 000 per quality-adjusted life year was used to determine cost-effectiveness, in alignment with the American College of Cardiology/American Heart Association practice guidelines and as supported by the World Health Organization and contemporary literature. Results: The base case incremental cost-effectiveness ratio of the antibacterial envelope compared with standard-of-care was $112 603/quality-adjusted life year. The incremental cost-effectiveness ratio remained lower than the willingness-to-pay threshold in 74% of iterations in the probabilistic sensitivity analysis and was most sensitive to the following model inputs: infection-related mortality, life expectancy, and infection cost. Conclusions: The absorbable antibacterial envelope was associated with a cost-effectiveness ratio below contemporary benchmarks in the WRAP-IT patient population, suggesting that the envelope provides value for the US healthcare system by reducing the incidence of cardiac implantable electronic device infection. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02277990.

2020 - Cytokine Profile in Striated Muscle Laminopathies: New Promising Biomarkers for Disease Prediction [Articolo su rivista]
Cappelletti, Cristina; Tramacere, I.; Cavalcante, P.; Schena, E.; Politano, L.; Carboni, N.; Gambineri, A.; D'Amico, A.; Ruggiero, L.; Ricci, G.; Siciliano, G.; Boriani, G.; Mongini, T. E.; Vercelli, L.; Biagini, E.; Ziacchi, M.; D'Apice, M. R.; Lattanzi, G.; Mantegazza, R.; Maggi, L.; Bernasconi, P.
abstract

Laminopathies are a wide and heterogeneous group of rare human diseases caused by mutations of the LMNA gene or related nuclear envelope genes. The variety of clinical phenotypes and the wide spectrum of histopathological changes among patients carrying an identical mutation in the LMNA gene make the prognostic process rather difficult, and classical genetic screens appear to have limited predictive value for disease development. The aim of this study was to evaluate whether a comprehensive profile of circulating cytokines may be a useful tool to differentiate and stratify disease subgroups, support clinical follow-ups and contribute to new therapeutic approaches. Serum levels of 51 pro- and anti-inflammatory molecules, including cytokines, chemokines and growth factors, were quantified by a Luminex multiple immune-assay in 53 patients with muscular laminopathy (Musc-LMNA), 10 with non-muscular laminopathy, 22 with other muscular disorders and in 35 healthy controls. Interleukin-17 (IL-17), granulocyte colony-stimulating factor (G-CSF) and transforming growth factor beta (TGF-β2) levels significantly discriminated Musc-LMNA from controls; interleukin-1β (IL-1β), interleukin-4 (IL-4) and interleukin-8 (IL-8) were differentially expressed in Musc-LMNA patients compared to those with non-muscular laminopathies, whereas IL-17 was significantly higher in Musc-LMNA patients with muscular and cardiac involvement. These findings support the hypothesis of a key role of the immune system in Musc-LMNA and emphasize the potential use of cytokines as biomarkers for these disorders.

2020 - Degree of left ventricular dilatation at end-diastole: Correlation and prognostic utility of quantitative volumes by 2D-echocardiography versus linear dimensions in patients with asymptomatic aortic regurgitation [Articolo su rivista]
Barbieri, A.; Benfari, G.; Giubertoni, E.; Manicardi, M.; Bursi, F.; Rossi, A.; Maritan, L.; Venturi, G.; Boriani, G.
abstract

Background: Guideline recommendations for aortic valve replacement (AVR) in asymptomatic patients with chronic aortic regurgitation (AR) have historically focused on linear dimensions without normalization for the body surface area (BSA). Values for grading the severity of end-diastolic volume dilatation by 2D echocardiography remain to be established. Methods and Results: We retrospectively analyzed 543 consecutive asymptomatic patients with pure chronic moderate/severe AR (mean age 66 ± 17 years, 37.7% males). Applying the ASE/EACVI guidelines, BSA-indexed LV end-diastolic volume (LVEDVi) and indexed LV end-diastolic diameter (LVEDDi) were assessed. Then, we identified 192 patients with at least mild LV end-diastolic dilatation by volumetric or linear measurements. The outcome endpoint was the combination of cardiac death, hospitalization for acute heart failure or AVR during a median follow-up of 4.5 ± 3.6 years. Multivariable Cox regression analyses including age, LV ejection fraction (EF) and AR severity showed an independent prognostic value of the LVEDDi and LVEDVi (P <.001 and P <.01, respectively). Congruent severe LVEDDi and LVEDVi dilatation was associated with a higher event rate compared to discordant severe LV end-diastolic dilatation or nonsevere LV dilatation (P =.001) even after landmark analysis (P =.02). In patients with EF > 50%, only the LVEDVi showed and independent prognostic value (P <.001). Conclusions: In a cohort of asymptomatic patients with AR, the presence of severe LV volume and diameter dilatation on the basis of the cutoff values proposed by current recommendations and normalized for BSA may be instrumental in the identification of patients at increased risk of clinical progression regardless of EF.

2020 - Driving restriction in patients with cardiac implantable electronic devices: an overview of worldwide regulations [Articolo su rivista]
Imberti, J. F.; Vitolo, M.; Proietti, M.; Diemberger, I.; Ziacchi, M.; Biffi, M.; Boriani, G.
abstract

Introduction: It is common belief that driving with an implantable cardioverter defibrillator (ICD)/pacemaker (PM) might be associated with sudden cardiac incapacitation, road traffic accidents, and chance to harm to self and others. On the other hand, the ability to drive is highly valuable in the modern era, representing a cornerstone of daily living and employment. National regulations try to balance the right to drive of ICD/PM patients and the risk they pose to public safety, but rules for granting them a driving license are considerably different worldwide. For the same subset of patients driving restrictions may vary between 1 week and 1 year depending on the local law. Areas covered: In this article we systematically review driving restrictions in ICD/PM patients in 16 countries all over the world, highlighting their differences and analyzing data from the literature that underlie their formulation. Expert opinion: Current regulations are mainly based on historical data that do not take into account improvements in ICD/PM technologies and driving environment, which have made driving with an ICD/PM is substantially safe. Newer studies and updated regulatory documents are warranted to set the best driving restrictions and reach homogeneity worldwide.

2020 - Edoxaban and the Issue of Drug-Drug Interactions: From Pharmacology to Clinical Practice [Articolo su rivista]
Corsini, A.; Ferri, N.; Proietti, M.; Boriani, G.
abstract

Edoxaban, a direct factor Xa inhibitor, is the latest of the non-vitamin K antagonist oral anticoagulants (NOACs). Despite being marketed later than other NOACs, its use is now spreading in current clinical practice, being indicated for both thromboprophylaxis in patients with non-valvular atrial fibrillation (NVAF) and for the treatment and prevention of venous thromboembolism (VTE). In patients with multiple conditions, the contemporary administration of several drugs can cause relevant drug-drug interactions (DDIs), which can affect drugs’ pharmacokinetics and pharmacodynamics. Usually, all the NOACs are considered to have significantly fewer DDIs than vitamin K antagonists; notwithstanding, this is actually not true, all of them are affected by DDIs with drugs that can influence the activity (induction or inhibition) of P-glycoprotein (P-gp) and cytochrome P450 3A4, both responsible for the disposition and metabolism of NOACs to a different extent. In this review/expert opinion, we focused on an extensive report of edoxaban DDIs. All the relevant drugs categories have been examined to report on significant DDIs, discussing the impact on edoxaban pharmacokinetics and pharmacodynamics, and the evidence for dose adjustment. Our analysis found that, despite a restrained number of interactions, some strong inhibitors/inducers of P-gp and drug-metabolising enzymes can affect edoxaban concentration, just as it happens with other NOACs, implying the need for a dose adjustment. However, our analysis of edoxaban DDIs suggests that given the small propensity for interactions of this agent, its use represents an acceptable clinical decision. Still, DDIs can be significant in certain clinical situations and a careful evaluation is always needed when prescribing NOACs.

2020 - Effect on mortality of different routes of administration and loading dose of aspirin in patients with ST-segment elevation acute myocardial infarction treated with primary angioplasty [Articolo su rivista]
Rossi, Rosario; Bagnacani, Alessandra; Sgura, Fabio; Enrique Monopoli, Daniel; Coppi, Francesca; Talarico, Marisa; Rolando, Cristina; Boriani, Giuseppe
abstract

Aspirin is the cornerstone of the anti-platelet therapy during the acute phase of ST-segment elevation myocardial infarction (STEMI), and it can be administrated orally or intravenously. The oral loading dose of aspirin is well characterized, whereas there are little data on the optimal intravenous (IV) loading dose.

2020 - Effects of Anti-vitamin k oral anticoagulants on bone and cardiovascular health [Articolo su rivista]
Marietta, M.; Coluccio, V.; Boriani, G.; Luppi, M.
abstract

Vitamin K antagonist oral anticoagulants (VKAs) have been proven over 50 years to be highly effective and acceptably safe in many settings and are still used by millions of people worldwide. The main concern about the safety of VKAs regards the risk of bleeding, but there is accumulation evidence of their potentially negative effects beyond hemostasis. Indeed, VKAs impair the action of several Vitamin-K Dependent Proteins (VKDP), such as Bone Gla protein, Matrix Gla protein, Gas6 Protein, Periostin and Gla-Ric Protein, involved in bone and vascular metabolism, thus exerting a detrimental effect on bone and vascular health. Indeed, although the evidence regarding this issue is not compelling, it has been shown that VKAs use decreases bone mass density, increases the risk of bone fractures and accelerates the process of vascular and valvular calcification. Vascular calcification is a major concern in Chronic Kidney Disease (CKD) patients, also in absence of VKAs, because of mineral metabolism derangement, chronic inflammation and oxidative stress. Direct Oral AntiCoagulants (DOACs) do not affect VKDP involved in vascular and valvular calcification, and do not induce calcific valve degeneration in animal models, being a possible alternative to AVK for CKD patients. However, the efficacy and safety of DOACs in this population, suggested by some recent observations, requires confirmation by dedicated, randomized study. We reviewed here the effects of VKAs in bone and vascular health as compared to DOACs, in order to provide the physicians with some data useful to wisely choose the most suitable anticoagulant for every patient.

2020 - European Heart Rhythm Association (EHRA) international consensus document on how to prevent, diagnose, and treat cardiac implantable electronic device infections - Endorsed by the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS), the Latin American Heart Rhythm Society (LAHRS), International Society for Cardiovascular Infectious Diseases (ISCVID) and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS) [Articolo su rivista]
Blomstrom-Lundqvist, C.; Traykov, V.; Erba, P. A.; Burri, H.; Nielsen, J. C.; Bongiorni, M. G.; Poole, J.; Boriani, G.; Costa, R.; Deharo, J. -C.; Epstein, L. M.; Saghy, L.; Snygg-Martin, U.; Starck, C.; Tascini, C.; Strathmore, N.; Kalarus, Z.; Boveda, S.; Dagres, N.; Rinaldi, C. A.; Biffi, M.; Geller, L.; Sokal, A.; Birgersdotter-Green, U.; Lever, N.; Tajstra, M.; Kutarski, A.; Rodriguez, D. A.; Hasse, B.; Zinkernagel, A.; Mangoni, E.
abstract

Pacemakers, implantable cardiac defibrillators, and cardiac resynchronization therapy devices are potentially life-saving treatments for a number of cardiac conditions, but are not without risk. Most concerning is the risk of a cardiac implantable electronic device (CIED) infection, which is associated with significant morbidity, increased hospitalizations, reduced survival, and increased healthcare costs. Recommended preventive strategies such as administration of intravenous antibiotics before implantation are well recognized. Uncertainties have remained about the role of various preventive, diagnostic, and treatment measures such as skin antiseptics, pocket antibiotic solutions, anti-bacterial envelopes, prolonged antibiotics post-implantation, and others. Guidance on whether to use novel device alternatives expected to be less prone to infections and novel oral anticoagulants is also limited, as are definitions on minimum quality requirements for centres and operators and volumes. Moreover, an international consensus document on management of CIED infections is lacking. The recognition of these issues, the dissemination of results from important randomized trials focusing on prevention of CIED infections, and observed divergences in managing device-related infections as found in an European Heart Rhythm Association worldwide survey, provided a strong incentive for a 2019 International State-of-the-art Consensus document on risk assessment, prevention, diagnosis, and treatment of CIED infections.

2020 - European Heart Rhythm Association (EHRA) international consensus document on how to prevent, diagnose, and treat cardiac implantable electronic device infections - Endorsed by the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS), the Latin American Heart Rhythm Society (LAHRS), International Society for Cardiovascular Infectious Diseases (ISCVID) and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS) [Articolo su rivista]
Blomstrom-Lundqvist, C.; Traykov, V.; Erba, P. A.; Burri, H.; Nielsen, J. C.; Bongiorni, M. G.; Poole, J.; Boriani, G.; Costa, R.; Deharo, J. -C.; Epstein, L. M.; Saghy, L.; Snygg-Martin, U.; Starck, C.; Tascini, C.; Strathmore, N.; Kalarus, Z.; Boveda, S.; Dagres, N.; Rinaldi, C. A.; Biffi, M.; Geller, L.; Sokal, A.; Birgersdotter-Green, U.; Lever, N.; Tajstra, M.; Kutarski, A.; Rodriguez, D. A.; Hasse, B.; Zinkernagel, A.; Mangoni, E.
abstract

Pacemakers, implantable cardiac defibrillators, and cardiac resynchronization therapy devices are potentially life-saving treatments for a number of cardiac conditions, but are not without risk. Most concerning is the risk of a cardiac implantable electronic device (CIED) infection, which is associated with significant morbidity, increased hospitalizations, reduced survival, and increased healthcare costs. Recommended preventive strategies such as administration of intravenous antibiotics before implantation are well recognized. Uncertainties have remained about the role of various preventive, diagnostic, and treatment measures such as skin antiseptics, pocket antibiotic solutions, anti-bacterial envelopes, prolonged antibiotics post-implantation, and others. Guidance on whether to use novel device alternatives expected to be less prone to infections and novel oral anticoagulants is also limited, as are definitions on minimum quality requirements for centres and operators and volumes. Moreover, an international consensus document on management of CIED infections is lacking. The recognition of these issues, the dissemination of results from important randomized trials focusing on prevention of CIED infections, and observed divergences in managing device-related infections as found in an European Heart Rhythm Association worldwide survey, provided a strong incentive for a 2019 International State-of-the-art Consensus document on risk assessment, prevention, diagnosis, and treatment of CIED infections.

2020 - European Heart Rhythm Association (EHRA) international consensus document on how to prevent, diagnose, and treat cardiac implantable electronic device infections-endorsed by the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS), the Latin American Heart Rhythm Society (LAHRS), International Society for Cardiovascular Infectious Diseases (ISCVID), and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS) [Articolo su rivista]
Blomstrom-Lundqvist, C.; Traykov, V.; Erba, P. A.; Burri, H.; Nielsen, J. C.; Bongiorni, M. G.; Poole, J.; Boriani, G.; Costa, R.; Deharo, J. -C.; Epstein, L. M.; Saghy, L.; Snygg-Martin, U.; Starck, C.; Tascini, C.; Strathmore, N.
abstract

Pacemakers, implantable cardiac defibrillators, and cardiac resynchronization therapy devices are potentially lifesaving treatments for a number of cardiac conditions but are not without risk. Most concerning is the risk of a cardiac implantable electronic device (CIED) infection, which is associated with significant morbidity, increased hospitalizations, reduced survival, and increased health care costs. Recommended preventive strategies such as administration of intravenous antibiotics before implantation are well-recognized. Uncertainties have remained about the role of various preventive, diagnostic, and treatment measures such as skin antiseptics, pocket antibiotic solutions, antibacterial envelopes, prolonged antibiotics post-implantation, and others. When compared with previous guidelines or consensus statements, the present consensus document gives guidance on the use of novel device alternatives, novel oral anticoagulants, antibacterial envelopes, prolonged antibiotics post-implantation, as well as definitions on minimum quality requirements for centres and operators and volumes. The recognition that an international consensus document focused on management of CIED infections is lacking, the dissemination of results from new important randomized trials focusing on prevention of CIED infections, and observed divergences in managing device-related infections as found in an European Heart Rhythm Association worldwide survey, provided a strong incentive for a Novel 2019 International State-of-the-art Consensus document on risk assessment, prevention, diagnosis, and treatment of CIED infections.

2020 - Female sex and stroke in atrial fibrillation: an intriguing relationship [Articolo su rivista]
Boriani, G.; Colella, J.; Imberti, J.; Fantecchi, E.; Vitolo, M.
abstract

2020 - Ferric carboxymaltose for iron deficiency at discharge after acute heart failure: a multicentre, double-blind, randomised, controlled trial [Articolo su rivista]
Ponikowski, P.; Kirwan, B. -A.; Anker, S. D.; Mcdonagh, T.; Dorobantu, M.; Drozdz, J.; Fabien, V.; Filippatos, G.; Gohring, U. M.; Keren, A.; Khintibidze, I.; Kragten, H.; Martinez, F. A.; Metra, M.; Milicic, D.; Nicolau, J. C.; Ohlsson, M.; Parkhomenko, A.; Pascual-Figal, D. A.; Ruschitzka, F.; Sim, D.; Skouri, H.; van der Meer, P.; Lewis, B. S.; Comin-Colet, J.; von Haehling, S.; Cohen-Solal, A.; Danchin, N.; Doehner, W.; Dargie, H. J.; Motro, M.; Butler, J.; Friede, T.; Jensen, K. H.; Pocock, S.; Jankowska, E. A.; Azize, G.; Fernandez, A.; Zapata, G. O.; Garcia Pacho, P.; Glenny, A.; Ferre Pacora, F.; Parody, M. L.; Bono, J.; Beltrano, C.; Hershson, A.; Vita, N.; Luquez, H. A.; Cestari, H. G.; Fernandez, H.; Prado, A.; Berli, M.; Garcia Duran, R.; Thierer, J.; Diez, M.; Lobo Marquez, L.; Borelli, R. R.; Hominal, M. A.; Metra, M.; Ameri, P.; Agostoni, P.; Salvioni, A.; Fattore, L.; Gronda, E.; Ghio, S.; Turrini, F.; Uguccioni, M.; Di Biase, M.; Piepoli, M.; Savonitto, S.; Mortara, A.; Terrosu, P.; Fucili, A.; Boriani, G.; Midi, P.; Passamonti, E.; Cosmi, F.; van der Meer, P.; Van Bergen, P.; van de Wetering, M.; Al-Windy, N. Y. Y.; Tanis, W.; Meijs, M.; Groutars, R. G. E. J.; The, H. K. S.; Kietselaer, B.; van Kesteren, H. A. M.; Beelen, D. P. W.; Heymeriks, J.; Van de Wal, R.; Schaap, J.; Emans, M.; Westendorp, P.; Nierop, P. R.; Nijmeijer, R.; Manintveld, O. C.; Dorobantu, M.; Darabantiu, D. A.; Zdrenghea, D.; Toader, D. M.; Petrescu, L.; Militaru, C.; Crisu, D.; Tomescu, M. C.; Stanciulescu, G.; Rodica Dan, A.; Iosipescu, L. C.; Serban, D. L.; Drozdz, J.; Szachniewicz, J.; Bronisz, M.; Tycinska, A.; Wozakowska-Kaplon, B.; Mirek-Bryniarska, E.; Gruchala, M.; Nessler, J.; Straburzynska-Migaj, E.; Mizia-Stec, K.; Szelemej, R.; Gil, R.; Gasior, M.; Gotsman, I.; Halabi, M.; Shochat, M.; Shechter, M.; Witzling, V.; Zukermann, R.; Arbel, Y.; Flugelman, M.; Ben-Gal, T.; Zvi, V.; Kinany, W.; Weinstein, J. M.; Atar, S.; Goland, S.; Milicic, D.; Horvat, D.; Tusek, S.; Udovicic, M.; Sutalo, K.; Samodol, A.; Pesek, K.; Artukovic, M.; Ruzic, A.; Sikic, J.; Mcdonagh, T.; Trevelyan, J.; Wong, Y. -K.; Gorog, D.; Ray, R.; Pettit, S.; Sharma, S.; Kabir, A.; Hamdan, H.; Tilling, L.; Baracioli, L.; Nigro Maia, L.; Dutra, O.; Reis, G.; Pimentel Filho, P.; Saraiva, J. F.; Kormann, A.; dos Santos, F. R.; Bodanese, L.; Almeida, D.; Precoma, D.; Rassi, S.; Costa, F.; Kabbani, S.; Abdelbaki, K.; Abdallah, C.; Arnaout, M. S.; Azar, R.; Chaaban, S.; Raed, O.; Kiwan, G.; Hassouna, B.; Bardaji, A.; Zamorano, J.; del Prado, S.; Gonzalez Juanatey, J. R.; Ga Bosa Ojeda, F. I.; Gomez Bueno, M.; Molina, B. D.; Pascual Figal, D. A.; Sim, D.; Yeo, T. J.; Loh, S. Y.; Soon, D.; Ohlsson, M.; Smith, J. G.; Gerward, S.; Khintibidze, I.; Lominadze, Z.; Chapidze, G.; Emukhvari, N.; Khabeishvili, G.; Chumburidze, V.; Paposhvili, K.; Shaburishvili, T.; Parhomenko, O.; Kraiz, I.; Koval, O.; Zolotaikina, V.; Malynovsky, Y.; Vakaliuk, I.; Rudenko, L.; Tseluyko, V.; Stanislavchuk, M.
abstract

Background: Intravenous ferric carboxymaltose has been shown to improve symptoms and quality of life in patients with chronic heart failure and iron deficiency. We aimed to evaluate the effect of ferric carboxymaltose, compared with placebo, on outcomes in patients who were stabilised after an episode of acute heart failure. Methods: AFFIRM-AHF was a multicentre, double-blind, randomised trial done at 121 sites in Europe, South America, and Singapore. Eligible patients were aged 18 years or older, were hospitalised for acute heart failure with concomitant iron deficiency (defined as ferritin <100 μg/L, or 100–299 μg/L with transferrin saturation <20%), and had a left ventricular ejection fraction of less than 50%. Before hospital discharge, participants were randomly assigned (1:1) to receive intravenous ferric carboxymaltose or placebo for up to 24 weeks, dosed according to the extent of iron deficiency. To maintain masking of patients and study personnel, treatments were administered in black syringes by personnel not involved in any study assessments. The primary outcome was a composite of total hospitalisations for heart failure and cardiovascular death up to 52 weeks after randomisation, analysed in all patients who received at least one dose of study treatment and had at least one post-randomisation data point. Secondary outcomes were the composite of total cardiovascular hospitalisations and cardiovascular death; cardiovascular death; total heart failure hospitalisations; time to first heart failure hospitalisation or cardiovascular death; and days lost due to heart failure hospitalisations or cardiovascular death, all evaluated up to 52 weeks after randomisation. Safety was assessed in all patients for whom study treatment was started. A pre-COVID-19 sensitivity analysis on the primary and secondary outcomes was prespecified. This study is registered with ClinicalTrials.gov, NCT02937454, and has now been completed. Findings: Between March 21, 2017, and July 30, 2019, 1525 patients were screened, of whom 1132 patients were randomly assigned to study groups. Study treatment was started in 1110 patients, and 1108 (558 in the carboxymaltose group and 550 in the placebo group) had at least one post-randomisation value. 293 primary events (57·2 per 100 patient-years) occurred in the ferric carboxymaltose group and 372 (72·5 per 100 patient-years) occurred in the placebo group (rate ratio [RR] 0·79, 95% CI 0·62–1·01, p=0·059). 370 total cardiovascular hospitalisations and cardiovascular deaths occurred in the ferric carboxymaltose group and 451 occurred in the placebo group (RR 0·80, 95% CI 0·64–1·00, p=0·050). There was no difference in cardiovascular death between the two groups (77 [14%] of 558 in the ferric carboxymaltose group vs 78 [14%] in the placebo group; hazard ratio [HR] 0·96, 95% CI 0·70–1·32, p=0·81). 217 total heart failure hospitalisations occurred in the ferric carboxymaltose group and 294 occurred in the placebo group (RR 0·74; 95% CI 0·58–0·94, p=0·013). The composite of first heart failure hospitalisation or cardiovascular death occurred in 181 (32%) patients in the ferric carboxymaltose group and 209 (38%) in the placebo group (HR 0·80, 95% CI 0·66–0·98, p=0·030). Fewer days were lost due to heart failure hospitalisations and cardiovascular death for patients assigned to ferric carboxymaltose compared with placebo (369 days per 100 patient-years vs 548 days per 100 patient-years; RR 0·67, 95% CI 0·47–0·97, p=0·035). Serious adverse events occurred in 250 (45%) of 559 patients in the ferric carboxymaltose group and 282 (51%) of 551 patients in the placebo group. Interpretation: In patients with iron deficiency, a left ventricular ejection fraction of less than 50%, and who were stabilised after an episode of acute heart failure, treatment with ferric carboxymaltose was safe and reduced the risk of heart failure hospitalisations, with no apparent effec

2020 - From meta-analysis to the individual patient with atrial fibrillation and coronary artery disease: the complexity of antithrombotic treatment in real-world clinical practice and the need for a tailored approach [Articolo su rivista]
Boriani, G.; Imberti, J. F.; Vitolo, M.
abstract

2020 - Impact of COVID-19 pandemic on the clinical activities related to arrhythmias and electrophysiology in Italy: results of a survey promoted by AIAC (Italian Association of Arrhythmology and Cardiac Pacing) [Articolo su rivista]
Boriani, G.; Palmisano, P.; Guerra, F.; Bertini, M.; Zanotto, G.; Lavalle, C.; Notarstefano, P.; Accogli, M.; Bisignani, G.; Forleo, G. B.; Landolina, M.; D'Onofrio, A.; Ricci, R.; De Ponti, R.; Luise, R.; Grieco, P.; Pangallo, A.; Quirino, G.; Talarico, A.; De Bonis, S.; Carbone, A.; De Simone, A.; D'Onofrio, A.; Nappi, F.; Rotondi, F.; Stabile, G.; Uran, C.; Bertini, M.; Balla, C.; Boggian, G.; Carinci, V.; Barbato, G.; Corzani, A.; Sabbatani, P.; Erminio, M.; Imberti, J. F.; Malavasi, N.; Pastori, P.; Quartieri, F.; Bottoni, N.; Saporito, D.; Virzi, S.; Sassone, B.; Zardini, M.; Placci, A.; Ziacchi, M.; Massaro, G.; Adamo, F.; Scaccia, A.; Spampinato, A.; Biscione, F.; Castro, A.; Cauti, F.; Rossi, P.; Cinti, C.; Gatto, M.; Kol, A.; Narducci, M. L.; Pelargonio, G.; Patruno, N.; Pignalberi, C.; Ricci, R. P.; Ricciardi, D.; Santini, L.; Tancredi, M.; Di Belardino, N.; Pentimalli, F.; Zoni-Berisso, M.; Belotti, G.; Chieffo, E.; Cilloni, S.; Doni, L. A.; Forleo, G. B.; Gardini, A.; Malaspina, D.; Mazzone, P.; Della Bella, P.; Negro, R.; Perego, G. B.; Rordorf, R.; Cipolletta, L.; Russo, A. D.; Luzi, M.; Amellone, C.; Ebrille, E.; Favro, E.; Lucciola, M. T.; Devecchi, C.; Rametta, F.; Devecchi, F.; Matta, M.; Sant'Andrea, A. O.; Santagostino, M.; Dell'Era, G.; Candida, T. R.; Bonfantino, V. M.; Gianfrancesco, D.; Guido, A.; Pellegrino, P. L.; Pisano, E. C. L.; Rillo, M.; Palama, Z.; Sai, R.; Santobuono, V. E.; Favale, S.; Scicchitano, P.; Nissardi, V.; Campisi, G.; Sgarito, G.; Arena, G.; Casorelli, E.; Fumagalli, S.; Giaccardi, M.; Notarstefano, P.; Nesti, M.; Padeletti, M.; Rossi, A.; Piacenti, M.; Del Greco, M.; Catanzariti, D.; Manfrin, M.; Werner, R.; Marini, M.; Andreoli, C.; Fedeli, F.; Mazza, A.; Pagnotta, F.; Ridarelli, M.; Molon, G.; Rossillo, A.
abstract

COVID-19 outbreak had a major impact on the organization of care in Italy, and a survey to evaluate provision of for arrhythmia during COVID-19 outbreak (March–April 2020) was launched. A total of 104 physicians from 84 Italian arrhythmia centres took part in the survey. The vast majority of participating centres (95.2%) reported a significant reduction in the number of elective pacemaker implantations during the outbreak period compared to the corresponding two months of year 2019 (50.0% of centres reported a reduction of > 50%). Similarly, 92.9% of participating centres reported a significant reduction in the number of implantable cardioverter-defibrillator (ICD) implantations for primary prevention, and 72.6% a significant reduction of ICD implantations for secondary prevention (> 50% in 65.5 and 44.0% of the centres, respectively). The majority of participating centres (77.4%) reported a significant reduction in the number of elective ablations (> 50% in 65.5% of the centres). Also the interventional procedures performed in an emergency setting, as well as acute management of atrial fibrillation had a marked reduction, thus leading to the conclusion that the impact of COVID-19 was disrupting the entire organization of health care, with a massive impact on the activities and procedures related to arrhythmia management in Italy.

2020 - Impact of Cardiac Implantable Electronic Device Infection: A Clinical and Economic Analysis of the WRAP-IT Trial [Articolo su rivista]
Wilkoff, B. L.; Boriani, G.; Mittal, S.; Poole, J. E.; Kennergren, C.; Corey, G. R.; Love, J. C.; Augostini, R.; Faerestrand, S.; Wiggins, S. S.; Healey, J. S.; Holbrook, R.; Lande, J. D.; Lexcen, D. R.; Willey, S.; Tarakji, K. G.
abstract

Background: Current understanding of the impact of cardiac implantable electronic device (CIED) infection is based on retrospective analyses from medical records or administrative claims data. The WRAP-IT (Worldwide Randomized Antibiotic Envelope Infection Prevention Trial) offers an opportunity to evaluate the clinical and economic impacts of CIED infection from the hospital, payer, and patient perspectives in the US healthcare system. Methods: This was a prespecified, as-treated analysis evaluating outcomes related to major CIED infections: mortality, quality of life, disruption of CIED therapy, healthcare utilization, and costs. Payer costs were assigned using medicare fee for service national payments, while medicare advantage, hospital, and patient costs were derived from similar hospital admissions in administrative datasets. Results: Major CIED infection was associated with increased all-cause mortality (12-month risk-adjusted hazard ratio, 3.41 [95% CI, 1.81-6.41]; P<0.001), an effect that sustained beyond 12 months (hazard ratio through all follow-up, 2.30 [95% CI, 1.29-4.07]; P=0.004). Quality of life was reduced (P=0.004) and did not normalize for 6 months. Disruptions in CIED therapy were experienced in 36% of infections for a median duration of 184 days. Mean costs were $55 547±$45 802 for the hospital, $26 867±$14 893, for medicare fee for service and $57 978±$29 431 for Medicare Advantage (mean hospital margin of -$30 828±$39 757 for medicare fee for service and -$6055±$45 033 for medicare advantage). Mean out-of-pocket costs for patients were $2156±$1999 for medicare fee for service, and $1658±$1250 for medicare advantage. Conclusions: This large, prospective analysis corroborates and extends understanding of the impact of CIED infections as seen in real-world datasets. CIED infections severely impact mortality, quality of life, healthcare utilization, and cost in the US healthcare system. Registration: URL: https://www.clinicaltrials.gov Unique Identifier: NCT02277990.

2020 - Influence of BMI and geographical region on prescription of oral anticoagulants in newly diagnosed atrial fibrillation: The GLORIA-AF Registry Program [Articolo su rivista]
Boriani, G.; Huisman, M. V.; Teutsch, C.; Marler, S.; Franca, L. R.; Lu, S.; Lip, G. Y. H.
abstract

Objective: To investigate the association between body mass index (BMI) and oral anticoagulant (OAC) prescription in atrial fibrillation (AF). Methods: Patients with newly diagnosed non-valvular AF (<3 months) with ≥1 stroke risk factors enrolled in the Global Registry on Long-Term Oral Antithrombotic Treatment in Patients with Atrial Fibrillation (GLORIA-AF) in Asia, Europe and North America were evaluated. Results: The cohort (n = 13,793) comprised patients from all BMI categories (kg/m2): 1.4% were underweight (<18.5), 27.3% had a normal BMI (18.5 to <25), 37.9% were overweight (25 to <30), 19.3% were moderately obese (30 to <35), and 12.7% were morbidly obese (≥35). The highest proportion of Asians had a BMI of 18.5 to <25 kg/m2, while the highest proportion of patients from Europe and North America were overweight and a substantial proportion of North Americans morbidly obese. In the multivariable analysis, the probability ratio of non-prescription of OAC, as compared to normal BMI, decreased for overweight (RR = 0.907), moderately obese (RR = 0.802) and severe very severe obese patients (RR = 0.659). Moreover, the probability ratio of non-prescription of OACs was increased in the Asia or North America regions, as compared with Europe, in patients aged <65 years or female patients, as well as in patients with prior bleeding or vascular disease. Conclusions: The distribution of BMI differed among the continents. An increased BMI was associated with a lower probability of non-prescription of OACs, as compared with a normal BMI. The probability of non-prescription of OACs was increased in the Asia or North America regions, as compared with Europe.

2020 - Intrahospital organizational model of remote monitoring data sharing, for a global management of patients with cardiac implantable electronic devices: a document of the Italian Association of Arrhythmology and Cardiac Pacing [Articolo su rivista]
Zanotto, G.; Melissano, D.; Baccillieri, S.; Campana, A.; Caravati, F.; Maines, M.; Platania, F.; Zuccaro, L.; Landolina, M.; Berisso, M. Z.; Boriani, G.; Ricci, R. P.
abstract

: In recent years, the increasing number of patients with a cardiac implantable electronic device (CIED) has required different approaches in terms of the device's control and surveillance. It is increasingly difficult to keep the traditional in-office protocol device's control: we must think of a different organization dedicated to the activity of remote control and monitoring (RC/RM) of devices and patients.A CIED team structured with nurses, technicians and physicians should be organized inside the hospital, with the aim of CIED patients' managing and of creating a network between the various departments.Small hospitals may not be able to manage independently the CIEDs RC/RM and it is possible to hypothesize the creation of a collaborative network between neighbouring structures.This activity must combine the use of technology with the ability to take care of patients and to maintain adequate and meaningful relationships.

2020 - Kidney dysfunction and short term all-cause mortality after transcatheter aortic valve implantation [Articolo su rivista]
Sgura, F. A.; Arrotti, S.; Magnavacchi, P.; Monopoli, D.; Gabbieri, D.; Banchelli, F.; Tondi, S.; Denegri, A.; D'Amico, R.; Guiducci, V.; Vignali, L.; Boriani, G.
abstract

Background: Acute kidney injury (AKI) after transcatheter aortic valve implantation (TAVI) has been associated with worse outcomes. However, the impact on outcome of AKI in TAVI-patients is not well established. Methods: Inoperable patients with severe aortic stenosis (AS) undergoing TAVI in 2010-2018 were enrolled in this study. AKI and chronic kidney disease (CKD) were defined according to KDIGO guidelines. Patients were divided in two groups according to post-procedural AKI development. The primary endpoint was 30-day all-cause mortality across the two groups. Results: A total of 373 patients (mean age 82.3 ± 6) were analyzed. Compared to non-AKI patients, those who developed AKI, were treated more frequently with trans-apical TAVI (66% vs 35%, p<0.01), with greater amount of contrast medium (200.6 vs 170.4 ml, p=0.02) and in presence of clinically significant peripheral artery disease (PAD, 33% vs 21%, p=0.04). Trans-apical access (OR 3.24, 95% CI 1.76-5.60, p<0.01) was associated with a 3-fold risk of AKI. After adjustment for age, Society of Thoracic Surgery risk score (STS), PAD, access type, EF and contrast medium amount, patients with AKI presented an increased risk of 30-day all-cause mortality (HR=1.25, 95%CI 1.09-1.69, p=0.008). Patients with CKD IV and V, who developed AKI, presented a 9-fold 30-day mortality risk (HR=9.71, 95% CI 2.40-39.2, p=0.001). Conclusion: In our analysis, AKI was a strong predictor of 30-day all-cause mortality. Particularly, patients with severe CKD with AKI showed the highest 30-day mortality risk. Thus, this group of patients might benefit from closer monitoring and specific kidney protection therapies.

