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<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Aims</div>Cardiac magnetic resonance (CMR) imaging for tissue characterization offers valuable insights for risk stratification among patients with cardiomyopathy. This study aimed to assess the prognostic value of CMR-based tissue characterization in predicting response to cardiac resynchronization therapy (CRT) in patients with non-ischaemic cardiomyopathy (NICM).<div class="boxTitle">Methods and results</div>Retrospective analysis was performed on CMR data from NICM patients before CRT implantation. Various CMR parameters, including the late gadolinium enhancement (LGE), native T1, T2, and extracellular volume (ECV), were analysed. Among the 101 patients (mean age: 66 years, male: 52.5%), 72 (71.3%) were CRT responders. The CRT responders had lower LGE burden (13.1 vs. 35.3%, <span style="font-style:italic;">P</span> < 0.001), native T1 (1334.5 vs. 1371.6 ms, <span style="font-style:italic;">P</span> = 0.012), T2 (42.2 vs. 45.7 ms, <span style="font-style:italic;">P</span> < 0.001), and ECV (30.8 vs. 36.8%, <span style="font-style:italic;">P</span> < 0.001) compared with CRT non-responders. After adjusting for other risk factors, LGE burden ≤ 20% [odds ratio (OR): 22.61, 95% confidence interval (CI): 4.73–176.68, <span style="font-style:italic;">P</span> < 0.001], ECV ≤ 34% (OR: 15.93, 95% CI: 3.01–115.13, <span style="font-style:italic;">P</span> = 0.002), and T2 ≤ 45 ms (OR: 8.10, 95% CI: 1.82–43.75, <span style="font-style:italic;">P</span> = 0.008) were identified as predictors of good CRT response and favourable clinical outcomes (log-rank <span style="font-style:italic;">P</span> < 0.001).<div class="boxTitle">Conclusion</div>Cardiac magnetic resonance-based tissue parameters effectively predict CRT response and clinical outcomes in patients with NICM, independently of conventional predictors.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>Epicardial access during electrophysiology procedures offers valuable insights and therapeutic options for managing ventricular arrhythmias (VAs). The current clinical consensus statement on epicardial VA ablation aims to provide clinicians with a comprehensive understanding of this complex clinical scenario. It offers structured advice and a systematic approach to patient management. Specific sections are devoted to anatomical considerations, criteria for epicardial access and mapping evaluation, methods of epicardial access, management of complications, training, and institutional requirements for epicardial VA ablation. This consensus is a joint effort of collaborating cardiac electrophysiology societies, including the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, the Latin American Heart Rhythm Society, and the Canadian Heart Rhythm Society.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Aims</div>Despite increasing prevalence, the general population lacks knowledge regarding diagnosis, implications, and management of cardiac arrhythmias (CA). This study aims to assess public perception of CA and identify knowledge gaps.<div class="boxTitle">Methods and results</div>The 36-item <span style="font-style:italic;">PULSE</span> survey was disseminated via social media to the general population and conducted under the auspices of the European Heart Rhythm Association Scientific Initiatives Committee (EHRA SIC) with EHRA patient committee support. Among 3924 participants (2177 healthy, 1747 with previously diagnosed CA; 59% female, 90% European), 81% reported fear of CA. Females were more likely to be ‘very’ or ‘moderately afraid’ than males [odds ratio (OR) 1.159 (1.005, 1.337), <span style="font-style:italic;">P</span> = 0.046]. While most recognized complications of CA—heart failure (82%), stroke (80%), and death (75%)—43% were unaware that CA can be asymptomatic. Those with cardiopulmonary resuscitation (CPR) training in the past 5 years were 2.6 times and 4.7 times more confident identifying sudden cardiac death and initiating CPR (<span style="font-style:italic;">P</span> < 0.001). Confidence was lower in retired participants [OR 0.574 (0.499, 0.660), <span style="font-style:italic;">P</span> < 0.001] and Southern Europeans [OR 0.703 (0.600, 0.824), <span style="font-style:italic;">P</span> < 0.001]. Without CPR training, only 15% felt confident initiating CPR. Among CA participants, 28% reported severe to disabling daily symptoms. Males were more often asymptomatic (20% vs. 9%, <span style="font-style:italic;">P</span> < 0.001). Treatment rates were comparable between sex categories (81% vs. 79%, <span style="font-style:italic;">P</span> = 0.413). Interdisciplinary shared decision-making processes were reported by 4%. Notably, 1 in 10 CA cases was self-diagnosed using a wearable device, and 30% of CA participants used smartwatches for self-monitoring.<div class="boxTitle">Conclusion</div>Significant knowledge gaps regarding CA exist in the general population. Targeted educational initiatives could be a viable tool to enhance public knowledge, confidence in detecting and managing arrhythmias, particularly for women, who experience greater fear and symptom severity despite similar treatment rates.