Author's Accepted Manuscript
Sudden cardiac arrest recorded during Holter monitoring: Prevalence, antecedent electrical events and outcomes Eiichi Watanabe MD, Teruhisa Tanabe MD, PhD, Motohisa Osaka MD, Akiko Chishaki MD, Bonpei Takase MD, FACC, FAHA, Shinichi Niwano MD, Ichiro Watanabe MD, Kaoru Sugi MD, Takao Katoh MD, Kan Takayanagi MD, FACC, FHRS, Koushi Mawatari MD, Minoru Horie MD, Ken Okumura MD, Hiroshi Inoue MD, Hirotsugu Atarashi MD, FESC, Iwao Yamaguchi MD, FACC, Susumu Nagasawa MD, Kazuo Moroe MD, Itsuo Kodama MD, Tsuneaki Sugimoto MD, Yoshifusa Aizawa MD
PII: DOI: Reference:
S1547-5271(14)00498-6 http://dx.doi.org/10.1016/j.hrthm.2014.04.036 HRTHM5757
To appear in:
Heart Rhythm
www.elsevier.com/locate/buildenv
Cite this article as: Eiichi Watanabe MD, Teruhisa Tanabe MD, PhD, Motohisa Osaka MD, Akiko Chishaki MD, Bonpei Takase MD, FACC, FAHA, Shinichi Niwano MD, Ichiro Watanabe MD, Kaoru Sugi MD, Takao Katoh MD, Kan Takayanagi MD, FACC, FHRS, Koushi Mawatari MD, Minoru Horie MD, Ken Okumura MD, Hiroshi Inoue MD, Hirotsugu Atarashi MD, FESC, Iwao Yamaguchi MD, FACC, Susumu Nagasawa MD, Kazuo Moroe MD, Itsuo Kodama MD, Tsuneaki Sugimoto MD, Yoshifusa Aizawa MD, Sudden cardiac arrest recorded during Holter monitoring: Prevalence, antecedent electrical events and outcomes, Heart Rhythm, http://dx.doi.org/10.1016/j. hrthm.2014.04.036 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
JHRM-D-14-00050R1
Sudden cardiac arrest recorded during Holter monitoring: Prevalence, antecedent electrical events and outcomes
Eiichi Watanabe MD1), Teruhisa Tanabe MD, PhD2), Motohisa Osaka MD 3), Akiko Chishaki MD, 4), Bonpei Takase MD, FACC, FAHA 5), Shinichi Niwano MD 6), Ichiro Watanabe MD 7), Kaoru Sugi MD 8), Takao Katoh MD, 9), Kan Takayanagi MD, FACC, FHRS 10), Koushi Mawatari MD 11), Minoru Horie MD 12), Ken Okumura MD 13), Hiroshi Inoue MD 14), Hirotsugu Atarashi MD, FESC 15), Iwao Yamaguchi MD, FACC 16), Susumu Nagasawa MD 17), Kazuo Moroe MD18), Itsuo Kodama MD 19), Tsuneaki Sugimoto MD 20), and Yoshifusa Aizawa MD 21)
1) Department of Cardiology, Fujita Health University School of Medicine, Toyoake, Japan 2) Department of Cardiology, Tokai University School of Medicine, Isehara, Japan 3) Department of Basic Science, Nippon Veterinary and Life Science University, Tokyo, Japan 4) Department of Health Sciences, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan 5) Department of Intensive Care Unit, National Defense Medical College, Tokorozawa, Japan 6) Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Japan. 7) Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan 8) Division of Cardiovascular Medicine, Toho University Ohashi Medical Center, Tokyo, Japan 9) International University of Health and Welfare, Mita Hospital, Tokyo, Japan 10) Department of Cardiology, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Japan. 11) Department of Cardiology, Kagoshima Seikyo Hospital, Kagoshima, Japan 12) Department of Cardiovascular and Respiratory Medicine, Shiga University of Medical Science, Otsu, Japan 13) Department of Cardiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan 14) Second Department of Internal Medicine, Toyama University Hospital, Toyama, Japan 15) Department of Cardiology, Nippon Medical School, Tama-Nagayama Hospital, Tokyo,
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Japan 16) Tsukuba University School of Medicine, Tsukuba, Japan 17) Cardiovascular Division, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan 18) Fukuoka University School of Medicine, Fukuoka, Japan 19) Nagoya University, Nagoya, Japan 20) Kanto Central Hospital, Tokyo, Japan 21) Division of Research and Development, Tachikawa Medical Center, Nagaoka, Japan
Short title: Sudden cardiac arrest during Holter recording This work was supported by the Vehicle Racing Commemorative Foundation and Suzuken Memorial Foundation. This work does not have any relationships with the industries. Conflict of Interest: Eiichi Watanabe received speaker fees from Bayer and Boehringer Ingelheim. Takao Katoh received consultant fees from Kissei Pharmaceutical and Dai Nippon Sumitomo Pharmaceutical, and received manuscript fee from Astellas and Ono Pharmaceutical. Kaoru Sugi received scholarship funds from Sanofi Aventis, Mochida Pharmaceutical, Daiichi Sankyo and Dai Nippon Sumitomo Pharmaceutical, and speaker fees from Bayer and Boehringer Ingelheim. Hirotsugu Atarashi received consultant fees from Teijin, Otsuka Pharmaceutical and Eisai, and received speaker fees from Daiichi Sankyo, Boehringer Ingelheim, and Bayer, and received research funds from Boehringer Ingelheim. Address for Correspondence Eiichi Watanabe MD Department of Cardiology Fujita Health University School of Medicine 1-98 Dengakugakubo, Kutsukake-cho Toyoake, Aichi 470-1192, JAPAN E-mail: [email protected]; TEL: +81-562-93-2312 FAX: +81-562-93-2315 Word count: 4965
