Death, Sudden, Cardiac

IJCS

Editorial

You Can Only Improve What You Measure: The Importance of the Rapid Response Team in Improving Patient Care

Sebastian Garcia-Zamora et al. Zain Somani Adrian Baranchuk

Sudden death among hospitalized patients, most often manifesting as in-hospital cardiac arrest, is a global problem that poses major challenges for prediction, timely diagnosis, and expeditious treatment. Incidence and outcomes vary considerably across health systems but remain sobering. Hospitalized patients with acute illness are vulnerable to intercurrent events that can precipitate rapid deterioration. Caring for these patients requires advanced competencies, such as airway management, treatment of arrhythmias, and hemodynamic support, all of which are challenging to acquire and maintain across all medical professionals on general wards. This is why rapid response teams have been utilized as a system-level strategy to recognize early deterioration of patients and bring concentrated expertise to the bedside.

In this issue of the International Journal of Cardiovascular Sciences, Salvadori et al. report a prospective, single-center, five-year evaluation of a rapid response team program in a quaternary Brazilian hospital. Over the study period, the team attended 4,805 emergencies, consisting of 551 cardiac arrests and 4,254 non-arrest deteriorations. Survival among patients with non-arrest emergencies improved significantly (from 57.1% to 64.5%; p = 0.003), whereas survival after cardiac arrest remained low and unchanged. The study has several strengths: it is a large, real-world, prospective analysis that captures process-of-care metrics beyond outcomes, such as time to epinephrine, time to first shock, and time to advanced airway. This level of granularity in the data is crucial in the care of critically ill patients. Outcomes may be unfavorable despite coordinated, appropriate care because of underlying severity, and conversely, occasional survival may occur despite suboptimal response. Measuring processes in detail allows teams to distinguish signal from noise and thereby improve performance over time.

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Original Article

Dysautonomia Evaluation by Holter in Chagas Heart Disease

Michele Alves Rocha de Oliveira et al. Thais Aguiar Nascimento Gilson Soares Feitosa-Filho Luiz Eduardo Fonteles Ritt … Constança Margarida Sampaio Cruz Mário de Seixas Rocha

Abstract

Background

Sudden cardiac death is the main lethal mechanism associated with Chagas cardiomyopathy. Studies suggest that dysautonomia may represent a relevant, intense, independent, and early phenomenon in the natural history of the disease, even when ventricular systolic function is preserved, and may also be the mechanism that triggers malignant ventricular arrhythmias.

Objective

To evaluate the degree of dysautonomia and its possible association with ventricular arrhythmias in patients with Chagas cardiomyopathy, according to different categories of mortality risk, as defined by the score proposed by Rassi, used as a surrogate outcome for death.

Methods

A cross-sectional study involving 43 patients with Chagas cardiomyopathy stratified into risk categories based on the Rassi score, with 23 being classified as low risk and 20 as intermediate-to-high risk. Heart rate variability (HRV) was assessed using Holter monitoring for long-term recordings of 24 hours (time domain) and for short-term recordings of 5 minutes (frequency domain) at rest and after autonomic tests: deep breathing and Valsalva maneuver. The HRV variables were compared between the groups using the Student’s t-test and α=0.05.

Results

Comparison of the results between the risk stratification groups showed no differences in HRV indexes, either in the time or frequency domain. However, results showed a significant increase in the number of arrhythmias as a function of increased risk (p=0.02).

Conclusion

There was no association between the degree of dysautonomia, evaluated by Holter monitoring, and the categories of mortality risk, despite a direct association between the rate of arrhythmias and the higher risk group.

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Original Article

Cost-Effectiveness Analysis of Implantable Cardioverter Defibrillator Therapy for Primary Prevention Patients with Additional Risk Factors in Brazil

Kael Wherry et al. Reece Holbrook Lucas Higuera Francis Fujii Diego A. Rodriguez

Abstract

Background:

Implantable cardiac defibrillators (ICDs) therapy for primary prevention (PP) of sudden cardiac arrest (SCA) is well-established but underutilized globally. The Improve SCA study has identified a cohort of patients called 1.5 primary prevention (1.5PP), based on PP patients with the presence of documented risk factors: non-sustained ventricular tachycardia, frequent premature ventricular contractions, left ventricular ejection fraction < 25%, and pre-syncope or syncope.

Objective:

This study evaluated the cost-effectiveness of ICD therapy compared to no ICD among 1.5PP patients in the Brazilian public healthcare system.

