Pre-participation Cardiac Screening in Young Athletes: Models and Criteria

This is the second of two review articles focusing on the value of preparticipation cardiac screening in young athletes. The article focuses on the efficacy of the resting 12-lead electrocardiogram (ECG), physical examination, and medical history questionnaire, which commonly make up the first stage of a cardiac screening protocol. The review then focuses on specific structural and electrical abnormalities which are responsible for sudden cardiac death (SCD) in young athletes – the most common of which is hypertrophic cardiomyopathy. The identification of appropriate ‘red flag’ signs and symptoms is essential for teasing out potential pathological conditions and allowing differentiation from often benign physiological adaptations. The final section provides guidance on how the resting 12-lead ECG can be used to separate pathological from physiological adaptations in young athletes

Arrhythmic risk in elderly patients candidates to transcatheter aortic valve replacement. predicative role of repolarization temporal dispersion

Degenerative aortic valve stenosis (AS) is associated to ventricular arrhythmias and sudden cardiac death, as well as mental stress in specific patients. In such a context, substrate, autonomic imbalance as well as repolarization dispersion abnormalities play an undoubted role. Aim of the study was to evaluate the increase of premature ventricular contractions (PVC) and complex ventricular arrhythmias during mental stress in elderly patients candidate to the transcatheter aortic valve replacement (TAVR). In eighty-one elderly patients with AS we calculated several short-period RRand QT-derived variables at rest, during controlled breathing and during mild mental stress, the latter being represented by a mini-mental state evaluation (MMSE). All the myocardial repolarization dispersion markers worsened during mental stress (p < 0.05). Furthermore, during MMSE, low frequency component of the RR variability increased significantly both as absolute power (LFRR) and normalized units (LFRRNU) (p < 0.05) as well as the low-high frequency ratio (LFRR/HFRR) (p < 0.05). Eventually, twenty-four (30%) and twelve (15%) patients increased significantly PVC and, respectively, complex ventricular arrhythmias during the MMSE administration. At multivariate logistic regression analysis, the standard deviation of QTend (QTesd), obtained at rest, was predictive of increased PVC (odd ratio: 1.54, 95% CI 1.14–2.08; p = 0.005) and complex ventricular arrhythmias (odd ratio: 2.31, 95% CI 1.40–3.83; p = 0.001) during MMSE. The QTesd showed the widest sensitive-specificity area under the curve for the increase of PVC (AUC: 0.699, 95% CI: 0.576–0.822, p < 0.05) and complex ventricular arrhythmias (AUC: 0.801, 95% CI: 0.648–0.954, p < 0.05). In elderly with AS ventricular arrhythmias worsened during a simple cognitive assessment, this events being a possible further burden on the outcome of TAVR. QTesd might be useful to identify those patients with the highest risk of ventricular arrhythmias. Whether the TAVR could led to a QTesd reduction and, hence, to a reductionof thearrhythmicburdenin thissettingofpatients isworthytobe investigated

International criteria for electrocardiographic interpretation in athletes: Consensus statement.

Sudden cardiac death (SCD) is the leading cause of mortality in athletes during sport. A variety of mostly hereditary, structural or electrical cardiac disorders are associated with SCD in young athletes, the majority of which can be identified or suggested by abnormalities on a resting 12-lead electrocardiogram (ECG). Whether used for diagnostic or screening purposes, physicians responsible for the cardiovascular care of athletes should be knowledgeable and competent in ECG interpretation in athletes. However, in most countries a shortage of physician expertise limits wider application of the ECG in the care of the athlete. A critical need exists for physician education in modern ECG interpretation that distinguishes normal physiological adaptations in athletes from distinctly abnormal findings suggestive of underlying pathology. Since the original 2010 European Society of Cardiology recommendations for ECG interpretation in athletes, ECG standards have evolved quickly, advanced by a growing body of scientific data and investigations that both examine proposed criteria sets and establish new evidence to guide refinements. On 26-27 February 2015, an international group of experts in sports cardiology, inherited cardiac disease, and sports medicine convened in Seattle, Washington (USA), to update contemporary standards for ECG interpretation in athletes. The objective of the meeting was to define and revise ECG interpretation standards based on new and emerging research and to develop a clear guide to the proper evaluation of ECG abnormalities in athletes. This statement represents an international consensus for ECG interpretation in athletes and provides expert opinion-based recommendations linking specific ECG abnormalities and the secondary evaluation for conditions associated with SCD