2020 - Managing atrial fibrillation: the need for an individualized approach even in the emergency department [Articolo su rivista]
Boriani, G.; Imberti, J. F.; Valenti, A. C.; Malavasi, V. L.; Vitolo, M.
abstract

2020 - Obesity Paradox in Atrial Fibrillation: Implications for Outcomes and Relationship with Oral Anticoagulant Drugs [Articolo su rivista]
Proietti, M.; Boriani, G.
abstract

In the last 40 years, concern about the obesity epidemic has increased. Data from the current literature highlight a strong relationship between obesity and atrial fibrillation (AF), particularly in relation to an increased risk for incident and recurrent AF. A phenomenon called the “obesity paradox” has emerged: the apparently counterintuitive evidence from epidemiological data indicating that overweight and obese patients may have a better prognosis than healthy-weight patients. A differential impact of oral anticoagulants (OACs) in terms of effectiveness and safety in the various body mass index categories has been postulated, particularly in the comparison between non-vitamin-K antagonist oral anticoagulants and vitamin K antagonists. This review aims to summarize the evidence on the impact of obesity in patients with AF, focusing on descriptions of the obesity paradox and its relationships with OAC treatment.

2020 - One-year clinical events and management of patients with atrial fibrillation hospitalized in cardiology centers: Data from the BLITZ-AF study [Articolo su rivista]
Cemin, R.; Colivicchi, F.; Maggioni, A. P.; Boriani, G.; De Luca, L.; Di Lenarda, A.; Di Pasquale, G.; Fabbri, G.; Lucci, D.; Gulizia, M. M.
abstract

Background: The management of atrial fibrillation (AF) has changed with the introduction of direct anticoagulants (DOACs) and new techniques such as catheter ablation. An update collection of data from “real world” AF patients followed by cardiologists is useful to obtain information on both management, outcomes and guideline adherence in clinical practice. Methods: Follow-up information on survival, embolic and bleeding events and hospital readmission, persistence of oral anticoagulant (OAC) therapy was collected in 84 centers participating to the BLITZ-AF study. Results: Patients were followed for a median of 366 days (IQR: 356–378) and vital status was available for 2159 patients. Mortality was 9.2%. Heart failure was the most common cardiovascular cause of death (70%) followed by arrhythmias (6.7%), acute coronary syndrome (5.0%) and ischemic stroke (2.5%). During follow-up 18.1% of the patients were readmitted, mainly (81.3%) for cardiovascular causes. Patients on OAC were 83.4%, 9.1% were on antiplatelets and 7.5% did not receive antithrombotic therapy. The use of DOACs increased from 42.1% to 46.4% during the follow-up, OAC discontinuation occurred in 9.1%. AF recurrences occurred in 23.4% of the patients discharged in sinus rhythm. Rate control strategy was adopted in 55.9% and beta-blockers were the most used drugs (81.9%). Amiodarone (22%) and flecainide (9.7%) were the most frequent used antiahrrythmic drugs. Conclusions: The follow-up of the BLITZ-AF study provide an up to date picture of the clinical course of patients with AF, who appear frequently affected by heart failure and severe comorbidities which might have led to the high mortality rate.

2020 - Optimal Use of Echocardiography in Management of Thrombosis After Anterior Myocardial Infarction [Articolo su rivista]
Barbieri, A.; Mantovani, F.; Bursi, F.; Faggiano, A.; Boriani, G.; Faggiano, P.
abstract

Despite advancement in therapy and management, left ventricular thrombus (LVT) after anterior myocardial infarction (MI) is sporadically encountered and remains associated with a very high risk of major cardiovascular events and mortality. Cardiac magnetic resonance (CMR) is considered the gold standard technique for LVT detection, but it is a time-consuming and expensive test not available in all centers, especially when repeated examinations are necessary. Transthoracic echocardiography represents a useful tool to screen for LVT and to identify predictors of high risk of developing LVT. The advances in ultrasound technology and the use of contrast agents may potentially help clinicians to identify LVT and the use of sequential echocardiography for each patient with acute MI complicated by LVT may provide an opportunity to quantify regression and its correlation with outcomes to tailor the management of these patients. Hence, this narrative review focuses on the added value of echocardiographic-guided LVT management in patients with recent anterior MI to reduce mortality and morbidity excess related to LVT based on current evidence.

2020 - Optimized Implementation of cardiac resynchronization therapy - a call for action for referral and optimization of care [Articolo su rivista]
Mullens, Wilfried; Auricchio, Angelo; Martens, Pieter; Witte, Klaus; Cowie, Martin R; Delgado, Victoria; Dickstein, Kenneth; Linde, Cecilia; Vernooy, Kevin; Leyva, Francisco; Bauersachs, Johann; Israel, Carsten W; Lund, Lars; Donal, Erwan; Boriani, Giuseppe; Jaarsma, Tiny; Berruezo, Antonio; Traykov, Vassil; Yousef, Zaheer; Kalarus, Zbigniew; Nielsen, Jens Cosedis; Steffel, Jan; Vardas, Panos; Coats, Andrew; Seferovic, Petar; Edvardsen, Thor; Heidbuchel, Hein; Ruschitzka, Frank; Leclercq, Christophe
abstract

Cardiac resynchronization therapy (CRT) is one of the most effective therapies for heart failure with reduced ejection fraction and leads to improved quality of life, reductions in heart failure hospitalization rates and reduces all-cause mortality. Nevertheless, up to two-thirds of eligible patients are not referred for CRT. Furthermore, post implantation follow-up is often fragmented and suboptimal, hampering the potential maximal treatment effect. This joint position statement from three ESC Associations, HFA, EHRA and EACVI focuses on optimized implementation of CRT. We offer theoretical and practical strategies to achieve more comprehensive CRT referral and post-procedural care by focusing on four actionable domains; (I) overcoming CRT under-utilization, (II) better understanding of pre-implant characteristics, (III) abandoning the term 'non-response' and replacing this by the concept of disease modification, and (IV) implementing a dedicated post-implant CRT care pathway.

2020 - Position paper of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC) on driving by patients with cardiac implantable electronic devices [Articolo su rivista]
Palmisano, P.; Guerra, F.; Bisignani, G.; Forleo, G. B.; Landolina, M.; Soldati, E.; Stabile, G.; Zanotto, G.; Berisso, M. Z.; De Ponti, R.; Boriani, G.; Ricci, R. P.
abstract

In patients with cardiac implantable electronic devices (CIEDs) (implantable cardioverter-defibrillators [ICDs] and pacemakers [PMs]), the potential risk of suddenly being unable to drive, and hence of causing road accidents, is higher than in the general population. In ICD patients, this risk stems from the possibility that an arrhythmic event leading to loss of consciousness may occur while driving. In PM patients, it may be the result of a device malfunction in a PM-dependent patient. To determine a CIED patient's ability to drive, two variables must be taken into account: (i) the risk of events, which depends on the type of underlying heart disease (ICD patients have a higher risk than PM patients); (ii) the time spent driving and the type of vehicle driven (professional drivers are at higher risk than private drivers). This position paper reports the recommendations of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC) regarding driving by patients with CIEDs, on the basis of the available literature and the European reference recommendations.

2020 - Protective role of chronic treatment with direct oral anticoagulants in elderly patients affected by interstitial pneumonia in COVID-19 era [Articolo su rivista]
Rossi, R.; Coppi, F.; Talarico, M.; Boriani, G.
abstract

2020 - Protective role of statins in COVID 19 patients: importance of pharmacokinetic characteristics rather than intensity of action [Articolo su rivista]
Rossi, R.; Talarico, M.; Coppi, F.; Boriani, G.
abstract

2020 - Radiotherapy-induced malfunctions of cardiac implantable electronic devices in cancer patients [Articolo su rivista]
Malavasi, V. L.; De Marco, G.; Imberti, J. F.; Placentino, F.; Vitolo, M.; Mazzeo, E.; Cicoria, G.; Casali, E.; Turco, V.; Lohr, F.; Boriani, G.
abstract

The number of patients with cardiac implantable electronic devices (CIEDs) requiring radiation therapy (RT) for cancer treatment is increasing. The purpose of this study is to estimate the prevalence, possible predictors, and clinical impact of RT-related CIEDs malfunctions. We retrospectively reviewed the medical records of all pacemaker (PM)/implantable cardioverter-defibrillator (ICD) patients who underwent RT in the last 14 years. One hundred and twenty-seven patients who underwent 150 separate RT courses were analysed (99 with a PM and 27 with an ICD). Of note, 21/127 (16.6%) patients were PM-dependent. Neutron-producing RT was used in 37/139 (26.6%) courses, whereas non-neutron-producing RT was used in 102/139 (73.4%) courses. The cumulative dose (Dmax) delivered to the CIED exceeded 5 Gy only in 2/132 (1.5%) cases. Device malfunctions were observed in 3/150 (2%) RT courses, but none was life-threatening or led to a major clinical event and all were resolved by CIED reprogramming. In all cases, the Dmax delivered to the CIED was < 2 Gy. Two malfunctions occurred in the 37 patients treated with neutron-producing RT (5.4%), and 1 malfunction occurred in the 102 patients treated with non-neutron-producing RT (1%) (p = 0.17). Device relocation from the RT field was performed in 2/127 (1.6%) patients. RT in patients with CIED is substantially safe if performed in an appropriately organized environment, with uncommon CIEDs malfunctions and no major clinical events. Neutron-producing energies, rather than Dmax, seem to increase the risk of malfunctions. Device interrogation on a regular basis is advised to promptly manage CIED malfunctions.

2020 - Shoulder Function After Cardioverter-Defibrillator Implantation: 5-Year Follow-up [Articolo su rivista]
Martignani, Cristian; Massaro, Giulia; Mazzotti, Andrea; Pegreffi, Francesco; Ziacchi, Matteo; Biffi, Mauro; Porcellini, Giuseppe; Boriani, Giuseppe; Diemberger, Igor
abstract

2020 - Tailored oral anticoagulant prescription in patients with atrial fibrillation: Use and misuse of clinical risk prediction scores [Articolo su rivista]
Proietti, M.; Vitolo, M.; Boriani, G.
abstract

2020 - Temporal patterns of premature atrial complexes predict atrial fibrillation occurrence in bradycardia patients continuously monitored through pacemaker diagnostics [Articolo su rivista]
Boriani, G.; Botto, G. L.; Pieragnoli, P.; Ricci, R.; Biffi, M.; Marini, M.; Sagone, A.; Avella, A.; Pignalberi, C.; Ziacchi, M.; Ricciardi, G.; Tartaglione, E.; Grammatico, A.; Gasparini, M.
abstract

The frequency of premature atrial complexes (PACs) has been related with atrial fibrillation (AF) occurrence and adverse prognosis. Research objective was to evaluate whether temporal patterns of PACs are directly associated with AF onset in pacemaker patients with continuous monitoring of the atrial rhythm. Overall, 193 pacemaker patients (49% female, 72 ± 9 years old), enrolled in a national registry, were analyzed. Frequency of daily PACs was measured in a 14-day initial observation period, during which patients were in sinus rhythm. In the following period, temporal occurrence and frequency of daily PACs and eventual onset of AF were derived by pacemaker diagnostics. In the run-in period, median PACs frequency was 614 PACs/day (interquartile range 70–3056). Subsequently, in a median follow-up of 6 months, AF occurred in 109 patients, in particular in 37/96 (38.5%) patients with a PAC rate < 614 PACs/day and in 72/97 (74.2%) patients with PAC rate ≥ 614 PACs/day (p < 0.001). In patients with AF occurrence, the number of daily PACs, normalized by dividing for the average of PACs in ten preceding days, progressively increased in the 5 days preceding AF. Cox model predictive analysis showed that the risk of AF was significantly higher in patients with a relative increase of the daily PACs higher than 30% compared with PACs average number in ten preceding days [hazard ratio (95% confidence interval) 3.67 (2.40–5.59), p < 0.001]. PACs frequency increases in the 5 days preceding AF onset. A relative increase of the daily PACs is significantly associated with the risk of AF occurrence.

2020 - Temporary transvenous cardiac pacing: a survey on current practice [Articolo su rivista]
Diemberger, I.; Massaro, G.; Rossillo, A.; Chieffo, E.; Dugo, D.; Guarracini, F.; Pellegrino, P. L.; Perna, F.; Landolina, M.; De Ponti, R.; Berisso, M. Z.; Ricci, R. P.; Boriani, G.
abstract

BACKGROUND: Temporary transvenous cardiac pacing (TTCP) is a standard procedure in current practice, despite limited coverage in consensus guidelines. However, many authors reported several complications associated with TTCP, especially development of infections of cardiac implantable electronic devices (CIED). The aim of this survey was to provide a country-wide picture of current practice regarding TTCP. METHODS: Data were collected using an online survey that was administered to members of the Italian Association of Arrhythmology and Cardiac Pacing. RESULTS: We collected data from 102 physicians, working in 81 Italian hospitals from 17/21 regions. Our data evidenced that different strategies are adopted in case of acute bradycardia with a tendency to limit TTCP mainly to advanced atrioventricular block. However, some centers reported a greater use in elective procedures. TTCP is usually performed by electrophysiologists or interventional cardiologists and, differently from previous reports, mainly by a femoral approach and with nonfloating catheters. We found high inhomogeneity regarding prevention of infections and thromboembolic complications and in post-TTCP management, associated with different TTCP volumes and a strategy for management of acute bradyarrhythmias. CONCLUSION: This survey evidenced a high inhomogeneity in the approaches adopted by Italian cardiologists for TTCP. Further studies are needed to explore if these divergences are associated with different long-term outcomes, especially incidence of CIED-related infections.

2020 - The Euro Heart Survey and EURObservational Research Programme (EORP) in atrial fibrillation registries: contribution to epidemiology, clinical management and therapy of atrial fibrillation patients over the last 20 years [Articolo su rivista]
Vitolo, M.; Proietti, M.; Harrison, S.; Lane, D. A.; Potpara, T. S.; Boriani, G.; Lip, G. Y. H.
abstract

Management of atrial fibrillation (AF) may be challenging in clinical practice. Given the complexity of AF patients and the continuous advances in AF clinical management, there is a need for standardized programmes aimed at collecting so-called ‘real-world clinical practice data’ regarding the epidemiology, diagnostic/therapeutic/management practices and assessing adherence to guidelines. Over the past 20 years, the number of registries and surveys based on real-world AF patients has been dramatically increased. In Europe, based on the Euro Heart Survey (EHS) and the EURObservational Research Programme (EORP), a large series of studies based on these prospective, observational, large-scale multicentre registries on AF have been published. This narrative review gives an overview of these two projects on AF led by the European Society of Cardiology, focusing mainly on the contribution that these studies have provided to AF management and patient outcomes. Both the EHS and the EORP registries have collected a large amount of data regarding contemporary clinical practice, and despite some limitations, mainly related to their observational nature, these registries have contributed to our knowledge and clinical management of AF patients.

2020 - The Pacemaker and Implantable Cardioverter-Defibrillator Registry of the Italian Association of Arrhythmology and Cardiac Pacing - Annual report 2018 [Articolo su rivista]
Proclemer, A.; Zecchin, M.; D'Onofrio, A.; Boriani, G.; Ricci, R. P.; Rebellato, L.; Ghidina, M.; Bianco, G.; Bernardelli, E.; Miconi, A.; Zorzin, A. F.; Gregori, D.
abstract

BACKGROUND: The pacemaker (PM) and implantable cardioverter-defibrillator (ICD) Registry of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC) monitors the main epidemiological data in real-world practice. The survey for the 2018 activity collects information about demographics, clinical characteristics, main indications for PM/ICD therapy and device types from the Italian collaborating centers. METHODS: The Registry collects prospectively national PM and ICD implantation activity on the basis of European cards. RESULTS: PM Registry: data about 23 912 PM implantations were collected (20 084 first implants and 3828 replacements). The number of collaborating centers was 180. Median age of treated patients was 81 years (75 quartile I; 86 quartile III). ECG indications included atrioventricular conduction disorders in 34.5% of first PM implants, sick sinus syndrome in 18.3%, atrial fibrillation plus bradycardia in 13.0%, other in 34.2%. Among atrioventricular conduction defects, third-degree atrioventricular block was the most common type (19.2% of first implants). Use of single-chamber PMs was reported in 24.9% of first implants, of dual-chamber PMs in 67.6%, of PMs with cardiac resynchronization therapy (CRT) in 1.6%, and of single lead atrial-synchronized ventricular stimulation (VDD/R PMs) in 5.9%. ICD Registry: data about 18 353 ICD implantations were collected (13 944 first implants and 4359 replacements). The number of collaborating centers was 433. Median age of treated patients was 71 years (63 quartile I; 78 quartile III). Primary prevention indication was reported in 84.3% of first implants, secondary prevention in 15.7% (cardiac arrest in 5.3%). A single-chamber ICD was used in 27.9% of first implants, dual-chamber ICD in 31.9% and biventricular ICD in 40.2%. CONCLUSIONS: The PM and ICD Registry appears fundamental for monitoring PM and ICD utilization on a large national scale with rigorous examination of demographics and clinical indications. The PM Registry showed stable electrocardiographic and symptom indications, with an important prevalence of dual-chamber pacing. The use of CRT-PM regards a very limited number of patients. The ICD Registry documented a large use of prophylactic and biventricular ICD, reflecting a favorable adherence to trials and guidelines in clinical practice. In order to increase and optimize the cooperation of Italian implanting centers, online data entry (http://www.aiac.it/riprid) should be adopted at large scale.

2020 - The unmet needs of sudden cardiac death. The role of the wearable cardioverter defibrillator when the risk is transient or uncertain [Articolo su rivista]
Guerra, F.; Palmisano, P.; Bisignani, G.; Forleo, G.; Landolina, M.; Soldati, E.; Stabile, G.; Zanotto, G.; Berisso, M. Z.; Boriani, G.; De Ponti, R.; Ricci, R. P.
abstract

Sudden cardiac death is defined as a natural death due to termination of cardiac activity associated with loss of consciousness, spontaneous breathing and circulation. Nowadays, the prevention of sudden cardiac death represents a major issue and many areas of uncertainty are not met by current evidences. Among those, reliable tools for risk stratification are still lacking, as well as solution for patients in which the risk of sudden cardiac death is due to a transient or correctable condition.The concept of the wearable cardioverter defibrillator is based on a potential solution for such grey areas. It merges long-term monitoring capabilities, shockable rhythm discrimination and shock delivery without the need for bystander assistance or invasive procedures. The present review aims to summarize current problems in dealing with this insidious condition, and to discuss potential options for patients in whom sudden cardiac death could be prevented more safely and cost-effectively.

2020 - What do we do about atrial high rate episodes? [Articolo su rivista]
Boriani, Giuseppe; Vitolo, Marco; Imberti, Jacopo Francesco; Potpara, Tatjana S; Lip, Gregory Y H
abstract

Atrial high rate episodes (AHREs) are defined as asymptomatic atrial tachyarrhythmias detected by cardiac implantable electronic devices with atrial sensing, providing automated continuous monitoring and tracings storage, occurring in subjects with no previous clinical atrial fibrillation (AF) and with no AF detected at conventional electrocardiogram recordings. AHREs are associated with an increased thrombo-embolic risk, which is not negligible, although lower than that of clinical AF. The thrombo-embolic risk increases with increasing burden of AHREs, and moreover, AHREs burden shows a dynamic pattern, with tendency to progression along with time, with potential transition to clinical AF. The clinical management of AHREs, in particular with regard to prophylactic treatment with oral anticoagulants (OACs), remains uncertain and heterogeneous. At present, in patients with confirmed AHREs, as a result of device tracing analysis, an integrated, individual and clinically-guided assessment should be applied, taking into account the patients' risk of stroke (to be reassessed regularly) and the AHREs burden. The use of OACs, preferentially non-vitamin K antagonists OACs, may be justified in selected patients, such as those with longer AHREs durations (in the range of several hours or ≥24 h), with no doubts on AF diagnosis after device tracing analysis and with an estimated high/very high individual risk of stroke, accounting for the anticipated net clinical benefit, and informed patient's preferences. Two randomized clinical trials on this topic are currently ongoing and are likely to better define the role of anticoagulant therapy in patients with AHREs.

2020 - ‘Real-world’ observational studies in arrhythmia research: data sources, methodology, and interpretation. A position document from European Heart Rhythm Association (EHRA), endorsed by Heart Rhythm Society (HRS), Asia-Pacific HRS (APHRS), and Latin America HRS (LAHRS) [Articolo su rivista]
Torp-Pedersen, Christian; Goette, Andreas; Nielsen, Peter Bronnum; Potpara, Tatjana; Fauchier, Laurent; John Camm, Alan; Arbelo, Elena; Boriani, Giuseppe; Skjoeth, Flemming; Rumsfeld, John; Masoudi, Frederick; Guo, Yutao; Joung, Boyoung; Refaat, Marwan M; Kim, Young-Hoon; Albert, Christine M; Piccini, Jonathan; Avezum, Alvaro; Lip, Gregory Y H; Gorenek, Bulent; Dagres, Nikolaos; Violi, Francesco; Du, Xin; Akao, Masaharu; Choi, Eue-Keun; Lopes, Renato D; Ozcan, Evren Emin; Lane, Deirdre; Marin, Francisco; Gale, Christopher Peter; Vernooy, Kevin; Kudaiberdieva, Gulmira; Kutyifa, Valentina; Traykov, Vassil B; Guevara, Carolina; Chao, Tze-Fan; Al-Khatib, Sana M
abstract

2019 - 2017 Catheter Ablation Registry of the Italian Association of Arrhythmology and Cardiac Pacing [Articolo su rivista]
Stabile, G.; Bertaglia, E.; Guerra, F.; Palmisano, P.; Berisso, M. Z.; Soldati, E.; Bisignani, G.; Forleo, G. B.; Zanotto, G.; Landolina, M.; De Ponti, R.; Boriani, G.; Ricci, R. P.
abstract

Background. This report describes the findings of the 2017 Catheter Ablation Registry of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC). Methods. Data collection was retrospective. A standardized questionnaire was completed by each of the participating centers. Results. A total of 15 601 ablation procedures were performed by 91 institutions, with a mean of 184 ± 213 procedures per center. The most frequently treated arrhythmia was atrial fibrillation (34%), followed by atrioventricular nodal reentrant tachycardia (25%) and common atrial flutter (14%). About 10% of overall ablation procedures were performed in patients with ventricular arrhythmias. On-site cardiothoracic surgery was available in 42% of the centers performing ablation and in 49% of the centers performing atrial fibrillation ablation. In most patients, the ablation procedure was guided by a three-dimensional mapping system, and in 15% of patients a near-zero X-ray strategy was used. Conclusions. The Italian Catheter Ablation Registry systematically collected 1-year data on ablation procedures performed in Italy, revealing that atrial fibrillation is the most commonly treated arrhythmia in the ablation centers with an increasing number of patients treated for ventricular tachycardia.

2019 - Association between antithrombotic treatment and outcomes at 1-year follow-up in patients with atrial fibrillation: The EORP-AF General Long-Term Registry [Articolo su rivista]
Boriani, G.; Proietti, M.; Laroche, C.; Fauchier, L.; Marin, F.; Nabauer, M.; Potpara, T.; Dan, G. -A.; Kalarus, Z.; Tavazzi, L.; Maggioni, A. P.; Lip, G. Y. H.
abstract

Aims: In recent years, stroke prevention in patients with atrial fibrillation (AF) has radically changed, with increasing use of non-vitamin K antagonist oral anticoagulants (NOACs). Contemporary European data on AF thromboprophylaxis are needed. Methods and results: We report 1-year follow-up data from the EURObservational Research Programme in Atrial Fibrillation (EORP-AF) General Long-Term Registry. Outcomes were assessed according to antithrombotic therapy. At 1-year follow-up, 9663 (88.0%) patients had available data for analysis: 586 (6.1%) were not treated with any antithrombotic; 681 (7.0%) with antiplatelets only; 4066 (42.1%) with vitamin K antagonist (VKA) only; 3167 (32.8%) with NOACs only; and 1163 (12.0%) with antiplatelet and oral anticoagulant. At 1-year follow-up, there was a low rate of stroke (0.7%) and any thromboembolic event (TE) (1.2%), while haemorrhagic events occurred in 222 patients (2.3%). Cardiovascular (CV) death and all-cause death occurred in 3.9% and 5.2% of patients, respectively. Cumulative survival for all the three main outcomes considered was highest amongst patients treated only with NOACs (P < 0.0001). Multivariable-adjusted Cox regression analysis found that VKA or NOACs use was independently associated with a lower risk for any TE/acute coronary syndrome/CV death, while all treatments were independently associated with a lower risk for CV death and all-cause death. Conclusion: The 1-year follow-up of EORP-AF General Long-Term Registry reported a low occurrence of thromboembolic and haemorrhagic events, although mortality was high. Both VKA and NOACs were associated with a lower risk of all main adverse outcomes. All treatments were associated with a lower risk for CV death and all-cause death.

2019 - Atrial fibrillation in patients with active malignancy and use of anticoagulants: Under-prescription but no adverse impact on all-cause mortality [Articolo su rivista]
Malavasi, Vincenzo Livio; Fantecchi, Elisa; Gianolio, Laura; Pesce, Francesca; Longo, Giuseppe; Marietta, Marco; Cascinu, Stefano; Lip, Gregory Y. H.; Boriani, Giuseppe
abstract

Prescription of anticoagulants (ACs) in patients with cancer and atrial fibrillation (AF) is challenging and the impact on survival is not defined. In this study data prospectively collected in Oncology Units were retrospectively evaluated. Among 4664 patients admitted for malignancy, 394 patients (8.4%) had documented AF (mean age of 74 ± 9) and AC was prescribed to 155 patients (40%). Neither the type of cancer, the stage of the disease (metastatic or not) nor the ongoing treatments were significantly associated with prescription of AC, which was independently associated with BMI (OR 1.10; CI 95% 1.03–1.17; p =.003), valvular heart disease (OR 3.76; CI95% 1.59–8.87; p =.002), and previous venous thromboembolism (OR 6.67; 95%CI 2.67–16.70; p <.001). During a median follow-up of 212 days, survival from all-cause death was 37%, 28% and 18% at 6 months, 1 and 2 years, respectively. Only variables related to neoplastic disease or to patient clinical complexity were independently associated with mortality. A CHA2DS2VASc ≥ 4 was significantly associated with mortality (HR 1.33; 95%CI 1.06–1.67; p =.013). Treatment with ACs was not significantly related to mortality, neither in the whole cohort of patients, nor in patients with metastatic malignancies. In conclusion the prescription of ACs in patients with AF and active cancer was suboptimal, with one fourth of the patients not treated with ACs and one third using LMWH at prophylactic, non-therapeutic doses. Only few variables (BMI, valvular heart disease and previous venous thromboembolism) predicted prescription of ACs. Prescription of ACs was not associated with all-cause mortality, even in the subgroup with metastasis.

2019 - Atrial fibrillation in patients with cardiac implantable electronic devices: New perspectives with important clinical implications [Articolo su rivista]
Boriani, G.; Vitolo, M.
abstract

2019 - Atrial high rate episodes in patients with cardiac implantable electronic devices: implications for clinical outcomes [Articolo su rivista]
Miyazawa, K.; Pastori, D.; Li, Y. -G.; Szekely, O.; Shahid, F.; Boriani, G.; Lip, G. Y. H.
abstract

Background: Atrial high rate episodes (AHREs) detected by cardiac implantable electronic devices (CIEDs) are associated with an increased risk of stroke. However, the impact of AHRE on improving stroke risk stratification scheme remains uncertain. Objective: The purpose of this study was to assess the impact of AHRE on prognosis in relation with cardiovascular events and risk stratification. Methods: A total of 856 consecutive patients who had dual-chamber CIEDs implanted were retrospectively analyzed. To detect AHREs, they were monitored for 6 months after CIEDs’ implantation and were followed for a mean of 4.0 years for clinical outcomes such as thromboembolism or death. Results: Overall, 125 (14.6%) of patients developed AHREs within the first 6 months (median age 72.0 years, 39.3% female). Patients with AHREs had a high rate of thromboembolism (2.6%/year) and mortality (3.0%/year). On multivariate analysis, AHRE was significantly associated with increased risk of thromboembolism [hazard ratio (HR) 3.40; 95% confidence interval (CI) 1.38–8.37, P = 0.01] and death (HR 3.47; 95% CI 1.51–7.95; P < 0.01). The predictive abilities of the CHADS2 and CHA2DS2-VASc scores were modest, with no significant improvements by adding AHRE to those scores. However, the integrated discrimination improvement and net reclassification improvement showed that the addition of AHRE to the CHADS2 and CHA2DS2-VASc scores statistically improved their predictive ability for the composite outcome. Conclusions: AHRE was an independent factor associated with increased risk of clinical outcomes. The addition of AHRE to the clinical risk scores significantly improved discrimination for thromboembolism or death.

2019 - CHRONIC KIDNEY DISEASE AND ARRHYTHMIAS: CONCLUSIONS FROM A KIDNEY DISEASE: IMPROVING GLOBAL OUTCOMES (KDIGO) CONTROVERSIES CONFERENCE [Articolo su rivista]
Turakhia, M. P.; Blankestijn, P. J.; Carrero, J. -J.; Clase, C. M.; Deo, R.; Herzog, C. A.; Kasner, S. E.; Passman, R. S.; Pecoits-Filho, R.; Reinecke, H.; Shroff, G. R.; Zareba, W.; Cheung, M.; Wheeler, D. C.; Winkelmayer, W. C.; Wanner, C.; Amann, K.; Banerjee, D.; Bansal, N.; Boriani, G.; Bunch, J.; Chan, C. T.; Charytan, D. M.; Conen, D.; Friedman, A. N.; Genovesi, S.; Holden, R. M.; House, A. A.; Jadoul, M.; Jar-Dine, A. G.; Johnson, D. W.; Jun, M.; Labriola, L.; Mark, P. B.; Mccullough, P. A.; Nolin, T. D.; Potpara, T. S.; Pun, P. H.; Ribeiro, A. L. P.; Rossignol, P.; Shen, J. I.; Sood, M. M.; Tsukamoto, Y.; Yee-Moon Wang, A.; Weir, M. R.; Wetmore, J. B.; Wranicz, J. K.; Yamasaki, H.
abstract

Patients with chronic kidney disease (CKD) are predisposed to heart rhythm disorders, including atrial fibrillation (AF)/atrial flutter, supraventricular tachycardias, ventricular arrhythmias, and sudden cardiac death (SCD). While treatment options, including drug, device, and procedural therapies, are available, their use in the setting of CKD is complex and limited. Patients with CKD and end-stage kidney disease have historically been under-represented or excluded from randomized trials of arrhythmia treatment strategies, 1 although this situation is changing. Cardiovascular society consensus documents have recently identified evidence gaps for treating patients with CKD and heart rhythm disorders. To identify key issues relevant to the optimal prevention, management, and treatment of arrhythmias and their complications in patients with kidney disease, Kidney Disease: Improving Global Outcomes (KDIGO) convened an international, multidisciplinary Controversies Conference in Berlin, Germany, titled CKD and Arrhythmias in October 2016.

2019 - Cancer and atrial fibrillation. Author's reply [Articolo su rivista]
Malavasi, V. L.; Marietta, M.; Lip, G. Y. H.; Boriani, G.
abstract

2019 - Cardiac arrhythmias in the emergency settings of acute coronary syndrome and revascularization: An European Heart Rhythm Association (EHRA) consensus document, endorsed by the European Association of Percutaneous Cardiovascular Interventions (EAPCI), and European Acute Cardiovascular Care Association (ACCA) [Articolo su rivista]
Kalarus, Z.; Svendsen, J. H.; Capodanno, D.; Dan, G. -A.; De Maria, E.; Gorenek, B.; Jedrzejczyk-Patej, E.; Mazurek, M.; Podolecki, T.; Sticherling, C.; Tfelt-Hansen, J.; Traykov, V.; Lip, G. Y. H.; Fauchier, L.; Boriani, G.; Mansourati, J.; Blomstrom-Lundqvist, C.; Mairesse, G. H.; Rubboli, A.; Deneke, T.; Dagres, N.; Steen, T.; Ahrens, I.; Kunadian, V.; Berti, S.
abstract

Despite major therapeutic advances over the last decades, complex supraventricular and ventricular arrhythmias (VAs), particularly in the emergency setting or during revascularization for acute myocardial infarction (AMI), remain an important clinical problem. Although the incidence of VAs has declined in the hospital phase of acute coronary syndromes (ACS), mainly due to prompt revascularization and optimal medical therapy, still up to 6% patients with ACS develop ventricular tachycardia and/or ventricular fibrillation within the first hours of ACS symptoms. Despite sustained VAs being perceived predictors of worse in-hospital outcomes, specific associations between the type of VAs, arrhythmia timing, applied treatment strategies and long-term prognosis in AMI are vague. Atrial fibrillation (AF) is the most common supraventricular tachyarrhythmia that may be asymptomatic and/or may be associated with rapid haemodynamic deterioration requiring immediate treatment. It is estimated that over 20% AMI patients may have a history of AF, whereas the new-onset arrhythmia may occur in 5% patients with ST elevation myocardial infarction. Importantly, patients who were treated with primary percutaneous coronary intervention for AMI and developed AF have higher rates of adverse events and mortality compared with subjects free of arrhythmia. The scope of this position document is to cover the clinical implications and pharmacological/non-pharmacological management of arrhythmias in emergency presentations and during revascularization. Current evidence for clinical relevance of specific types of VAs complicating AMI in relation to arrhythmia timing has been discussed.

2019 - Cardiac resynchronization therapy: Need to synchronize patients and device longevities with comorbidities [Articolo su rivista]
Boriani, G.; Vitolo, M.; Kutyifa, V.
abstract

2019 - Cardiomyopathy associated with long-term right ventricular pacing: an intriguing clinical issue [Articolo su rivista]
Boriani, G.; Vitolo, M.; Proietti, M.
abstract

2019 - Clinical and organizational management of cardiac implantable electronic device replacements: An Italian Survey promoted by AIAC (Italian Association of Arrhythmology and Cardiac Pacing) [Articolo su rivista]
Palmisano, P.; Ziacchi, M.; Belotti, G.; Rapacciuolo, A.; Santini, L.; Stabile, G.; Zoni Berisso, M.; De Ponti, R.; Landolina, M.; Ricci, R. P.; Boriani, G.
abstract

AimsThe aim of this survey was to assess the management and organization of cardiac implantable electronic device (CIED) replacement in Italy.MethodsA questionnaire consisting of 24 questions on organizational aspects and on the peri-procedural management of anticoagulant therapies and antibiotic prophylaxis was sent via the Internet to 154 Italian arrhythmia centers.ResultsA total of 103 out of 154 centers completed the questionnaire (67% response rate). In 43% of the centers, the procedures were performed under day-case admission, in 40% under ordinary admission, and in 17% under either day-case or ordinary admission. The most frequent reason (66%) for choosing ordinary admission rather than day-case admission was to obtain full reimbursement. Although warfarin therapy was continued in 73% of the centers, nonvitamin K oral anticoagulants were discontinued, without bridging, 24h or less prior to replacement procedures in 88%. Prophylactic antibiotic therapy was systematically administered in all centers; in 97%, the first antibiotic dose was administered 1-2h prior to procedures. Local antibacterial envelopes were also used in 43% of the centers in patients with a higher risk of device infection.ConclusionThis survey provides a representative picture of how CIED replacements are organized and managed in current Italian clinical practice. The choice of the type of hospitalization (short versus ordinary) was more often motivated by economic reasons (reimbursement of the procedure) than by clinical and organizational factors. Peri-procedural management of anticoagulation and prophylactic antibiotic therapy was consistent with current scientific evidence.

2019 - Clinical characteristics of heart failure patients undergoing atrial fibrillation ablation today in Europe. Data from the atrial fibrillation registries of the European Society of Cardiology and the European Heart Rhythm Association [Articolo su rivista]
Temporelli, P. L.; Tilz, R. R.; Arbelo, E.; Dagres, N.; Laroche, C.; Crijns, H. J.; Blomstrom-Lundqvist, C.; Kirchhof, P.; Lip, G. Y. H.; Boriani, G.; Pokushalov, E.; Nakou, E.; Brugada, J.; Tavazzi, L.
abstract

2019 - Clinical practice and implementation of guidelines for the prevention, diagnosis and management of cardiac implantable electronic device infections: results of a worldwide survey under the auspices of the European Heart Rhythm Association [Articolo su rivista]
Traykov, V.; Bongiorni, M. G.; Boriani, G.; Burri, H.; Costa, R.; Dagres, N.; Deharo, J. -C.; Epstein, L. M.; Erba, P. A.; Snygg-Martin, U.; Nielsen, J. C.; Poole, J. E.; Saghy, L.; Starck, C.; Strathmore, N.; Blomstrom-Lundqvist, C.
abstract

AIMS: Cardiac implantable electronic device (CIED) infection rates are increasing. Worldwide compliance and disparities to published guidelines for the prevention, diagnosis and management of these conditions are not well elucidated. The purpose of this survey, therefore, was to clarify these issues through an inquiry to arrhythmia-related associations and societies worldwide. METHODS AND RESULTS: A questionnaire comprising 15 questions related to CIED infections was distributed among members of seven arrhythmia societies worldwide. A total of 234 centres in 62 countries reported implantation rates of which 159 (68.0%) performed more than 200 device implantations per year and 14 (6.0%) performed fewer than 50 implantations per year. The reported rates of CIED infections for 2017 were ≤2% in 78.7% of the centres, while the infection rates exceeded 5% in 7.8% of the centres. Preventive measures for CIED infection differed from published recommendations and varied among different regions mainly in terms of pocket irrigation and administering post-operative antimicrobial therapy the use of which was reported by 39.9% and 44% of the respondents, respectively. Antibacterial envelopes were used by 37.7% of the respondents in selected circumstances. In terms of pocket infection management, 62% of the respondents applied complete system removal as an initial step. Diagnostic pocket needle aspiration and pocket surgical debridement were reported by 15.8% and 11.8% of centres, respectively. CONCLUSION: Clinical practices for prevention and management of CIED do not fully comply with current recommendations and demonstrate considerable regional disparities. Further education and programmes for improved implementation of guidelines are mandatory.