Methods:

Modified inputs to a published Markov model were applied to compare costs and outcomes of ICD therapy to no ICD therapy from the Brazilian payer’s perspective. Mortality and utility estimates were obtained from the IMPROVE SCA trial. Additional effectiveness inputs were sourced from the literature. Cost inputs were obtained from the Brazilian Unified Health System and the Ministry of Health. Costs were discounted at 4.7%; quality-adjusted life years (QALYs) were discounted at 1.45%. This study applied a willingness-to-pay (WTP) value of three times Brazil’s gross domestic product (GDP) in 2017, R$105,723 (Brazilian Real).

Results:

The total discounted lifetime costs for ICD therapy were R$100,920 compared to R$43,866 for no ICD therapy. Total discounted QALYs for ICD therapy and no ICD therapy were 9.85 and 7.15, respectively. The incremental cost effectiveness ratio was R$21,156 per QALY and less than the R$105,723 WTP threshold. Results from sensitivity analyses were consistent with base case results.

Conclusions:

ICD therapy compared to no ICD therapy is cost-effective in the 1.5PP population in Brazil. (Int J Cardiovasc Sci. 2021; [online].ahead print, PP.0-0)

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Case Report

Cardiac Arrest and Exercise-Induced Polymorphic Ventricular Tachycardia: An Elusive Diagnosis

Nestor Rodrigues de Oliveira et al. William Santos de Oliveira Adalberto Atsushi Porto Fabio Mastrocola … Ana Eloisa Novaes Roberto Moreno Mendonça Júlio César Vieira de Sousa

Introduction

Polymorphic ventricular tachycardia (VT) is defined as a rapid rhythm with continuously changing ventricular activation. In the absence of QT interval prolongation, its evaluation is a challenging activity with a series of differential diagnoses. The present study reports on a case of a young man who had an out-of-hospital cardiac arrest and and who later presented an episode of exercise-induced polymorphic VT. A rational investigation is discussed based on the patient’s clinical findings and baseline ECG.

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Case Report

Brugada Pattern, Brugada Phenocopy, What to Think?

José Luis Martins et al. Raquel Ferreira Jesus Viana José Santos

Introduction

Propafenone is a class 1 anti-arrhythmic medication with beta-adrenergic and calcium channel blocker properties.

Brugada syndrome (BrS) has a typical electrocardiographic pattern characterized by increased propensity for malignant ventricular arrhythmias and sudden death in patients with no structural heart disease.

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Case Report

Biventricular Arrhythmogenic Cardiomyopathy: A New Paradigm?

João Augusto et al. João Abecasis Victor Gil

Abstract

Arrhythmogenic right ventricular dysplasia is a classic form of chronic myocardial disease with a broad phenotypical spectrum. We report an atypical case of a patient with biventricular arrhythmogenic cardiomyopathy. Although the current diagnosis criteria are the most widely accepted ones, they focus solely on the right ventricular phenotype. The use of late gadolinium enhancement in cardiac magnetic resonance in this patient was essential for the diagnosis and assessment of the left ventricular involvement extent. This tool allows a broader use of current diagnosis criteria for this disease.

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Case Report

Monomorphic Ventricular Tachycardia as the First Manifestation in a Patient with Anomalous Coronary Artery

Júlio César Vieira de Sousa et al. Raiana Maciel Miranda Gabriela Melchuna Madruga Domitila Costa de Farias … Paula de Medeiros Nacácio e Silva Nastassja Morgana de Sousa Figueiredo

Introduction

Coronary artery anomalies comprise a heterogeneous group of rare congenital heart defects, being classified according to their origin, course and distal bed, with an incidence ranging between 0.3% and 1.5% in the overall population. Dodge-Khatami et al. subdivided them into seven categories, according to their clinical complexity: coronary arteries originating from the pulmonary artery, coronary arteries with anomalous aortic origin, congenital atresia of the left main coronary artery, coronary arteriovenous fistulas, coronary arteries forming myocardial bridges, coronary artery aneurysms and coronary stenosis. The Texas Children’s Hospital classification uses angiotomography with virtual angioscopy and divides the classification into three topics: origin of the anomalous coronary artery, coronary artery course and ostium morphology. From the viewpoint of anatomical risk, the anomalous left coronary artery with an interarterial course, presence of intramurality and a slit-like ostium are the main predictive factors of severity.^–

A specific type is the anomalous origin of the left coronary artery from the right coronary sinus with an interarterial course, which is associated with hard outcomes in approximately 60% of the cases. Clinically, patients may present with nonspecific symptoms, ranging from palpitations, chest pain, post-exertion syncope or remain asymptomatic throughout life, with sudden death being the first and only manifestation of this condition.

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