Transcranial direct current stimulation improves the QT variability index and autonomic cardiac control in healthy subjects older than 60 years

Background: Noninvasive brain stimulation technique is an interesting tool to investigate the causal relation between cortical functioning and autonomic nervous system (ANS) responses. Objective: The objective of this report is to evaluate whether anodal transcranial direct current stimulation (tDCS) over the temporal cortex influences short-period temporal ventricular repolarization dispersion and cardiovascular ANS control in elderly subjects. Subjects and methods: In 50 healthy subjects (29 subjects younger than 60 years and 21 subjects older than 60 years) matched for gender, short-period RR and systolic blood pressure spectral variability, QT variability index (QTVI), and noninvasive hemodynamic data were obtained during anodal tDCS or sham stimulation. Results: In the older group, the QTVI, low-frequency (LF) power expressed in normalized units, the ratio between LF and high-frequency (HF) power, and systemic peripheral resistances decreased, whereas HF power expressed in normalized units and α HF power increased during the active compared to the sham condition (P,0.05). Conclusion: In healthy subjects older than 60 years, tDCS elicits cardiovascular and autonomic changes. Particularly, it improves temporal ventricular repolarization dispersion, reduces sinus sympathetic activity and systemic peripheral resistance, and increases vagal sinus activity and baroreflex sensitivity

THE EFFECT OF HABITS AND STOCKS ON CONSUMER EXPENDITURE

Consumer/Household Economics,

Physiological Influences of Active and Passive Acute Mental Stress on Cardiac Repolarization: A Preliminary Investigation into Pathophysiological Mechanisms of Adult Cardiac Arrhythmias

Background: Adult cardiac arrhythmias cause adverse health effects including death. While the underlying mechanisms of arrhythmiogenesis have yet to be elucidated, the cardiac autonomic nervous system (ANS) is suggested to play a notable role. As part of the stress response the cardiac ANS is activated under conditions of acute mental stress, yet, little is known about the cardiac ANS stress response and adult arrhythmiogenesis in acute mental stress conditions. This systematic review offers insight into the influences of acute mental active and passive stress and their potential roles in generating proarrhythmic environments, and provides a primary foundation for future clinical research investigating prospective arrhythmiogenic pathophysiological pathways for the prediction, prevention and treatment of adult arrhythmias. Methods: An extensive literature search was performed by two independent reviewers using Pubmed, PsycINFO, and Scopus electronic databases (up to December 2018). All English language articles which assessed adult cardiac electrophysiological, autonomic, and hemodynamic responses, to acute mental stress conditions were included. Results: Eleven studies were identified; 5 studies included active stress tasks, 3 studies included passive stress tasks, and 3 studies included both active and passive stress tasks. Both active and passive stress were associated with pro-arrhythmic electrocardiographic changes, along with increased hemodynamic and autonomic responses. Conclusions: Active and passive stress create a pro-arrhythmic environment through repolarization alterations, increased sympathetic nervous system activity, and concurrent diminished parasympathetic activity. Further studies should include distinctions between active and passive stress cardiac electrophysiology profiles to better understand how mental stress contributes to cardiac arrhythmia etiology

Anxiety in Individuals Affected by Long QT Syndrome as Experienced by Members of an Online User Group