2019 - Contribution of PET imaging to mortality risk stratification in candidates to lead extraction for pacemaker or defibrillator infection: a prospective single center study [Articolo su rivista]
Diemberger, Igor; Bonfiglioli, Rachele; Martignani, Cristian; Graziosi, Maddalena; Biffi, Mauro; Lorenzetti, Stefano; Ziacchi, Matteo; Nanni, Cristina; Fanti, Stefano; Boriani, Giuseppe
abstract

Purpose: 18F-FDG PET/CT is an emerging technique for diagnosis of cardiac implantable electronic devices infection (CIEDI). Despite the improvements in transvenous lead extraction (TLE), long-term survival in patients with CIEDI is poor. The aim of the present study was to evaluate whether the extension of CIEDI at 18F-FDG PET/CT can improve prediction of survival after TLE. Methods: Prospective, monocentric observational study enrolling consecutive candidates to TLE for a diagnosis of CIEDI. 18F-FDG PET/CT was performed in all patients prior TLE. Results: There were 105 consecutive patients with confirmed CIEDI enrolled. An increased 18F-FDG uptake was limited to cardiac implantable electrical device (CIED) pocket in 56 patients, 40 patients had a systemic involvement. We had nine negative PET in patients undergoing prolonged antimicrobial therapy (22.5 ± 14.0 days vs. 8.6 ± 13.0 days; p = 0.005). Implementation of 18F-FDG PET/CT in modified Duke Criteria lead to reclassification of 23.8% of the patients. After a mean follow-up of 25.0 ± 9.0 months, 31 patients died (29.5%). Patients with CIED pocket involvement at 18F-FDG PET/CT presented a better survival independently of presence/absence of systemic involvement (HR 0.493, 95%CI 0.240–0.984; p = 0.048). After integration of 18F-FDG PET/CT data, absence of overt/hidden pocket involvement in CIEDI and a (glomerular filtration rate) GFR < 60 ml/min were the only independent predictors of mortality at long term. Conclusions: Patient with CIEDI and a Cold Closed Pocket (i.e., a CIED pocket without skin erosion/perforation nor increased capitation at 18F-FDG PET/CT) present worse long-term survival. Patient management can benefit by systematic adoption of pre-TLE 18F-FDG PET/CT through improved identification of CIED related endocarditis (CIEDIE) and hidden involvement of CIED pocket.

2019 - Corrected QT interval prolongation in psychopharmacological treatment and its modulation by genetic variation [Articolo su rivista]
Corponi, F.; Fabbri, C.; Boriani, G.; Diemberger, I.; Albani, D.; Forloni, G.; Serretti, A.
abstract

Several antipsychotics and antidepressants have been associated with electrocardiogram alterations, the most clinically relevant of which is the heart rate-corrected QT interval (QT c ) prolongation, a risk factor for sudden cardiac death. Genetic variants influence drug-induced QT c prolongation and can provide valuable information for precision medicine. The effect of genetic variants on QT c prolongation as well as the possible interaction between polymorphisms and risk medications in determining QT c prolongation were investigated. Medications were classified according to their known risk of inducing QT c prolongation (high-to-moderate, low, and no risk). QT c duration and risk of QT c > median value were investigated in a sample of 77 patients with mood or psychotic disorders being treated with antidepressants and antipsychotics, and who had at least 1 ECG recording. A secondary analysis considered QT c percentage change in patients (n = 25) with 2 ECG recordings. Single-nucleotide polymorphisms previously associated with QT c prolongation during treatment with psychotropic medications were investigated. No association survived after multiple-testing correction. The best results for modulation of QT c duration were identified for rs10808071 (the ABCB1 gene, nominal p = 0.007) when at least 1 medication with a moderate-to-high risk was prescribed, and for rs12029454 (the NOS1AP gene) in patients taking at least 1 medication with a cardiovascular risk (nominal p = 0.008). In the secondary analysis, rs2072413 (the KCNH2 gene) was the top finding for the modulation of QT c percentage change (nominal p = 0.001) when 1 drug with a moderate-to-high risk was added compared to baseline. Despite the limited power of this study, our results suggest that ABCB1, NOS1AP, and KCNH2 may play a role in QT c duration/prolongation during treatment with psychotropic drugs.

2019 - Differences in cardiac phenotype and natural history of laminopathies with and without neuromuscular onset [Articolo su rivista]
Ditaranto, R.; Boriani, G.; Biffi, M.; Lorenzini, M.; Graziosi, M.; Ziacchi, M.; Pasquale, F.; Vitale, G.; Berardini, A.; Rinaldi, R.; Lattanzi, G.; Potena, L.; Martin Suarez, S.; Bacchi Reggiani, M. L.; Rapezzi, C.; Biagini, E.
abstract

Objective: To investigate differences in cardiac manifestations of patients affected by laminopathy, according to the presence or absence of neuromuscular involvement at presentation. Methods: We prospectively analyzed 40 consecutive patients with a diagnosis of laminopathy followed at a single centre between 1998 and 2017. Additionally, reports of clinical evaluations and tests prior to referral at our centre were retrospectively evaluated. Results: Clinical onset was cardiac in 26 cases and neuromuscular in 14. Patients with neuromuscular presentation experienced first symptoms earlier in life (11 vs 39 years; p < 0.0001) and developed atrial fibrillation/flutter (AF) and required pacemaker implantation at a younger age (28 vs 41 years [p = 0.013] and 30 vs 44 years [p = 0.086] respectively), despite a similar overall prevalence of AF (57% vs 65%; p = 0.735) and atrio-ventricular (A-V) block (50% vs 65%; p = 0.500). Those with a neuromuscular presentation developed a cardiomyopathy less frequently (43% vs 73%; p = 0.089) and had a lower rate of sustained ventricular tachyarrhythmias (7% vs 23%; p = 0.387). In patients with neuromuscular onset rhythm disturbances occurred usually before evidence of cardiomyopathy. Despite these differences, the need for heart transplantation and median age at intervention were similar in the two groups (29% vs 23% [p = 0.717] and 43 vs 46 years [p = 0.593] respectively). Conclusions: In patients with laminopathy, the type of disease onset was a marker for a different natural history. Specifically, patients with neuromuscular presentation had an earlier cardiac involvement, characterized by a linear and progressive evolution from rhythm disorders (AF and/or A-V block) to cardiomyopathy.

2019 - Direct oral anticoagulants vs non-vitamin K antagonist in atrial fibrillation: A prospective, propensity score adjusted cohort study [Articolo su rivista]
Marietta, M.; Banchelli, F.; Pavesi, P.; Manotti, C.; Quintavalla, R.; Sinigaglia, T.; Guazzaloca, G.; Pattacini, C.; Urbinati, S.; Malavasi, V. L.; Boriani, G.; Voci, C.; D'Amico, R.; Magrini, N.
abstract

2019 - EHRA White Paper: Knowledge gaps in arrhythmia management - Status 2019 [Articolo su rivista]
Goette, A.; Auricchio, A.; Boriani, G.; Braunschweig, F.; Terradellas, J. B.; Burri, H.; Camm, A. J.; Crijns, H.; Dagres, N.; Deharo, J. -C.; Dobrev, D.; Hatala, R.; Hindricks, G.; Hohnloser, S. H.; Leclercq, C.; Lewalter, T.; Lip, G. Y. H.; Merino, J. L.; Mont, L.; Prinzen, F.; Proclemer, A.; Purerfellner, H.; Savelieva, I.; Schilling, R.; Steffel, J.; Van Gelder, I. C.; Zeppenfeld, K.; Zupan, I.; Heidbuchel, H.; Boveda, S.; Defaye, P.; Brignole, M.; Chun, J.; Guerra Ramos, J. M.; Fauchier, L.; Svendsen, J. H.; Traykov, V. B.; Heinzel, F. R.
abstract

Clinicians accept that there are many unknowns when we make diagnostic and therapeutic decisions. Acceptance of uncertainty is essential for the pursuit of the profession: bedside decisions must often be made on the basis of incomplete evidence. Over the years, physicians sometimes even do not realize anymore which the fundamental gaps in our knowledge are. As clinical scientists, however, we have to halt and consider what we do not know yet, and how we can move forward addressing those unknowns. The European Heart Rhythm Association (EHRA) believes that scanning the field of arrhythmia / cardiac electrophysiology to identify knowledge gaps which are not yet the subject of organized research, should be undertaken on a regular basis. Such a review (White Paper) should concentrate on research which is feasible, realistic, and clinically relevant, and should not deal with futuristic aspirations. It fits with the EHRA mission that these White Papers should be shared on a global basis in order to foster collaborative and needed research which will ultimately lead to better care for our patients. The present EHRA White Paper summarizes knowledge gaps in the management of atrial fibrillation, ventricular tachycardia/sudden death and heart failure.

2019 - Early or Delayed Cardioversion in Recent-Onset Atrial Fibrillation [Articolo su rivista]
Boriani, G; Biffi, M
abstract

To the Editor: Pluymaekers et al. (April 18 issue)(1) evaluated the occurrence of spontaneous cardioversion in patients with recent-onset (<36 hours) atrial fibrillation. The proposed wait-and-see approach included cardioversion within 48 hours in the absence of spontaneous resumption of sinus rhythm, and delayed cardioversion was actually necessary in 28% of the patients randomly assigned to this strategy. We think that the idea of waiting for spontaneous cardioversion of atrial fibrillation is interesting, but for practical reasons, better patient targeting would be required. In two previous prospective, randomized trials, we found that in patients with recent-onset atrial fibrillation, spontaneous cardioversion can . . .

2019 - Effect of PR interval and pacing mode on persistent atrial fibrillation incidence in dual chamber pacemaker patients: A sub-study of the international randomized MINERVA trial [Articolo su rivista]
Boriani, G.; Pieragnoli, P.; Botto, G. L.; Puererfellner, H.; Mont, L.; Ziacchi, M.; Manolis, A. S.; Gulizia, M.; Tukkie, R.; Landolina, M.; Ricciardi, G.; Cicconelli, M.; Grammatico, A.; Biffi, M.
abstract

Aims Per standard of care, dual-chamber pacemakers are programmed in DDDR mode with fixed atrioventricular (AV) delay or with long AV delay to minimize ventricular pacing. We aimed to evaluate whether the PR interval may be a specific criterion of choice between standard DDDR, to preserve AV synchrony in long PR patients, and managed ventricular pacing (MVP), to avoid ventricular desynchronization imposed by right ventricle apical pacing, in short PR patients. Methods and results In the MINERVA trial, 1166 patients were randomized to Control DDDR, MVP, or atrial anti-tachycardia pacing plus MVP (DDDRP + MVP). We evaluated the interaction of PR interval with pacing mode by comparing the risk of atrial fibrillation (AF) longer than 7 consecutive days as a function of PR interval. Out of 906 patients with available data, the median PR interval was 180 ms. The PR interval was found to significantly (P = 0.012) interact with pacing mode for AF incidence: The risk of AF > 7 days was lower [hazard ratio (HR) 0.58, 95% confidence interval (95% CI) 0.34-0.99; P = 0.047] in patients with short PR (shorter than median PR) if programmed in MVP mode compared with DDDR mode and it was lower (HR 0.65, 95% CI 0.43-0.99; P = 0.049) in patients with long PR (equal to or longer than median PR) if programmed in DDDR mode compared with MVP. Conclusion Our data show that PR interval may be used as a selection criterion to identify the optimal physiological pacing mode. Persistent AF incidence was lower in short PR patients treated by right ventricular pacing minimization and in long PR patients treated by standard dual-chamber pacing.

2019 - Effects of cardiac resynchronization therapy on right ventricular function during rest and exercise, as assessed by radionuclide angiography, and on NT-proBNP levels [Articolo su rivista]
Valzania, Cinzia; Biffi, Mauro; Bonfiglioli, Rachele; Fallani, Francesco; Martignani, Cristian; Diemberger, Igor; Ziacchi, Matteo; Frisoni, Jessica; Tomasi, Luciana; Fanti, Stefano; Rapezzi, Claudio; Boriani, Giuseppe
abstract

Aim: We carried out this study to investigate mid-term effects of cardiac resynchronization therapy (CRT) on right ventricular (RV) function and neurohormonal response, expressed by N-terminal pro-brain natriuretic peptide (NT-proBNP), in heart failure patients stratified by baseline RV ejection fraction (RVEF). Methods and Results: Thirty-six patients with nonischemic dilated cardiomyopathy underwent technetium-99m radionuclide angiography with bicycle exercise immediately after CRT implantation (during spontaneous rhythm and after CRT activation) and 3 months later. Plasma NT proBNP was assessed before implantation and after 3 months. At baseline, RVEF was impaired (≤35%) in 14 patients, preserved (>35%) in 22. At 3 months, RVEF improved during rest and exercise (P = .02) in patients with impaired RV function, while remaining unchanged in patients with preserved RV function. Rest and exercise RV dyssynchrony decreased in both groups at follow-up (P < .05). A similar mid-term improvement in left ventricular (LV) function and NT-proBNP was observed in patients with impaired and preserved RVEF. In the former, the decrease in NT-proBNP correlated with the improvements both in LV and RV dyssynchrony and functions. Conclusion: CRT may improve RV performance, during rest and exercise, and neurohormonal response in heart failure patients with nonischemic dilated cardiomyopathy and baseline RV dysfunction. RV dysfunction should not be considered per se a primary criterion for excluding candidacy to CRT.

2019 - European Heart Rhythm Association (EHRA) consensus document on management of arrhythmias and cardiac electronic devices in the critically ill and post-surgery patient, endorsed by endorsed by Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), Cardiac Arrhythmia Society of Southern Africa (CASSA), and Latin American Heart Rhythm Society (LAHRS) [Articolo su rivista]
Boriani, Giuseppe; Fauchier, Laurent; Aguinaga, Luis; Beattie, James M; Blomstrom Lundqvist, Carina; Cohen, Ariel; Dan, Gheorghe-Andrei; Genovesi, Simonetta; Israel, Carsten; Joung, Boyoung; Kalarus, Zbigniew; Lampert, Rachel; Malavasi, Vincenzo L; Mansourati, Jacques; Mont, Lluis; Potpara, Tatjana; Thornton, Andrew; Lip, Gregory Y H
abstract

NA

2019 - Favorable Trend of Implantable Cardioverter-Defibrillator Service Life in a Large Single-Nation Population: Insights From 10-Year Analysis of the Italian Implantable Cardioverter-Defibrillator Registry [Articolo su rivista]
Poli, S.; Boriani, G.; Zecchin, M.; Facchin, D.; Gasparini, M.; Landolina, M.; Ricci, R. P.; Lanera, C.; Gregori, D.; Proclemer, A.
abstract

Background: Implantable cardioverter-defibrillators (ICDs) are widely employed for the prevention of sudden cardiac death. Despite technological improvements, patients often need to undergo generator replacement, which entails the risk of periprocedural complications. Our aim was to estimate the service life of ICDs over a 10-year interval and to assess the main causes of replacement on the basis of data from the National ICD Registry of the Italian Society of Arrhythmology and Cardiac Pacing (AIAC). Methods and Results: The registry includes data from over 400 hospitals in Italy. We included all patients who underwent device replacement from calendar years 2007 to 2016. The median service life of the ICDs and its trend over the years was estimated across the 3 types of devices (single-chamber, dual-chamber, cardiac resynchronization therapy defibrillator) and the indication to implantation. The causes of replacement were also analyzed. We included 29 158 records from 27 676 patients (80.9% men; mean age at device replacement 65.8±12.0 years). The median service life was 57.3 months (interquartile range 27.8 months). Over the years, service life showed an increasing trend. The majority of patients underwent elective replacement because of battery end of life, and over the years there was a significant reduction of replacement for recalls, erosion/infections, and cardiac resynchronization therapy upgrading. Conclusions: Our data from a large single-nation population showed that the trend of ICD service life, independently from ICD type, indication, and settings, significantly improved over time. Moreover, there was a striking reduction of interventions for upgrading and infection/erosion. This favorable trend has important clinical, organizational, and financial implications.

2019 - Home care for heart failure: can caregiver education prevent hospital admissions? A randomized trial in primary care [Articolo su rivista]
Padula, Maria S; D'Ambrosio, Gaetano Giorgio; Tocci, Marina; D'Amico, Roberto; Banchelli, Federico; Angeli, Letizia; Scarpa, Marina; Capelli, Oreste; Cricelli, Claudio; Boriani, Giuseppe
abstract

To assess the feasibility and effectiveness of a low-complexity, low-cost model of caregiver education in primary care, targeted to reduce hospitalizations of heart failure patients.

2019 - Imaging functional stress test for stable chest pain symptoms in patients at low pretest probability of coronary artery disease: Current practice and long-term outcome [Articolo su rivista]
Gaibazzi, N.; Barbieri, A.; Boriani, G.; Benatti, G.; Codazzo, G.; Manicardi, M.; Bursi, F.; Siniscalchi, C.
abstract

Background: Stress testing in patients with low pretest probability (PTP) of coronary artery disease (CAD) has become an increasing practice, potentially leading to underestimation of its true clinical value. Our aim was to describe the current use of most employed imaging functional tests and their prognostic value. Methods and Results: We selected patients with low PTP of CAD (CAD consortium clinical score < 15%) who underwent exercise or dipyridamole stress echocardiography or single photon emission computed tomography for suspected angina. Main exclusions were age < 45, known CAD, and abnormal rest wall motion. Of the 2279 subjects undergoing stress test, 883 (39%) had low PTP, and 91 (10.3%) had a positive test for ischemia. After a median follow-up of 5.8 years, 36 patients had events (21 died, 14 had nonfatal myocardial infarction). The percentage of events in the abnormal and normal stress test groups were similar (5 [5.5%] vs 31 [3.9%], P = ns), as the annualized event rate (0.87% vs 0.62%, P = ns). Age was the only variable associated with outcome in the regression analysis (hazard ratio 1.072, 95% CI 1.034–1.113, P < 0.001). An abnormal result was not associated with worse outcome in each of the subgroups of functional tests. Conclusions: In our geographical area, a considerable proportion of patients undergoing imaging functional tests for stable chest pain have a low estimated PTP of CAD. Of these, 1 in 10 resulted positive for inducible ischemia. However, none of the most common imaging functional tests, single photon emission computed tomography (SPECT), and stress echocardiography offer prognostic information in these patients.

2019 - Impact of Body Mass Index on Outcomes in the Edoxaban Versus Warfarin Therapy Groups in Patients Underwent Cardioversion of Atrial Fibrillation (from ENSURE-AF) [Articolo su rivista]
Lip, Gregory Y H; Merino, Jose L; Banach, Maciej; de Groot, Joris R; Maier, Lars S; Themistoclakis, Sakis; Boriani, Giuseppe; Jin, James; Melino, Michael; Winters, Shannon M; Goette, Andreas
abstract

In the EdoxabaN versus warfarin in subjectS UndeRgoing cardiovErsion of Atrial Fibrillation study (NCT 02072434), edoxaban showed similar efficacy and safety versus enoxaparin-warfarin in patients underwent electrical cardioversion of nonvalvular atrial fibrillation. In this ancillary analysis, we compared the primary efficacy (composite of stroke, systemic embolic event, myocardial infarction, cardiovascular death, and overall study period) and safety (composite of major and clinically relevant nonmajor bleeding, on-treatment) end points in relation to body mass index (BMI; <30 vs ≥30 kg/m2). We also compared cardioversion outcomes in relation to BMI. Of 2,199 patients enrolled, 1,095 were randomized to edoxaban and 1,104 to enoxaparin-warfarin. Mean age was 64 ± 10 and 64 ± 11 years and mean BMI 30.6 and 30.7 kg/m2, respectively. Cardiovascular and metabolic diseases were more prevalent in obese (n = 1067) than nonobese patients. Overall ischemic event rates were low; rates in the BMI <30 kg/m2 subgroup were numerically lower than the ≥30 kg/m2 subgroup, but not significantly different (odds ratio [OR], 0.74 [95% confidence interval 0.23, 2.24]). Composite major + clinically relevant nonmajor bleeding rates were low and numerically lower, but not significantly different (OR 0.88 [0.38, 2.04]), between the edoxaban and enoxaparin-warfarin arms and across weight categories. Successful cardioversion rate was higher in the BMI <30 versus ≥30 kg/m2 subgroup (73.9% vs 69.9%; OR 1.22 [1.01 to 1.48]). In EdoxabaN versus warfarin in subjectS UndeRgoing cardiovErsion of Atrial Fibrillation, BMI did not significantly impact the relative efficacy and safety of edoxaban versus enoxaparin-warfarin. Nevertheless, the nonobese group had a higher rate of cardioversion success than the obese group.

2019 - Infective endocarditis in patients with cardiac implantable electronic devices: Impact of comorbidities on outcome [Articolo su rivista]
Diemberger, I.; Lorenzetti, S.; Vitolo, M.; Boriani, G.
abstract

2019 - International longitudinal registry of patients with atrial fibrillation and treated with rivaroxaban: RIVaroxaban Evaluation in Real life setting (RIVER) [Articolo su rivista]
Beyer-Westendorf, J.; Camm, A. J.; Fox, K. A. A.; Le Heuzey, J. -Y.; Haas, S.; Turpie, A. G. G.; Virdone, S.; Kakkar, A. K.; Pieper, K. S.; Kayani, G.; Gersh, B. J.; Hildebrandt, P.; Dominguez, H.; Comuth, W.; Frost, L.; Moller, D. S.; Christensen, H.; Bruun, L. M.; Milhem, A.; Gauthier, J.; Mielot, C.; Chanseaume, S.; Chopra, S.; Amlaiky, A.; Tricot, O.; Sierra, V.; Dompnier, A.; Zannad, N.; Pinzani, A.; Quatre, A.; Mansourati, J.; Fauchier, L.; Badenco, N.; Gandjbakhch, E.; Chachoua, K. F.; Malquarti, V.; Pierron, F.; Sacher, F.; Taieb, J.; Davy, J. M.; Marijon, E.; Lellouche, N.; Leenhardt, A.; Salem, A.; Lesto, I.; Muller, J. J.; Garcia, R.; Neau, J. P.; Berneau, J. B.; Schon, N.; Gulba, D.; Appel, K. F.; Merke, J.; Dshabrailov, J.; Bauknecht, C.; Scheuermann, O.; Schroder, T.; Jung, W.; Kopf, A.; Brachmann, J.; Leschke, M.; Taggeselle, J.; Seige, M.; Lassig, T.; Appel, S.; Schmiedl, M.; Muller, K.; Heinz, G. U.; Axthelm, C.; Eberhard, K.; Hugl, B.; Schwarz, T.; Sechtem, U.; Falanga, A.; Rubino, V.; Calo, L.; Ageno, W.; Massari, F.; Imberti, D.; Di Gennaro, L.; Gaita, F.; Margonato, A.; Cannava, G.; Capasso, F.; Diemberger, I.; Pelliccia, F.; Cafolla, A.; Bardari, S.; Mattei, L.; Ruocco, L.; Boriani, G.; Poli, D.; Testa, S.; Indolfi, C.; Quintavalla, R.; Mos, L.; Ladyjanskaia, G.; Aksoy, I.; Van De Wetering, M.; Theunissen, L.; Den Hartog, F.; Nijmeijer, R.; Van De Wal, R.; Reinders, S.; Patterson, M.; Melker, E. D.; Troquay, R.; Korecki, J.; Szyszka, A.; Diks, F.; Sumis, J.; Cygler, J.; Miklaszewicz, B.; Litwiejko-Pietrynczak, E.; Napora, P.; Drelich, G.; Kawka-Urbanek, T.; Wranicz, J. K.; Mierzejewski, M.; Drzewiecka, A.; Wronska, D.; Fares, I.; Baska, J.; Stania, K.; Krzyzanowski, W.; Miekus, P.; Tyminski, M.; Dronov, D.; Zenin, S.; Isaeva, E.; Lopukhov, A.; Yakusevich, V.; Kuznetsov, D.; Kameneva, T.; Pokushalov, E.; Karetnikova, V.; Dik, I.; Karpushina, I.; Nikolin, D.; Doletsky, A.; Ardashev, A.; Timofeeva, A.; Miller, O.; Lyamina, N.; Shubik, Y.; Boldueva, S.; Blanco Coronado, J. L.; Gonzalez Juanatey, C.; Otero, E.; Alonso, D.; Torres Llergo, J.; Gonzalez Lama, J.; De Prada Tiffe, J. A. V.; Garcia Seara, F. J.; Gomez Doblas, J. J.; Riancho, J. A.; Clua-Espuny, J. L.; Motero, J.; Arrarte, V. I.; Martin Raymondi, D.; Isasti Aizpurua, G.; Marin, F.; Nieto, J. A.; Fernandez Portales, J.; Alvarez Garcia, P.; Torstensson, I.; Cederin, B.; Kalm, T.; Rosenqvist, U.; Thulin, J.; Hajimirsadeghi, A.; Crisby, M.; Manoj, A.; Bakhai, A.; Mistri, A.; Krishnan, M.; Kumar, S.; Kirubakaran, S.; Thomas, H.; Camm, J.; Ahmed, F.; Ross, A. M.; Barry, K.; Stockwell, R.; Broadley, A.; Mamun, M.; Chatterjee, K.; Cooke, J.; Mccready, J.; Dutta, D.; John, K.; Pandya, P.; Howlett, R.; Vinson, P.; Lim, ; Foley, P.; Bruce, D.; Dixit, A.; Broughton, D.; Taylor, J.; Schilling, R.; Leon, K.; Saeed, K.; Shaheen, S.; Tawfik, M.; Mortadda, A.; Seleem, M.; Aly, M. S. I.; Kazamel, G.; Elbadry, M.; Kamal, S.; Hassan, M.; Mostafa, M.; Medhat, M. E. S.; Ekhlas, ; Ghaleb, R.; Taha, M. O.; Daoud, I.; Al Din, H.; Imam, A. M.; El Hameed, M. A.; Helmy, ; Al-Murayeh, M.; Akhtar, N.; Matto, B. M.; Ghani, M. A.; Amoudi, O. A.; Morsy, M. M.; Bashir, A. A. F.; Al Hossni, Y. M.; Al Ghamdi, B.; Zia-Ul-Sabah, ; Mir, S.; Dardir, D.; Masswary, A.; Al Shehri, A. R.; Masswary, A.; Iqbal, J.; Almansori, M. A. J.; Venkitachalam, C. G.; Kurian, J.; Rao, J.; Aisheh, A.; Albawab, A. A.; Subbaraman, B.; Amanat, A.; Esfehani, K. J.; Lochan, R.; Bin Brek, A.; Mittal, B.; Ghazi, Y.; Krishna, M.; Tabatabaei, S. B.; Thoppil, P. S.; Nasim, S.; El Khider Nour, S.; Barros, P.; Almeida, A. P.; Andrade, M.; Garbelini, B.; Silvestrini, T. L.; Alves, A. R.; De Lima, C. E. B.; Kormann, A.; De Lima, G. G.; Halperin, C.; Salvadori Junior, D.; Freitas, A. F.; Gemelli, J. R.; Ornelas, C. E.; Dantas, J. M. M.; Aziz, J. L.; Backes, L. M.; Barroso, W. S.; Paiva, M. S.; De Figueiredo Neto, J. A.; Dos Santos, F. R.; De Lima Neto, J. A.; Bergo, R.; Salvador Junior, P. R.; Lopez, A. G.; Alva, J. C. P.
abstract

Background: Real-world data on non-vitamin K oral anticoagulants (NOACs) are essential in determining whether evidence from randomised controlled clinical trials translate into meaningful clinical benefits for patients in everyday practice. RIVER (RIVaroxaban Evaluation in Real life setting) is an ongoing international, prospective registry of patients with newly diagnosed non-valvular atrial fibrillation (NVAF) and at least one investigator-determined risk factor for stroke who received rivaroxaban as an initial treatment for the prevention of thromboembolic stroke. The aim of this paper is to describe the design of the RIVER registry and baseline characteristics of patients with newly diagnosed NVAF who received rivaroxaban as an initial treatment. Methods and results: Between January 2014 and June 2017, RIVER investigators recruited 5072 patients at 309 centres in 17 countries. The aim was to enroll consecutive patients at sites where rivaroxaban was already routinely prescribed for stroke prevention. Each patient is being followed up prospectively for a minimum of 2-years. The registry will capture data on the rate and nature of all thromboembolic events (stroke / systemic embolism), bleeding complications, all-cause mortality and other major cardiovascular events as they occur. Data quality is assured through a combination of remote electronic monitoring and onsite monitoring (including source data verification in 10% of cases). Patients were mostly enrolled by cardiologists (n = 3776, 74.6%), by internal medicine specialists 14.2% (n = 718) and by primary care/general practice physicians 8.2% (n = 417). The mean (SD) age of the population was 69.5 (11.0) years, 44.3% were women. Mean (SD) CHADS2 score was 1.9 (1.2) and CHA2DS2-VASc scores was 3.2 (1.6). Almost all patients (98.5%) were prescribed with once daily dose of rivaroxaban, most commonly 20 mg (76.5%) and 15 mg (20.0%) as their initial treatment; 17.9% of patients received concomitant antiplatelet therapy. Most patients enrolled in RIVER met the recommended threshold for AC therapy (86.6% for 2012 ESC Guidelines, and 79.8% of patients according to 2016 ESC Guidelines). Conclusions: The RIVER prospective registry will expand our knowledge of how rivaroxaban is prescribed in everyday practice and whether evidence from clinical trials can be translated to the broader cross-section of patients in the real world.

2019 - Lead choice in cardiac implantable electronic devices: an Italian survey promoted by AIAC (Italian Association of Arrhythmias and Cardiac Pacing) [Articolo su rivista]
Ziacchi, M.; Palmisano, P.; Biffi, M.; Guerra, F.; Stabile, G.; Forleo, G. B.; Zanotto, G.; D'Onofrio, A.; Landolina, M.; De Ponti, R.; Zoni Berisso, M.; Ricci, R. P.; Boriani, G.
abstract

Background: Few data are available regarding lead preferences of electrophysiologists during cardiac implantable electronic devices (CIEDs) implantation. Aim of this survey is to evaluate the leads used, and the reasons behind these choices, in a large population of implanters. Methods: A questionnaire was sent to all 314 Italian centers with experience in CIED implantation. Results: 103 operators from 100 centers (32% of centers) responded. For atrium, passive leads represented first choice for pacemakers and defibrillators (71% and 64% of physicians, respectively), mainly for safety. For right ventricle, active fixation was preferred (61% and 93% operators in pacemaker and defibrillator patients), for higher versatility in positioning and lower dislodgement risk. For left ventricular stimulation, quadripolar leads were preferred by more than 80% of respondents, for better phrenic nerve and myocardial threshold management; active-fixation leads represent a second choice, in order to prevent or manage dislodgement (78% and 17% of respondents, respectively), but 44% of operators considered them dangerous. Conclusions: The choice of leads is heterogeneous. Trends are toward active-fixation right ventricular leads and passive-fixation atrial leads (particularly in pacemaker patients, considered frailer). For left ventricular stimulation, operators’ majority want to disposition all kind of leads, although quadripolar leads are the favorites.

2019 - Long-Term Implications of Atrial Fibrillation in Patients With Degenerative Mitral Regurgitation [Articolo su rivista]
Grigioni, F.; Benfari, G.; Vanoverschelde, J. -L.; Tribouilloy, C.; Avierinos, J. -F.; Bursi, F.; Suri, R. M.; Guerra, F.; Pasquet, A.; Rusinaru, D.; Marcelli, E.; Theron, A.; Barbieri, A.; Michelena, H.; Lazam, S.; Szymanski, C.; Nkomo, V. T.; Capucci, A.; Thapa, P.; Enriquez-Sarano, M.; for the MIDA Investigators Clavel, M. A.; Maalouf, J.; Trojette, F.; Szymanski, C.; Touati, G.; Remadi, J. P.; Russo, A.; Biagini, E.; Pasquale, F.; Ferlito, M.; Rapezzi, C.; Savini, C.; Marinelli, G.; Pacini, D.; Gargiulo, G. D.; Di Bartolomeo, R.; Boulif, J.; de Meester, C.; El Khoury, G.; Gerber, B.; Noirhomme, P.; Vancraeynest, D.; Collard, F.; Habib, G.; Mantovani, F.; Lugli, R.; Modena, M. G.; Boriani, G.; Bacchi-Reggiani, L.
abstract

Background: Scientific guidelines consider atrial fibrillation (AF) complicating degenerative mitral regurgitation (DMR) a debated indication for surgery. Objectives: This study analyzed the prognostic/therapeutic implications of AF at DMR diagnosis and long-term. Methods: Patients were enrolled in the MIDA (Mitral Regurgitation International Database) registry, which reported the consecutive, multicenter, international experience with DMR due to flail leaflets echocardiographically diagnosed. Results: Among 2,425 patients (age 67 ± 13 years; 71% male, 67% asymptomatic, ejection fraction 64 ± 10%), 1,646 presented at diagnosis with sinus rhythm (SR), 317 with paroxysmal AD, and 462 with persistent AF. Underlying clinical/instrumental characteristics progressively worsened from SR to paroxysmal to persistent AF. During follow-up, paroxysmal and persistent AF were associated with excess mortality (10-year survival in SR and in paroxysmal and persistent AF was 74 ± 1%, 59 ± 3%, and 46 ± 2%, respectively; p < 0.0001), that persisted 20 years post-diagnosis and independently of all baseline characteristics (p values <0.0001). Surgery (n = 1,889, repair 88%) was associated with better survival versus medical management, regardless of all baseline characteristics and rhythm (adjusted hazard ratio: 0.26; 95% confidence interval: 0.23 to 0.30; p < 0.0001) but post-surgical outcome remained affected by AF (10-year post-surgical survival in SR and in paroxysmal and persistent AF was 82 ± 1%, 70 ± 4%, and 57 ± 3%, respectively; p < 0.0001). Conclusions: AF is a frequent occurrence at DMR diagnosis. Although AF is associated with older age and more severe presentation of DMR, it is independently associated with excess mortality long-term after diagnosis. Surgery is followed by improved survival in each cardiac rhythm subset, but persistence of excess risk is observed for each type of AF. Our study indicates that detection of AF, even paroxysmal, should trigger prompt consideration for surgery.

2019 - Long-Term Relationship Between Atrial Fibrillation, Multimorbidity and Oral Anticoagulant Drug Use [Articolo su rivista]
Proietti, M.; Marzona, I.; Vannini, T.; Tettamanti, M.; Fortino, I.; Merlino, L.; Basili, S.; Mannucci, P. M.; Boriani, G.; Lip, G. Y. H.; Roncaglioni, M. C.; Nobili, A.
abstract

Objectives: To analyze the relationship between atrial fibrillation (AF) and Charlson comorbidity index (CCI) in a population-based cohort study over a long-term follow-up period, in relation to oral anticoagulant (OAC) prescriptions and outcomes. Patients and Methods: We used data from the administrative health databases of Lombardy. All patients with AF and age 40 years and older and who were admitted to the hospital in 2002 were considered for analysis and followed up to 2014. AF diagnosis and CCI were established according to codes from the International Classification of Diseases, Ninth Revision. Results: In 2002, 24,040 patients were admitted with a diagnosis of AF. CCI was higher in patients with AF than in those without AF (1.8±2.1 vs 0.2±0.9; P<.001). Over 12 years of follow-up, AF was associated with an increased risk of higher CCI (beta coefficient, 1.69; 95% CI, 1.67-1.70). In patients with AF, CCI was inversely associated with OAC prescription at baseline (P<.001) and at the end of the follow-up (P=.03). Patients with AF and a high CCI (≥4) had a higher cumulative incidence of stroke, major bleeding, and all-cause death (all P<.001), compared with those with low CCI (range, 0-3). Adjusted Cox regression analysis revealed that time-dependent continuous CCI was associated with an increased risk for stroke, major bleeding, and all-cause death (all P<.001). Conclusions: In hospitalized patients, AF is associated with an increase in CCI that is inversely associated with OAC prescriptions during follow-up. CCI is independently associated with an increased risk of stroke, major bleeding, and all-cause death.