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>Conduction system pacing (CSP) is being increasingly adopted as a more physiological alternative to right ventricular and biventricular pacing. Since the 2021 European Society of Cardiology pacing guidelines, there has been growing evidence that this therapy is safe and effective. Furthermore, left bundle branch area pacing was not covered in these guidelines due to limited evidence at that time. This Clinical Consensus Statement provides advice on indications for CSP, taking into account the significant evolution in this domain.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Aims</div>We studied the blood pressure (BP) decrease after carotid sinus massage to study cardioinhibition (CI) and arterial vasodepression (aVD), whether CI and aVD occur independent of one another, and how the BP decrease ends.<div class="boxTitle">Methods and results</div>We measured BP, heart rate (HR), stroke volume, and total peripheral resistance (TPR) retrospectively in carotid sinus massage cohorts in two Dutch syncope centres. Cardioinhibition and aVD were defined as HR and TPR decreasing below 3 SD under pre-massage baseline means. We used the logratio method to analyse changes relative to baseline and tested whether CI and aVD occurred together more often than through chance and whether the responses depended on massage duration and on corrective BP increases. Cardioinhibition occurred in 48% and aVD in 30% of 244 massages of 90 persons. Cardioinhibition and aVD did not occur together more often than randomly. Compared with aVD, CI occurred more often, earlier, faster, and shorter with a larger maximal but similar overall BP-decreasing effect. Longer massage duration yielded a larger BP decrease through stronger aVD. The BP decrease evoked corrective increases of HR and TPR.<div class="boxTitle">Conclusion</div>Cardioinhibition appears as a phasic response to the onset of massage, independent of aVD, which is a more latent response sensitive to ongoing massage. Blood pressure corrections probably depend on the contralateral carotid sinus and aortic baroreceptors. The BP decrease after sinus massage may in part depend on the efficacy of corrective responses.</span>
<span class="paragraphSection">We read with great interest the article by de Lange <span style="font-style:italic;">et al</span>.<sup><a href="#euaf058-B1" class="reflinks">1</a></sup> on carotid sinus massage (CSM) and that CSM requires ‘re-implementation’ in clinical practice in patients with syncope, cardiovascular autonomic dysfunction (CVAD), and arrhythmias. We would like to comment on several aspects.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Aims</div>Adherence to an ideal cardiovascular health (CVH) might contribute to lower the burden of sudden cardiac death (SCD) in the community. We aimed to examine the association between the number of ideal CVH metrics at baseline and of its change over 10 years with the risk of SCD.<div class="boxTitle">Methods and results</div>The Copenhagen City Heart Study is a community-based prospective cohort study. The number of ideal CVH metrics (range 0–6; non-smoking and ideal level of body mass index, physical activity, untreated glucose, untreated systolic blood pressure, and untreated total cholesterol levels) at baseline in 1991–94 and its 10-year change thereof between 1981–83 and 1991–94 were evaluated. Definite SCD was defined as a death occurring within 1 h (eye-witnessed case) or within 24 h (non-eye–witnessed) of symptoms onset, with the presence of confirmed ventricular tachycardia and the exclusion of non-cardiac cause at autopsy. Fine and Gray sub-distribution HRs (sHRs) were calculated to account for competing risk. The study population includes 8837 participants (57% women; mean age 57 years, ±15 years) in 1991–94. After a median follow-up of 22.6 years from 1 January 1993 up to 31 December 2016, 56 definite SCD occurred. The risk of definite SCD decreased gradually with the number of ideal metrics in 1991–94 [sHR = 0.58; 95% confidence interval (CI): 0.44–0.75 per additional ideal metric] and with the change (i.e. improvement) in the number of ideal metrics between 1981–83 and 1991–94 (sHR = 0.68; 0.50–0.93 per change in the number of ideal metrics). Effect size was lower for coronary death, all-cause mortality, and coronary heart disease events.<div class="boxTitle">Conclusion</div>Adherence to a higher number of ideal cardiovascular health was related to a substantial lower risk of definite SCD.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Aims</div>The clinical spectrum of cardiac implantable electronic device (CIED) infections includes isolated pocket infection (IPI), pocket infection complicated by infective endocarditis (PIRIE), and lead-related infective endocarditis (LRIE). The aim of this study was to assess the risk factors, clinical course, and outcomes in patients with CIED infections and to demonstrate differences between PIRIE and LRIE.