Jan
Issue
19 43 Richard Sutton:
The first 60 years of cardiac pacing
Page 7
Haran Burri:
Profile
Caroline Broughton: Page 8
AF and obstructive sleep apnoea
Page 11
“No serious adverse outcomes” with ICD shocks in young athletes playing sport A post-hoc analysis of the ICD Sports Registry—which has already indicated that many patients with implantable cardioverter defibrillators (ICD) can safely participate in vigorous or competitive sports—shows that shocks are not infrequent in young ICD patients who play competitive sports but that these shocks are not associated with serious adverse outcomes.
E
lizabeth Vickers Saarel (Cleveland Clinic Children’s Paediatric Cardiology, Cleveland, USA) and others write in Circulation: Arrhythmia and Electrophysiology that, over the past few years, the perception of the safety of ICD patients participating in sport has changed. They note: “Growing evidence suggests that risks of sports participation for athletes with ICDs may be lower than hypothesised.” They add that the ICD Sports Registry found that while appropriate and inappropriate shocks occurred during sports, there were no deaths, resuscitated arrests or arrhythmia-related injuries during sports. Vickers Saarel comments that the study is “reassuring” because it suggests safe sports participation for patients with ICDs, but its results are “difficult to apply to children and adolescents”. Therefore, the aim of the present post-hoc analysis was to “better understand this young population”. Reviewing data from the ICD Sports Registry, the authors identified 129 athletes aged ≤21 years of age. Of these, 9% were aged 10 to 12 years of age, 26% were aged 13 to 15 years of age, 41% were aged 16
to 18 years of age, and 24% were aged practice, a rate of 1.5 appropriate shocks 19 to 31 years of age. As with all of during sports, per hundred person-years.” the patients in the registry, the young They add that this finding suggests athletes had an ICD and participated in “restriction from this activity [i.e. sports] sports that were associated with a more would not have a large impact on the than low cardiovascular demand (in this overall burden of treated arrhythmias”. post-hoc analysis, 117 did competitive Furthermore, according to Vickers Saarel sports and 12 did dangerous sports). The et al, “all of the youths” in the post-hoc primary endpoint was a serious adverse analysis benefitted from participating event during or ≤2 hours after sports (e.g. Elizabeth Vickers Saarel in sports, noting that 82% only stopped tachyarrhythmic death). participating in competitive sports after During the median 42 months of follow-up, no graduating from secondary school. tachyarrhythmic deaths or externally resuscitated The authors say the present report adds to the data tachyarrhythmias during or after sports participation already provided by the ICD Sports Registry and occurred; there were also no severe injuries resulting “will further inform the dialogue and shared decisionfrom arrhythmia-induced syncope or shock during making concerning sports participation in the important sports. However, 27% of athletes experienced at least population of young athletes involved in school and one shock (49 shocks overall). Vickers Saarel et al college [university] sports”. They conclude that the comment “There were 29 appropriate shocks occurring decision to return to sport participation after an ICD in 18 individuals; of which, six appropriate shocks “should be individualised and discussed between in four individuals occurred during competition or physician, athlete and parents”.
Computerised-decision support has the potential to be a “powerful tool” for preventing cardiovascular events in AF patients Data presented at the 2018 American Heart Association (AHA) scientific sessions (10–12 November, Chicago, USA) indicate that the use of alert-based computerised-decision support significantly increases the rate of anticoagulation prescription among patients who are hospitalised with atrial fibrillation (AF). Furthermore, the use of such software is associated with a significant decrease in major adverse cardiac events. PRESENTING THE AF-ALERT study at the AHA, Gregory Piazza (Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, USA) reported that he and his fellow investigators had previously found, in a study of patients hospitalised with AF, that “antithrombotic therapy was omitted in nearly 40% of those at risk”. Noting that alert-based computerised decision support strategies “have been successfully implemented to improve underutilisation of venous thromboembolism prophylaxis in high-risk hospitalised patients”, Piazza stated that the objective of AF-Alert
was to determine the impact of alertbased computerised-decision support on the prescription of anticoagulation among patients with AF. The hypothesis of the study, he explained, was that “alert-based computerised-decision support will increase prescription of anticoagulation in high-risk hospitalised patients with atrial fibrillation who were not being prescribed anticoagulation”. In the study, 458 patients who were hospitalised for AF and who were not already receiving anticoagulation were randomised to standard care plus alertbased computerised-decision support (248) or standard therapy alone (210).
The primary efficacy endpoint was the rate of anticoagulation prescription during hospitalisation, at discharge and at 90 days, and the primary safety endpoint was the occurrence of major bleeding or clinically relevant non-major bleeding. At all follow-up points (during hospitalisation, discharge, and at 90 days), the rate of anticoagulation prescription was significantly higher among the alert group patients. This meant that the rate of the primary efficacy endpoint, according to Piazza, “nearly tripled” in the alert group: 19.4% vs. 7.1% for the control group
(p<0.001). There were no significant differences in the rate of the primary safety endpoint between groups. Also, the rate of the secondary efficacy endpoint (a composite of death, myocardial infarction, transient ischaemic attack or systemic embolic event at 90 days) was significantly lower in the alert group: 11.3% vs. 21.9% for the control group (p<0.002); a 50% reduction. Furthermore, aside from death, the individual components of this endpoint were significantly lower in the alert group. This meant that the alert group had significantly higher rates of freedom from major adverse cardiac events (MACE) and from major adverse events (MAE) at 90 days compared with the control group (p=0.004 and p=0.001 for the comparisons). Piazza commented that the reduction in MACE was “beyond what was anticipated from the increase in prescription of anticoagulation”. “Computerised-decision support has the potential to be a powerful tool in prevention of cardiovascular events in patients with AF,” Piazza concluded.