2019 - Management of asymptomatic arrhythmias: a European Heart Rhythm Association (EHRA) consensus document, endorsed by the Heart Failure Association (HFA), Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), Cardiac Arrhythmia Society of Southern Africa (CASSA), and Latin America Heart Rhythm Society (LAHRS) [Articolo su rivista]
Arnar, David O; Mairesse, Georges H; Boriani, Giuseppe; Calkins, Hugh; Chin, Ashley; Coats, Andrew; Deharo, Jean-Claude; Svendsen, Jesper Hastrup; Heidbüchel, Hein; Isa, Rodrigo; Kalman, Jonathan M; Lane, Deirdre A; Louw, Ruan; Lip, Gregory Y H; Maury, Philippe; Potpara, Tatjana; Sacher, Frederic; Sanders, Prashanthan; Varma, Niraj; Fauchier, Laurent
abstract

Asymptomatic arrhythmias are frequently encountered in clinical practice. Although studies specifically dedicated to these asymptomatic arrhythmias are lacking, many arrhythmias still require proper diagnostic and prognostic evaluation and treatment to avoid severe consequences, such as stroke or systemic emboli, heart failure, or sudden cardiac death. The present document reviews the evidence, where available, and attempts to reach a consensus, where evidence is insufficient or conflicting.

2019 - Management of atrial fibrillation in the emergency room and in the cardiology ward: the BLITZ AF study [Articolo su rivista]
Gulizia, Michele Massimo; Cemin, Roberto; Colivicchi, Furio; De Luca, Leonardo; Di Lenarda, Andrea; Boriani, Giuseppe; Di Pasquale, Giuseppe; Nardi, Federico; Scherillo, Marino; Lucci, Donata; Fabbri, Gianna; Maggioni, Aldo Pietro
abstract

To assess the number of admissions to the emergency room (ER) of patients with atrial fibrillation (AF) or atrial flutter (af) and their subsequent management. To evaluate the clinical profile and the use of antithrombotics and antiarrhythmic therapy in patients with AF admitted to cardiology wards.

2019 - Nationwide survey on the current practice of ventricular tachycardia ablation [Articolo su rivista]
Vergara, P.; Casella, M.; Barbato, G.; De Ruvo, E.; Grandinetti, G.; Notarstefano, P.; Tola, G.; Calvi, V.; Santini, L.; Nissardi, V.; Nonis, A.; Ricci, R. P.; Boriani, G.; Tondo, C.; Della Bella, P.
abstract

MethodsWe performed a nationwide survey on the current practice of ventricular tachycardia catheter ablation in Italy during the year 2016.ResultsAmong 145 operators participating in the survey, 58 (40.0%) did not perform any ventricular tachycardia ablation in 2016. Among those performing ventricular tachycardia ablation, 9 operators (6.2%) performed only right ventricular endocardial catheter ablation, 52 (35.9%) performed endocardial catheter ablation both in the right and left ventricle (LV) and 26 (17.9%) performed both endocardial and epicardial LV catheter ablations. Seventy operators (89.7%) among the 78 performing LV and epicardial ablations treated patients with ischemic cardiomyopathy; ablations in the setting of other causes were less frequently performed. The following were considered as minimum requirements for ventricular tachycardia ablation: presence of a three-dimensional mapping system (120 operators, 82.8%), ICU in the hospital (118 operators, 81.4%), operator's training in high volume centers (93 operators, 64.1%). Twenty-eight operators (19.3%) performed catheter ablation in patients with electrical storm only after hemodynamic stabilization, 41 operators (28.3%) also during the acute phase and 9 operators (6.2%) never performed catheter ablation in electrical storm patients; the remaining 67 operators did not perform ventricular tachycardia ablation at all, or performed ablations only in the right ventricle.ConclusionThe present survey provides a snapshot of the current invasive treatment of ventricular tachycardia by catheter ablation. The procedure, especially in the setting of ischemic cardiomyopathy, is performed nationwide. Complex cases, including those with electrical storm, should be managed within a preestablished integrated network of regional referral centers able to transfer patients as soon as possible.

2019 - Neuro-arrhythmology: A challenging field of action and research: A review from the Task Force of Neuro-arrhythmology of Italian Association of Arrhythmias and Cardiac Pacing [Articolo su rivista]
Strano, S.; Toni, D.; Ammirati, F.; Sanna, T.; Tomaino, M.; Brignole, M.; Mazza, A.; Nguyen, B. L.; Di Bonaventura, C.; Ricci, R. P.; Boriani, G.
abstract

There is a growing interest in the study of the mechanisms of heart and brain interactions with the aim to improve the management of high-impact cardiac rhythm disorders, first of all atrial fibrillation. However, there are several topics to which the scientific interests of cardiologists and neurologists converge constituting the basis for enhancing the development of neuro-arrhythmology. This multidisciplinary field should cover a wide spectrum of diseases, even beyond the classical framework corresponding to stroke and atrial fibrillation and include the complex issues of seizures as well as loss of consciousness and syncope. The implications of a more focused interaction between neurologists and cardiologists in the field of neuro-arrhythmology should include in perspective the institution of research networks specifically devoted to investigate 'from bench to bedside' the complex pathophysiological links of the abovementioned diseases, with involvement of scientists in the field of biochemistry, genetics, molecular medicine, physiology, pathology and bioengineering. An investment in the field could have important implications in the perspectives of a more personalized approach to patients and diseases, in the context of 'precision'medicine. Large datasets and electronic medical records, with the approach typical of 'big data' could enhance the possibility of new findings with potentially important clinical implications. Finally, the interaction between neurologists and cardiologists involved in arrythmia management should have some organizational implications, with new models of healthcare delivery based on multidisciplinary assistance, similarly to that applied in the case of syncope units.

2019 - New classification of geometric patterns considering left ventricular volume in patients with chronic aortic valve regurgitation: Prevalence and association with adverse cardiovascular outcomes [Articolo su rivista]
Barbieri, Andrea; Giubertoni, Elisa; Bartolacelli, Ylenia; Bursi, Francesca; Manicardi, Marcella; Boriani, Giuseppe
abstract

Background: Left ventricular (LV) remodeling due to aortic regurgitation (AR) often leads to maladaptive responses. We assessed the prevalence and clinical implications of LV remodeling considering LV volume, mass, and relative wall thickness at the time of AR diagnosis. Methods and Results: Between 2008 and 2017, 370 consecutive patients (mean age 67.3 ± 16.1 years, 56.5% males), with moderate or severe AR, were retrospectively analyzed. LV geometric patterns and clinical outcomes (cardiovascular death, hospitalization for heart failure, or aortic valve replacement) were evaluated. LV dilatation (LV end-diastolic volume >75 mL/m2) was present in 228 patients (61.6%). Applying the new LV remodeling classification system, 40 (10.8%) patients had normal geometry, 14 (3.8%) concentric remodeling, 43 (11.6%) concentric hypertrophy (LVH), 45 (12.2%) indeterminate LVH, 38 (10.3%) mixed LVH, 93 (25.1%) dilated LVH, 54 (14.6%) eccentric LVH, and 43 (11.6%) eccentric remodeling. During a median follow-up of 3.48 years (25th–75th percentile 0.91–5.57), 97 (26.2%) had the combined endpoint. LV dilation (P < 0.001), LVH (P < 0.001), and LV remodeling patterns were significantly associated with the combined endpoint. After multivariable adjustment for age, EF, aortic stenosis, CAD history, and moderate mitral regurgitation, dilated LVH (HR 7.61, IC 95% 1.82–31.80; P = 0.005) and eccentric LVH (HR 7.91, IC 95% 1.82–34.38; P = 0.006) were associated with adverse outcome compared to eccentric remodeling, that showed the best event-free survival rate. Conclusions: In a contemporary cohort of patients with AR, applying the new LV remodeling classification system, only a minority had normal geometry. Dilated LVH and eccentric LVH showed distinct outcome penalty after adjustment for confounders.

2019 - Occurrence of atrial fibrillation in pacemaker patients and its association with sleep apnea and heart rate variability [Articolo su rivista]
Mazza, A.; Bendini, M. G.; Valsecchi, S.; Lovecchio, M.; Leggio, M.; De Cristofaro, R.; Boriani, G.
abstract

Aims: Sleep apnea (SA) is a risk factor for atrial fibrillation (AF) occurrence. Sympathovagal imbalance is a mechanism that predisposes to the development of AF and that occurs in SA. Some pacemakers can detect SA events and continuously measure a time domain measure of heart rate variability (HRV), i.e. the standard deviation of 5-min median atrial–atrial sensed intervals (SDANN). We evaluated the association between the occurrence of AF and device-detected SA and SDANN in patients who received pacemakers. Methods: We enrolled 150 consecutive patients undergoing implantation of a dual-chamber pacemaker, capable of SA and SDANN estimation. The SA was defined as severe if the Respiratory Disturbance Index was ≥30 episodes/h for at least one night during the first week after implantation. Results: Sixteen patients in permanent AF were excluded from our analysis. During follow-up, AF (cumulative device-detected AF duration > 6 h/day) occurred in 24(18%) patients out of the remaining 134 patients. Severe SA was detected in 84 patients. SDANN values were available in 74 patients and the median value was 76 ms [25°–75°percentile:58–77]. The risk of AF was higher in patients with severe SA (log-rank test; p = .033). The presence of either or both conditions (severe SA and SDANN < 76 ms) was associated with shorter time to AF event (p = .042) and was an independent predictor of AF (hazard ratio: 2.37; 95%CI:1.08 to 5.21; p = .033). Conclusion: In pacemaker patients, device-diagnosed severe SA and reduced SDANN are associated with a higher risk of AF.

2019 - Oral anticoagulation for subclinical atrial tachyarrhythmias detected by implantable cardiac devices: an international survey of the AF-SCREEN Group [Articolo su rivista]
Boriani, G.; Healey, J. S.; Schnabel, R. B.; Lopes, R. D.; Calkins, H.; Camm, J. A.; Freedman, B.
abstract

Aims: At present, there is little evidence on how to treat subclinical atrial fibrillation (SCAF) or atrial high rate episodes (AHREs) detected by cardiac implantable electronic devices (CIEDs). Our aim was to assess current practice around oral anticoagulation (OAC) in such patients. Methods: A web-based survey undertaken by 310 physicians: 59 AF-SCREEN International Collaboration members and 251 non-members. Results: In patients with SCAF/AHRE and a CHA2DS2VASc ≥ 2 in males or ≥ 3 in female the amount of SCAF/AHRE triggering use of OAC was variable but <2% of respondents considered that no AHRE would require OAC. Around one third (34%) considered SCAF/AHRE duration of >5–6 min as the basis for OAC prescription, while 16% and 18% required a burden of at least 5.5 h or 24 h, respectively. The propensity to prescribe OAC for a low burden of AHREs differed according to certain respondent characteristics (greater propensity to prescribe OAC for neurologists). When the clinical scenario included a prior stroke or a prior cardioembolic stroke, stated prescription of OAC was very high. More than 96% felt that any SCAF/AHRE should be treated with OAC. Conclusions: There is substantial heterogeneity in the perception of the risk of stroke/systemic embolism associated with SCAF/AHRE of variable duration. The threshold of AHRE burden that would trigger initiation of OAC is highly variable, and differs according to the clinical scenario (lower threshold in case of previous stroke). Ongoing trials will clarify the real benefit and risk/benefit ratio of OAC in this specific clinical setting.

2019 - Reactive atrial-based antitachycardia pacing therapy reduces atrial tachyarrhythmias [Articolo su rivista]
Crossley, G. H.; Padeletti, L.; Zweibel, S.; Hudnall, J. H.; Zhang, Y.; Boriani, G.
abstract

Background: Reactive atrial-based antitachycardia pacing (rATP) aims to terminate atrial tachyarrhythmia/atrial fibrillation (AT/AF) episodes when they spontaneously organize to atrial flutter or atrial tachycardia; however, its effectiveness in the real-world has not been studied. We used a large device database (Medtronic CareLink, Medtronic, Minneapolis, MN, USA) to evaluate the effects of rATP at reducing AT/AF. Methods: Pacemaker, defibrillator, and resynchronization device transmission data were analyzed. Eligible patients had device detected AT/AF during a baseline period but were not in persistent AT/AF immediately preceding first transmission. Note that 1:1 individual matching between groups was conducted using age, sex, device type, pacing mode, AT/AF, and percent ventricular pacing at baseline. Risks of AT/AF events were compared between patients with rATP-enabled versus control patients with rATP-disabled or not available in the device. For matched patients, AT/AF event rates at 2 years were estimated by Kaplan-Meier method, and hazard ratios (HRs) were calculated by Cox proportional hazard models. Results: Of 43,440 qualifying patients, 4,203 had rATP on. Matching resulted in 4,016 pairs, totaling 8,032 patients for analysis. The rATP group experienced significantly lower risks of AT/AF events lasting ≥1 day (HR 0.81), ≥7 days (HR 0.64), and ≥30 days (HR 0.56) compared to control (P < 0.0001 for all). In subgroup analysis, rATP was associated with reduced risks of AT/AF events across age, sex, device type, baseline AT/AF, and preventive atrial pacing. Conclusions: Among real-world patients from a large device database, rATP therapy was significantly associated with a reduced risk of AT/AF. This association was independent of whether the patient had a pacemaker, defibrillator, or resynchronization device.

2019 - Relationship between body mass index and outcomes in patients with atrial fibrillation treated with edoxaban or warfarin in the ENGAGE AF-TIMI 48 trial [Articolo su rivista]
Boriani, G.; Ruff, C. T.; Kuder, J. F.; Shi, M.; Lanz, H. J.; Rutman, H.; Mercuri, M. F.; Antman, E. M.; Braunwald, E.; Giugliano, R. P.
abstract

Aims To investigate the relationship between body mass index (BMI) and outcomes in patients with atrial fibrillation (AF). Methods and results In the ENGAGE AF-TIMI 48 trial, patients with AF were randomized to warfarin (international normalized ratio 2.0–3.0) or edoxaban. The cohort (N = 21 028) included patients across BMI categories (kg/m2): underweight (<18.5) in 0.8%, normal (18.5 to <25) in 21.4%, overweight (25 to <30) in 37.6%, moderately obese (30 to <35) in 24.8%, severely obese (35 to <40) in 10.0%, and very severely obese (≥40) in 5.5%. In an adjusted analysis, higher BMI (continuous, per 5 kg/m2 increase) was significantly and independently associated with lower risks of stroke/ systemic embolic event (SEE) [hazard ratio (HR) 0.88, P = 0.0001], ischaemic stroke/SEE (HR 0.87, P < 0.0001), and death (HR 0.91, P < 0.0001), but with increased risks of major (HR 1.06, P = 0.025) and major or clinically relevant non-major bleeding (HR 1.05, P = 0.0007). There was a significant interaction between sex and increasing BMI category, with lower risk of ischaemic stroke/SEE in males and increased risk of bleeding in women. Trough edoxaban concentration and anti-Factor Xa activity were similar across BMI groups >18.5 kg/m2, while time in therapeutic range for warfarin improved significantly as BMI increased (P < 0.0001). The effects of edoxaban vs. warfarin on stroke/SEE, major bleeding, and net clinical outcome were similar across BMI groups. Conclusion An increased BMI was independently associated with a lower risk of stroke/SEE, better survival, but increased risk of bleeding. The efficacy and safety profiles of edoxaban were similar across BMI categories ranging from 18.5 to >40.

2019 - Remodeling classification system considering left ventricular volume in patients with aortic valve stenosis: Association with adverse cardiovascular outcomes [Articolo su rivista]
Barbieri, A.; Bartolacelli, Y.; Bursi, F.; Manicardi, M.; Boriani, G.
abstract

Background: To assess prevalence and clinical implications of left ventricular (LV) remodeling considering: LV volume, mass and relative wall thickness at the time of aortic valve stenosis diagnosis. Methods and Results: We retrospectively analyzed 343 patients (age 79.2 ± 9.5 years, 48.1% males) with functional aortic valve area (AVA) ≤ 1.5 cm 2 . LV geometric patterns and clinical outcomes (combined death, cardiac hospitalization, aortic valve replacement [AVR]) were evaluated. According to the new LV remodeling classification, 4.9% had normal geometry, 7.5% concentric remodeling, 39.3% concentric hypertrophy (LVH), 22.4% mixed LVH, 12.5% dilated LVH, 3.2% eccentric LVH and 4.3% eccentric remodeling, 5.5% had not classifiable LVH. Indexed stroke volume (SVi) was higher in patients with concentric LVH (40.3 ± 11.9 mL/m 2 ) and mixed LVH (41.6 ± 13.4 mL/m 2 ) and lower in patients with eccentric LVH (24.9 ± 7.7 mL/m 2 ), concentric (36.6 ± 12.7 mL/m 2 ) and eccentric remodeling (34.9 ± 9.5 mL/m 2 ), P = 0.003. During a median follow-up of 2.2 years, 260 (75.8%) had the combined end point. A significant association between the combined end point and LV dilation (P = 0.010) or LV remodeling patterns (P = 0.0001) was found. After multivariable adjustment for AVR, concentric remodeling (HR 3.12, IC 95% 1.14–8.55; P = 0.02) and dilated LVH (HR 3.48, IC 95% 1.31–9.27; P = 0.01) were strongly associated with death or cardiac hospitalizations. Conclusions: In patients with AVA ≤ 1.5 cm 2 , when the new LV remodeling classification system is applied, only a minority had normal geometry and less than half had “classic” concentric LVH or remodeling. LV volume dilatation is frequent and associated with adverse outcome. Concentric remodeling, eccentric remodeling, dilated LVH had the worst noninvasive hemodynamic profile and prognosis.

2019 - Safety and efficacy of dronedarone from clinical trials to real-world evidence: Implications for its use in atrial fibrillation [Articolo su rivista]
Boriani, G.; Blomstrom-Lundqvist, C.; Hohnloser, S. H.; Bergfeldt, L.; Botto, G. L.; Capucci, A.; Lozano, I. F.; Goette, A.; Israel, C. W.; Merino, J. L.; Camm, A. J.
abstract

Efficacy and safety of dronedarone was shown in the ATHENA trial for paroxysmal or persistent atrial fibrillation (AF) patients. Further trials revealed safety concerns in patients with heart failure and permanent AF. This review summarizes insights from recent real-world studies and meta-analyses, including reports on efficacy, with focus on liver safety, mortality risk in patients with paroxysmal/persistent AF, and interactions of dronedarone with direct oral anticoagulants. Reports of rapidly progressing liver failure in dronedarone-prescribed patients in 2011 led to regulatory cautions about potential liver toxicity. Recent real-world evidence suggests dronedarone liver safety profile is similar to other antiarrhythmics and liver toxicity could be equally common with many Class III antiarrhythmics. Dronedarone safety concerns (increased mortality in patients with permanent AF) were raised based on randomized controlled trials (RCT) (ANDROMEDA and PALLAS), but comedication with digoxin may have increased the mortality rates in PALLAS, considering the dronedarone-digoxin pharmacokinetic (PK) interaction. Real-world data on apixaban-dronedarone interactions and edoxaban RCT observations suggest no significant safety risks for these drug combinations. Median trough plasma concentrations of dabigatran 110 mg during concomitant use with dronedarone are at acceptable levels, while PK data on the rivaroxaban-dronedarone interaction are unavailable. In RCTs and real-world studies, dronedarone significantly reduces AF burden and cardiovascular hospitalizations, and demonstrates a low risk for proarrhythmia in patients with paroxysmal or persistent AF. The concerns on liver safety must be balanced against the significant reduction in hospitalizations in patients with non-permanent AF and low risk for proarrhythmias following dronedarone treatment.

2019 - Screening for atrial fibrillation: Need for an integrated, structured approach [Articolo su rivista]
Boriani, G.; Proietti, M.
abstract

2019 - Searching for Atrial Fibrillation Poststroke: A White Paper of the AF-SCREEN International Collaboration [Articolo su rivista]
Schnabel, R. B.; Haeusler, K. G.; Healey, J. S.; Freedman, B.; Boriani, G.; Brachmann, J.; Brandes, A.; Bustamante, A.; Casadei, B.; Crijns, H. J. G. M.; Doehner, W.; Engstrom, G.; Fauchier, L.; Friberg, L.; Gladstone, D. J.; Glotzer, T. V.; Goto, S.; Hankey, G. J.; Harbison, J. A.; Hobbs, F. D. R.; Johnson, L. S. B.; Kamel, H.; Kirchhof, P.; Korompoki, E.; Krieger, D. W.; Lip, G. Y. H.; Lochen, M. -L.; Mairesse, G. H.; Montaner, J.; Neubeck, L.; Ntaios, G.; Piccini, J. P.; Potpara, T. S.; Quinn, T. J.; Reiffel, J. A.; Ribeiro, A. L. P.; Rienstra, M.; Rosenqvist, M.; Sakis, T.; Sinner, M. F.; Svendsen, J. H.; Van Gelder, I. C.; Wachter, R.; Wijeratne, T.; Yan, B.
abstract

Cardiac thromboembolism attributed to atrial fibrillation (AF) is responsible for up to one-third of ischemic strokes. Stroke may be the first manifestation of previously undetected AF. Given the efficacy of oral anticoagulants in preventing AF-related ischemic strokes, strategies of searching for AF after a stroke using ECG monitoring followed by oral anticoagulation (OAC) treatment have been proposed to prevent recurrent cardioembolic strokes. This white paper by experts from the AF-SCREEN International Collaboration summarizes existing evidence and knowledge gaps on searching for AF after a stroke by using ECG monitoring. New AF can be detected by routine plus intensive ECG monitoring in approximately one-quarter of patients with ischemic stroke. It may be causal, a bystander, or neurogenically induced by the stroke. AF after a stroke is a risk factor for thromboembolism and a strong marker for atrial myopathy. After acute ischemic stroke, patients should undergo 72 hours of electrocardiographic monitoring to detect AF. The diagnosis requires an ECG of sufficient quality for confirmation by a health professional with ECG rhythm expertise. AF detection rate is a function of monitoring duration and quality of analysis, AF episode definition, interval from stroke to monitoring commencement, and patient characteristics including old age, certain ECG alterations, and stroke type. Markers of atrial myopathy (eg, imaging, atrial ectopy, natriuretic peptides) may increase AF yield from monitoring and could be used to guide patient selection for more intensive/prolonged poststroke ECG monitoring. Atrial myopathy without detected AF is not currently sufficient to initiate OAC. The concept of embolic stroke of unknown source is not proven to identify patients who have had a stroke benefitting from empiric OAC treatment. However, some embolic stroke of unknown source subgroups (eg, advanced age, atrial enlargement) might benefit more from non-vitamin K-dependent OAC therapy than aspirin. Fulfilling embolic stroke of unknown source criteria is an indication neither for empiric non-vitamin K-dependent OAC treatment nor for withholding prolonged ECG monitoring for AF. Clinically diagnosed AF after a stroke or a transient ischemic attack is associated with significantly increased risk of recurrent stroke or systemic embolism, in particular, with additional stroke risk factors, and requires OAC rather than antiplatelet therapy. The minimum subclinical AF duration required on ECG monitoring poststroke/transient ischemic attack to recommend OAC therapy is debated.

2019 - Stroke Prevention, Evaluation of Bleeding Risk, and Anticoagulant Treatment Management in Atrial Fibrillation Contemporary International Guidelines [Articolo su rivista]
Proietti, M.; Lane, D. A.; Boriani, G.; Lip, G. Y. H.
abstract

In recent years the management of atrial fibrillation patients has progressively and substantially changed because of the introduction of new treatments and the availability of new data regarding the epidemiology and clinical management of these patients. In the past 2 years alone, there have been 7 new guidelines or guideline updates that have been published, which have introduced new recommendations and significantly revised previously published ones. Two updates for Canadian guidelines were published in 2016 and 2018, whereas guidelines from the European Society of Cardiology in 2016, Asia Pacific Heart Rhythm Society were published in 2017, National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand, American College of Chest Physicians, and Korean Heart Rhythm Society have been published in 2018. In this narrative review we provide a comparison of these contemporary international guidelines, with particular attention on the evaluation of thromboembolic and bleeding risks and management of oral anticoagulant therapy. From the analysis of contemporary guidelines on the management of atrial fibrillation, a general agreement is evident about the baseline evaluation of thromboembolic and bleeding risk, as well as a preference for the use of non-vitamin K antagonist oral anticoagulants. Also, regarding the concomitant use of oral anticoagulant and antiplatelet drugs in patients with acute coronary syndromes, undergoing elective percutaneous coronary intervention, catheter ablation, and cardioversion procedures, all of the guidelines agree on the general principles and are supported by evidence. More data are still needed to better substantiate recommendations for specific atrial fibrillation subpopulations. The need for an integrated approach and holistic management is highlighted in the more recently published guidelines.

2019 - The 12-lead ECG: A continuous reference for the cardiologist [Articolo su rivista]
Boriani, G.; Vitolo, M.
abstract

2019 - The Pacemaker and Implantable Cardioverter-Defibrillator Registry of the Italian Association of Arrhythmology and Cardiac Pacing - Annual Report 2017 [Articolo su rivista]
Proclemer, A; Zecchin, M; D'Onofrio, A; Ricci, Rp; Boriani, G; Facchin, D; Rebellato, L; Ghidina, M; Bianco, G; Bernardelli, E; Miconi, A; Zorzin, Af; Gregori, D
abstract

Background. The pacemaker (PM) and implantable cardioverter-defibrillator (ICD) Registry of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC) monitors the main epidemiological data in real-world practice. The survey for the 2017 activity collects information about demographics, clinical characteristics, main indications for PM/ICD therapy and device types from the Italian collaborating centers.Methods. The Registry collects prospectively national PM and ICD implantation activity on the basis of European cards.Results. PM Registry: data about 23 457 PM implantations were collected (19 378 first implant and 4079 replacements). The number of collaborating centers was 185. Median age of treated patients was 81 years (75 quartile I; 86 quartile III). ECG indications included atrioventricular conduction disorders in 37.1% of first PM implants, sick sinus syndrome in 19.5%, atrial fibrillation plus bradycardia in 13.2%, other in 30.2%. Among atrioventricular conduction defects, third-degree atrioventricular block was the most common type (21.0% of first implants). Use of single-chamber PMs was reported in 25.6% of first implants, of dual-chamber PMs in 66.7%, of PMs with cardiac resynchronization therapy (CRT) in 1.4%, and of single lead atrial-synchronized ventricular stimulation (VDD/R PMs) in 6.3%. ICD Registry: data about 19 023 ICD implantations were collected (13 898 first implants and 5125 replacements). The number of collaborating centers was 437. Median age of treated patients was 71 years (63 quartile I; 78 quartile III). Primary prevention indication was reported in 81.8% of first implants, secondary prevention in 18.2% (cardiac arrest in 6.4%). A single-chamber ICD was used in 27.0% of first implants, dual-chamber in 33.6% and biventricular in 39.3%.Conclusions. The PM and ICD Registry appears fundamental for monitoring PM and ICD utilization on a large national scale with rigorous examination of demographics and clinical indications. The PM Registry showed stable electrocardiographic and symptom indications, with an important prevalence of dual-chamber pacing. The use of CRT-PM regards a very limited number of patients. The ICD Registry documented a large use of prophylactic and biventricular ICD, reflecting a favorable adherence to trials and guidelines in clinical practice. In order to increase and optimize the cooperation of Italian implanting centers, online data entry (http://www.aiac.it/riprid) should be adopted at large scale.

2019 - The future of continuing medical education: the roles of medical professional societies and the health care industry: Position paper prepared with contributions from the European Society of Cardiology Committees for Advocacy, Education and Industry Relations, Endorsed by the Board of the European Society of Cardiology [Articolo su rivista]
Bax, Jeroen; Casadei, Barbara; Graham, Ian; Pinto, Fausto; Anker, Stefan; Badimon, Lina; Merkaly, Bela; Bueno, Hector; Clarke, Sarah; Fitzsimons, Donna; Leclerq, Christophe; Linde, Cecilia; Weidinger, Franz; Lettino, Maddalena; Popescu, Bogdan; Grobbee, Diederick; Haude, Michael; Hindricks, Gerhard; Ruschitzka, Frank; Achenbach, Stephan; Clarke, Nigel; Cosentino, Francesco; Filippatos, Gerasimos; Kearney, Peter; Kirchhof, Paulus; Kristensen, Steen Dalby; Luscher, Thomas; Olsson, Gunnar; Vahanian, Alec; Windecker, Stephan; Zamorano, Jose; Simoons, Maarten; Kearney, Peter; de Boer, Rudolf; Bueno, Hector; Byrne, Robert; Caiani, Enrico Gianluca; Cowie, Martin; Fraser, Alan; James, Stefan; Kautzner, Josef; Maniadakis, Nikos; Perk, Joep; Pries, Axel Radlach; Ryden, Lars; Vardas, Panos; Van de Werf, Frans; Kirchhof, Paulus; Baldus, Stephan; van der Bilt, Ivo; Burri, Harran; Fox, Kevin; Gonçalves, Lino; Grapsa, Julia; von Haehing, Stephan; Juantaney, Jose Ramon; Kearney, Peter; Kjaergaard, Jesper; Kletsiou, Eleni; Kontsevaya, Anna; Kotecha, Dipak; Landmesser, Ulf; Milicic, Davor; Mulder, Barbara; Pasquet, Agnes; Price, Susanna; Ribeiras, Regina; Sadaba, Rafael; Sirnes, Per Anton; Sionis, Alessandro; Tanner, Felix; Varenne, Olivier; Verhost, Patrick; Simoons, Maarten; Boriani, Giuseppe; Byrne, Robert; Cosentino, Francesco; Dickstein, Kenneth; Fox, Kim; Haude, Michael; Pilgrim, Thomas; Ryden, Lars; Van de Werf, Frans; Delmas, Aoife
abstract

In recent years, wide ranging biomedical innovation has provided powerful new approaches for prevention, diagnosis and management of diseases. In order to translate such innovation into effective practice, physicians must frequently update their knowledge base and skills through continuing medical education and training. Medical Professional Societies, run as not-for-profit organizations led by peers, are uniquely placed to deliver balanced, disease oriented and patient centred education. The medical industry has a major role in the development of new, improved technology, devices and medication. In fact, the best innovations have been achieved through collaboration with scientists, clinical academics and practicing physicians. Industry has for many years been committed to ensure the optimal and safe application of its products by providing unrestricted support of medical education developed and delivered by international and national learned societies. Recently adopted Codes of Practice for the Pharmaceutical and Device industry were intended to enhance public trust in the relationship between biomedical industry and physicians. Unexpectedly, changes resulting from adoption of the Codes have limited the opportunity for unconditional industry support of balanced medical education in favour of a more direct involvement of industry in informing physicians about their products. We describe the need for continuing medical education in Cardiovascular Medicine in Europe, interaction between the medical profession and medical industry, and propose measures to safeguard the provision of high quality, balanced medical education.

2019 - The role of physical activity in individuals with cardiovascular risk factors: an opinion paper from Italian Society of Cardiology-Emilia Romagna-Marche and SIC-Sport [Articolo su rivista]
Nasi, Milena; Patrizi, Giampiero; Pizzi, Carmine; Landolfo, Matteo; Boriani, Giuseppe; Dei Cas, Alessandra; Cicero, Arrigo F G; Fogacci, Federica; Rapezzi, Claudio; Sisca, Giovanbattista; Capucci, Alessandro; Vitolo, Marco; Galiè, Nazzareno; Borghi, Claudio; Berrettini, Umberto; Piepoli, Massimo; Mattioli, Anna V
abstract

: Regular physical activity is a cornerstone in the prevention and treatment of atherosclerotic cardiovascular disease (CVD) due to its positive effects in reducing several cardiovascular risk factors. Current guidelines on CVD suggest for healthy adults to perform at least 150 min/week of moderate intensity or 75 min/week of vigorous intensity aerobic physical activity. The current review explores the effects of physical activity on some risk factors, specifically: diabetes, dyslipidemia, hypertension and hyperuricemia. Physical activity induces an improvement in insulin sensitivity and in glucose control independently of weight loss, which may further contribute to ameliorate both diabetes-associated defects. The benefits of adherence to physical activity have recently proven to extend beyond surrogate markers of metabolic syndrome and diabetes by reducing hard endpoints such as mortality. In recent years, obesity has greatly increased in all countries. Weight losses in these patients have been associated with improvements in many cardiometabolic risk factors. Strategies against obesity included caloric restriction, however greater results have been obtained with association of diet and physical activity. Similarly, the beneficial effect of training on blood pressure via its action on sympathetic activity and on other factors such as improvement of endothelial function and reduction of oxidative stress can have played a role in preventing hypertension development in active subjects. The main international guidelines on prevention of CVD suggest to encourage and to increase physical activity to improve lipid pattern, hypertension and others cardiovascular risk factor. An active action is required to the National Society of Cardiology together with the Italian Society of Sports Cardiology to improve the prescription of organized physical activity in patients with CVD and/or cardiovascular risk factors.

2019 - Usefulness of Red Cells Distribution Width to Predict Worse Outcomes in Patients With Atrial Fibrillation [Articolo su rivista]
Malavasi, V. L.; Proietti, M.; Spagni, S.; Valenti, A. C.; Battista, A.; Pettorelli, D.; Colella, J.; Vitolo, M.; Lip, G. Y.; Boriani, G.
abstract

Red cells distribution width (RDW) is a measure of red cell size variability, but little is known about the relation between RDW and outcomes in atrial fibrillation (AF).The aims of our study were to evaluate the association between RDW values, AF patients’ profile and outcomes. Consecutive patients with ECG-confirmed AF were divided in 3 groups according to tertiles of RDW values (≤13.5%, 13.6% to 14.6%, >14.6%).We enrolled 457 patients, 61.9% males, median (interquartile range) age 74 (66 to 80). Both CHA2DS2-VASc and HAS-BLED scores increased progressively according to RDW tertiles. During follow-up, there was an increased risk for all-cause death and the composite end point in the highest RDW tertile (p <0.001 for both outcomes). On multivariate Cox regression analysis, the highest RDW tertile was independently associated with all-cause death (hazard ratio [HR] 3.23, 95% confidence interval [CI] 1.04 to 10.00) and the composite end point (HR 2.04, 95% CI 1.12 to 3.70). RDW as a continuous variable was also independently associated with all cause death and the composite outcome (HR 1.16, 95% CI 1.02 to 1.31 and HR 1.16, 95% CI 1.05 to 1.27, respectively). In conclusion, in a real-life AF population, RDW is associated with clinical factors indicating a worse profile and is independently associated with increased risks of all-cause death and other clinical events.

2018 - 12-year Temporal Trend in Referral Pattern and Test Results of Stress Echocardiography in a Tertiary Care Referral Center with Moderate Volume Activities and Cath-lab Facility [Articolo su rivista]
Barbieri, Andrea; Mantovani, Francesca; Bursi, Francesca; Bartolacelli, Ylenia; Manicardi, Marcella; Lauria, Maria Giulia; Boriani, Giuseppe
abstract

Background: Data on stress echocardiography (SE) time-related changes in referral patterns and diagnostic yield for detection of inducible ischemia could enhance Echo Lab quality benchmarks and performance measures. Aim: This study aims to evaluate temporal trends in SE test results among ambulatory patients with suspected or known coronary artery disease (CAD) in a tertiary care referral center with moderate (>100/year) volume SE activities and Cath-Lab facility. Methods: From January 2004 to December 2015, 1954 patients (mean age 62 ± 12 years, 42% women, 27% with known CAD) underwent SE (1673 exercise SE, 86%, 246 pharmacological SE, 12%, 35 pacing SE, 2%). Time was grouped into three 4 year periods, where clinical data and test results were evaluated. Results: Our series comprised low-to-intermediate pretest probability of CAD throughout the observation period (overall pretest probability of CAD 19% ± 15%). A progressive decline over time in the rate of pharmacological SE instead of a dramatic increment of exercise SE (79%-96%, P < 0.0001) was noted. The use of beta-blockers increased (from 43% to 66%, P < 0.0001), while the use of nitrates decreased (from 11% to 4%, P < 0.0001) over time. We noted a very uncommon occurrence of abnormal test results with a further decrease in the last period (from 11% to 3%, P < 0.0001). Conclusions: We observed, over a 12-year period, a progressive decrease in the frequency of inducible myocardial ischemia among patients with known or suspected CADe referred to our Echo Lab for SE with Cath-Lab facility, and this trend was parallel to changes in SE referral practice. These findings are particularly relevant if we consider the practical implications on diagnostic SE accuracy and risk assessment.