<div class="boxTitle">Methods and results</div>The retrospective analysis of data from 3847 patients undergoing transvenous lead extraction for non-infectious (2640; 68.62%) and infectious (1207; 31.38%) indications, including 361 (29.91%) IPI, 472 (39.11%) PIRIE, and 374 (30.99%) LRIE, showed some differences in risk factors, clinical course, and outcomes between the subgroups. Unlike PIRIE, diabetes [hazard ratio (HR) = 1.488; 95% confidence interval (CI; 1.178–1.879), <span style="font-style:italic;">P</span> < 0.001] and lead abrasion [HR = 2.117; 95% CI (1.665–2.691), <span style="font-style:italic;">P</span> < 0.001] increased the risk of LRIE. The risk of pocket infection spread was greater with <span style="font-style:italic;">Staphylococcus aureus</span> infection [HR = 1.596; 95% CI (1.202–2.120), <span style="font-style:italic;">P</span> < 0.001]. Compared with LRIE, patients with PIRIE had lower levels of inflammatory markers and lower prevalence of vegetations. Mortality in PIRIE compared with LRIE patients was lower (53.18 vs. 62.30%; <span style="font-style:italic;">P</span> < 0.001) and comparable to IPI (50.69%; <span style="font-style:italic;">P</span> = 0.162) at long-term [median 1828 (815–3139) days] follow-up.<div class="boxTitle">Conclusion</div>Cardiac implantable electronic device infections share common risk factors; however, diabetes and intra-cardiac lead abrasion predispose to LRIE, whereas multiple leads and <span style="font-style:italic;">S. aureus</span> in pocket culture are risk factors for pocket infection spread. Compared with LRIE, the clinical course of PIRIE was milder, and short- and long-term mortalities were lower, but comparable with IPI after >1 year. This may be an argument in favour of categorization into primary LRIE and secondary endocarditis, i.e. PIRIE.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Aims</div>Advanced technologies such as charge density mapping (CDM) show promise in guiding adjuvant ablation in patients with persistent atrial fibrillation (AF); however, their limited availability restricts widespread adoption. We sought to determine whether regions of the left atrium containing CDM-identified pivoting and rotational propagation patterns during AF could also be reliably identified using more conventional contact mapping techniques.<div class="boxTitle">Methods and results</div>Twenty-two patients undergoing <span style="font-style:italic;">de novo</span> ablation of persistent AF underwent both CDM and electroanatomic voltage mapping during AF and sinus rhythm with multiple pacing protocols. Through the use of a left atrium statistical shape model, the location of distinctive propagation patterns identified by CDM was compared with low-voltage areas (LVAs) and regions of slow conduction velocity (CV). Neither LVA nor CV mapping during paced rhythms reliably identified regions containing CDM propagation patterns. Conduction velocity mapping during AF did correlate with these regions (ρ = −0.63, <span style="font-style:italic;">P</span> < 0.0001 for pivoting patterns; ρ = −0.54, <span style="font-style:italic;">P</span> < 0.0001 for rotational patterns). These propagation patterns consistently occurred in two specific anatomical regions across patients: the anteroseptal and inferoposterior walls of the left atrium.<div class="boxTitle">Conclusion</div>Mapping techniques during paced rhythms do not reliably correspond with regions of CDM-identified propagation patterns in persistent AF. However, these propagation patterns are consistently observed in two specific anatomical regions, suggesting a predisposition to abnormal electrophysiological properties. While further research is needed, these regions may serve as promising targets for empirical ablation, potentially reducing the reliance on complex mapping techniques.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Aims</div>Genome-wide association studies (GWASs) identified common single-nucleotide polymorphisms (SNPs) in more than 100 genomic regions associated with atrial fibrillation (AF). We aimed to identify novel AF genes in Taiwanese population by multi-stage GWAS.<div class="boxTitle">Methods and results</div>In exploratory stage, we did GWAS with whole-genome genotypes (4 512 191 SNPs) in 516 patients with AF from the National Taiwan University AF Registry and 5160 normal sinus rhythm controls from the Taiwan Biobank. Significant loci were replicated in 1002 independent patients and 2003 controls and in the UK Biobank. Expression quantitative trait locus (eQTL) mapping and transcriptome-wide association study (TWAS) were performed to implicate functional significance. Stage I GWAS revealed three loci associated with AF with a genome-wide significance level, including one close to <span style="font-style:italic;">PITX2</span> gene (chromosome 4q25, rs2723329, minor allele frequency [MAF] 0.50 vs. 0.41, <span style="font-style:italic;">P</span> = 1.53 × 10<sup>−10</sup>), another close to <span style="font-style:italic;">RAP1A</span> gene (also to previous <span style="font-style:italic;">KCND3</span>; chromosome 1p13.2, rs7525578, MAF 0.17 vs. 0.07, <span style="font-style:italic;">P</span> = 1.24 × 10<sup>−26</sup>), and one novel locus close to <span style="font-style:italic;">HNF4G</span> gene (chromosome 8q21.13, rs2980218, MAF 0.44 vs. 0.35, <span style="font-style:italic;">P</span> = 2.19 × 10<sup>−9</sup>). They were validated in Stage II population. The eQTL analyses showed significant colocalization of 1p13.2 locus with <span style="font-style:italic;">RAP1A</span> gene expression in fibroblasts and 8q21.13 locus with <span style="font-style:italic;">HNF4G</span> expression in lymphocytes. There is a significant association of <span style="font-style:italic;">RAP1A</span> gene expression in fibroblasts and <span style="font-style:italic;">HNF4G</span> in lymphocytes and brain with AF in TWAS.