Long QT Syndrome (LQTS) is a cardiac condition that affects approximately 1 in 2,500 persons. This condition has been vastly understudied with regard to psychosocial aspects. LQTS patients have the potential for experiencing life threatening cardiac events and prevention requires significant lifestyle modifications. Although there has not been a significant amount of research on this specific syndrome, other research on chronic illnesses suggests that many individuals experience significant psychosocial aspects after diagnosis. This study specifically examined anxiety within the LQTS population through a qualitative research design. An archived database from a LQTS user group involving approximately 780 members was used to ascertain anxiety related themes. Results of the research provided two distinct periods in which participants expressed anxiety related to the diagnosis. These results are discussed within a cognitive behavioral context to elaborate upon identified themes within this population, including ways in which these responses could become maladaptive. Although the primary goal of this research was to identify specific themes related to anxiety, it also serves as a stepping-stone for future research within the LQTS population

Fathers of Children with Long QT Syndrome: Their Concerns and Ways of Coping

Congenital long QT syndrome (LQTS) is a genetic disorder of the heart that may result in syncope, seizures, and sometimes sudden cardiac death. The wide-ranging clinical presentation of LQTS can lead to fear and uncertainty in families of children diagnosed with LQTS, while treatment and lifestyle modifications can significantly reduce the level of risk. Despite the far-reaching implications of this syndrome on the lives of children and families, very little is known about the psychosocial aspects of having a child with this syndrome. The purpose of this qualitative study was to describe the experiences of fathers of children with LQTS and to investigate their concerns and ways of coping. Fathers’ responses to children’s LQTS have not been previously examined separate from the responses of mothers. A total of 13 fathers of children with LQTS participated in this study, six of whom took part in a one-to-one semi-structured interview and seven of whom completed an online questionnaire. Fathers experienced fear and confusion when their children were initially diagnosed with LQTS. Initial fears were moderated over time with increasing knowledge about LQTS, children’s positive response to treatment and management, and fathers’ perception of LQTS as a manageable condition. Background worries, however, remained related to the uncertain threat of LQTS-related symptoms developing in their children. The level of psychosocial stress that fathers experience over time may vary according to a number of LQTS-related and psychosocial variables, and fathers appeared to utilize a range of strategies to manage stress associated with their children’s LQTS

Stressi ja pitkä QT -oireyhtymä : stressiherkkyyden ja stressaavan ympäristön vaikutukset