2018 - 2018 EHRA expert consensus statement on lead extraction: Recommendations on definitions, endpoints, research trial design, and data collection requirements for clinical scientific studies and registries: Endorsed by APHRS/HRS/LAHRS [Articolo su rivista]
Bongiorni, Maria G; Burri, Haran; Deharo, Jean C; Starck, Christoph; Kennergren, Charles; Saghy, Laszlo; Rao, Archana; Tascini, Carlo; Lever, Nigel; Kutarski, Andrzej; Fernandez Lozano, Ignacio; Strathmore, Neil; Costa, Roberto; Epstein, Laurence; Love, Charles; Blomstrom-Lundqvist, Carina; Fauchier, Laurent; Defaye, Pascal; Arnar, David O; Klug, Didier; Boveda, Serge; Nielsen, Jens Cosedis; Boriani, Giuseppe; Zhang, Shu; Martin, Andrew Paul; Prutkin, Jordan M; De Zuloaga, Claudio
abstract

NA

2018 - A closer look into the complexity of our practice: Outcome research for transvenous temporary cardiac pacing [Articolo su rivista]
Boriani, Giuseppe; Diemberger, Igor
abstract

NA

2018 - Acute hemodynamic effects of intravenous adenosine in patients with associated pulmonary arterial hypertension: Comparison with intravenous epoprostenol [Articolo su rivista]
Rossi, Rosario; Coppi, Francesca; Sgura, Fabio; Monopoli, Daniel Enrique; Boriani, Giuseppe
abstract

Exogenous intravenous (IV) adenosine and epoprostenol are effective vasodilator agents, causing a substantial reduction in pulmonary vascular resistance in patients affected by idiopathic pulmonary arteriolar hypertension (PAH). Their action, in patients with PAH associated with other pathological conditions, is not well defined. In the present paper the authors retrospectively analyzed the acute hemodynamic effects of intravenous adenosine and epoprostenol in 30 consecutive patients (mean age: 58 ± 15 years; 21 females, and 9 males) affected by PAH associated with other pathological conditions, as determined by changes from baseline in systemic and pulmonary hemodynamic parameters. Acute IV administration of adenosine decreased pulmonary vascular resistance index (PVRI) by 3 Wood U/m(2) (- 20%) compared to baseline (p = 0.02). We noted a slight, not significant, decrease in mean pulmonary artery pressure (mPAP) of 4 mmHg. Cardiac index (CI) increased by 0.5 L/min/m(2) (15% increase respect to baseline; p = 0.03). The heart rate and mean systemic blood pressure (BP) did not change significantly. Acute IV administration of epoprostenol decreased PVRI by 6 mmHg (- 40%) respect to baseline (p < 0.0001). CI increased by 1.4 L/min/m(2) (p < 0.0001); while mPAP decreased by 5 mmHg (nearly 10%) (p = 0.04). This decrease of mPAP was accompanied by a mean BP decrease of 11 mmHg compared to baseline (p = 0.003). Our results indicates that, in patients with PAH associated with other pathological conditions, adenosine is predominantly a positive inotropic agent; and epoprostenol a potent vasodilator of both pulmonary and systemic vessels, and a strong positive inotropic agent.

2018 - Antiarrhythmic drugs-clinical use and clinical decision making: A consensus document from the European Heart Rhythm Association (EHRA) and European Society of Cardiology (ESC) Working Group on Cardiovascular Pharmacology, endorsed by the Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS) and International Society of Cardiovascular Pharmacotherapy (ISCP) [Articolo su rivista]
Dan, Gheorghe-Andrei; Martinez-Rubio, Antoni; Agewall, Stefan; Boriani, Giuseppe; Borggrefe, Martin; Gaita, Fiorenzo; Van Gelder, Isabelle; Gorenek, Bulent; Kaski, Juan Carlos; Kjeldsen, Keld; Lip, Gregory Y. H.; Merkely, Bela; Okumura, Ken; Piccini, Jonathan P.; Potpara, Tatjana; Poulsen, Birgitte Klindt; Saba, Magdi; Savelieva, Irina; Tamargo, Juan L.; Wolpert, Christian; Sticherling, Christian; Ehrlich, Joachim R.; Schilling, Richard; Pavlovic, Nikola; De Potter, Tom; Lubinski, Andrzej; Svendsen, Jesper Hastrup; Ching, Keong; Sapp, John Lewis; Chen-Scarabelli, Carol; Martinez, Felipe
abstract

NA

2018 - Antithrombotic Therapy for Atrial Fibrillation: CHEST Guideline and Expert Panel Report [Articolo su rivista]
Lip, Gregory Y H; Banerjee, Amitava; Boriani, Giuseppe; Chiang, Chern En; Fargo, Ramiz; Freedman, Ben; Lane, Deirdre A.; Ruff, Christian T.; Turakhia, Mintu; Werring, David; Patel, Sheena; Moores, Lisa
abstract

BACKGROUND: The risk of stroke is heterogeneous across different groups of patients with atrial fibrillation (AF), being dependent on the presence of various stroke risk factors. We provide recommendations for antithrombotic treatment based on net clinical benefit for patients with AF at varying levels of stroke risk and in a number of common clinical scenarios. METHODS: Systematic literature reviews were conducted to identify relevant articles published from the last formal search perfomed for the Antithrombotic and Thrombolytic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (9th Edition). The overall quality of the evidence was assessed using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach. Graded recommendations and ungraded consensus-based statements were drafted, voted on, and revised until consensus was reached. RESULTS: For patients with AF without valvular heart disease, including those with paroxysmal AF, who are at low risk of stroke (eg, CHA2DS2-VASc [congestive heart failure, hypertension, age&nbsp;≥ 75 (doubled), diabetes, stroke (doubled)-vascular disease, age 65-74 and sex category (female)] score of 0 in males or 1 in females), we suggest no antithrombotic therapy. The next step is to consider stroke prevention (ie, oral anticoagulation therapy) for patients with 1 or more non-sex CHA2DS2-VASc stroke risk factors. For patients with a single non-sex CHA2DS2-VASc stroke risk factor, we suggest oral anticoagulation rather than no therapy, aspirin, or combination therapy with aspirin and clopidogrel; and for those at high risk of stroke (eg, CHA2DS2-VASc&nbsp;≥ 2 in males or&nbsp;≥ 3 in females), we recommend oral anticoagulation rather than no therapy, aspirin, or combination therapy with aspirin and clopidogrel. Where we recommend or suggest in favor of oral anticoagulation, we suggest using a non-vitamin K antagonist oral anticoagulant drug rather than adjusted-dose vitamin K antagonist therapy. With the latter, it is important to aim for good quality anticoagulation control with a time in therapeutic range &gt; 70%. Attention to modifiable bleeding risk factors (eg, uncontrolled BP, labile international normalized ratios, concomitant use of aspirin or nonsteroidal antiinflammatory drugs in an anticoagulated patient, alcohol excess) should be made at each patient contact, and HAS-BLED (hypertension, abnormal renal/liver function [1 point each], stroke, bleeding history or predisposition, labile international normalized ratio, elderly (0.65), drugs/alcohol concomitantly [1 point each]) score used to assess the risk of bleeding where high risk patients (≥ 3) should be reviewed and followed up more frequently. CONCLUSIONS: Oral anticoagulation is the optimal choice of antithrombotic therapy for patients with AF with&nbsp;≥1 non-sex CHA2DS2-VASc stroke risk factor(s).

2018 - Arterial hypertension in patients with atrial fibrillation in Europe: A report from the EURObservational Research Programme pilot survey on atrial fibrillation [Articolo su rivista]
Dan, G. A.; Badila, E.; Weiss, E.; Laroche, C.; Boriani, G.; Dan, A.; Tavazzi, L.; Maggioni, A. P.; Crijns, H. J.; Popescu, R.; Blommaert, D.; Streb, W.; Lip, G. Y. H.
abstract

Background: Hypertension (HTN) is the most prevalent co-morbidity among atrial fibrillation (AF) patients; the relationship between the two is bidirectional, with an incremental effect on adverse outcomes. Purpose: To study clinical features, treatment patterns and 1 year outcomes amongst AF patients with HTN in the EURObservational Research Programme Atrial Fibrillation (EORP-AF) Pilot Registry, a prospective multi-national survey conducted by the European Society of Cardiology in 9 European countries. Methods: Of 3119 enrolled AF patients, 2194 were diagnosed with HTN (AF-HTN) and 909 were normotensive (AF-NT) (16 patients had unknown HTN status). We compared baseline clinical features, management strategy and 1-year outcomes in terms of all-cause death, cardiovascular (CV) death, and any thrombosis-related event (TE: stroke, transient ischemic attack, acute coronary syndrome, coronary intervention, cardiac arrest, peripheral/pulmonary embolism) in AF-HTN vs AF-NT patients. Results: The AF-HTN patients had more prevalent CV risk factors and comorbidities (median CHA2DS2-VASc score (IQR) 4 (3, 5) in AF-HTN, versus 2 (1, 3) in AF-NT; p &lt; 0.01). Crude rate of all-cause death and any TE event was higher in AF-HTN (194 (11.2%) versus 60 (8.2%), p = 0.02). Kaplan-Meier analysis curves for death by hypertensive status showed no significant differences between the subgroups (log rank test, p = 0.22). On logistic regression analysis, HTN did not emerge as an independent risk factor for outcomes (OR 1.08, 95% CI 0.76–1.54). Conclusion: AF-HTN patients have a higher prevalence of comorbidities and this conferred a higher risk for a composite endpoint of all-cause death and thromboembolic events. In this cohort HTN did not independently predict all-cause mortality at 1-year.

2018 - Atrial fibrillation and prediction of mortality by conventional clinical score systems according to the setting of care [Articolo su rivista]
Diemberger, Igor; Fantecchi, Elisa; Reggiani, Maria Letizia Bacchi; Martignani, Cristian; Angeletti, Andrea; Massaro, Giulia; Ziacchi, Matteo; Biffi, Mauro; Lip, Gregory Y. H.; Boriani, Giuseppe
abstract

Background: Atrial fibrillation (AF) is associated with high morbidity and mortality, also among anticoagulated patients. Our aim was to evaluate the predictive role for long-term mortality of a series of risk stratification scores associated with cardiovascular or thromboembolic outcomes (CHADS2, CHA2DS2-VASc, ATRIA, TIMI-AF), and bleeding complications (HAS-BLED) in an unselected population of patients with AF. Methods: Single center, observational, prospective registry of consecutive patients with AF, undergoing clinical/echocardiographic evaluation in a University Hospital, as either in-patients or out-patients. We assessed the role of each single score as predictors of long-term survival according to clinical setting. Results: We enrolled 1051 patients, mean age 72 ± 12 years, who were followed for 797 ± 298 days. All the tested scores showed a good performance in prediction of mortality, together with several clinical factors (older age, chronic heart failure, diabetes, renal impairment, previous transient ischemic attack, left ventricular ejection fraction). The values at C-statistics ranged between modest (0.608–0.684) of inpatients to good (0.708–0.751) in outpatients without any statistical difference between the scores, excepted a lower performance of HAD-BLED. Conclusions: Risk scores currently adopted for decision making on starting oral anticoagulation provide good prediction of long-term survival in unselected AF patients, especially in the outpatient setting.

2018 - Atrial fibrillation prevention: An appraisal of current evidence [Articolo su rivista]
Boriani, Giuseppe; Proietti, Marco
abstract

Atrial fibrillation (AF), which is the most diagnosed arrhythmia, is becoming a significant issue for health policy-makers. In particular, more and more attention is being devoted to AF prevention. Indeed, several studies recently published point out how targeted interventions could be useful in reducing the risk of AF occurrence (or recurrence). In this review, we briefly summarised the role of the major risk factors associated with the incidence of AF, as well as the effectiveness of interventions aimed at controlling these risk factors. Several general risk factors, such as alcohol consumption, physical activity, smoking habit, as well as specific cardiovascular risk factors as diabetes mellitus, hypertension and obesity have a relevant impact in determining the occurrence of AF, along with a strong clinical evidence of a dose-effect response mechanism for most of the factors examined. Specific interventions aimed at controlling risk factors have been showed to clearly reduce the risk of AF in several cohorts. Even more importantly, integrated programmes aimed at controlling for multiple risk factors would be more efficient in terms of reducing risk of AF, in particular whena stricter control is observed. AF prevention requires a series of initiatives focused on the many risk factors that we reviewed, as well as a more integrated approach, which should involve many stakeholders at different levels. In this light and also considering the constantly changing epidemiology, AF prevention may constitute a future 'win-win' strategy for all the stakeholders.

2018 - Atrioventricular junction ablation in patients with atrial fibrillation treated with cardiac resynchronization therapy: positive impact on ventricular arrhythmias, implantable cardioverter-defibrillator therapies and hospitalizations [Articolo su rivista]
Gasparini, Maurizio; Kloppe, Axel; Lunati, Maurizio; Anselme, Frédéric; Landolina, Maurizio; Martinez-Ferrer, Jose Bautista; Proclemer, Alessandro; Morani, Giovanni; Biffi, Mauro; Ricci, Renato; Rordorf, Roberto; Mangoni, Lorenza; Manotta, Laura; Grammatico, Andrea; Leyva, Francisco; Boriani, Giuseppe
abstract

Aims: We sought to determine whether atrioventricular junction ablation (AVJA) in patients with cardiac resynchronization therapy (CRT) implantable cardioverter-defibrillator (ICD) and with permanent atrial fibrillation (AF) has a positive impact on ICD shocks and hospitalizations compared with rate-slowing drugs. Methods and results: This is a pooled analysis of data from 179 international centres participating in two randomized trials and one prospective observational research. The co-primary endpoints were all-cause ICD shocks and all-cause hospitalizations. Out of 3358 CRT-ICD patients (2720 male, 66.6 years), 2694 (80%) were in sinus rhythm (SR) and 664 (20%) had permanent AF—262 (8%) treated with AVJA (AF + AVJA) and 402 (12%) treated with rate-slowing drugs (AF + Drugs). Median follow-up was 18 months. The mean (95% confidence intervals) annual rate of all-cause ICD shocks per 100 patient years was 8.0 (5.3–11.9) in AF + AVJA, 43.6 (37.7–50.4) in AF + Drugs, and 34.4 (32.5–36.5) in SR patients, resulting in incidence rate ratio (IRR) reductions of 0.18 (0.10–0.32) for AF + AVJA vs. AF + Drugs (P &lt; 0.001) and 0.48 (0.35–0.66) for AF + AVJA vs. SR (P &lt; 0.001). These reductions were driven by significant reductions in both appropriate ICD shocks [IRR 0.23 (0.13–0.40), P &lt; 0.001, vs. AF + Drugs] and inappropriate ICD shocks [IRR 0.09 (0.04–0.21), P &lt; 0.001, vs. AF + Drugs]. Annual rate of all-cause hospitalizations was significantly lower in AF + AVJA vs. AF + Drugs [IRR 0.57 (0.41–0.79), P &lt; 0.001] and SR [IRR 0.85 (073–0.98), P = 0.027]. Conclusion: In AF patients treated with CRT, AVJA results in a lower incidence and burden of all-cause, appropriate and inappropriate ICD shocks, as well as to fewer all-cause and heart failure hospitalizations. Clinical Trial Registration: NCT00147290, NCT00617175, NCT01007474.

2018 - Battery longevity of implantable cardioverter-defibrillators and cardiac resynchronization therapy defibrillators: technical, clinical and economic aspects. An expert review paper from EHRA [Articolo su rivista]
Boriani, Giuseppe; Merino, Josè; Wright, David J; Gadler, Fredrik; Schaer, Beat; Landolina, Maurizio
abstract

In recent years an extension of devices longevity has been obtained for implantable cardioverter-defibrillators (ICDs), including ICDs for cardiac resynchronization therapy (CRT-D) through improved battery chemistry and device technology and this implies important clinical benefits (reduced need for device replacements and associated complications, particularly infections), as well as economic benefits, in line with patient preferences and needs. From a clinical point of view, the availability of this improvement in technology allows to better tune the choice of the device to be implanted, taking into account that the reasons supporting the value of an extended device longevity as a clinical priority may differ according to the clinical setting (purely electrical diseases or left ventricular dysfunction/heart failure, respectively). From an economic point of view, extension of device longevity may have an important impact in reducing long-term costs of device therapy, with substantial daily savings in favour of devices with extended longevity, up to 30%, depending on clinical scenarios. In studies based on projections, an extension of device longevity allowed to calculate that the cost per day of ICDs may be substantially reduced, and this allows to overcome the frequent perception of ICD and CRT-D devices as treatments with unaffordable costs and to overturn the misconception that up-front costs are the only metric with which to value device treatments. In view of its clinical and economic value, device longevity should be a determining factor in device choice by physicians and healthcare commissioners and should be appropriately considered and valued in comparative tenders.

2018 - Cardiac involvement in systemic sclerosis: identification of high-risk patient profiles in different patterns of clinical presentation [Articolo su rivista]
Coppi, Francesca; Giuggioli, Dilia; Spinella, Amelia; Colaci, Michele; Lumetti, Federica; Farinetti, Alberto; Migaldi, Mario; Rossi, Rosario; Ferri, Clodoveo; Boriani, Giuseppe; Mattioli, Anna Vittoria
abstract

Systemic sclerosis (SSc) is a chronic connective tissue disease characterized by widespread microvascular damage, dysregulation of fibroblasts with collagen overproduction and excessive fibrosis of the skin and internal organs, as well as complex immune system abnormalitie….

2018 - Cardiac resynchronization therapy and electrical storm: results of the OBSERVational registry on long-term outcome of ICD patients (OBSERVO-ICD) [Articolo su rivista]
Guerra, Federico; Palmisano, Pietro; Dell'Era, Gabriele; Ziacchi, Matteo; Ammendola, Ernesto; Pongetti, Giulia; Bonelli, Paolo; Patani, Francesca; Devecchi, Chiara; Accogli, Michele; Occhetta, Eraldo; Nigro, Gerardo; Biffi, Mauro; Boriani, Giuseppe; Capucci, Alessandro
abstract

Electrical storm (ES) is a condition defined as three or more episodes of ventricular fibrillation (VF) or ventricular tachycardia (VT) within 24 h, and usually coexist with advanced heart failure in patients with structural heart disease. The aim of the present study is to test whether cardiac resynchronization therapy (CRT) can be associated with a lower incidence of ES.

2018 - Cardiac resynchronization therapy in the real world: need to upgrade outcome research [Articolo su rivista]
Boriani, Giuseppe; Diemberger, Igor
abstract

NA

2018 - Cardiac resynchronization therapy: How did consensus guidelines from Europe and the United States evolve in the last 15 years? [Articolo su rivista]
Boriani, Giuseppe; Ziacchi, Matteo; Nesti, Martina; Battista, Antonella; Placentino, Filippo; Malavasi, Vincenzo Livio; Diemberger, Igor; Padeletti, Luigi
abstract

Cardiac resynchronization therapy (CRT) was proposed around 20 years ago, and its clinical use rapidly moved from pioneering experiences to randomized controlled trials (RCT). Since 2002 recommendations for CRT have been included in international consensus guidelines that even in an early phase recommended CRT as an effective treatment for improving symptoms, reducing hospitalizations and mortality in well-selected patients with wide QRS, left ventricular dysfunction and moderate to severe heart failure (NYHA classes III–IV), on optimal medical therapy. Subsequently the indications were extended to mild (NYHA class II) heart failure (associated with left ventricular dysfunction and wide QRS) and more recently also to appropriately selected patients with conventional indications for pacing having a left ventricular ejection fraction of 50% or less and NYHA class I–III. While all the guidelines strongly recommend CRT in case of LBBB with QRS duration &gt;150 ms, lower strength of recommendations, with some heterogeneity, appears when QRS duration is 130–150 ms, especially if not associated with LBBB. Of note, according to recent guidelines, CRT is not recommended in case of QRS duration &lt;130 ms, which is now the lower limit for candidacy to CRT, differently from the 120 ms limit used before. Despite consensus guidelines, many data indicate that CRT is still underused, with great heterogeneity in its implementation, both in North America and Europe, thus requiring a more organized patient referral.

2018 - Cardiac resynchronization therapy: a comparison among left ventricular bipolar, quadripolar and active fixation leads [Articolo su rivista]
Ziacchi, M.; Diemberger, I.; Corzani, A.; Martignani, C.; Mazzotti, A.; Massaro, G.; Valzania, C.; Rapezzi, C.; Boriani, G.; Biffi, M.
abstract

We evaluated the performance of 3 different left ventricular leads (LV) for resynchronization therapy: bipolar (BL), quadripolar (QL) and active fixation leads (AFL). We enrolled 290 consecutive CRTD candidates implanted with BL (n = 136) or QL (n = 97) or AFL (n = 57). Over a minimum 10 months follow-up, we assessed: (a) composite technical endpoint (TE) (phrenic nerve stimulation at 8 V@0.4 ms, safety margin between myocardial and phrenic threshold &lt;2V, LV dislodgement and failure to achieve the target pacing site), (b) composite clinical endpoint (CE) (death, hospitalization for heart failure, heart transplantation, lead extraction for infection), (c) reverse remodeling (RR) (reduction of end systolic volume &gt;15%). Baseline characteristics of the 3 groups were similar. At follow-up the incidence of TE was 36.3%, 14.3% and 19.9% in BL, AFL and QL, respectively (p &lt; 0.01). Moreover, the incidence of RR was 56%, 64% and 68% in BL, AFL and QL respectively (p = 0.02). There were no significant differences in CE (p = 0.380). On a multivariable analysis, “non-BL leads” was the single predictor of an improved clinical outcome. QL and AFL are superior to conventional BL by enhancing pacing of the target site: AFL through prevention of lead dislodgement while QL through improved management of phrenic nerve stimulation.

2018 - Cardiolaminopathies from bench to bedside: challenges in clinical decision-making with focus on arrhythmia-related outcomes [Articolo su rivista]
Boriani, G.; Biagini, E.; Ziacchi, M.; Malavasi, V. L.; Vitolo, Marco; Talarico, Marisa; Mauro, E.; Gorlato, G.; Lattanzi, G.
abstract

Lamin A/C gene mutations can be associated with cardiac diseases, usually referred to as 'cardiolaminopathies' characterized by arrhythmic disorders and/or left ventricular or biventricular dysfunction up to an overt picture of heart failure. The phenotypic cardiac manifestations of laminopathies are frequently mixed in complex clinical patterns and specifically may include bradyarrhythmias (sinus node disease or atrioventricular blocks), atrial arrhythmias (atrial fibrillation, atrial flutter, atrial standstill), ventricular tachyarrhythmias and heart failure of variable degrees of severity. Family history, physical examination, laboratory findings (specifically serum creatine phosphokinase values) and ECG findings are often important 'red flags' in diagnosing a 'cardiolaminopathy'. Sudden arrhythmic death, thromboembolic events or stroke and severe heart failure requiring heart transplantation are the most dramatic complications of the evolution of cardiolaminopathies and appropriate risk stratification is clinically needed combined with clinical follow-up. Treatment with cardiac electrical implantable devices is indicated in case of bradyarrhythmias (implant of a device with pacemaker functions), risk of life-threatening ventricular tachyarrhythmias (implant of an ICD) or in case of heart failure with wide QRS interval (implant of a device for cardiac resynchronization). New technologies introduced in the last 5&nbsp;years can help physicians to reduce device-related complications, thanks to the extension of device longevity and availability of leadless pacemakers or defibrillators, to be implanted in appropriately selected patients. An improved knowledge of the complex pathophysiological pathways involved in cardiolaminopathies and in the determinants of their progression to more severe forms will help to improve clinical management and to better target pharmacological and non-pharmacological treatments.

2018 - Changes to oral anticoagulant therapy and risk of death over a 3-year follow-up of a contemporary cohort of European patients with atrial fibrillation final report of the EURObservational Research Programme on Atrial Fibrillation (EORP-AF) pilot general registry [Articolo su rivista]
Boriani, Giuseppe; Proietti, Marco; Laroche, Cécile; Diemberger, Igor; Popescu, Mircea Ioachim; Riahi, Sam; Shantsila, Alena; Dan, Gheorghe-Andrei; Tavazzi, Luigi; Maggioni, Aldo P.; Lip, Gregory Y. H.
abstract

Background: Contemporary European data regarding patients with atrial fibrillation (AF) allow us to assess the use of oral anticoagulants (OACs) and long-term outcomes. Methods: Patients with AF presenting to cardiologists in 9 European Society of Cardiology participating countries were enrolled and followed-up for 3-years. Results: Among the 2119 patients (40.4% female; mean age 69 ± 11 years) the prevalent types of AF at baseline were first-detected (30.5%) and paroxysmal AF (27.0%). The composite of stroke/TIA/peripheral embolism/all-cause death at 3-years occurred in 18.2%, with first detected AF and permanent AF reporting the highest event rates (22.5% and 27.3%, respectively; p &lt; 0.0001). Age, diabetes mellitus, heart failure, restrictive cardiomyopathy, chronic kidney disease and no physical activity were significant predictors of all-cause death. Paroxysmal and persistent AF patients were more likely to be hospitalised than other types of AF (34.1% and 37.9%, p &lt; 0.0001). At follow-up, OAC drugs were used in 80.1% of patients, with non-vitamin K antagonists (NOACs) accounting for 24.3% of patients. OAC treatment at follow-up visits changed throughout time, with a shift from VKA to NOACs reported in 5.4% of the cases, while the reverse shift (from NOACs to VKA) occurred in 8.6%. Discontinuation of OAC was recorded in while in 9.5% of visits. Conclusions: Patients outcomes at 3-years follow-up differ according to type of AF at baseline, with worse outcomes in patients presenting with first-detected or permanent AF. Changes in the type of OAC use with shifts from NOACs to VKA and vice-versa are not uncommon, as were interruptions of OAC.

2018 - Chronic kidney disease and arrhythmias: Conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference [Articolo su rivista]
Turakhia, Mintu P.; Blankestijn, Peter J.; Carrero, Juan-Jesus; Clase, Catherine M.; Deo, Rajat; Herzog, Charles A.; Kasner, Scott E.; Passman, Rod S.; Pecoits-Filho, Roberto; Reinecke, Holger; Shroff, Gautam R.; Zareba, Wojciech; Cheung, Michael; Wheeler, David C.; Winkelmayer, Wolfgang C.; Wanner, Christoph; Boriani, Giuseppe
abstract

N/A

2018 - Clinical Course and Quality of Life in High-Risk Patients with Hypertrophic Cardiomyopathy and Implantable Cardioverter-Defibrillators [Articolo su rivista]
Maron, Barry J.; Casey, Susan A.; Olivotto, Iacopo; Sherrid, Mark V.; Semsarian, Christopher; Autore, Camillo; Ahmed, Aisha; Boriani, Giuseppe; Francia, Pietro; Winters, Stephen L.; Giudici, Michael; Koulova, Anna; Garberich, Ross; Rowin, Ethan J.; Sears, Samuel F.; Maron, Martin S.; Spirito, Paolo
abstract

Background: High-risk patients with hypertrophic cardiomyopathy (HCM) are identified by contemporary risk stratification and effectively treated with implantable cardioverter-defibrillators (ICDs). However, long-term HCM clinical course after ICD therapy for ventricular tachyarrhythmias is incompletely understood. Methods and Results: Cohort of 486 high-risk HCM patients with ICDs was assembled from 8 international centers. Clinical course and device interventions were addressed, and survey questionnaires assessed patient anxiety level and psychological well-being related to ICD therapy. Of 486 patients, 94 (19%) experienced appropriate ICD interventions terminating ventricular tachycardia/ventricular fibrillation, 3.7% per year for primary prevention, over 6.4±4.7 years. Of 94 patients, 87 were asymptomatic or only mildly symptomatic at the time of appropriate ICD interventions; 74 of these 87 (85%) remained in classes I/II without significant change in clinical status over the subsequent 5.9±4.9 years (up to 22). Among the 94 patients, there was one sudden death (caused by device failure; 1.1%); 3 patients died from other HCM-related processes unrelated to arrhythmic risk (eg, end-stage heart failure). Post-ICD intervention, freedom from HCM mortality was 100%, 97%, and 92% at 1, 5, and 10 years, distinctly lower than in ischemic or nonischemic cardiomyopathy ICD trials. HCM patients with ICD interventions reported heightened anxiety in expectation of future shocks, but with intact general psychological well-being and quality of life. Conclusions: In HCM, unlike ischemic heart disease, prevention of sudden death with ICD therapy is unassociated with significant increase in cardiovascular morbidity or mortality, or transformation to heart failure deterioration. ICD therapy does not substantially impair overall psychological and physical well-being.

2018 - Clinically oriented device programming in bradycardia patients: Part 2 (atrioventricular blocks and neurally mediated syncope). Proposals from AIAC (Italian association of arrhythmology and cardiac pacing) [Articolo su rivista]
Palmisano, Pietro; Ziacchi, Matteo; Biffi, Mauro; Ricci, Renato P.; Landolina, Maurizio; Zoni-Berisso, Massimo; Occhetta, Eraldo; Maglia, Giampiero; Botto, Gianluca; Padeletti, Luigi; Boriani, Giuseppe
abstract

The purpose of this two-part consensus document is to provide specific suggestions (based on an extensive literature review) on appropriate pacemaker setting in relation to patients' clinical features. In part 2, criteria for pacemaker choice and programming in atrioventricular blocks and neurally mediate syncope are proposed. The atrioventricular blocks can be paroxysmal or persistent, isolated or associated with sinus node disease. Neurally mediated syncope can be related to carotid sinus syndrome or cardioinhibitory vasovagal syncope. In sinus rhythm, with persistent atrioventricular block, we considered appropriate the activation of mode-switch algorithms, and algorithms for auto-adaptive management of the ventricular pacing output. If the atrioventricular block is paroxysmal, in addition to algorithms mentioned above, algorithms to maximize intrinsic atrioventricular conduction should be activated. When sinus node disease is associated with atrioventricular block, the activation of rate-responsive function in patients with chronotropic incompetence is appropriate. In permanent atrial fibrillation with atrioventricular block, algorithms for auto-adaptive management of the ventricular pacing output should be activated. If the atrioventricular block is persistent, the activation of rate-responsive function is appropriate. In carotid sinus syndrome, adequate rate hysteresis should be programmed. In vasovagal syncope, specialized sensing and pacing algorithms designed for reflex syncope prevention should be activated.

2018 - Clinically oriented device programming in bradycardia patients: part 1 (sinus node disease). Proposals from AIAC (Italian association of arrhythmology and cardiac pacing) [Articolo su rivista]
Ziacchi, Matteo; Palmisano, Pietro; Biffi, Mauro; Ricci, Renato P.; Landolina, Maurizio; Zoni-Berisso, Massimo; Occhetta, Eraldo; Maglia, Giampiero; Botto, Gianluca; Padeletti, Luigi; Boriani, Giuseppe
abstract

Modern pacemakers have an increasing number of programable parameters and specific algorithms designed to optimize pacing therapy in relation to the individual characteristics of patients. When choosing the most appropriate pacemaker type and programing, the following variables must be taken into account: the type of bradyarrhythmia at the time of pacemaker implantation; the cardiac chamber requiring pacing, and the percentage of pacing actually needed to correct the rhythm disorder; the possible association of multiple rhythm disturbances and conduction diseases; the evolution of conduction disorders during follow-up. The goals of device programing are to preserve or restore the heart rate response to metabolic and hemodynamic demands; to maintain physiological conduction; to maximize device longevity; to detect, prevent, and treat atrial arrhythmia. In patients with sinus node disease, the optimal pacing mode is DDDR. Based on all the available evidence, in this setting, we consider appropriate the activation of the following algorithms: rate responsive function in patients with chronotropic incompetence; algorithms to maximize intrinsic atrioventricular conduction in the absence of atrioventricular blocks; mode-switch algorithms; algorithms for autoadaptive management of the atrial pacing output; algorithms for the prevention and treatment of atrial tachyarrhythmias in the subgroup of patients with atrial tachyarrhythmias/atrial fibrillation. The purpose of this two-part consensus document is to provide specific suggestions (based on an extensive literature review) on appropriate pacemaker setting in relation to patients’ clinical features.

2018 - Comparison of cryoballoon and radiofrequency ablation techniques for atrial fibrillation: a meta-analysis [Articolo su rivista]
Maltoni, Susanna; Negro, Antonella; Camerlingo, Maria D.; Pecoraro, Valentina; Sassone, Biagio; Biffi, Mauro; Boriani, Giuseppe
abstract

AIMS: To perform an updated meta-analysis to assess efficacy, safety and technical performance of pulmonary vein isolation using cryoballoon or radiofrequency catheter ablation in patients with paroxysmal or persistent atrial fibrillation.METHODS: In June 2017, databases and websites were systematically searched for systematic reviews, randomized controlled trials and observational studies reporting data on efficacy, safety and technical performance outcomes at follow-up at least 12 months. Researchers independently assessed records' eligibility, inclusion and methodological quality of included studies.RESULTS: Six randomized controlled trials and 25 observational studies - 11 853 patients were included. Studies on paroxysmal atrial fibrillation were 29 and included 11 635 patients. Meta-analysis results showed no difference between cryoballoon and radiofrequency in terms of recurrent atrial fibrillation [risk ratio 1.04, 95% confidence interval (CI) 0.98-1.10] or atrial tachyarrhythmias (risk ratio 1.04, 95% CI 1-1.08) and fluoroscopy time (mean difference -1.92 min, 95% CI -4.89 to 1.05). Cryoballoon ablation was associated with fewer reablations (risk ratio 0.79, 95% CI 0.64-0.98), lower incidence of pericardial effusion (risk ratio 0.52, 95% CI 0.31-0.89) and cardiac tamponade (risk ratio 0.33, 95% CI 0.18-0.62) and shorter total procedural time (mean difference -23.48 min, 95% CI -37.97; -9.02) but with higher incidence of phrenic nerve palsy (risk ratio 5.43, 95% CI 2.67-11.04). Prespecified subgroup analysis confirmed overall results as for freedom from atrial fibrillation and atrial tachyarrhythmias. Only two observational studies included patients with persistent atrial fibrillation, thus hindering any conclusion in this population.CONCLUSION: In patients with paroxysmal atrial fibrillation, cryoballoon and radiofrequency ablation produce similar results in terms of freedom from recurrent atrial fibrillation or atrial tachyarrhythmias but with a different safety profile, being cryoballoon ablation less associated with cardiac complications but more likely to cause phrenic nerve palsy.

2018 - Contemporary stroke prevention strategies in 11 096 European patients with atrial fibrillation: A report from the EURObservational Research Programme on Atrial Fibrillation (EORP-AF) Long-Term General Registry [Articolo su rivista]
Boriani, Giuseppe; Proietti, Marco; Laroche, Cécile; Fauchier, Laurent; Marin, Francisco; Nabauer, Michael; Potpara, Tatjana; Dan, Gheorghe-Andrei; Kalarus, Zbigniew; Diemberger, Igor; Tavazzi, Luigi; Maggioni, Aldo P.; Lip, Gregory Y. H.
abstract

Aims: Contemporary data regarding atrial fibrillation (AF) management and current use of oral anticoagulants (OACs) for stroke prevention are needed. Methods and results: The EURObservational Research Programme on AF (EORP-AF) Long-Term General Registry analysed consecutive AF patients presenting to cardiologists in 250 centres from 27 European countries. From 2013 to 2016, 11 096 patients were enrolled (40.7% female; mean age 69 ± 11 years). At discharge, OACs were used in 9379 patients (84.9%), with non-vitamin K antagonists (NOACs) accounting for 40.9% of OACs. Antiplatelet therapy alone was used by 20% of patients, while no antithrombotic treatment was prescribed in 6.4%. On multivariable analysis, age, hypertension, previous ischaemic stroke, symptomatic AF and planned cardioversion or ablation were independent predictors of OAC use, whereas lone AF, previous haemorrhagic events, chronic kidney disease and admission for acute coronary syndrome (ACS) or non-cardiovascular causes independently predicted OAC non-use. Regarding the OAC type, coronary artery disease, history of heart failure, or valvular heart disease, planned cardioversion and non-AF reasons for admission independently predicted the use of vitamin K antagonists (VKAs). Wide variability among the European regions was observed in the use of NOACs, independently from other clinical factors. Conclusion: The EORP-AF Long-Term General Registry provides a full picture of contemporary use of OAC in European AF patients. The overall rate of OACs use was generally high (84.9%), and a series of factors were associated with the prescription of OAC. A significant geographical heterogeneity in prescription of NOACs vs. VKAs was evident.

2018 - Detection of new atrial fibrillation in patients with cardiac implanted electronic devices and factors associated with transition to higher device-detected atrial fibrillation burden [Articolo su rivista]
Boriani, Giuseppe; Glotzer, Taya V.; Ziegler, Paul D.; De Melis, Mirko; Mangoni di S. Stefano, Lorenza; Sepsi, Milan; Landolina, Maurizio; Lunati, Maurizio; Lewalter, Thorsten; Camm, A. John
abstract

Background: In patients with cardiac implanted electronic devices, detection of new atrial fibrillation (AF) is associated with an increased risk of stroke. Objective: To characterize daily AF burden at first detection and the rate of temporal transition to higher device-detected AF burden. Methods: A pooled analysis of data from 3 prospective projects was analyzed, and 6580 patients (mean age 68 ± 12 years, 72% male) with no history of AF and no use of anticoagulants at baseline were identified. Various thresholds of daily AF burden (5 minutes and 1, 6, 12, and 23 hours) were analyzed. Results: Among the study population of 6580 patients, a new AF, with an AF burden of ≥5 minutes, was detected in 2244 patients (34%) during a follow-up period of 2.4 ± 1.7 years. Among these patients, 1091 (49.8%) transitioned to a higher AF-burden threshold during follow-up. A higher duration of daily AF burden manifest at first detection and CHADS2 score ≥2 were associated with faster transition to a subsequent higher burden. Approximately 24% of patients transitioned from a lower threshold to a daily AF burden of ≥23 hours during follow-up. Conclusion: More than one-third of patients with no history of AF developed device-detected AF, with attainment of different thresholds of daily AF burden over time. Continuous long-term monitoring, especially when the initial detection corresponds to a higher daily AF burden and the CHADS2 score is ≥2, could support timely clinical decisions on anticoagulation by capturing transitions to higher AF-burden thresholds.