Key words: electrocardiogram; sudden death; arrhythmia; survivor; Holter recording
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Abbreviations list SCA = sudden cardiac arrest ECG = electrocardiogram ICD = implantable cardioverter-defibrillator VTA = ventricular tachyarrhythmia VT = ventricular tachycardia VF = ventricular fibrillation TdP = torsades de pointes AF = atrial fibrillation AV = atrioventricular PVC = premature ventricular complex ACS = acute coronary syndrome OMI = old myocardial infarction AAD = antiarrhythmic drug
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Abstract
Background: Causative arrhythmias of sudden cardiac arrest (SCA) are changing in this age of improved coronary care. Objectives: We examined the frequency of terminal arrhythmias and the electrical events prior to SCA. Methods: We analyzed 24-h Holter recordings in 132 patients enrolled from 41 institutions who either died (n = 88) or had an aborted death (n = 44). The Holter recordings were performed for diagnosing and evaluating diseases and arrhythmias in those without any episodes suggestive of SCA. Results: In 97 (73%) patients, the SCA was associated with ventricular tachyarrhythmias and in 35 (27%) with bradyarrhythmias. The bradyarrhythmia-related SCA patients were older than those with a tachyarrhythmia-related SCA (70±13 years vs. 58±19 years, p100 beats/min, bradycardias with any rhythm having a rate of 3 s, atrioventricular (AV) block, paroxysmal atrial fibrillation (AF), and a high frequency (>10/h) of premature atrial complexes or premature ventricular complexes (PVC). Paroxysmal AF was defined as an arrhythmia of a supraventricular origin associated with a grossly irregular ventricular rhythm and no visible P waves that lasted for >10 s. VT was considered present when at least 3 consecutive PVCs occurred at a rate of >120 beats/min. VF required a disorganized ventricular rhythm with no discrete QRS complexes. Torsades de pointes (TdP) was defined as a distinctive form of polymorphic VT characterized by smooth changes in the amplitude and twisting of the QRS complexes around the isoelectric line. The R on T phenomenon was defined as a superimposition of a PVC on the T wave of a preceding beat. T wave alternans was defined as alternans in either the amplitude or shape of the T wave. Any ST elevation >1 mm or ST depression < -1 mm for >10s was considered to be a reflection of ischemia. Finally, we noted whether the cardiac rhythm was reestablished, and whether the patient survived or not. Several preceding electrical events were observed in each patient, but they had only one terminal arrhythmia before the SCA. The tachycardic terminal arrhythmia types were categorized into four types, namely, as VT degenerating to VF (VT/VF type), VF without any antecedent VT (primary VF type), TdP, or VT throughout the arrest (VT type). The bradycardic terminal arrhythmia types were classified into asystole or AV block. Definition We employed a commonly used definition of SCA, i.e., death from an unexpected circulatory arrest, due to a cardiac arrhythmia occurring within an hour of the onset of symptoms. 1 The survivors in this study were those who had aborted death that was defined as either VTAs lasting >1 min or pauses lasting >10 s, but terminating spontaneously or being
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reversed by resuscitation and leading to the patient’s survival. For the purpose of analyzing the circadian distribution of the SCA, the SCA event time was defined as the time of day when the final, lethal arrhythmia began, whether it was aborted or not. Statistical analysis Differences in the frequency were tested using the chi-square test or Fisher’s exact t-test for categorical data. A Student’s t-test or one-way analysis of variance was used to evaluate continuous variables, where appropriate. Arrhythmias were analyzed as dichotomous outcomes. Stepwise multiple logistic regression analyses were performed to determine which potential variables had significant effects on each of the outcome variables by controlling for other significant variables. Only significant variables (p