<div class="boxTitle">Conclusion</div>Genome-wide association study in Taiwan revealed <span style="font-style:italic;">PITX2</span> and <span style="font-style:italic;">RAP1A/KCND3</span> loci and novel AF locus (<span style="font-style:italic;">HNF4G</span>) with the most significant locus in the <span style="font-style:italic;">RAP1A</span> locus. <span style="font-style:italic;">RAP1A</span> and <span style="font-style:italic;">HNF4G</span> genes may implicate fibrosis, metabolic, and neurogenic pathways in pathogenesis of AF.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Aims</div>The aim of this study was to perform an external validation of an automatic machine learning (ML) algorithm for heart rhythm diagnostics using smartphone photoplethysmography (PPG) recorded by patients with atrial fibrillation (AF) and atrial flutter (AFL) pericardioversion in an unsupervised ambulatory setting.<div class="boxTitle">Methods and results</div>Patients undergoing cardioversion for AF or AFL performed 1-min heart rhythm recordings pericardioversion at least twice daily for 4–6 weeks, using an iPhone 7 smartphone running a PPG application (CORAI Heart Monitor) simultaneously with a single-lead electrocardiogram (ECG) recording (KardiaMobile). The algorithm uses support vector machines to classify heart rhythm from smartphone-PPG. The algorithm was trained on PPG recordings made by patients in a separate cardioversion cohort. Photoplethysmography recordings in the external validation cohort were analysed by the algorithm. Diagnostic performance was calculated by comparing the heart rhythm classification output to the diagnosis from the simultaneous ECG recordings (gold standard). In total, 460 patients performed 34 097 simultaneous PPG and ECG recordings, divided into 180 patients with 16 092 recordings in the training cohort and 280 patients with 18 005 recordings in the external validation cohort. Algorithmic classification of the PPG recordings in the external validation cohort diagnosed AF with sensitivity, specificity, and accuracy of 99.7%, 99.7% and 99.7%, respectively, and AF/AFL with sensitivity, specificity, and accuracy of 99.3%, 99.1% and 99.2%, respectively.<div class="boxTitle">Conclusion</div>A machine learning-based algorithm demonstrated excellent performance in diagnosing atrial fibrillation and atrial flutter from smartphone-PPG recordings in an unsupervised ambulatory setting, minimizing the need for manual review and ECG verification, in elderly cardioversion populations.<div class="boxTitle">Clinical Trial Registration</div><a href="http://Clinicaltrials.gov">Clinicaltrials.gov</a>, NCT04300270</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Aims</div>The aim of this study was to examine differences in incidence rates of all-cause mortality (ACM) and sudden cardiac death (SCD) in persons of differing socio-economic position (SEP).<div class="boxTitle">Methods and results</div>All deaths in Denmark from 1 January to 31 December 2010 (1 year) were included. Autopsy reports, death certificates, discharge summaries, and nationwide health registries were reviewed to identify cases of SCD. Socio-economic position was measured as either household income or highest achieved educational level and analysed separately. Hazard rates were calculated using univariate and multivariable Cox regression models adjusting for age, sex, and selected comorbidities. A total of 53 452 deaths were included, of which 6820 were classified as SCDs. Incidence rates of ACM and SCD increased with age and were higher in the lower SEP groups. The greatest difference in SCD incidence was found between the low and high education level groups, with an incidence rate ratio of 5.1 (95% confidence interval 3.8–6.8). The hazard ratios for ACM and SCD were significantly higher for low SEP groups, independent of comorbidities. Compared with the highest income group, the low-income group had adjusted hazard ratios of ACM and SCD that were 2.17 (2.01–2.34) and 1.72 (1.67–1.76), respectively.<div class="boxTitle">Conclusion</div>We observed an inverse association between both income and education level and the risk of ACM and SCD in the general population, which persisted independently of baseline comorbidities. Our results indicate a need for further research into the mechanisms behind socio-economic disparities in healthcare and targeted preventative strategies.</span>
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