2018 - Efficacy of cardiac resynchronization therapy in patients with isolated ventricular noncompaction with dilated cardiomyopathy: a systematic review of the literature [Articolo su rivista]
Bertini, Matteo; Balla, Cristina; Pavasini, Rita; Boriani, Giuseppe
abstract

: This is a systematic review of current evidence regarding the efficacy of cardiac resynchronization therapy (CRT) on patients with dilated cardiomyopathy and isolated left ventricular noncompaction (IVNC). This systematic review was performed following Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. Records were searched in Pubmed, Cochrane Library, Google Scholar, Biomed Central. We included only studies focused on ventricular noncompaction patients treated with CRT. Of 46 records screened, we included 14 studies involving a total of 70 patients. All studies showed a reduction of New York Heart Association class and an increase of the ejection fraction that ranges from 8 to 36% at follow-up after CRT. Analyzing the type of response to CRT, approximately 50% of the patients were classified as responders to the therapy and most of them were super-responders. In conclusion, CRT provides beneficial effects in terms of clinical status and left ventricular function on IVNC patients with heart failure. CRT responders seem to have a great left ventricular reverse remodeling supporting the theory that CRT is able to provide an additional benefit in the IVNC disease, improving the performance of IVNC segments, when paced.

2018 - Elevated TGF β2 serum levels in Emery-Dreifuss Muscular Dystrophy: Implications for myocyte and tenocyte differentiation and fibrogenic processes [Articolo su rivista]
Bernasconi, Pia; Carboni, Nicola; Ricci, Giulia; Siciliano, Gabriele; Politano, Luisa; Maggi, Lorenzo; Mongini, Tiziana; Vercelli, Liliana; Rodolico, Carmelo; Biagini, Elena; Boriani, Giuseppe; Ruggiero, Lucia; Santoro, Lucio; Schena, Elisa; Prencipe, Sabino; Evangelisti, Camilla; Pegoraro, Elena; Morandi, Lucia; Columbaro, Marta; Lanzuolo, Chiara; Sabatelli, Patrizia; Cavalcante, Paola; Cappelletti, Cristina; Bonne, Gisèle; Muchir, Antoine; Lattanzi, Giovanna
abstract

Among rare diseases caused by mutations in LMNA gene, Emery-Dreifuss Muscular Dystrophy type 2 and Limb-Girdle muscular Dystrophy 1B are characterized by muscle weakness and wasting, joint contractures, cardiomyopathy with conduction system disorders. Circulating biomarkers for these pathologies have not been identified. Here, we analyzed the secretome of a cohort of patients affected by these muscular laminopathies in the attempt to identify a common signature. Multiplex cytokine assay showed that transforming growth factor beta 2 (TGF β2) and interleukin 17 serum levels are consistently elevated in the vast majority of examined patients, while interleukin 6 and basic fibroblast growth factor are altered in subgroups of patients. Levels of TGF β2 are also increased in fibroblast and myoblast cultures established from patient biopsies as well as in serum from mice bearing the H222P Lmna mutation causing Emery-Dreifuss Muscular Dystrophy in humans. Both patient serum and fibroblast conditioned media activated a TGF β2-dependent fibrogenic program in normal human myoblasts and tenocytes and inhibited myoblast differentiation. Consistent with these results, a TGF β2 neutralizing antibody avoided fibrogenic marker activation and myogenesis impairment. Cell intrinsic TGF β2-dependent mechanisms were also determined in laminopathic cells, where TGF β2 activated AKT/mTOR phosphorylation. These data show that TGF β2 contributes to the pathogenesis of Emery-Dreifuss Muscular Dystrophy type 2 and Limb-Girdle muscular Dystrophy 1B and can be considered a potential biomarker of those diseases. Further, the evidence of TGF β2 pathogenetic effects in tenocytes provides the first mechanistic insight into occurrence of joint contractures in muscular laminopathies.

2018 - European Heart Rhythm Association (EHRA) consensus document on the management of supraventricular arrhythmias, endorsed by Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulación Cardiaca y Electrofisiologia (SOLAECE) [Articolo su rivista]
Katritsis, Demosthenes G.; Boriani, Giuseppe; Cosio, Francisco G.; Hindricks, Gerhard; Jais, Pierre; Josephson, Mark E.; Keegan, Roberto; Kim, Young-Hoon; Knight, Bradley P.; Kuck, Karl-Heinz; Lane, Deirdre A.; Lip, Gregory Y. H.; Malmborg, Helena; Oral, Hakan; Pappone, Carlo; Themistoclakis, Sakis; Wood, Kathryn A.; Blomström-Lundqvist, Carina
abstract

NA

2018 - European Heart Rhythm Association (EHRA) position paper on arrhythmia management and device therapies in endocrine disorders, endorsed by Asia Pacific Heart Rhythm Society (APHRS) and Latin American Heart Rhythm Society (LAHRS) [Articolo su rivista]
Gorenek, Bulent; Boriani, Giuseppe; Dan, Gheorge-Andrei; Fauchier, Laurent; Fenelon, Guilherme; Huang, He; Kudaiberdieva, Gulmira; Lip, Gregory Y. H.; Mahajan, Rajiv; Potpara, Tatjana; Ramirez, Juan David; Vos, Marc A.; Marin, Francisco; Blomstrom-Lundqvist, Carina; Rinaldi, Aldo; Bongiorni, Maria Grazia; Sciaraffia, Elena; Nielsen, Jens Cosedis; Lewalter, Thorsten; Zhang, Shu; Gutiérrez, Oswaldo; Fuenmayor, Abdel
abstract

Endocrine disorders are associated with various tachyarrhythmias, including atrial fibrillation (AF), ventricular tachycardia (VT), ventricular fibrillation (VF), and bradyarrhythmias. Along with underlying arrhythmia substrate, electrolyte disturbances, glucose, and hormone levels, accompanying endocrine disorders contribute to development of arrhythmia. Arrhythmias may be life-threatening, facilitate cardiogenic shock development and increase mortality. The knowledge on the incidence of tachy- and bradyarrhythmias, clinical and prognostic significance as well as their management is limited; it is represented in observational studies and mostly in case reports on management of challenging cases. It should be also emphasized, that the topic is not covered in detail in current guidelines. Therefore, cardiologists and multidisciplinary teams participating in care of such patients do need the evidence-based, or in case of limited evidence expert-opinion based recommendations, how to treat arrhythmias using contemporary approaches, prevent their complications and recurrence in patients with endocrine disorders. In recognizing this close relationship between endocrine disorders and arrhythmias, the European Heart Rhythm Association (EHRA) convened a Task Force, with representation from Asia-Pacific Heart Rhythm Society (APHRS) and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLAECE), with the remit of comprehensively reviewing the available evidence and publishing a joint consensus document on endocrine disorders and cardiac arrhythmias, and providing up-to-date consensus recommendations for use in clinical practice.

2018 - European Society of Cardiology-Proposed Diagnostic Echocardiographic Algorithm in Elective Patients with Clinical Suspicion of Infective Endocarditis: Diagnostic Yield and Prognostic Implications in Clinical Practice [Articolo su rivista]
Barbieri, A.; Mantovani, F.; Lugli, R.; Bursi, F.; Fabbri, M.; Bartolacelli, Y.; Manicardi, M.; Stefanelli, G.; Mussini, C.; Boriani, G.
abstract

Echocardiography plays a central role in diagnosing infective endocarditis (IE). Accordingly, the European Society of Cardiology (ESC) has proposed a diagnostic echocardiographic algorithm. However, new studies are still needed to evaluate the degree of implementation of these guidelines in clinical practice and their consequences on incidence and prognosis of IE.

2018 - European Society of Cardiology: Cardiovascular disease statistics 2017 [Articolo su rivista]
Timmis, Adam; Townsend, Nick; Gale, Chris; Grobbee, Rick; Maniadakis, Nikos; Flather, Marcus; Wilkins, Elizabeth; Wright, Lucy; Vos, Rimke; Bax, Jeroen; Blum, Maxim; Pinto, Fausto; Vardas, Panos; Boriani, Giuseppe
abstract

Aims: The European Society of Cardiology (ESC) Atlas has been compiled by the European Heart Agency to document cardiovascular disease (CVD) statistics of the 56 ESC member countries. A major aim of this 2017 data presentation has been to compare high-income and middle-income ESC member countries to identify inequalities in disease burden, outcomes, and service provision. Methods and results: The Atlas utilizes a variety of data sources, including the World Health Organization, the Institute for Health Metrics and Evaluation, and the World Bank to document risk factors, prevalence, and mortality of cardiovascular disease and national economic indicators. It also includes novel ESC-sponsored survey data of health infrastructure and cardiovascular service provision provided by the national societies of the ESC member countries. Data presentation is descriptive with no attempt to attach statistical significance to differences observed in stratified analyses. Important differences were identified between the high-income and middle-income member countries of the ESC with regard to CVD risk factors, disease incidence, and mortality. For both women and men, the age-standardized prevalence of hypertension was lower in high-income countries (18% and 27%) compared with middle-income countries (24% and 30%). Smoking prevalence in men (not women) was also lower (26% vs. 41%) and together these inequalities are likely to have contributed to the higher CVD mortality in middle-income countries. Declines in CVD mortality have seen cancer becoming a more common cause of death in a number of high-income member countries, but in middle-income countries declines in CVD mortality have been less consistent where CVD remains the leading cause of death. Inequalities in CVD mortality are emphasized by the smaller contribution they make to potential years of life lost in high-income countries compared with middle-income countries both for women (13% vs. 23%) and men (20% vs. 27%). The downward mortality trends for CVD may, however, be threatened by the emerging obesity epidemic that is seeing rates of diabetes increasing across all the ESC member countries. Survey data from the National Cardiac Societies showed that rates of cardiac catheterization and coronary artery bypass surgery, as well as the number of specialist centres required to deliver them, were greatest in the high-income member countries of the ESC. The Atlas confirmed that these ESC member countries, where the facilities for the contemporary treatment of coronary disease were best developed, were often those in which declines in coronary mortality have been most pronounced. Economic resources were not the only driver for delivery of equitable cardiovascular health care, as some middle-income ESC member countries reported rates for interventional procedures and device implantations that matched or exceeded the rates in wealthier member countries. Conclusion: In documenting national CVD statistics, the Atlas provides valuable insights into the inequalities in risk factors, health care delivery, and outcomes of CVD across the ESC member countries. The availability of these data will underpin the ESC's ambitious mission 'to reduce the burden of cardiovascular disease' not only in its member countries but also in nation states around the world.

2018 - Extending survival by reducing sudden death with implantable cardioverter-defibrillators: a challenging clinical issue in non-ischaemic and ischaemic cardiomyopathies [Articolo su rivista]
Boriani, Giuseppe; Malavasi, Vincenzo Livio
abstract

NA

2018 - Five year trends (2008-2012) in cardiac implantable electrical device utilization in five European nations: A case study in cross-country comparisons using administrative databases [Articolo su rivista]
Banks, Helen; Torbica, Aleksandra; Valzania, Cinzia; Varabyova, Yauheniya; Prevolnik Rupel, Valentina; Taylor, Rod S; Hunger, Theresa; Walker, Simon; Boriani, Giuseppe; Fattore, Giovanni
abstract

Aims Common methodologies for analysis of analogous data sets are needed for international comparisons of treatment and outcomes. This study tests using administrative hospital discharge (HD) databases in five European countries to investigate variation/trends in pacemaker (PM) and implantable cardioverter defibrillator (ICD) implant rates in terms of patient characteristics/management, device subtype, and initial implantation vs. replacement, and compares findings with existing literature and European Heart Rhythm Association (EHRA) reports. Methods and results HD databases from 2008 to 2012 in Austria, England, Germany, Italy and Slovenia were interrogated to extract admissions (without patient identification) associated with PM and ICD implants and replacements, using direct cross-referencing of procedure codes and common methodology to compare aggregate data. 1 338 199 records revealed 212 952 PM and 62 567 ICD procedures/year on average for a 204.4 million combined population, a crude implant rate of about 104/100 000 inhabitants for PMs and 30.6 for ICDs. The first implant/replacement rate ratios were 81/24 (PMs) and 25/7 (ICDs). Rates have increased, with cardiac resynchronization therapy (CRT) subtypes for both devices rising dramatically. Significant between- and within-country variation persists in lengths of stay and rates (Germany highest, Slovenia lowest). Adjusting for age lessened differences for PM rates, scarcely affected ICDs. Male/female ratios remained stable at 56/44% (PMs) and 79/21% (ICDs). About 90% of patients were discharged to home; 85-100% were inpatient admissions. Conclusion To aid in policymaking and track outcomes, HD administrative data provides a reliable, relatively cheap, methodology for tracking implant rates for PMs and ICDs across countries, as comparisons to EHRA data and the literature indicated.

2018 - Health care cost analysis of enhanced pacing modalities in bradycardia patients: Portuguese case study on the results of the MINERVA trial [Articolo su rivista]
de Sousa, João; Marques, Pedro; Martins, Vítor; Hipólito-Reis, António; Duarte, Luís; Joaquim, Inês; Monteiro, Diogo; Boriani, Giuseppe; Wolff, Claudia; Grammatico, Andrea; Padeletti, Luigi
abstract

Introduction: The MINERVA trial established that atrial preventive pacing and atrial antitachycardia pacing (DDDRP) in combination with managed ventricular pacing (MVP) reduces progression to permanent atrial fibrillation (AF) in patients with paroxysmal or persistent AF and bradycardia who need cardiac pacing, compared to standard dual-chamber pacing (DDDR). It was shown that AF-related health care utilization was significantly lower in the DDDRP + MVP group than in the control group. Cost analysis demonstrated significant savings related to this new algorithm, based on health care costs from the USA, Italy, Spain and the UK. Objective: To calculate the savings associated with reduced health care utilization due to enhanced pacing modalities in the Portuguese setting. Methods: The impact on costs was estimated based on tariffs for AF-related hospitalizations and costs for emergency department and outpatient visits in Portugal. Results: The MINERVA trial showed a 42% reduction in AF-related health care utilization thanks to the new algorithm. In Portugal, this represents a potential cost saving of 2323 euros per 100 patients in the first year and 17 118 euros over a 10-year period. Considering the number of patients who could benefit from this new algorithm, Portugal could save a total of 75 369 euros per year and 555 410 euros over 10 years. Additional savings could accrue if heart failure and stroke hospitalizations were considered. Conclusion: The combination of atrial preventive pacing, atrial antitachycardia pacing and an algorithm to minimize the detrimental effect of right ventricular pacing reduces recurrent and permanent AF. The new DDDRP + MVP pacing mode could contribute to significant costs savings in the Portuguese health care setting.

2018 - Impact of pacemaker longevity on expected device replacement rates: Results from computer simulations based on a multicenter registry (ESSENTIAL) [Articolo su rivista]
Boriani, Giuseppe; Bertini, Matteo; Saporito, Davide; Belotti, Giuseppina; Quartieri, Fabio; Tomasi, Corrado; Pucci, Angelo; Boggian, Giulio; Mazzocca, Gian Franco; Giorgi, Davide; Diotallevi, Paolo; Sassone, Biagio; Grassini, Diego; Gargaro, Alessio; Biffi, Mauro
abstract

Background: The rate of device replacement in pacemaker recipients has not been investigated in detail. Hypothesis: Current pacemakers with automatic management of atrial and ventricular pacing output provide sufficient longevity to minimize replacement rate. Methods: We considered a cohort of 542 pacemaker patients (age 78 ± 9 years, 60% male, 71% de-novo implants) and combined 1-month projected device longevity with survival data and late complication rate in a 3-state Markov model tested in several Monte Carlo computer simulations. Predetermined subgroups were: age &lt; or ≥ 70; gender; primary indication to cardiac pacing. Results: At the 1-month follow-up the reported projected device longevity was 153 ± 45 months. With these values the proportion of patients expected to undergo a device replacement due to battery depletion was higher in patients aged &lt;70 (49.9%, range 32.1%-61.9%) than in age ≥70 (24.5%, range 19.9%-28.8%); in women (39.9%, range 30.8%-48.1%) than in men (32.0%, range 24.7%-37.5%); in sinus node dysfunction (41.5%, range 30.2%-53.0%) than in atrio-ventricular block (33.5%, range 27.1-38.8%) or atrial fibrillation with bradycardia (27.9%, range 18.5%-37.0%). The expected replacement rate was inversely related to the assumed device longevity and depended on age class: a 50% increase in battery longevity implied a 5% reduction of replacement rates in patients aged ≥80. Conclusions: With current device technology 1/4 of pacemaker recipients aged ≥70 are expected to receive a second device in their life. Replacement rate depends on age, gender, and primary indication owing to differences in patients' survival expectancy. Additional improvements in device service time may modestly impact expected replacement rates especially in patients ≥80 years.

2018 - Implantable cardioverter-defibrillator–computed respiratory disturbance index accurately identifies severe sleep apnea: The DASAP-HF study [Articolo su rivista]
D'Onofrio, Antonio; La Rovere, Maria Teresa; Emdin, Michele; Capucci, Alessandro; Sinagra, Gianfranco; Bianchi, Valter; Pisanò, Ennio C. L.; Pieragnoli, Paolo; Tespili, Maurizio; Luzi, Mario; Talarico, Antonello; Zecchin, Massimo; Rapacciuolo, Antonio; Piacenti, Marcello; Indolfi, Ciro; Arias, Miguel Angel; Diemberger, Igor; Checchinato, Catia; Boriani, Giuseppe; Padeletti, Luigi
abstract

Background: Sleep apnea (SA) is a relevant issue in the management of patients with heart failure for risk stratification and for implementing treatment strategies. Objective: The purpose of this study was to evaluate in patients with implantable cardioverter-defibrillators (ICDs) the performance of the respiratory disturbance index (RDI) computed by the ApneaScan algorithm (Boston Scientific Inc., Natick, MA) as a discriminator of severe SA. Methods: ICD-indicated patients with left ventricular ejection fraction ≤35% were enrolled. One month after implantation, patients underwent a polysomnographic study. We evaluated the accuracy of the RDI for the prediction of severe SA (apnea-hypopnea index [AHI] ≥30 episodes/h) and the agreement between RDI and AHI during the sleep study night. Results: Two hundred sixty-five patients were enrolled to obtain the required sample of 173 patients with AHI and RDI data for analysis. The mean AHI was 21 ± 15 episodes/h and severe SA was diagnosed in 38 patients (22%), while the mean RDI was 33 ± 13 episodes/h. On the basis of the receiver operating characteristic curve analysis of RDI values, the area under the curve was 0.77 (95% confidence interval [CI] 0.70–0.83; P &lt;.001). At an RDI value of 31 episodes/h, severe SA was detected with 87% (95% CI 72%–96%) sensitivity and 56% (95% CI 48%–66%) specificity. RDI closely correlated with AHI recorded during the same night (r = 0.74; 95% CI 0.57–0.84; P &lt;.001), and the Bland-Altman agreement analysis revealed a bias of 11 episodes/h, with limits of agreement being −10 to 32 episodes/h. Conclusion: The RDI accurately identified severe SA and demonstrated good agreement with AHI. Therefore, it may serve as an efficient tool for screening patients at risk of SA.

2018 - Increased burden of comorbidities and risk of cardiovascular death in atrial fibrillation patients in Europe over ten years: A comparison between EORP-AF pilot and EHS-AF registries [Articolo su rivista]
Proietti, Marco; Laroche, Cécile; Nieuwlaat, Robby; Crijns, Harry J. G. M.; Maggioni, Aldo P.; Lane, Deirdre A.; Boriani, Giuseppe; Lip, Gregory Y. H.
abstract

Background: In 2002, the European Society of Cardiology conducted the Euro Heart Survey (EHS), while in 2014concluded 1-year follow-up of the EURObservational Research Programme AF (EORP-AF) Pilot Registry. Methods: We analysed differences in clinical profiles, therapeutic approaches and outcomes between these two cohorts after propensity score matching (PSM). Results: After PSM, 5206 patients were analysed. In EORP-AF there were more elderly patients than EHS (p &lt;.001). EORP-AF patients were more burdened with cardiovascular (CV) and non-CV comorbidities, with a higher proportion of patients with high thromboembolic risk. EORP-AF patients used more oral-anticoagulant (OAC) (p &lt;.001). At 1-year follow-up EORP-AF patients had lower risk for thromboembolic and CV events, readmission for AF and other CV reasons (all p &lt;.001), showing conversely a higher risk for CV death (p =.015). Kaplan-Meier curves showed that EORP-AF patients had higher risk for CV death (p &lt;.0001) and all-cause death (p =.0019). Cox regression confirmed that EORP-AF patients were at higher risk for CV death (p =.021). Conclusions: We found significant changes in AF epidemiology over a decade in Europe, with older patients, more burdened with comorbidities. A greater use of OAC was found. Despite a reduction in risk for thromboembolic events, a high risk of CV-related death was still evident.

2018 - Integrating new approaches to atrial fibrillation management: The 6th AFNET/EHRA Consensus Conference [Articolo su rivista]
Kotecha, Dipak; Breithardt, Günter; Camm, A. John; Lip, Gregory Y. H.; Schotten, Ulrich; Ahlsson, Anders; Arnar, David; Atar, Dan; Auricchio, Angelo; Bax, Jeroen; Benussi, Stefano; Blomstrom-Lundqvist, Carina; Borggrefe, Martin; Boriani, Giuseppe; Brandes, Axel; Calkins, Hugh; Casadei, Barbara; Castellá, Manuel; Chua, Winnie; Crijns, Harry; Dobrev, Dobromir; Fabritz, Larissa; Feuring, Martin; Freedman, Ben; Gerth, Andrea; Goette, Andreas; Guasch, Eduard; Haase, Doreen; Hatem, Stephane; Haeusler, Karl Georg; Heidbuchel, Hein; Hendriks, Jeroen; Hunter, Craig; Kääb, Stefan; Kespohl, Stefanie; Landmesser, Ulf; Lane, Deirdre A.; Lewalter, Thorsten; Mont, Lluís; Nabauer, Michael; Nielsen, Jens C.; Oeff, Michael; Oldgren, Jonas; Oto, Ali; Pison, Laurent; Potpara, Tatjana; Ravens, Ursula; Richard-Lordereau, Isabelle; Rienstra, Michiel; Savelieva, Irina; Schnabel, Renate; Sinner, Moritz F.; Sommer, Philipp; Themistoclakis, Sakis; Van Gelder, Isabelle C.; Vardas, Panagiotis E.; Verma, Atul; Wakili, Reza; Weber, Evelyn; Werring, David; Willems, Stephan; Ziegler, André; Hindricks, Gerhard; Kirchhof, Paulus
abstract

There are major challenges ahead for clinicians treating patients with atrial fibrillation (AF). The population with AF is expected to expand considerably and yet, apart from anticoagulation, therapies used in AF have not been shown to consistently impact on mortality or reduce adverse cardiovascular events. New approaches to AF management, including the use of novel technologies and structured, integrated care, have the potential to enhance clinical phenotyping or result in better treatment selection and stratified therapy. Here, we report the outcomes of the 6th Consensus Conference of the Atrial Fibrillation Network (AFNET) and the European Heart Rhythm Association (EHRA), held at the European Society of Cardiology Heart House in Sophia Antipolis, France, 17-19 January 2017. Sixty-two global specialists in AF and 13 industry partners met to develop innovative solutions based on new approaches to screening and diagnosis, enhancing integration of AF care, developing clinical pathways for treating complex patients, improving stroke prevention strategies, and better patient selection for heart rate and rhythm control. Ultimately, these approaches can lead to better outcomes for patients with AF.

2018 - Is ventricular sensing always right, when it is left? [Articolo su rivista]
Biffi, Mauro; de Zan, Giulia; Massaro, Giulia; Angeletti, Andrea; Martignani, Cristian; Boriani, Giuseppe; Diemberger, Igor; Ziacchi, Matteo
abstract

Background: Ventricular sensing in transvenous cardiac implantable electronic devices (CIEDs) occurs conventionally from the right ventricular (RV) channel, though it evolved from epicardial sensing both in pacemakers and implantable cardioverter-defibrillators (ICDs). Hypothesis: The objective of this study was to observe the reliability of left ventricular (LV) sensing by transvenous leads placed in coronary veins. Methods: LV leads were used for sensing and arrhythmia detection in clinical situations where placement of an RV lead across the tricuspid valve was either not preferred or not feasible, or RV signal was unsuitable for arrhythmia detection, or in the event of sensing failure of an RV lead under advisory in cardiac resynchronization therapy defibrillator (CRTD) recipients. Results: Thirty-seven patients had an IS-1 LV lead connected to the RV port of CIEDs (17 pacemakers, 5 cardiac resynchronization therapy pacemaker [CRTP], 2 ICDs, and 13 CRTDs). Along a median 41 (25-67) months follow-up, lead performance remained stable; there were neither undersensing nor oversensing of non-cardiac signals. VT/VF were correctly detected and terminated by ATP and shocks (one and three patients, respectively); no inappropriate arrhythmia detection. Device reprogramming occurred in four CRTD recipients because of transient counting the QRS (short intervals) when paced in LV-only, and in two with T-wave oversensing. Conclusions: Ventricular sensing by an LV lead is feasible in transvenous devices. Sensing programmability is an unmet need: to fix RV lead sensing issues in cardiac resynchronization therapy (CRT) recipients at no risk of infection (no pocket opening); to avoid interaction with the tricuspid valve; to avoid lead redundancy in the vasculature. Moreover, it will be mandatory owing to the loss of lead interchangeability due to the adoption of DF-4 and quadripolar leads.

2018 - Letter responding to Screening for atrial fibrillation: A European Heart Rhythm Association (EHRA) consensus document endorsed by the Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), and Societad Latinoamericana de Estimulation Cardiaca y Electrofisiologia (SOLAECE) - Authors' reply [Articolo su rivista]
Mairesse, Georges H.; Boriani, Giuseppe
abstract

NA

2018 - Long-term progression of rhythm and conduction disturbances in pacemaker recipients: findings from the Pacemaker Expert Programming study [Articolo su rivista]
Palmisano, Pietro; Ziacchi, Matteo; Ammendola, Ernesto; Dell'Era, Gabriele; Guerra, Federico; Aspromonte, Vittorio; Boriani, Giuseppe; Nigro, Gerardo; Occhetta, Eraldo; Capucci, Alessandro; Ricci, Renato Pietro; Maglia, Giampiero; Biffi, Mauro; Accogli, Michele
abstract

AIMS: Knowledge of the long-term progression of rhythm disorders requiring pacemaker implantation could have significant implications for the choice of device and its management during follow-up. Accordingly, we conducted an observational study to analyse the long-term progression of rhythm disorders requiring pacemaker implantation. METHODS: This multicentre, observational study enrolled 1810 pacemaker patients (age 71.6 ± 13.3 years, men 53.8%) consecutively evaluated during scheduled pacemaker follow-up visits. To evaluate the long-term progression of rhythm disorders, we analysed the patient's rhythm disorders at the time of device implantation and during follow-up. After pacemaker implantation, the rhythm disorders were reassessed and recorded at each scheduled pacemaker follow-up visit, and the spontaneous rhythm was analysed during pacemaker interrogation. RESULTS: During a median follow-up of 61.6 months, we observed a progression of the primary rhythm disorder in 295 patients (16.3%; worsening of the preexisting rhythm disorder in 7.7%; occurrence of a new rhythm disorder added to the preexisting one in 8.6%). Specifically, the cumulative per-year risks of developing the following disorders were: atrioventricular block (AVB) in patients implanted for sinus node disease (SND), 0.3%; permanent atrial fibrillation in SND patients, 2.9%; SND in AVB patients, 0.7%; and persistent AVB in patients implanted for chronic bifascicular block 3.0%. CONCLUSION: Our results revealed that rhythm disorders requiring pacemaker implantation show long-term progression in a significant number of cases. In many cases, the progression is substantial and may require a change in pacing mode.

2018 - Management and prognosis of atrial fibrillation in diabetic patients: An EORP-AF General Pilot Registry report [Articolo su rivista]
Fumagalli, Stefano; Said, Salah A.; Laroche, Cecile; Gabbai, Debbie; Boni, Serena; Marchionni, Niccolò; Boriani, Giuseppe; Maggioni, Aldo P.; Musialik-Lydka, Agata; Sokal, Adam; Petersen, Jens; Crijns, Harry J. G. M; Lip, Gregory Y. H.
abstract

Aims Diabetes mellitus (DM) is one of the most important cardiovascular risk factors. The aim of this study was to evaluate clinical correlates of DM, including management and outcomes, in the EURObservational Research Programme (EORP)-Atrial Fibrillation (AF) General Pilot (EORP-AF) Registry of the European Society of Cardiology. Methods and results We studied consecutive patients (N= 3101) enrolled in 70 centres of nine European countries between February 2012 and March 2013, and compared diabetics with non-diabetics during a 1-year follow-up. In the overall cohort, the prevalence of DM was 20.6%. Diabetics were older (71 ± 9 vs. 68 ± 12 years, P &lt; 0.0001) and had more comorbidities, higher CHA2DS2-VASc score (4.6 ± 1.6 vs. 2.9 ± 1.7, P &lt; 0.0001) and higher prevalence of permanent AF (21.5 vs. 16.0%, P = 0.0022). Quality of life amongst DM patients was significantly worse [atrial fibrillation quality of life questionnaire (AF-QoL) score 45.2 ± 19.2 vs. 49.3 ± 20.1, P &lt; 0.0001]. Amongst diabetics, the use of electrical cardioversion (16.2 vs. 24.6%, P &lt; 0.0001) and catheter ablation (3.3 vs. 8.6%, P &lt; 0.0001) was lower, whilst oral anticoagulants were more often prescribed (84.3 vs. 78.9%, P = 0.0027). After one year, diabetic patients had significantly higher all-cause (11.9 vs. 4.9%, P &lt; 0.0001), cardiovascular (6.2 vs. 1.9%, P &lt; 0.0001), and non-cardiovascular mortality (2.3 vs. 1.1%, P = 0.0356). Conclusion In AF patients, DM is associated with a higher prevalence of comorbidities and a worse quality of life. After one year, all-cause, cardiovascular, and non-cardiovascular mortality were significantly higher in diabetic subjects.

2018 - Management of cardiopulmonary disease in patients with systemic sclerosis: cardiorheumatology clinic and patient care standardization proposal [Articolo su rivista]
Spinella, Amelia; Coppi, Francesca; Mattioli, Anna Vittoria; Lumetti, Federica; Rossi, Rosario; Cocchiara, Emanuele; Colaci, Michele; Boriani, Giuseppe; Ferri, Clodoveo; Salvarani, Carlo; Giuggioli, Dilia
abstract

Management of cardiopulmonary disease in patients with systemic sclerosis: cardiorheumatology clinic and patient care standardization proposal

2018 - Management of patients with cardiac implantable electronic devices (CIED) undergoing radiotherapy: A consensus document from Associazione Italiana Aritmologia e Cardiostimolazione (AIAC), Associazione Italiana Radioterapia Oncologica (AIRO), Associazione Italiana Fisica Medica (AIFM) [Articolo su rivista]
Zecchin, Massimo; Severgnini, Mara; Fiorentino, Alba; Malavasi, Vincenzo Livio; Menegotti, Loris; Alongi, Filippo; Catanzariti, Domenico; Jereczek-Fossa, Barbara Alicja; Stasi, Michele; Russi, Elvio; Boriani, Giuseppe
abstract

The management of patients with a cardiac implanted electronic device (CIED) receiving radiotherapy (RT) is challenging and requires a structured multidisciplinary approach. A consensus document is presented as a result of a multidisciplinary working group involving cardiac electrophysiologists, radiation oncologists and physicists in order to stratify the risk of patients with CIED requiring RT and approaching RT sessions appropriately. When high radiation doses and beam energy higher than 6 MV are used, CIED malfunctions can occur during treatment. In our document, we reviewed the different types of RT and CIED behavior in the presence of ionizing radiations and electromagnetic interferences, from the cardiologist's, radiation oncologist's and medical physicist's point of view. We also reviewed in vitro and in vivo literature data and other national published guidelines on this issue so far. On the basis of literature data and consensus of experts, a detailed approach based on risk stratification and appropriate management of RT patients with CIEDs is suggested, with important implications for clinical practice.

2018 - Meta-analysis of clinical outcomes of electrical cardioversion and catheter ablation in patients with atrial fibrillation and chronic kidney disease [Articolo su rivista]
Diemberger, Igor; Genovesi, Simonetta; Massaro, Giulia; Reggiani, Maria Letizia Bacchi; Frisoni, Jessica; Gorlato, Giulia; Mauro, Erminio; Padeletti, Margherita; Vincenti, Antonio; Boriani, Giuseppe
abstract

Background: Chronic kidney disease (CKD) is associated with adverse outcomes in presence of atrial fibrillation (AF). However, the literature shows limited data on non-pharmacological management of AF in CKD patients. Aim: summarizing the available data on outcomes associated with electrical cardioversion (ECV) and AF catheter ablation (CA) in CKD patients. Methods: We searched MEDLINE and the Cochrane Central Register of Controlled Trials and performed a meta-analysis. The primary outcome was recurrence of AF. The secondary outcomes were occurrence of thromboembolic events (TEs) and estimated glomerular filtration rate (eGFR) modification. Results: Literature search yielded 26 eligible papers: 22 on CA and 4 concerning ECV. CKD patients presented more AF recurrences 30 days after ECV (OR 2.62, 95%CI 1.28-5.34; p <0.001). Patients with eGFR<60-68 ml/min and on dialysis presented a higher incidence of AF recurrences after CA, median follow up 26.0 and 29.9 months (HR 1.75, 95%CI 1.46-2.09, p <0.001; and HR 1.69, 95%CI 1.22-2.33, p <0.001; respectively). Peri-procedural TEs were rare and not associated with CKD or dialysis. However, patients with CKD were at increased risk for delayed TEs after CA (HR 2.61, 95%CI 1.04-6.54; p <0.001). No significant modification of eGFR was associated with ECV or CA in the overall population. Conclusion: ECV and CA for sinus rhythm restoration/maintenance in AF patients, albeit theoretically promising, seem to be associated with lower efficacy at medium to long-term in patients with CKD. Further studies are needed to better define the role of ECV and CA in CKD.

2018 - Overweight and obesity in patients with atrial fibrillation: Sex differences in 1-year outcomes in the EORP-AF General Pilot Registry [Articolo su rivista]
Boriani, Giuseppe; Laroche, Cécile; Diemberger, Igor; Fantecchi, Elisa; Meeder, Joan; Kurpesa, Malgorzata; Baluta, Monica Mariana; Proietti, Marco; Tavazzi, Luigi; Maggioni, Aldo P.; Lip, Gregory Y. H.
abstract

Background: The impact of overweight and obesity on outcomes in “real world” patients with atrial fibrillation (AF) is not fully defined. Second, sex differences in AF outcomes may also exist. Methods and results: The aim was to investigate outcomes at 1 year follow-up for AF patients enrolled in the EORP-AF Registry, according to BMI (kg/m2), comparing patients with normal BMI (18.5 to&nbsp;&lt;&nbsp;25&nbsp;kg/m2), overweight (25 to&nbsp;&lt;&nbsp;30&nbsp;kg/m2) and obesity (≥ 30&nbsp;kg/m2), in relation to sex differences. Among 2,540 EORP AF patients (38.9% female; median age 69) with 1 year follow-up data available, 720 (28.3%) had a normal BMI, 1,084 (42.7%) were overweight, and 736 (29.0%) were obese. Obese patients were younger and with more prevalent diabetes mellitus and hypertension (P&nbsp;&lt;&nbsp;0. 001). One-year outcomes showed that all-cause mortality was significantly different according to BMI among female patients (9.3% normal BMI, 5.3% overweight, and 4.3 % obese, P&nbsp;=&nbsp;0.023), but not among male patients (P&nbsp;=&nbsp;0.748). The composite outcome of thromboembolic events and death was also significantly different, being lower in obese females (P&nbsp;=&nbsp;0.035). Among male patients, bleeding events were significantly more frequent in obese subjects (P&nbsp;=&nbsp;0.035). On multivariable Cox analysis, BMI was not independently associated with all-cause mortality. Conclusions: Among AF patients, overweight and obesity are common and associated with better outcomes in females (a finding previously reported as “obesity paradox”), while no significant differences in outcomes are detected among male patients. Final multivariable model found that increasing BMI was not associated with increased risk of all-cause death; conversely, age and comorbidities persisted as major determinants.