Sudden cardiac arrest recorded during Holter monitoring: Prevalence, antecedent electrical events and outcomes Eiichi Watanabe MD, Teruhisa Tanabe MD, PhD, Motohisa Osaka MD, Akiko Chishaki MD, Bonpei Takase MD, FACC, FAHA, Shinichi Niwano MD, Ichiro Watanabe MD, Kaoru Sugi MD, Takao Katoh MD, Kan Takayanagi MD, FACC, FHRS, Koushi Mawatari MD, Minoru Horie MD, Ken Okumura MD, Hiroshi Inoue MD, Hirotsugu Atarashi MD, FESC, Iwao Yamaguchi MD, FACC, Susumu Nagasawa MD, Kazuo Moroe MD, Itsuo Kodama MD, Tsuneaki Sugimoto MD, Yoshifusa Aizawa MD
PII: DOI: Reference:
S1547-5271(14)00498-6 http://dx.doi.org/10.1016/j.hrthm.2014.04.036 HRTHM5757
To appear in:
Heart Rhythm
www.elsevier.com/locate/buildenv
Cite this article as: Eiichi Watanabe MD, Teruhisa Tanabe MD, PhD, Motohisa Osaka MD, Akiko Chishaki MD, Bonpei Takase MD, FACC, FAHA, Shinichi Niwano MD, Ichiro Watanabe MD, Kaoru Sugi MD, Takao Katoh MD, Kan Takayanagi MD, FACC, FHRS, Koushi Mawatari MD, Minoru Horie MD, Ken Okumura MD, Hiroshi Inoue MD, Hirotsugu Atarashi MD, FESC, Iwao Yamaguchi MD, FACC, Susumu Nagasawa MD, Kazuo Moroe MD, Itsuo Kodama MD, Tsuneaki Sugimoto MD, Yoshifusa Aizawa MD, Sudden cardiac arrest recorded during Holter monitoring: Prevalence, antecedent electrical events and outcomes, Heart Rhythm, http://dx.doi.org/10.1016/j. hrthm.2014.04.036 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
JHRM-D-14-00050R1
Sudden cardiac arrest recorded during Holter monitoring: Prevalence, antecedent electrical events and outcomes
Eiichi Watanabe MD1), Teruhisa Tanabe MD, PhD2), Motohisa Osaka MD 3), Akiko Chishaki MD, 4), Bonpei Takase MD, FACC, FAHA 5), Shinichi Niwano MD 6), Ichiro Watanabe MD 7), Kaoru Sugi MD 8), Takao Katoh MD, 9), Kan Takayanagi MD, FACC, FHRS 10), Koushi Mawatari MD 11), Minoru Horie MD 12), Ken Okumura MD 13), Hiroshi Inoue MD 14), Hirotsugu Atarashi MD, FESC 15), Iwao Yamaguchi MD, FACC 16), Susumu Nagasawa MD 17), Kazuo Moroe MD18), Itsuo Kodama MD 19), Tsuneaki Sugimoto MD 20), and Yoshifusa Aizawa MD 21)
1) Department of Cardiology, Fujita Health University School of Medicine, Toyoake, Japan 2) Department of Cardiology, Tokai University School of Medicine, Isehara, Japan 3) Department of Basic Science, Nippon Veterinary and Life Science University, Tokyo, Japan 4) Department of Health Sciences, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan 5) Department of Intensive Care Unit, National Defense Medical College, Tokorozawa, Japan 6) Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Japan. 7) Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan 8) Division of Cardiovascular Medicine, Toho University Ohashi Medical Center, Tokyo, Japan 9) International University of Health and Welfare, Mita Hospital, Tokyo, Japan 10) Department of Cardiology, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Japan. 11) Department of Cardiology, Kagoshima Seikyo Hospital, Kagoshima, Japan 12) Department of Cardiovascular and Respiratory Medicine, Shiga University of Medical Science, Otsu, Japan 13) Department of Cardiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan 14) Second Department of Internal Medicine, Toyama University Hospital, Toyama, Japan 15) Department of Cardiology, Nippon Medical School, Tama-Nagayama Hospital, Tokyo,
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Japan 16) Tsukuba University School of Medicine, Tsukuba, Japan 17) Cardiovascular Division, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan 18) Fukuoka University School of Medicine, Fukuoka, Japan 19) Nagoya University, Nagoya, Japan 20) Kanto Central Hospital, Tokyo, Japan 21) Division of Research and Development, Tachikawa Medical Center, Nagaoka, Japan
Short title: Sudden cardiac arrest during Holter recording This work was supported by the Vehicle Racing Commemorative Foundation and Suzuken Memorial Foundation. This work does not have any relationships with the industries. Conflict of Interest: Eiichi Watanabe received speaker fees from Bayer and Boehringer Ingelheim. Takao Katoh received consultant fees from Kissei Pharmaceutical and Dai Nippon Sumitomo Pharmaceutical, and received manuscript fee from Astellas and Ono Pharmaceutical. Kaoru Sugi received scholarship funds from Sanofi Aventis, Mochida Pharmaceutical, Daiichi Sankyo and Dai Nippon Sumitomo Pharmaceutical, and speaker fees from Bayer and Boehringer Ingelheim. Hirotsugu Atarashi received consultant fees from Teijin, Otsuka Pharmaceutical and Eisai, and received speaker fees from Daiichi Sankyo, Boehringer Ingelheim, and Bayer, and received research funds from Boehringer Ingelheim. Address for Correspondence Eiichi Watanabe MD Department of Cardiology Fujita Health University School of Medicine 1-98 Dengakugakubo, Kutsukake-cho Toyoake, Aichi 470-1192, JAPAN E-mail: [email protected]; TEL: +81-562-93-2312 FAX: +81-562-93-2315 Word count: 4965