2018 - Pacemaker-detected severe sleep apnoea predicts new-onset atrial fibrillation: Author's reply [Articolo su rivista]
Mazza, Andrea; Bendini, Maria Grazia; De Cristofaro, Raffaele; Lovecchio, Mariolina; Valsecchi, Sergio; Boriani, Giuseppe
abstract

NA

2018 - Performance and clinical comparison between left ventricular quadripolar and bipolar leads in cardiac resynchronization therapy: Observational research [Articolo su rivista]
Ziacchi, M.; Zucchelli, G.; Ricciardi, D.; Morani, G.; De Ruvo, E.; Calzolari, V.; Viani, S.; Calabrese, V.; Tomasi, L.; Calo, L.; De Mattia, L.; Bongiorni, M. G.; Boriani, G.; Biffi, M.
abstract

Aim: To evaluate Attain Performa (Medtronic, Dublin, Ireland) quadripolar lead performance in clinical practice and, secondarily, to compare its long term clinical outcomes vs bipolar leads for left ventricular (LV) pacing. Methods and results: We retrospectively analyzed clinical, procedural and follow-up data of 215 patients implanted with a quadripolar lead. One hundred and twenty one patients implanted with bipolar lead were selected to compare long-term clinical outcomes. The quadripolar lead was implanted in the target vein in 196 patients (91%) without acute dislodgements. In 50% of patients the chosen final pacing configuration at implant would not have been available with bipolar leads. A dedicated quadripolar pacing vector was chosen more frequently when the LV tip location was apical than otherwise (65.6% vs 42.7%, p = 0.003). After a median follow-up of 14 months, the LV pacing threshold was less than 2.5 V at 0.4 ms in 98 patients (90%) with a safety margin between phrenic nerve and LV pacing threshold &gt;3 V in 97 patients (89%). We observed a slight trend toward a lower risk of heart failure worsening and a lower incidence of ventricular arrhythmias and pulmonary congestion in patients implanted with quadripolar leads compared with the control group. Conclusion: Quadripolar leads improve the management of phrenic nerve stimulation at no trade-off with pacing threshold and lead stability. Quadripolar leads seems to be associated with a lower incidence of VT/VF and pulmonary congestion, when compared with bipolar leads, but further investigations are necessary to confirm that this positive effect is associated with better LV reverse remodeling.

2018 - Physical activity measured by implanted devices predicts atrial arrhythmias and patient outcome: Results of IMPLANTED (Italian Multicentre Observational Registry on Patients With Implantable Devices Remotely Monitored) [Articolo su rivista]
Palmisano, Pietro; Guerra, Federico; Ammendola, Ernesto; Ziacchi, Matteo; Pisanó, Ennio Carmine Luigi; Dell'Era, Gabriele; Aspromonte, Vittorio; Zaccaria, Maria; Di Ubaldo, Francesco; Capucci, Alessandro; Nigro, Gerardo; Occhetta, Eraldo; Maglia, Giampiero; Ricci, Renato Pietro; Boriani, Giuseppe; Accogli, Michele; Botto, Gian Luca; Bertaglia, Emanuele; Berisso, Massimo Zoni; Nissardi, Vincenzo; Santini, Luca; Soldati, Ezio; Stabile, Giuseppe; Landolina, Maurizio; Padeletti, Luigi
abstract

Background--To determine whether daily physical activity (PA), as measured by implanted devices (through accelerometer sensor), was related to the risk of developing atrial arrhythmias during long-term follow-up in a population of heart failure (HF) patients with an implantable cardioverter defibrillator (ICD). Methods and Results--The study population was divided into 2 equally sized groups (PA cutoff point: 3.5 h/d) according to their mean daily PA recorded by the device during the 30- to 60-day period post-ICD implantation. Propensity score matching was used to compare 2 equally sized cohorts with similar characteristics between lower and higher activity patients. The primary end point was time free from the first atrial high-rate episode (AHRE) of duration ≥6 minutes. Secondary end points were: first AHRE ≥6 hours, first AHRE ≥48 hours, and a combined end point of death or HF hospitalization. Data from 770 patients (65±15 years; 66% men; left ventricular ejection fraction 35±12%) remotely monitored for a median of 25 months were analyzed. A PA =3.5 h/d was associated with a 38% relative reduction in the risk of AHRE ≥6 minutes (72-month cumulative survival: 75.0% versus 68.1%; log rank P=0.025), and with a reduction in the risk of AHRE ≥6 hours, AHRE ≥48 hours, and the combined end point of death or HF hospitalization (all P &lt; 0.05). Conclusions--In HF patients with ICD, a low level of daily PA was associated with a higher risk of atrial arrhythmias, regardless of the patients' baseline characteristics. In addition, a lower daily PA predicted death or HF hospitalization.

2018 - Practical management of ibrutinib in the real life: Focus on atrial fibrillation and bleeding [Articolo su rivista]
Boriani, Giuseppe; Corradini, Paolo; Cuneo, Antonio; Falanga, Anna; Foà, Robin; Gaidano, Gianluca; Ghia, Paolo Prospero; Martelli, Maurizio; Marasca, Roberto; Massaia, Massimo; Mauro, Francesca Romana; Minotti, Giorgio; Molica, Stefano; Montillo, Marco; Pinto, Antonio; Tedeschi, Alessandra; Vitolo, Umberto; Zinzani, Pier Luigi
abstract

The Bruton tyrosine kinase inhibitor ibrutinib (IB) has attained an important role in the treatment of patients with chronic lymphocytic leukaemia, mantle cell lymphoma, and Waldenström macroglobulinemia, significantly improving clinical outcomes. However, IB therapy has been associated with an increased risk of atrial fibrillation (AF) and bleeding. We report on the expert opinion that a group of Italian haematologists, cardiologists, and pharmacologists jointly released to improve the practical management of patients at risk for AF and bleeding during treatment with IB. A proper pretreatment assessment to identify patients who are at a higher risk, careful choice of concomitant drugs, regular monitoring, and multispecialist approach were characterized as the main principles of clinical management of these patients. For patients developing AF, anticoagulant and antiarrhythmic therapy must be guided by considerations about efficacy, safety, and risk of pharmacokinetic interactions with IB. For patients experiencing bleeding or requiring procedures that increase the risk of bleeding, considerations about platelet turnover, IB-related platelet dysfunctions, and bleeding worsening by concomitant anticoagulants or antiplatelet agents provide clues to manage bleeding. Overall, AF and bleeding are manageable clinical events in patients receiving IB, not requiring drug interruption in most cases. Preexisting AF should not represent an absolute contraindication to IB therapy. For each patient candidate for IB, strategies of risk assessment and mitigation may allow to exploit the life-saving effects of in chronic lymphocytic leukaemia and mantle cell lymphoma.

2018 - Predictors of long-term survival free from relapses after extraction of infected CIED [Articolo su rivista]
Diemberger, Igor; Biffi, Mauro; Lorenzetti, Stefano; Martignani, Cristian; Raffaelli, Elena; Ziacchi, Matteo; Rapezzi, Claudio; Pacini, Davide; Boriani, Giuseppe
abstract

Aims We explored the possible predictors of long-term prognosis after transvenous lead extraction (TLE) for a cardiac implantable device related infection (CIEDI), including the modified Duke score result. Methods and results We performed a single centre prospective observational study in a population of consecutive patients referred for TLE to a teaching hospital to treat a CIEDI without associated valve-endocarditis. 121 patients were enrolled between January 2012 and March 2016. According to the modified Duke criteria, the presence of CIED-related endocarditis was rejected in 54.5%, possible in 21.5%, and definite in 24.0%. 20/121 patients died after a mean follow-up of 46.0 ± 2.5 months, while 7 patients reported hospitalization for CIEDI recurrence/relapse in the same period. Modified Duke score was significantly associated with a poor prognosis at univariate Cox regression analysis (HR 1.847, 95% CI 1.160-2.941; P = 0.010). However, the three factors independently associated with death and/or CIEDI relapse/recurrence were: a 'closed' CIED pocket (HR 2.720; 95% CI 1.135-6.520), presence of ghost at post-TLE transoesophageal echocardiography (HR 3.469; 95% CI 1.420-8.878), and a GFR &lt;60 (HR 4.565; 95% CI 1.668-12.493). Conclusion CIEDI has a poor long-term prognosis despite an effective TLE. Renal failure, presence of 'ghosts' at post-TLE transoesophageal echocardiography and a closed CIED pocket are associated with a worse prognosis.

2018 - Rate vs. rhythm control and adverse outcomes among European patients with atrial fibrillation [Articolo su rivista]
Purmah, Yanish; Proietti, Marco; Laroche, Cecilé; Mazurek, Michal; Tahmatzidis, Dimitrios; Boriani, Giuseppe; Novo, Salvatore; Lip, Gregory Y. H.
abstract

The impact of rate and rhythm control strategies on outcomes in patients with atrial fibrillation (AF) remains controversial. Our aims were: to report use of rate and rhythm control strategies in European patients from the EURObservational Research Program AF General Pilot Registry. Secondly, to evaluate outcomes according to assigned strategies.

2018 - Registro Italiano Pacemaker e Defibrillatori: Bollettino Periodico 2016 Associazione Italiana di Aritmologia e Cardiostimolazione [Articolo su rivista]
Proclemer, Alessandro; Zecchin, Massimo; D'Onofrio, Antonio; Boriani, Giuseppe; Facchin, Domenico; Rebellato, Luca; Ghidina, Marco; Bianco, Giulia; Bernardelli, Emanuela; Pucher, Elsa; Gregori, Dario
abstract

Background: The pacemaker (PM) and implantable cardioverter-defibrillator (ICD) registry of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC) monitors the main epidemiological data in real-world practice. The survey for the 2016 activity collects information about demographics, clinical characteristics, main indications for PM/ICD therapy and device types from the Italian collaborating centers. Methods: The registry collects prospectively national PM and ICD implantation activity on the basis of European cards. Results: PM Registry: data about 23 496 PM implantations were collected (19 003 first implant and 4493 replacements). The number of collaborating centers was 204. Median age of treated patients was 81 years (75 quartile I; 86 quartile III). ECG indications included atrioventricular conduction disorders in 39.8% of first PM implants, sick sinus syndrome in 22.1%, atrial fibrillation plus bradycardia in 14.1%, other in 24.0%. Among atrioventricular conduction defects, third-degree atrioventricular block was the most common type (22.18% of first implants). Use of single-chamber PMs was reported in 26.9% of first implants, of dual-chamber PMs in 65.0%, of PMs with cardiac resynchronization therapy (CRT) in 1.5%, and of single lead atrial-synchronized ventricular stimulation (VDD/R PMs) in 6.6%. ICD Registry: data about 20 350 ICD implantations were collected (14 763 first implants and 5587 replacements). The number of collaborating centers was 430. Median age of treated patients was 72 years (63 quartile I; 78 quartile III]. Primary prevention indication was reported in 79.0% of first implants, secondary prevention in 21.0% (cardiac arrest in 7.9%). A single-chamber ICD was used in 32.2% of first implants, dual-chamber in 31.1% and biventricular in 36.7%. Conclusions: The PM and ICD Registry appears fundamental for monitoring PM and ICD utilization on a large national scale with rigorous examination of demographics and clinical indications. The PM Registry showed stable electrocardiographic and symptom indications, with an important prevalence of dual-chamber pacing. The use of CRT-PM regards a very limited number of patients. The ICD Registry documented a large use of prophylactic and biventricular ICD, reflecting a favorable adherence to trials and guidelines in clinical practice.

2018 - Risk stratification of cardiovascular and heart failure hospitalizations using integrated device diagnostics in patients with a cardiac resynchronization therapy defibrillator [Articolo su rivista]
Burri, Haran; Da Costa, Antoine; Quesada, Aurelio; Ricci, Renato Pietro; Favale, Stefano; Clementy, Nicolas; Boscolo, Gabriele; Villalobos, Federico Segura; Di Mangoni Stefano, Lorenza; Sharma, Vinod; Boriani, Giuseppe
abstract

Aims: Cardiac resynchronization therapy defibrillators (CRT-D) are able to monitor various parameters that may be combined by an automatic algorithm to provide a heart failure risk status (HFRS). We sought to validate the HFRS for stratifying patient risk, evaluate its association with heart failure (HF) symptoms, and investigate its utility for triage of automatic alerts. Methods and results: Data from 722 patients included in the MORE-CARE trial were analysed in a post hoc analysis. A high HFRS was associated with a significantly increased risk of admission over the next 30 days with a relative risk for cardiovascular hospitalization (CVH) of 4.5 (95% CI: 3.1-6.6, P &lt; 0.001), of HF hospitalization of 6.3 (95% CI: 3.9-10.2, P &lt; 0.001) and of non-HF related CVH of 3.5 (95% CI: 2.0-6.9, P &lt; 0.001). The negative predictive value of low or medium HFRS for these admissions was ≥98%. A high HFRS was associated with an increased risk of HF symptoms. Of all the automatic remote monitoring alerts generated during the study, only 10% had a high HFRS. Conclusion: The HFRS is able to risk-stratify CRT-D patients, which is potentially useful for managing automatic remote monitoring alerts, by focusing attention on the minority of high-risk patients.

2018 - Role of cardiovascular imaging in cardiac resynchronization therapy: A literature review [Articolo su rivista]
Sassone, Biagio; Nucifora, Gaetano; Mele, Donato; Valzania, Cinzia; Bisignani, Giovanni; Boriani, Giuseppe
abstract

Cardiac resynchronization therapy (CRT) is an established treatment in patients with symptomatic drug-refractory heart failure and broad QRS complex on the surface ECG. Despite the presence of either mechanical dyssynchrony or viable myocardium at the site where delivering left ventricular pacing being necessary conditions for a successfulCRT, their direct assessment by techniques of cardiovascular imaging, though feasible, is not recommended in clinical practice by the current guidelines. Indeed, even though there is growing body of data providing evidence of the additional value of an image-based approach as compared with routine approach in improving response to CRT, these results should be confirmed in prospective and large multicentre trials before their impact on CRT guidelines is considered.

2018 - Role of the tricuspid regurgitation after mitraclip and transcatheter aortic valve implantation: a systematic review and meta-analysis [Articolo su rivista]
Pavasini, Rita; Ruggerini, Sara; Grapsa, Julia; Biscaglia, Simone; Tumscitz, Carlo; Serenelli, Matteo; Boriani, Giuseppe; Squeri, Angelo; Campo, Gianluca
abstract

Treatment of tricuspid regurgitation (TR) is common after surgery for mitral and/or aortic valves. The prognostic role of moderate to severe TR in patients undergoing mitraclip or transcatheter aortic valve implantation (TAVI) is not well-defined. Thus, the aim of this article is to perform a systematic review and meta-analysis of articles valuing the prognostic role of TR for patients undergoing mitraclip and TAVI.

2018 - The 2018 European Heart Rhythm Association Practical Guide on the use of non-Vitamin K antagonist oral anticoagulants in patients with atrial fibrillation [Articolo su rivista]
Steffel, Jan; Verhamme, Peter; Potpara, Tatjana S.; Albaladejo, Pierre; Antz, Matthias; Desteghe, Lien; Haeusler, Karl Georg; Oldgren, Jonas; Reinecke, Holger; Roldan-Schilling, Vanessa; Rowell, Nigel; Sinnaeve, Peter; Collins, Ronan; Camm, A John; Heidbüchel, Hein; Boriani, Giuseppe
abstract

The current manuscript is the second update of the original Practical Guide, published in 2013 [Heidbuchel et al. European Heart Rhythm Association Practical Guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation. Europace 2013;15:625-651; Heidbuchel et al. Updated European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular atrial fibrillation. Europace 2015;17:1467-1507]. Non-vitamin K antagonist oral anticoagulants (NOACs) are an alternative for vitamin K antagonists (VKAs) to prevent stroke in patients with atrial fibrillation (AF) and have emerged as the preferred choice, particularly in patients newly started on anticoagulation. Both physicians and patients are becoming more accustomed to the use of these drugs in clinical practice. However, many unresolved questions on how to optimally use these agents in specific clinical situations remain. The European Heart Rhythm Association (EHRA) set out to coordinate a unified way of informing physicians on the use of the different NOACs. A writing group identified 20 topics of concrete clinical scenarios for which practical answers were formulated, based on available evidence. The 20 topics are as follows i.e., (1) Eligibility for NOACs; (2) Practical start-up and follow-up scheme for patients on NOACs; (3) Ensuring adherence to prescribed oral anticoagulant intake; (4) Switching between anticoagulant regimens; (5) Pharmacokinetics and drug-drug interactions of NOACs; (6) NOACs in patients with chronic kidney or advanced liver disease; (7) How to measure the anticoagulant effect of NOACs; (8) NOAC plasma level measurement: rare indications, precautions, and potential pitfalls; (9) How to deal with dosing errors; (10) What to do if there is a (suspected) overdose without bleeding, or a clotting test is indicating a potential risk of bleeding; (11) Management of bleeding under NOAC therapy; (12) Patients undergoing a planned invasive procedure, surgery or ablation; (13) Patients requiring an urgent surgical intervention; (14) Patients with AF and coronary artery disease; (15) Avoiding confusion with NOAC dosing across indications; (16) Cardioversion in a NOAC-treated patient; (17) AF patients presenting with acute stroke while on NOACs; (18) NOACs in special situations; (19) Anticoagulation in AF patients with a malignancy; and (20) Optimizing dose adjustments of VKA. Additional information and downloads of the text and anticoagulation cards in different languages can be found on an EHRA website (www.NOACforAF.eu).

2018 - The 2018 European Heart Rhythm Association Practical Guide on the use of non-Vitamin K antagonist oral anticoagulants in patients with atrial fibrillation: Executive summary [Articolo su rivista]
Steffel, Jan; Verhamme, Peter; Potpara, Tatjana S.; Albaladejo, Pierre; Antz, Matthias; Desteghe, Lien; Haeusler, Karl Georg; Oldgren, Jonas; Reinecke, Holger; Roldan-Schilling, Vanessa; Rowell, Nigel; Sinnaeve, Peter; Collins, Ronan; Camm, A. John; Heidbüchel, Hein; Boriani, Giuseppe
abstract

The current manuscript is the Executive Summary of the second update to the original Practical Guide, published in 2013. Non-vitamin K antagonist oral anticoagulants (NOACs) are an alternative for vitamin K antagonists (VKAs) to prevent stroke in patients with atrial fibrillation (AF), and have emerged as the preferred choice, particularly in patients newly started on anticoagulation. Both physicians and patients are becoming more accustomed to the use of these drugs in clinical practice. However, many unresolved questions on how to optimally use these agents in specific clinical situations remain. The European Heart Rhythm Association (EHRA) set out to co-ordinate a unified way of informing physicians on the use of the different NOACs. A writing group identified 20 topics of concrete clinical scenarios for which practical answers were formulated, based on available evidence. The 20 topics are (i) eligibility for NOACs; (ii) practical start-up and follow-up scheme for patients on NOACs; (iii) ensuring adherence to prescribed oral anticoagulant intake; (iv) switching between anticoagulant regimens; (v) pharmacokinetics and drug-drug interactions of NOACs; (vi) NOACs in patients with chronic kidney or advanced liver disease; (vii) how to measure the anticoagulant effect of NOACs; (viii) NOAC plasma level measurement: rare indications, precautions, and potential pitfalls; (ix) how to deal with dosing errors; (x) what to do if there is a (suspected) overdose without bleeding, or a clotting test is indicating a potential risk of bleeding; (xi) management of bleeding under NOAC therapy; (xii) patients undergoing a planned invasive procedure, surgery or ablation; (xiii) patients requiring an urgent surgical intervention; (xiv) patients with AF and coronary artery disease; (xv) avoiding confusion with NOAC dosing across indications; (xvi) cardioversion in a NOAC-treated patient; (xvii) AF patients presenting with acute stroke while on NOACs; (xviii) NOACs in special situations; (xix) anticoagulation in AF patients with a malignancy; and (xx) optimizing dose adjustments of VKA. Additional information and downloads of the text and anticoagulation cards in different languages can be found on an EHRA web site (www.NOACforAF.eu).

2018 - The struggle against infections of cardiac implantable electrical devices: the burden of costs requires new personalized solutions [Articolo su rivista]
Boriani, Giuseppe; Elsner, Christian; Diemberger, Igor
abstract

NA

2018 - The subtle connection between development of cardiac implantable electrical device infection and survival after complete system removal: An observational prospective multicenter study [Articolo su rivista]
Diemberger, Igor; Migliore, Federico; Biffi, Mauro; Cipriani, Alberto; Bertaglia, Emanuele; Lorenzetti, Stefano; Massaro, Giulia; Tanzarella, Gaia; Boriani, Giuseppe
abstract

Background Despite the improvements in transvenous lead extraction (TLE), patients with cardiac implantable device related infection (CIEDI) have a poor prognosis at long term. We explored the possible role of factors associated with development of CIEDI as predictors of post-TLE survival. Methods We performed a multi-center prospective observational study in a population of consecutive patients referred for TLE for CIEDI. We adopted a previously developed 10-point scale for CIEDI risk stratification and assessed its performance in predicting post-TLE survival. Results We enrolled 169 consecutive patients with CIEDI (systemic infection in 48.5% and vegetations in 24.5%). A Shariff score ≥ 3 was present in 102/169 (60.4%) of the enrolled patients. Complete radiological success of TLE was obtained in 163 patients. Twenty-seven patients (15.9%) died after a mean follow-up of 20.8 ± 12.0 months. Two factors were independently associated with post-TLE death: a Shariff score ≥ 3 (HR 10.833, 95% CI 2.544–46.129; p = 0.001) and the presence of vegetations at transesophageal echocardiography (HR 3.324, 95% CI 1.530–7.221; p = 0.002). Conclusions Risk factors for development of CIEDI are also predictive of post TLE mortality, together with the presence of vegetations. Improvement of our preventive strategies for CIEDI is crucial for enhancing the outcomes of CIED patients overall.

2018 - Use of idarucizumab in reversing dabigatran anticoagulant effect: a critical appraisal [Articolo su rivista]
Proietti, Marco; Boriani, Giuseppe
abstract

Use of non-vitamin K antagonist oral anticoagulants is spreading in the real world. Despite that, a strong need for antidotes/reversal agents is still reported by several physicians. Idarucizumab is a humanized monoclonal antibody fragment that binds specifically to dabigatran. Idarucizumab was approved in 2015 by the US Food and Drugs Administration and European Medicines Agency for reversal of anticoagulation activity in dabigatrantreated patients. This review briefly summarizes the experimental evidence about effectiveness and safety of idarucizumab. Furthermore, we review the current recommendations and experts' point of view about the use of antidotes/reversal agents in patients reporting a major bleeding event.

2018 - Variations in clinical management of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation according to different equations for estimating renal function: Post hoc analysis of a prospective cohort [Articolo su rivista]
Malavasi, Vincenzo Livio; Pettorelli, Daniele; Fantecchi, Elisa; Zoccali, Cristina; Laronga, Giuliana; Trenti, Tommaso; Lip, Gregory Yoke Hong; Boriani, Giuseppe
abstract

Prescription of non-vitamin K antagonist oral anticoagulants (NOACs) requires an assessment of renal function (RF) and the Cockcroft–Gault (CG) equation is traditionally recommended. The objective of the study was to evaluate the potential changes in NOACs management using different equations for estimating RF. In a post hoc analysis of a prospective cohort of patients with atrial fibrillation, we considered different equations: (1) CG for creatinine clearance (CrCl), (2) modification of diet in renal disease (MDRD), (3) CKD-EPI, (4) Berlin Initiative Study 1 (BIS-1) and (5) full age spectrum (FAS), for glomerular filtration rate (GFR). RF was classified according to CrCl in three categories: severely depressed (SD-RF) &lt; 30&nbsp;ml/min; moderately depressed (MD-RF) 30–49&nbsp;ml/min; preserved/mildly depressed (P-RF) ≥ 50&nbsp;ml/min. Concordances in the assignments were analyzed. A population of 402 patients (61.2% males, age 72 ± 11) was categorized according to CrCl: 12 patients (2.9%) as SD-RF, 81 (20.1%) as MD-RF, 309 (76.8%) as P-RF. A potential change in NOACs management could occur using GFR equations rather than CrCl in 16.9% of patients using MDRD formula, in 11.7% using BIS-1, in 14.7% using CKD-EPI and in 12.9% using the FAS equation. Important changes in RF estimates were more frequent in patients aged ≥ 75, but also BMI had a meaningful impact. Use of equations estimating GFR instead of the Cockcroft–Gault equation may result in changes in NOACs management in 12–17% of patients. In the elderly ≥ 75, more pronounced changes in RF classification are detectable according to different equations and NOACs dosing should be further investigated.

2018 - [Appropriateness criteria for the management of anticoagulant therapy in complex patients with atrial fibrillation. The opinion of a group of expert Italian cardiologists] [Articolo su rivista]
Botto, Giovanni Luca; Padeletti, Luigi; Ammirati, Fabrizio; Calò, Leonardo; Calvi, Valeria; Cappato, Riccardo; Capucci, Alessandro; D'Onofrio, Antonio; Grimaldi, Massimo; Lombardi, Federico; Lunati, Maurizio; Senatore, Gaetano; Themistoclackis, Sakis; Boriani, Giuseppe
abstract

Atrial fibrillation (AF) is a common arrhythmia often associated with high thromboembolic risk. The purpose of this position paper is to provide clinicians with recommendations useful in managing some important issues regarding the use of anticoagulant therapy in patients with AF in particularly complex clinical situations.The RAND/UCLA appropriateness method, validated to combine the best available scientific evidence with the collective judgment of experts, was used to assess the judgment of an expert panel of cardiologists. To this purpose, the benefit-to-harm ratio of 37 clinical scenarios was rated. Each indication was classified as "appropriate", "uncertain", or "inappropriate" in accordance with the panelists' median score.The present document reports the results of this consensus process, which led to the development of recommendations for clinical practice on how to use anticoagulant therapy in patients with AF in complex clinical settings, including the presence of comorbidities, cardioversion, or ablation. Non-vitamin K oral anticoagulants are a valid alternative to vitamin K antagonists in preventing embolic events in patients with non-valvular AF, particularly in case of clinical complexity.

2017 - 'Real-world' atrial fibrillation management in Europe: observations from the 2-year follow-up of the EURObservational Research Programme-Atrial Fibrillation General Registry Pilot Phase [Articolo su rivista]
Proietti, Marco; Laroche, Cécile; Opolski, Grzegorz; Maggioni, Aldo P; Boriani, Giuseppe; Lip, Gregory Y. H.
abstract

Atrial fibrillation (AF) is commonly associated with a high risk of stroke, thromboembolism, and mortality. The 1-year follow-up of the EURObservational Research Programme-Atrial Fibrillation (EORP-AF) Pilot Registry demonstrated a high mortality but good outcomes with European Society of Cardiology guideline-adherent therapy. Whether these 'real-world' observations on patients managed by European cardiologists extend to 2 years remains uncertain.

2017 - A first described case of cancer-associated non-bacterial thrombotic endocarditis in the era of direct oral anticoagulants [Articolo su rivista]
Mantovani, F.; Navazio, A.; Barbieri, A.; Boriani, Giuseppe
abstract

N/A

2017 - Adoption Decisions for Medical Devices in the Field of Cardiology: Results from a European Survey [Articolo su rivista]
Hatz, Maximilian H. M; Schreyögg, Jonas; Torbica, Aleksandra; Boriani, Giuseppe; Blankart, Carl R. B.
abstract

Decisions to adopt medical devices at the hospital level have consequences for health technology assessment (HTA) on system level and are therefore important to decision makers. Our aim was to investigate the characteristics of organizations and individuals that are more inclined to adopt and utilize cardiovascular devices based on a comprehensive analysis of environmental, organizational, individual, and technological factors and to identify corresponding implications for HTA. Seven random intercept hurdle models were estimated using the data obtained from 1249 surveys completed by members of the European Society of Cardiology. The major findings were that better manufacturer support increased the adoption probability of ‘new’ devices (i.e. in terms of CE mark approval dates), and that budget pressure increased the adoption probability of ‘old’ devices. Based on our findings, we suggest investigating the role of manufacturer support in more detail to identify diffusion patterns relevant to HTA on system level, to verify whether it functions as a substitute for medical evidence of new devices, and to receive new insights about its relationship with clinical effectiveness and cost-effectiveness. © 2017 The Authors. Health Economics published by John Wiley &amp; Sons, Ltd.

2017 - Adverse outcomes in patients with atrial fibrillation and peripheral arterial disease: a report from the EURObservational research programme pilot survey on atrial fibrillation [Articolo su rivista]
Proietti, Marco; Raparelli, Valeria; Laroche, Cécile; Dan, Georghe Andrei; Janion, Marianna; Popescu, Raluca; Sinagra, Gianfranco; Vijgen, Johan; Boriani, Giuseppe; Maggioni, Aldo P; Tavazzi, Luigi; Lip, Gregory Y. H.
abstract

Peripheral arterial disease (PAD) is highly prevalent in general population. Data on the prevalence of symptomatic PAD in patients with atrial fibrillation (AF) are limited, and the impact of PAD on adverse outcomes in AF patients is controversial. Our aims were: (i) to define the prevalence of symptomatic PAD in European AF patients and describe its associated clinical risk factors and (ii) to establish the relationship of PAD to adverse events in AF, especially all-cause death.

2017 - Antithrombotic Therapy in Atrial Fibrillation Associated with Valvular Heart Disease: Executive Summary of a Joint Consensus Document from the European Heart Rhythm Association (EHRA) and European Society of Cardiology Working Group on Thrombosis, Endorsed by the ESC Working Group on Valvular Heart Disease, Cardiac Arrhythmia Society of Southern Africa (CASSA), Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), South African Heart (SA Heart) Association and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLEACE) [Articolo su rivista]
Lip, Gregory Y. H.; Collet, Jean Philippe; De Caterina, Raffaele; Fauchier, Laurent; Lane, Deirdre A.; Larsen, Torben B.; Marin, Francisco; Morais, Joao; Narasimhan, Calambur; Olshansky, Brian; Pierard, Luc; Potpara, Tatjana; Sarrafzadegan, Nizal; Sliwa, Karen; Varela, Gonzalo; Vilahur, Gemma; Weiss, Thomas; Boriani, Giuseppe; Rocca, Bianca
abstract

Management strategies for patients with atrial fibrillation (AF) in association with valvular heart disease (VHD) have been less informed by randomized trials, which have largely focused on 'non-valvular AF' patients. Thromboembolic risk also varies according to valve lesion and may also be associated with CHA 2 DS 2 -VASc score risk factor components, rather than only the valve disease being causal. Given the need to provide expert recommendations for professionals participating in the care of patients presenting with AF and associated VHD, a task force was convened by the European Heart Rhythm Association (EHRA) and European Society of Cardiology (ESC) Working Group (WG) on Thrombosis, with representation from the ESC WG on Valvular Heart Disease, Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), South African Heart (SA Heart) Association and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLEACE) with the remit to comprehensively review the published evidence, and to produce a consensus document on the management of patients with AF and associated VHD, with up-to-date consensus statements for clinical practice for different forms of VHD, based on the principles of evidence-based medicine. This is an executive summary of a consensus document which proposes that the term 'valvular AF' is outdated and given that any definition ultimately relates to the evaluated practical use of oral anticoagulation (OAC) type, we propose a functional EHRA (Evaluated Heartvalves, Rheumatic or Artificial) categorization in relation to the type of OAC use in patients with AF, as follows: (1) EHRA (Evaluated Heartvalves, Rheumatic or Artificial) type 1 VHD, which refers to AF patients with 'VHD needing therapy with a vitamin K antagonist (VKA)' and (2) EHRA (Evaluated Heartvalves, Rheumatic or Artificial) type 2 VHD, which refers to AF patients with 'VHD needing therapy with a VKA or a non-VKA oral anticoagulant also taking into consideration CHA 2 DS 2 -VASc score risk factor components.

2017 - Antithrombotic therapy in atrial fibrillation associated with valvular heart disease: A joint consensus document from the European Heart Rhythm Association (EHRA) and European Society of Cardiology Working Group on Thrombosis, endorsed by the ESC Working Group on Valvular Heart Disease, Cardiac Arrhythmia Society of Southern Africa (CASSA), Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), South African Heart (SA Heart) Association and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLEACE) [Articolo su rivista]
Lip, Gregory Y. H; Collet, Jean Philippe; Caterina, Raffaele De; Fauchier, Laurent; Lane, Deirdre A; Larsen, Torben B; Marin, Francisco; Morais, Joao; Narasimhan, Calambur; Olshansky, Brian; Pierard, Luc; Potpara, Tatjana; Sarrafzadegan, Nizal; Sliwa, Karen; Varela, Gonzalo; Vilahur, Gemma; Weiss, Thomas; Boriani, Giuseppe; Rocca, Bianca; Gorenek, Bulent; Savelieva, Irina; Sticherling, Christian; Kudaiberdieva, Gulmira; Chao, Tze-Fan; Violi, Francesco; Nair, Mohan; Zimerman, Leandro; Piccini, Jonathan; Storey, Robert; Halvorsen, Sigrun; Gorog, Diana; Rubboli, Andrea; Chin, Ashley; Scott-Millar, Robert
abstract

Atrial fibrillation (AF) is a major public health problem1 with global prevalence rates (per 1000000 population) in 2010 being 596.2 (95% uncertainty interval (UI), 558.4-636.7) in men and 373.1 (95% UI, 347.9-402.2) in women; the incidence rates increased to 77.5 (95% UI, 65.2-95.4) in men and 59.5 (95% UI, 49.9-74.9) in women.2 Worldwide, AF in association with valvular heart disease (VHD) is also common, and management strategies for this group of patients have been less addressed by randomized trials. The latter have largely focused on 'non-valvular AF' patients leading to major uncertainties over how to define (and treat) such patients. There is also an important heterogeneity in the definition of valvular and non-valvular AF.3 Some physicians assume that any valve disease should be considered as 'valvular' AF. Others consider that only mechanical valve prosthesis and rheumatic mitral stenosis should be defined as 'valvular' AF. The term valvular AF has been arbitrarily applied and the 2016 ESC guidelines have avoided the term 'valvular AF' and refer simply to 'AF related to hemodynamically significant mitral stenosis or prosthetic mechanical heart valves'.4 AF clearly leads to an incremental risk for thromboembolism in patients with mitral valve stenosis, but there are limited data for other valvular diseases. Another proposal is to use the acronym MARM-AF as a simple acronym to designate 'Mechanical and Rheumatic Mitral AF' as an alternative to term 'valvular AF' to designate the clinical scenarios for which at the non-vitamin K antagonist oral anticoagulants (NOACs) are not indicated.5 For this document we recognize the uncertainty in terminology, and our scope largely relates to AF related to 'hemodynamically significant' rheumatic VHD (ie. severe enough to impact on patient's survival or necessitates an intervention or surgery) or prosthetic mechanical heart valves. Nonetheless, thrombo-embolic (TE) risk varies according to valve lesion and may be associated with CHA2DS2VASc score risk factor components, rather than the valve disease per se being causal.6,7 TE risk may also be influenced not only by type but also the severity of the lesion. For example, the degree of mitral regurgitation may matter when it comes to risk of TE as some studies suggest that mild (Grade 1) mitral regurgitation is associated with a 2.7-fold increased risk of stroke/TE, while severe forms may possibly have a 'protective' effect (HR = 0.45 for stroke and 0.27 for LA stasis.8 An appropriate definition of 'valvular AF' would need to identify a subgroup of patients with similar pathophysiology of thrombo-embolism, TE risk, and treatment strategies6,9; however, this would be challenging given the major heterogeneity of the condition. This consensus document proposes that the term 'valvular AF' is outdated and given that any definition ultimately relates to the evaluated practical use of oral anticoagulation (OAC) type, we propose a functional EHRA (EvaluatedHeartvalves, Rheumatic orArtificial) categorization in relation to the type of OAC use in patients with AF, as follows:Evaluated Heartvalves, Rheumatic or Artificial (EHRA) Type 1,which refers to AF patients with 'VHD needing therapy with a Vitamin K antagonist (VKA)'

2017 - Arrhythmias Originating in the Atria [Articolo su rivista]
Leonelli, Fabio; Bagliani, Giuseppe; Boriani, Giuseppe; Padeletti, Luigi
abstract

Atrial flutter, atrial tachycardias, and atrial fibrillation are the main sustained atrial tachycardias. Reentry, increased automaticity, and triggered activity are atrial arrhythmia's main mechanisms. Atrial flutter is the clinical and theoretical model of reentry. Its classification is based on the atrial chamber involved and the arrhythmia's anatomic path. Ablative procedures for atrial fibrillation have created several new reentrant tachycardias. Electrocardiography (ECG) identifies the site of origin of focal atrial tachycardias and the mechanism of these arrhythmias. ECG is fundamental in the diagnosis of atrial fibrillation and often allows understanding of its mechanism of origin and maintenance.

2017 - Atrial antitachycardia pacing and atrial remodeling: A substudy of the international, randomized MINERVA trial [Articolo su rivista]
Boriani, Giuseppe; Tukkie, Raymond; Biffi, Mauro; Mont, Lluis; Ricci, Renato; Pürerfellner, Helmut; Botto, Giovanni Luca; Manolis, Antonis S; Landolina, Maurizio; Gulizia, Michele; Hudnall, J. Harrison; Mangoni, Lorenza; Grammatico, Andrea; Padeletti, Luigi
abstract

Atrial tachycardia (AT) and atrial fibrillation (AF) are common in pacemaker patients and are associated with bad prognoses.

2017 - Can we predict new AF occurrence in single-chamber ICD patients? Insights from an observational investigation [Articolo su rivista]
Biffi, Mauro; Ziacchi, Matteo; Ricci, Renato Pietro; Facchin, Domenico; Morani, Giovanni; Landolina, Maurizio; Lunati, Maurizio; Iacopino, Saverio; Capucci, Alessandro; Bianchi, Stefano; Infusino, Tommaso; Botto, Giovanni Luca; Padeletti, Luigi; Boriani, Giuseppe
abstract

Background Atrial tachyarrhythmias (AT/AF) have been associated with an increased risk of mortality, morbidity and ischemic stroke. Up to now, single chamber ICD diagnostics was not able to detect AT/AF, therefore the incidence of new onset AT/AF in patients with single chamber ICD is not known. Objective To evaluate incidence and predictors of AT/AF occurrence in patients with dual-chamber ICD with no pacing indications and no history of AT/AF that strictly mimic single chamber ICD recipient. Methods &amp; results Consecutive dual-chamber ICD patients were prospectively followed by 47 Italian cardiologic centers in an observational research. Clinical and device data were reviewed by expert cardiologists to assess AT/AF occurrence. Multivariate regression analysis evaluated the risk of new-onset AT/AF and its association with patients’ baseline characteristics and with CHADS2 score. 428 (13.4% female, 64&nbsp;years old) patients were followed for a median observation period of 31&nbsp;months. AT/AF episodes occurred in 160 (37.4%) patients when considering at least 5&nbsp;min duration, in 95 (22.2%) for AT/AF ≥&nbsp;6&nbsp;h, in 47 (11.0%) for AT/AF ≥&nbsp;1&nbsp;day, in 29 (6.8%) for AT/AF ≥&nbsp;7&nbsp;days. Patients with CHADS2&nbsp;≥&nbsp;2, who comprised 36% of the whole population, showed higher incidence of AT/AF ≥&nbsp;6&nbsp;h compared with patients with CHADS2&nbsp;&lt;&nbsp;2 (Hazard Ratio&nbsp;=&nbsp;1.69, 95% Confidence Interval&nbsp;=&nbsp;1.13–2.53, p&nbsp;=&nbsp;0.011). Conclusions Our observations in a population of dual-chamber ICD patients with no pacing indications and no history of AT/AF, who strictly mimic single–chamber ICD recipients, highlight that AT/AF episodes occurred in the 37.5% of the population and CHADS2 score is predictive of new-onset AT/AF.

2017 - Cardiac Resynchronization Therapy: An Overview on Guidelines [Articolo su rivista]
Boriani, Giuseppe; Nesti, Martina; Ziacchi, Matteo; Padeletti, Luigi
abstract

Cardiac resynchronization therapy (CRT) is included in international consensus guidelines as a treatment with proven efficacy in well-selected patients on top of optimal medical therapy. Although all the guidelines strongly recommend CRT for LBBB with QRS duration greater than 150&nbsp;milliseconds, lower strength of recommendation is reported for QRS duration of 120&nbsp;to 150&nbsp;milliseconds, especially if not associated with LBBB. CRT is not recommended for a QRS of less than 120&nbsp;milliseconds. No indication emerges for guiding the implant based on echocardiographic evaluation of dyssynchrony. Many data indicate that CRT is underused and there is heterogeneity in its implementation.

2017 - Cardiac resynchronization therapy in the real world: need to focus on implant rates, patient selection, co-morbidities, type of devices, and complications [Articolo su rivista]
Boriani, Giuseppe; Diemberger, Igor
abstract

N/A

2017 - Clinically guided pacemaker choice and setting: pacemaker expert programming study [Articolo su rivista]
Ziacchi, Matteo; Palmisano, Pietro; Ammendola, Ernesto; Dell'Era, Gabriele; Guerra, Federico; Aquilani, Stefano; Aspromonte, Vittorio; Boriani, Giuseppe; Accogli, Michele; Del Giorno, Giuseppe; Occhetta, Eraldo; Capucci, Alessandro; Ricci, Renato Pietro; Maglia, Giampiero; Biffi, Mauro
abstract

The aim of this multicentre, observational, transversal study was to evaluate pacemaker (PM) choice and setting in a large number of patients, in order to understand their relationship with the patients' clinical characteristics.

2017 - Corrigendum: Glomerular filtration rate in patients with atrial fibrillation and 1-year outcomes (Scientific Reports (2016) 6 (30271) DOI: 10.1038/srep30271) [Articolo su rivista]
Boriani, Giuseppe; Laroche, Cécile; Diemberger, Igor; Popescu, Mircea Ioachim; Rasmussen, Lars Hvilsted; Petrescu, Lucian; Crijns, Harry J. G. M; Tavazzi, Luigi; Maggioni, Aldo P; Lip, Gregory Y. H.
abstract

This Article contains errors in the Acknowledgements section: "Abbott Vascular Int. (2011-2014), Amgen (2012-2018), AstraZeneca (2014-2017), Bayer (2013-2018), Boehringer Ingelheim (2013-2016), Boston Scientific (2010-2012), The Bristol Myers Squibb and Pfizer Alliance (2014-2016), The Alliance Daiichi Sankyo Europe GmbH and Eli Lilly and Company (2014-2017), Gedeon Richter Plc. (2014-2017), Menarini Int. Op. (2010-2012), MSD-Merck &amp; Co. (2011-2014), Novartis Pharma AG (2014-2017), ResMed (2014-2016), Sanofi (2010-2011), SERVIER (2012-2018)". should read: "Abbott Vascular Int. (2011-2014), Amgen (2009-2018), AstraZeneca (2014-2017), Bayer (2009-2018), Boehringer Ingelheim (2009-2016), Boston Scientific (2009-2012), The Bristol Myers Squibb and Pfizer Alliance (2011-2016), The Alliance Daiichi Sankyo Europe GmbH and Eli Lilly and Company (2011-2017), Gedeon Richter Plc. (2014-2017), Menarini Int. Op. (2009-2012), MSD-Merck &amp; Co. (2011-2014), Novartis Pharma AG (2014-2017), ResMed (2014-2016), Sanofi (2009-2011), SERVIER (2009-2018)".

2017 - Device-detected subclinical atrial tachyarrhythmias: Definition, implications and management - An European Heart Rhythm Association (EHRA) consensus document, endorsed by Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS) and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLEACE) [Articolo su rivista]
Gorenek, Bulent; Bax, Jeroen; Boriani, Giuseppe; Chen, Shih-Ann; Dagres, Nikolaos; Glotzer, Taya V.; Healey, Jeff S.; Israel, Carsten W.; Kudaiberdieva, Gulmira; Levin, Lars-Åke; Lip, Gregory Y. H.; Martin, David; Okumura, Ken; Svendsen, Jesper H.; Tse, Hung-Fat; Botto, Giovanni L.; Linde, Cecilia; Kutyifa, Valentina; Bernat, Robert; Scherr, Daniel; Lau, Chu-Pak; Iturralde, Pedro; Morin, Daniel P.; Savelieva, Irina
abstract

Among atrial tachyarrhythmias (AT), atrial fibrillation (AF) is the most common sustained arrhythmia. Many patients with AT have no symptoms during brief or even extended periods of the arrhythmia, making detection in patients at risk for stroke challenging. Subclinical atrial tachyarrhythmia and asymptomatic or silent atrial tachyarrhythmia often precede the development of clinical AF. Clinical AF and subclinical atrial fibrillation (SCAF) are associated with an increased risk of thromboembolism. Indeed, in many cases, SCAF is discovered only after complications such as ischaemic stroke or congestive heart failure have occurred.

2017 - Edoxaban in Atrial Fibrillation and Venous Thromboembolism—Ten Key Questions and Answers: A Practical Guide [Articolo su rivista]
De Caterina, Raffaele; Ageno, Walter; Boriani, Giuseppe; Colonna, Paolo; Ghirarduzzi, Angelo; Patti, Giuseppe; Rossini, Roberta; Rubboli, Andrea; Schinco, Piercarla; Agnelli, Giancarlo
abstract

Edoxaban is the fourth non-vitamin K antagonist oral anticoagulant now available for clinical use in the prevention of stroke/systemic embolism in atrial fibrillation (AF) and in the treatment of venous thromboembolism (VTE), after the completion of large-scale randomized comparative clinical trials with the vitamin K antagonist warfarin. Edoxaban has some peculiar pharmacological properties and outcome data. Here a group of experts in AF and VTE answers a set of questions on its practical use, trying to define the profile of patients that would be most appropriate for its use.

2017 - Effect of fixed-rate vs. Rate-RESPONSIve pacing on exercise capacity in patients with permanent, refractory atrial fibrillation and left ventricular dysfunction treated with atrioventricular junction aBLation and bivEntricular pacing (RESPONSIBLE): A prospective, multicentre, randomized, single-blind study [Articolo su rivista]
Palmisano, Pietro; Aspromonte, Vittorio; Ammendola, Ernesto; Dell'Era, Gabriele; Ziacchi, Matteo; Guerra, Federico; Aquilani, Stefano; Maglia, Giampiero; Del Giorno, Giuseppe; Giubertoni, Ailia; Boriani, Giuseppe; Capucci, Alessandro; Ricci, Renato Pietro; Accogli, Michele
abstract

Aims: Atrioventricular junction (AVJ) ablation followed by biventricular pacing is an established strategy for improving symptoms and morbidity in patients with permanent atrial fibrillation (AF), reduced left ventricular ejection fraction (LVEF), and uncontrolled ventricular rate. There is no clear evidence that such patients benefit from rate-responsive (RR) pacing. Methods and results: This prospective, randomized, single-blind, multicentre study was designed as an intra-patient comparison and enrolled 60 patients (age 69.5 ± 11.8 years, males 63.3%, NYHA 3.0 ±0.6) with refractory AF and reduced LVEF (mean 32.4±8.3%) treated with AVJ ablation and biventricular pacing. Two 6-minute walking tests (6MWT) were performed 1 week apart: one during VVI 70/min biventricular pacing and the other during VVIR 70-130/min biventricular pacing; patients were randomly and blindly assigned to Group A (n = 29, first 6MWT in VVIR mode) or B (n = 31, first 6MWT in VVI mode). Rate-responsive activation determined an increase of 18.8±24.4 m in the distance walked during the 6MWT (P &lt; 0.001). The increase was similar in both groups (P = 0.571). A &gt;5% increase in the distance walked was observed in 76.7% of patients. The increase in the distance walked was linearly correlated with the increase in heart rate recorded during the 6MWT in the VVIR mode (r = 0.54; P &lt; 0.001). Conclusion: In permanent AF patients with uncontrolled rate and reduced LVEF who had undergone AVJ ablation and biventricular pacing, RR pacing yields a significant gain in exercise capacity, which seems to be related to the RR-induced frequency during effort.

2017 - Effects of remote monitoring on clinical outcomes and use of healthcare resources in heart failure patients with biventricular defibrillators: results of the MORE-CARE multicentre randomized controlled trial [Articolo su rivista]
Boriani, Giuseppe; Da Costa, Antoine; Quesada, Aurelio; Ricci, Renato Pietro; Favale, Stefano; Boscolo, Gabriele; Clementy, Nicolas; Amori, Valentina; Lorenza, Mangoni di S. Stefano; Burri, Haran
abstract

Aims: The aim of this study was to evaluate the clinical efficacy and safety of remote monitoring in patients with heart failure implanted with a biventricular defibrillator (CRT-D) with advanced diagnostics. Methods and results: The MORE-CARE trial is an international, prospective, multicentre, randomized controlled trial. Within 8 weeks of de novo implant of a CRT-D, patients were randomized to undergo remote checks alternating with in-office follow-ups (Remote arm) or in-office follow-ups alone (Standard arm). The primary endpoint was a composite of death and cardiovascular (CV) and device-related hospitalization. Use of healthcare resources was also evaluated. A total of 865 eligible patients (mean age 66 ± 10 years) were included in the final analysis (437 in the Remote arm and 428 in the Standard arm) and followed for a median of 24 (interquartile range = 15–26) months. No significant difference was found in the primary endpoint between the Remote and Standard arms [hazard ratio 1.02, 95% confidence interval (CI) 0.80–1.30, P = 0.89] or in the individual components of the primary endpoint (P &gt; 0.05). For the composite endpoint of healthcare resource utilization (i.e. 2-year rates of CV hospitalizations, CV emergency department admissions, and CV in-office follow-ups), a significant 38% reduction was found in the Remote vs. Standard arm (incidence rate ratio 0.62, 95% CI 0.58–0.66, P &lt; 0.001) mainly driven by a reduction of in-office visits. Conclusions: In heart failure patients implanted with a CRT-D, remote monitoring did not reduce mortality or risk of CV or device-related hospitalization. Use of healthcare resources was significantly reduced as a result of a marked reduction of in-office visits without compromising patient safety. Trial registration: NCT00885677.

2017 - Electrical treatment of atrial arrhythmias in heart failure patients implanted with a dual defibrillator CRT device. Results from the TRADE-HF study [Articolo su rivista]
Botto, Giovanni Luca; Padeletti, Luigi; Covino, Gregorio; Pieragnoli, Paolo; Liccardo, Mattia; Mariconti, Barbara; Favale, Stefano; Molon, Giulio; De Filippo, Paolo; Bolognese, Leonardo; Landolina, Maurizio; Raciti, Giovanni; Boriani, Giuseppe
abstract

Background Ventricular and atrial arrhythmias commonly occur in heart failure patients and are a significant source of symptoms, morbidity and mortality. Some specific generators referred to as dual defibrillators, Dual CRT-Ds, have the ability to treat atrial and ventricular arrhythmias. TRADE-HF is a prospective two-arm randomized study aimed at assessing the benefits of complete automatic management of atrial arrhythmias in patients implanted with a dual CRT-D. Methods Primary objective of the TRADE-HF study was to document reduction of unplanned hospital admission for cardiac reasons or death for cardiovascular causes or progression to permanent AF, by comparing fully-automatic device driven therapy for atrial tachycardia or fibrillation (AT/AF) to an in-hospital approach for treatment of symptomatic AT/AF. Randomized Patients were followed every 6&nbsp;months for 3&nbsp;years to assess the primary objective. Results Four-hundred-twenty patients have been enrolled in the study. At the end of the study 30 subjects died for cardiovascular causes, 60 had at least one hospitalization for cardiovascular causes and 14 developed permanent AF. Eighty-seven patients experienced a composite event. Hazard Ratio for device-managed automatic therapy arm compared to traditional was 0.987 (95% CI: 0.684–1.503; p&nbsp;=&nbsp;0.951). The primary endpoint analysis resulted in no difference between the device managed and in-hospital treatment arm. Conclusion The TRADE-HF study failed to demonstrate a reduction in the composite of unplanned hospitalizations for cardiovascular causes or death for cardiovascular causes or progression to permanent AF using automatic atrial therapy compared to a traditional approach including hospitalization for symptomatic episodes and/or in-hospital treatment of AT/AF.

2017 - Electrocardiogram Alterations Associated With Psychotropic Drug Use and CACNA1C Gene Variants in Three Independent Samples [Articolo su rivista]
Fabbri, Chiara; Boriani, Giuseppe; Diemberger, Igor; Filippi, Maria Giulia; Ravegnini, Gloria; Hrelia, Patrizia; Minarini, Alessandro; Albani, Diego; Forloni, Gianluigi; Angelini, Sabrina; Serretti, Alessandro
abstract

Several antipsychotics and antidepressants have been associated with QTc prolongation or other electrocardiogram (ECG) alterations, but their impact is still debated and other risk factors are known to affect QTc. We investigated the effect of antidepressants and antipsychotics on QTc and other ECG intervals/waves in three samples. Two discovery samples (cross-sectional sample n = 145 and prospective sample n = 68, naturalistic treatment) and a replication prospective sample (Clinical Antipsychotic Trials of Intervention Effectiveness, n = 515, randomized treatment) were analysed. In both prospective samples, baseline/follow-up changes in ECG parameters were analysed in relation to the number of psychotropic drugs stratified according to their known cardiovascular risk. In the cross-sectional sample, ECG parameters were compared among drugs with different risk profile. The possible effect of single nucleotide polymorphisms (SNPs) in the CACNA1C gene on QTc was also investigated. There was no evidence of mean QTc prolongation or increased risk of clinically relevant QTc prolongation (≥20 msec.) in association with psychotropic drugs stratified according to their known cardiovascular risk. The prescription of drugs with cardiovascular risk was less common in older individuals or individuals with cardiovascular comorbidities. Other factors (gender, baseline QTc, renal function) affected QTc. rs1006737 and SNPs in linkage disequilibrium with it modulated QTc duration/changes in all samples. An association between risk drugs and shorter RR interval or higher heart rate was found in all samples. A relevant effect of psychotropic drugs with cardiovascular risk on QTc duration was not observed. A number of factors other than psychotropic drugs may influence QTc. CACNA1C rs1006737 may modulate QTc in patients treated with psychotropic drugs.

2017 - Emery-Dreifuss Muscular Dystrophy-Associated Mutant Forms of Lamin A Recruit the Stress Responsive Protein Ankrd2 into the Nucleus, Affecting the Cellular Response to Oxidative Stress [Articolo su rivista]
Angori, Silvia; Capanni, Cristina; Faulkner, Georgine; Bean, Camilla; Boriani, Giuseppe; Lattanzi, Giovanna; Cenni, Vittoria
abstract

Background: Ankrd2 is a stress responsive protein mainly expressed in muscle cells. Upon the application of oxidative stress, Ankrd2 translocates into the nucleus where it regulates the activity of genes involved in cellular response to stress. Emery-Dreifuss Muscular Dystrophy 2 (EDMD2) is a muscular disorder caused by mutations of the gene encoding lamin A, LMNA. As well as many phenotypic abnormalities, EDMD2 muscle cells also feature a permanent basal stress state, the underlying molecular mechanisms of which are currently unclear. Methods: Experiments were performed in EDMD2-lamin A overexpressing cell lines and EDMD2-affected human myotubes. Oxidative stress was produced by H2O2 treatment. Co-immunoprecipitation, cellular subfractionation and immunofluorescence analysis were used to validate the relation between Ankrd2 and forms of lamin A; cellular sensibility to stress was monitored by the analysis of Reactive Oxygen Species (ROS) release and cell viability. Results: Our data demonstrate that oxidative stress induces the formation of a complex between Ankrd2 and lamin A. However, EDMD2-lamin A mutants were able to bind and mislocalize Ankrd2 in the nucleus even under basal conditions. Nonetheless, cells co-expressing Ankrd2 and EDMD2-lamin A mutants were more sensitive to oxidative stress than the Ankrd2-wild type lamin A counterpart. Conclusions: For the first time, we present evidence that in muscle fibers from patients affected by EDMD2, Ankrd2 has an unusual nuclear localization. By introducing a plausible mechanism ruling this accumulation, our data hint at a novel function of Ankrd2 in the pathogenesis of EDMD2-affected cells.

2017 - European Heart Rhythm Association (EHRA)/European Association of Cardiovascular Prevention and Rehabilitation (EACPR) position paper on how to prevent atrial fibrillation endorsed by the Heart Rhythm Society (HRS) and Asia Pacific Heart Rhythm Society (APHRS) [Articolo su rivista]
Gorenek, Bulent; Pelliccia, Antonio; Benjamin, Emelia J.; Boriani, Giuseppe; Crijns, Harry J.; Fogel, Richard I.; Van Gelder, Isabelle C.; Halle, Martin; Kudaiberdieva, Gulmira; Lane, Deirdre A.; Larsen, Torben Bjerregaard; Lip, Gregory Y. H.; Løchen, Maja Lisa; Marín, Francisco; Niebauer, Josef; Sanders, Prashanthan; Tokgozoglu, Lale; Vos, Marc A.; Vanwagoner, David R.; Fauchier, Laurent; Savelieva, Irina; Goette, Andreas; Agewall, Stefan; Chiang, Chern En; Figueiredo, Marcio; Stiles, Martin; Dickfeld, Timm; Patton, Kristen; Piepoli, Massimo; Corra, Ugo; Marques Vidal, Pedro Manuel; Faggiano, Pompilio; Schmid, Jean Paul; Abreu, Ana
abstract

N/A

2017 - European Heart Rhythm Association (EHRA)/European Association of Cardiovascular Prevention and Rehabilitation (EACPR) position paper on how to prevent atrial fibrillation endorsed by the Heart Rhythm Society (HRS) and Asia Pacific Heart Rhythm Society (APHRS) [Articolo su rivista]
Gorenek, Bulent; Pelliccia, Antonio; Benjamin, Emelia J.; Boriani, Giuseppe; Crijns, Harry J.; Fogel, Richard I.; Van Gelder, Isabelle C.; Halle, Martin; Kudaiberdieva, Gulmira; Lane, Deirdre A.; Bjerregaard Larsen, Torben; Lip, Gregory Y. H.; Løchen, Maja Lisa; Marin, Francisco; Niebauer, Josef; Sanders, Prashanthan; Tokgozoglu, Lale; Vos, Marc A.; Van Wagoner, David R.; Fauchier, Laurent; Savelieva, Irina; Goette, Andreas; Agewall, Stefan; Chiang, Chern En; Figueiredo, Márcio; Stiles, Martin; Dickfeld, Timm; Patton, Kristen; Piepoli, Massimo; Corra, Ugo; Manuel Marques Vidal, Pedro; Faggiano, Pompilio; Schmid, Jean Paul; Abreu, Ana
abstract

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2017 - European heart rhythm association (EHRA) consensus document on the management of supraventricular arrhythmias, endorsed by Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulación Cardiaca y Electrofisiologia (SOLAECE) [Articolo su rivista]
Katritsis, Demosthenes G.; Boriani, Giuseppe; Cosio, Francisco G.; Hindricks, Gerhard; Jäis, Pierre; Josephson, Mark E.; Keegan, Roberto; Kim, Young Hoon; Knight, Bradley P.; Kuck, Karl Heinz; Lane, Deirdre A.; Lip, Gregory Y. H.; Malmborg, Helena; Oral, Hakan; Pappone, Carlo; Themistoclakis, Sakis; Wood, Kathryn A.; Blomström Lundqvist, Carina; Gorenek, Bulent; Dagres, Nikolaos; Dan, Gheorge Andrei; Vos, Marc A.; Kudaiberdieva, Gulmira; Crijns, Harry; Roberts Thomson, Kurt; Lin, Yenn Jiang; Vanegas, Diego; Caorsi, Walter Reyes; Cronin, Edmond; Rickard, Jack
abstract

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2017 - Evaluating adherence to non-vitamin-K antagonist oral anticoagulants in post-approval observational studies of patients with atrial fibrillation [Articolo su rivista]
Potpara, Tatjana S.; Boriani, Giuseppe; Lip, Gregory Y. H.
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2017 - How to RESPOND to the quest to increase the effectiveness of cardiac resynchronization therapy? [Articolo su rivista]
Boriani, Giuseppe
abstract

This editorial refers to 'Contractility sensor-guided optimization of cardiac resynchronization therapy: results from the RESPOND-CRT trial', by J. Brugada et al., on page 730.

2017 - Hypertension and cardiac arrhythmias: A consensus document from the European Heart Rhythm Association (EHRA) and ESC Council on Hypertension, endorsed by the Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS) and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLEACE) [Articolo su rivista]
Lip, Gregory Y. H.; Coca, Antonio; Kahan, Thomas; Boriani, Giuseppe; Manolis, Antonis S.; Olsen, Michael Hecht; Oto, Ali; Potpara, Tatjana S.; Steffel, Jan; Marín, Francisco; De Oliveira Figueiredo, Márcio Jansen; De Simone, Giovanni; Tzou, Wendy S.; Chiang, Chern-En; Williams, Bryan; Dan, Gheorghe-Andrei; Gorenek, Bulent; Fauchier, Laurent; Savelieva, Irina; Hatala, Robert; Van Gelder, Isabelle; Brguljan-Hitij, Jana; Erdine, Serap; Lovic, Dragan; Kim, Young-Hoon; Salinas-Arce, Jorge; Field, Michael
abstract

Hypertension is a common cardiovascular risk factor leading to heart failure (HF), coronary artery disease, stroke, peripheral artery disease and chronic renal insufficiency. Hypertensive heart disease can manifest as many cardiac arrhythmias, most commonly being atrial fibrillation (AF). Both supraventricular and ventricular arrhythmias may occur in hypertensive patients, especially in those with left ventricular hypertrophy (LVH) or HF. Also, some of the antihypertensive drugs commonly used to reduce blood pressure, such as thiazide diuretics, may result in electrolyte abnormalities (e.g. hypokalaemia, hypomagnesemia), further contributing to arrhythmias, whereas effective control of blood pressure may prevent the development of the arrhythmias such as AF. In recognizing this close relationship between hypertension and arrhythmias, the European Heart Rhythm Association (EHRA) and the European Society of Cardiology (ESC) Council on Hypertension convened a Task Force, with representation from the Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLEACE), with the remit to comprehensively review the available evidence to publish a joint consensus document on hypertension and cardiac arrhythmias, and to provide up-to-date consensus recommendations for use in clinical practice. The ultimate judgment regarding care of a particular patient must be made by the healthcare provider and the patient in light of all of the circumstances presented by that patient.

2017 - Hypertension and cardiac arrhythmias: executive summary of a consensus document from the European Heart Rhythm Association (EHRA) and ESC Council on Hypertension, endorsed by the Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLEACE) [Articolo su rivista]
Lip, Gregory Y. H; Coca, Antonio; Kahan, Thomas; Boriani, Giuseppe; Manolis, Antonis S; Olsen, Michael Hecht; Oto, Ali; Potpara, Tatjana S; Steffel, Jan; Marín, Francisco; de Oliveira Figueiredo, Márcio Jansen; de Simone, Giovanni; Tzou, Wendy S; En Chiang, Chern; Williams, Bryan
abstract

Hypertension (HTN) is a common cardiovascular risk factor leading to heart failure (HF), coronary artery disease (CAD), stroke, peripheral artery disease and chronic renal failure. Hypertensive heart disease can manifest as many types of cardiac arrhythmias, most commonly being atrial fibrillation (AF). Both supraventricular and ventricular arrhythmias may occur in HTN patients, especially in those with left ventricular hypertrophy (LVH), CAD, or HF. In addition, high doses of thiazide diuretics commonly used to treat HTN, may result in electrolyte abnormalities (e.g. hypokalaemia, hypomagnesaemia), contributing further to arrhythmias, while effective blood pressure control may prevent the development of the arrhythmias such as AF. In recognizing this close relationship between HTN and arrhythmias, the European Heart Rhythm Association (EHRA) and the European Society of Cardiology (ESC) Council on Hypertension convened a Task Force, with representation from the Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLEACE), with the remit of comprehensively reviewing the available evidence and publishing a joint consensus document on HTN and cardiac arrhythmias, and providing up-to-date consensus recommendations for use in clinical practice. The ultimate judgment on the care of a specific patient must be made by the healthcare provider and the patient in light of all individual factors presented. This is an executive summary of the full document co-published by EHRA in EP-Europace.

2017 - Investigating Regional Variation of Cardiac Implantable Electrical Device Implant Rates in European Healthcare Systems: What Drives Differences? [Articolo su rivista]
Torbica, Aleksandra; Banks, Helen; Valzania, Cinzia; Boriani, Giuseppe; Fattore, Giovanni
abstract

Despite established efficacy for cardiac implantable electrical devices (CIEDs), large differences in CIED implant rates have been documented across and within countries. The aim of this paper is to investigate the influence of socio-economic, epidemiological and supply side factors on CIED implant rates across 57 Regions in 5 EU countries and to assess the feasibility of using administrative data for this purpose. A total of 1&nbsp;330&nbsp;098 hospitalizations for CIED procedures extracted from hospital discharge databases in Austria, England, Germany, Italy and Slovenia from 2008 to 2012 was used in the analysis. Higher levels of tertiary education among the labour force and percent of aged population are positively associated with implant rates of CIED. Regional per capita GDP and number of implanting centres appear to have no significant effect. Institutional factors are shown to be important for the diffusion of CIED. Wide variation in CIED implant rates across and within five EU countries is undeniable. However, regional factors play a limited part in explaining these differences with few exceptions. Administrative databases are a valuable source of data for investigating the diffusion of medical technologies, while the choice of appropriate modelling strategy is crucial in identifying the drivers for variation across countries. © 2017 The Authors. Health Economics published by John Wiley &amp; Sons, Ltd.

2017 - Management of atrial high-rate episodes detected by cardiac implanted electronic devices [Articolo su rivista]
Freedman, Ben; Boriani, Giuseppe; Glotzer, Taya V.; Healey, Jeff S.; Kirchhof, Paulus; Potpara, Tatjana S.
abstract

Cardiac implanted electronic devices (CIEDs), including pacemakers and implantable defibrillators that perform atrial sensing typically using an atrial electrode, frequently detect subclinical atrial high-rate episodes (AHREs). When the intracardiac electrograms are carefully examined, the majority of AHREs are atrial fibrillation (AF) or other atrial tachyarrhythmias, which have been shown to be associated with both an increased risk of stroke, and subsequent development of clinical AF. However, the absolute risk of stroke among patients with AHREs is less than might be expected for clinically diagnosed paroxysmal AF. In addition, a close temporal relationship between AHREs and stroke is seen in only 15% of strokes in patients with a CIED: The majority have either no AHREs before the stroke, or AHREs very distant from incident stroke, suggesting that AHREs might be more of a risk marker than a risk factor for stroke. Management of AHREs should not be the same as for clinical AF, and a degree of uncertainty underpins the rationale for much-needed, ongoing, randomized trials of oral anticoagulation in patients with CIED-detected AHREs. We propose a management algorithm that takes into account both the stroke risk and the AHRE burden, but highlights the current uncertainty and evidence gaps for this condition.

2017 - Occupational radiation exposure in the electrophysiology laboratory with a focus on personnel with reproductive potential and during pregnancy: A European Heart Rhythm Association (EHRA) consensus document endorsed by the Heart Rhythm Society (HRS) [Articolo su rivista]
Sarkozy, Andrea; De Potter, Tom; Heidbuchel, Hein; Ernst, Sabine; Kosiuk, Jedrzej; Vano, Eliseo; Picano, Eugenio; Arbelo, Elena; Tedrow, Usha; Lip, Gregory YH; Potpara, Tatjana; Lundqvist, Carina Blomström; Mandrola, John; Lane, Deirdre A.; Dagres, Nikolaos; Chung, Mina K.; Wunderle, Kevin A.; Boriani, Giuseppe
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2017 - Oral loading of propafenone: restoring its role before restoring rhythm [Articolo su rivista]
Martignani, Cristian; Diemberger, Igor; Ziacchi, Matteo; Biffi, Mauro; Boriani, Giuseppe
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2017 - Outcomes with dronedarone in atrial fibrillation: What differences between real-world practice and trials? A meta-analysis and meta-regression analysis [Articolo su rivista]
Diemberger, Igor; Massaro, Giulia; Reggiani, Maria L. B.; Lorenzetti, Stefano; Biffi, Mauro; Ziacchi, Matteo; Martignani, Cristian; Boriani, Giuseppe
abstract

Dronedarone was found to have divergent safety profiles in randomized controlled trials (RCT) in term of cardiac death and overall mortality. We decided to evaluate all available evidence on the cardiovascular safety of this drug. A systematic search was made of the MEDLINE and the Cochrane Central Register of Controlled Trials from January 2003 through April 2016 for RCT comparing dronedarone to placebo/active control, to provide the most accurate estimate of the effects of this agent and observational cohort studies (OBS) reporting clinical outcomes in patients treated with dronedarone, according to current guidelines, to obtain a real-life comparator for the findings summarized by RTC analysis. The literature search yielded 2335 papers and after careful review we identified 12 RCT and 7 OBS studies. RCT meta-analysis showed that, despite high heterogeneity, dronedarone was not associated with increased all-cause mortality [OR (Odds Ratio) 1.36, 95%CI (Confidence Interval) 0.79-2.33; p=0.732, I2=57.0%] or cardiovascular mortality [OR 1.51 95%CI 0.74-3.08; p=0.860, I2=64.4%]. OBS studies had a trend toward a better survival with respect to RCT [ES (Effect Size) 2.03, 95%CI 0.53-3.53 vs. ES 3.03, 95%CI 1.23-4.83; p=0.115], reaching the significance when restricted to the cardiovascular mortality [ES 0.52, 95%CI 0.36-0.69 vs. ES 1.86, 95%CI 0.62-3.09; p<0.001]. Two variables, co-adiministration of digoxin and prevalence of non-permanent AF completely abolished the dishomogeneity among the analyzed RCT studies. In conclusion, use of dronedarone for prophylaxis of AF recurrences is not associated with an increased risk of death, either cardiovascular or total, and combination with digoxin should be avoided.

2017 - Pacemaker-detected severe sleep apnea predicts new-onset atrial fibrillation [Articolo su rivista]
Mazza, Andrea; Bendini, Maria Grazia; De Cristofaro, Raffaele; Lovecchio, Mariolina; Valsecchi, Sergio; Boriani, Giuseppe
abstract

Sleep apnea (SA) diagnosed on overnight polysomnography is a risk factor for atrial fibrillation (AF). Advanced pacemakers are now able to monitor intrathoracic impedance for automatic detection of SA events.

2017 - Patient outcome after implant of a cardioverter defibrillator in the ‘real world’: the key role of co-morbidities [Articolo su rivista]
Boriani, Giuseppe; Malavasi, Vincenzo Livio
abstract

This article refers to 'The impact of co-morbidity burden on appropriate implantable cardioverter defibrillator therapy and all-cause mortality: insight from Danish nationwide clinical registers,' by A.C. Ruwald et al., published in this issue on pages 377-386.

2017 - Pre-participation cardiovascular evaluation for athletic participants to prevent sudden death: Position paper from the EHRA and the EACPR, branches of the ESC. Endorsed by APHRS, HRS, and SOLAECE [Articolo su rivista]
Mont, Lluis; Pelliccia, Antonio; Sharma, Sanjay; Biffi, Alessandro; Borjesson, Mats; Terradellas, Josep Brugada; Carre, Francois; Guasch, Eduard; Heidbuchel, Hein; La Gerche, Andre; Lampert, Rachel; Mckenna, William; Papadakis, Michail; Priori, Silvia G.; Scanavacca, Mauricio; Thompson, Paul; Sticherling, Christian; Viskin, Sami; Wilson, Mathew; Corrado, Domenico; Gregory, Lip Y. H.; Gorenek, Bulent; Lundqvist, Carina Blomström; Merkely, Bela; Hindricks, Gerhard; Hernandez Madrid, Antonio; Lane, Deirdre; Boriani, Giuseppe; Narasimhan, Calambur; Marquez, Manlio F.; Haines, David; Mackall, Judith; Marques Vidal, Pedro Manuel; Corra, Ugo; Halle, Martin; Tiberi, Monica; Niebauer, Josef; Piepoli, Massimo
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2017 - Pre-participation cardiovascular evaluation for athletic participants to prevent sudden death: Position paper from the EHRA and the EACPR, branches of the ESC. Endorsed by APHRS, HRS, and SOLAECE [Articolo su rivista]
Mont, Lluís; Pelliccia, Antonio; Sharma, Sanjay; Biffi, Alessandro; Borjesson, Mats; Brugada Terradellas, Josep; Carré, Francois; Guasch, Eduard; Heidbuchel, Hein; La Gerche, André; Lampert, Rachel; Mckenna, William; Papadakis, Michail; Priori, Silvia G; Scanavacca, Mauricio; Thompson, Paul; Sticherling, Christian; Viskin, Sami; Wilson, Mathew; Corrado, Domenico; Lip, Gregory Y. H.; Gorenek, Bulent; Blomström Lundqvist, Carina; Merkely, Bela; Hindricks, Gerhard; Hernández Madrid, Antonio; Lane, Deirdre; Boriani, Giuseppe; Narasimhan, Calambur; Marquez, Manlio F.; Haines, David; Mackall, Judith; Manuel Marques Vidal, Pedro; Corra, Ugo; Halle, Martin; Tiberi, Monica; Niebauer, Josef; Piepoli, Massimo
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2017 - Prevalence and clinical significance of left bundle branch block according to classical or strict definition criteria in permanent pacemaker patients [Articolo su rivista]
Mazza, Andrea; Bendini, Maria Grazia; De Cristofaro, Raffaele; Lovecchio, Mariolina; Valsecchi, Sergio; Leggio, Massimo; Boriani, Giuseppe
abstract