Key words: electrocardiogram; sudden death; arrhythmia; survivor; Holter recording
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Abbreviations list SCA = sudden cardiac arrest ECG = electrocardiogram ICD = implantable cardioverter-defibrillator VTA = ventricular tachyarrhythmia VT = ventricular tachycardia VF = ventricular fibrillation TdP = torsades de pointes AF = atrial fibrillation AV = atrioventricular PVC = premature ventricular complex ACS = acute coronary syndrome OMI = old myocardial infarction AAD = antiarrhythmic drug
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Abstract
Background: Causative arrhythmias of sudden cardiac arrest (SCA) are changing in this age of improved coronary care. Objectives: We examined the frequency of terminal arrhythmias and the electrical events prior to SCA. Methods: We analyzed 24-h Holter recordings in 132 patients enrolled from 41 institutions who either died (n = 88) or had an aborted death (n = 44). The Holter recordings were performed for diagnosing and evaluating diseases and arrhythmias in those without any episodes suggestive of SCA. Results: In 97 (73%) patients, the SCA was associated with ventricular tachyarrhythmias and in 35 (27%) with bradyarrhythmias. The bradyarrhythmia-related SCA patients were older than those with a tachyarrhythmia-related SCA (70±13 years vs. 58±19 years, p100 beats/min, bradycardias with any rhythm having a rate of 3 s, atrioventricular (AV) block, paroxysmal atrial fibrillation (AF), and a high frequency (>10/h) of premature atrial complexes or premature ventricular complexes (PVC). Paroxysmal AF was defined as an arrhythmia of a supraventricular origin associated with a grossly irregular ventricular rhythm and no visible P waves that lasted for >10 s. VT was considered present when at least 3 consecutive PVCs occurred at a rate of >120 beats/min. VF required a disorganized ventricular rhythm with no discrete QRS complexes. Torsades de pointes (TdP) was defined as a distinctive form of polymorphic VT characterized by smooth changes in the amplitude and twisting of the QRS complexes around the isoelectric line. The R on T phenomenon was defined as a superimposition of a PVC on the T wave of a preceding beat. T wave alternans was defined as alternans in either the amplitude or shape of the T wave. Any ST elevation >1 mm or ST depression < -1 mm for >10s was considered to be a reflection of ischemia. Finally, we noted whether the cardiac rhythm was reestablished, and whether the patient survived or not. Several preceding electrical events were observed in each patient, but they had only one terminal arrhythmia before the SCA. The tachycardic terminal arrhythmia types were categorized into four types, namely, as VT degenerating to VF (VT/VF type), VF without any antecedent VT (primary VF type), TdP, or VT throughout the arrest (VT type). The bradycardic terminal arrhythmia types were classified into asystole or AV block. Definition We employed a commonly used definition of SCA, i.e., death from an unexpected circulatory arrest, due to a cardiac arrhythmia occurring within an hour of the onset of symptoms. 1 The survivors in this study were those who had aborted death that was defined as either VTAs lasting >1 min or pauses lasting >10 s, but terminating spontaneously or being
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reversed by resuscitation and leading to the patient’s survival. For the purpose of analyzing the circadian distribution of the SCA, the SCA event time was defined as the time of day when the final, lethal arrhythmia began, whether it was aborted or not. Statistical analysis Differences in the frequency were tested using the chi-square test or Fisher’s exact t-test for categorical data. A Student’s t-test or one-way analysis of variance was used to evaluate continuous variables, where appropriate. Arrhythmias were analyzed as dichotomous outcomes. Stepwise multiple logistic regression analyses were performed to determine which potential variables had significant effects on each of the outcome variables by controlling for other significant variables. Only significant variables (p