Sudden deaths among seemingly healthy young individuals often have a cardiac origin. The long QT-syndrome (LQTS) is one of such potentially lethal cardiac conditions. LQTS is inherited and congenital, and it is typically characterized by a prolonged QT- interval in the electrocardiogram. The mutations that cause LQTS are known and they form several different LQTS subtypes. These mutations most commonly affect the potassium-channel encoding genes KCNQ1 and KCNH2 which define subtypes LQTS1 and LQTS2, and the sodium-effecting ion channel gene SCN5A which defines the subtype LQTS3. It is still unknown why some LQTS mutation carriers become symptomatic while others do not. Previous studies have attempted to uncover the causes behind LQTS symptoms by asking patients about specific events in their imminent environments during symptom onset ( what were you doing/what happened before you had the arrhythmia ). However, these studies typically have not employed rigorous psychometric questionnaires. In the current studies, data from 70-259 symptomatic and 103-328 asymptomatic LQTS mutation carriers, 203 relatives and 79-2056 people from the general Finnish population were utilised. The goal of the thesis was to study what causes symptoms in LQTS. More specifically, it was studied whether or not the symptomatic LQTS mutation carriers differ from asymptomatic ones in their stress proneness, as measured by two temperament scales: Cloninger's TCI and Gray's RST. In addition, to assess environmental stress, questionnaires measuring work stress based on the models by Karasek and Siegrist and their job control-demand and effort-reward scales were employed. Also two additional measures (scales) were employed to assess the interaction between environment and personality traits related to experiencing stress. First, Framingham s type A scale was employed to assess stressful work involvement i.e., individual tendency to experience one's working environment as stressful. Second, the Cope questionnaire and Stressful life events scale were employed to measure the level of emotional distress subjects experienced in response to a stressful life event in the past 12 months. The results indicated that all LQTS mutation carriers (symptomatic and asymptomatic) were equally stress prone, as measured by stress-related temperament sub-scales (harm avoidance and behavioural inhibition). However, the symptomatic patients experienced higher levels of work stress of both scales. In addition, the symptomatic patients experienced higher levels of both stressful work involvement and emotional distress in response to a stressful life event in the past 12 months. Subsequent research should combine the data on the environmental stressors which most likely lead to symptoms, whereby a putative risk score system could be established. Risk scores would enable identifying individuals who are at high risk. Subsequently, pertinent interventions and medical and other attention could be directed at these individuals.Joka vuosi useita perusterveitä nuoria aikuisia kuolee äkillisesti Suomessa. Useimmiten syyt äkillisille kuolemille ovat sydänperäisiä. Pitkä QT -oireyhtymä (LQTS) on sydämen rytmihäiriösairaus, joka voi johtaa perusterveiden nuorten äkillisiin kuolemiin. LQTS:n aiheuttavat mutaatiot on selvitetty. Yleisimmät näistä ovat kaliumionikanavamutaatio KCNQ1:ssä tai KCNH2:ssa, jotka aiheuttavat alatyypit LQTS1 ja LQTS2, ja mutaatio natriumionikanavageenissä SCN5a joka aiheuttaa alatyypin LQTS3. LQTS:ää luonnehtii tyypillisesti pidentynyt QT-aika, joka näkyy sydänsähkökäyrässä. Kaikki mutaationkantajat eivät koskaan oireile. Ei täysin tiedetä, miksi jotkut mutaationkantajista saavat oireita ja toiset eivät. Aiemmissa samalla tutkimusaineistolla tehdyissä tutkimuksissa on selvinnyt, että esimerkiksi krooninen stressi saattaa altistaa oireille pitkä QT -oireyhtymässä. Muissa maissa tehdyissä tutkimuksissa on puolestaan selvitetty esimerkiksi sitä, millaisessa tilanteessa oireet ovat tulleet ( mitä teit/mitä tapahtui kun sait oireita ). On havaittu että LQTS -alatyypit poikkeavat toisistaan myös oireisiin liittyneen tilanteen suhteen. Ulkomaisissa tutkimuksissa asiaa ei ole kuitenkaan tutkittu vakiintuneilla psykometrisilla mittareilla. Tässä tutkimuksessa käytettiin 70 259 oireisen ja 103 328 oireettoman LQTS mutaationkantajan, 203 heidän sukulaisensa, ja 79 2056 Suomen yleisväestöön kuuluvan tietoja. Tutkimuksen päätavoite oli selvittää, mitkä tekijät johtavat oireisuuteen LQTS:ssä. Tavoitteena oli arvioida sisäisen stressiherkkyyden ja ympäristön stressin vaikutuksia. Yksi kysymys oli, poikkeavatko oireiset ja oireettomat LQTS mutaationkantajat toisistaan temperamenttiin liittyvässä stressiherkkyydessä, eli Cloningerin TCI ja Grayn RST -temperamenttimittareilla arvioituna. Ympäristöstä aiheutuvan stressin mittaamiseen käytettiin työstressimittareita, jotka perustuvat Karasekin ja Siegristin työstressimalleihin. Lisäksi hyödynnettiin kahta muuta stressiin liittyvää mittaria. Toisella näistä arvioitiin stressaavaa työhönsitoutumista (Framinghamin A-tyyppisyysmittarista [FTAS] muokatuilla kysymyksillä). Toisella puolestaan arvioitiin emotionaalista pahaa oloa 12 kuukauden sisällä sattuneesta elämäntapahtumasta (mittari perustui the Cope - ja Stressful life events scale -kyselyihin). Tulosten mukaan kaikki LQTS -mutaationkantajat ovat yhtä stressiherkkiä (temperamenttipiirteet vaikeuksien välttäminen ja käyttäytymisen estoisuus ). Toisaalta oireiset kokivat korkeampaa työstressiä (kontrolli-vaatimus-asteikko ja panostus-palkkio-asteikko). Lisäksi oireisilla havaittiin oireettomia korkeampaa stressaantuvaa työhönsitoutumista, ja vahvempaa emotionaalista pahaa oloa 12 kk:n sisällä stressaavasta elämäntapahtumasta. Tutkimustuloksille voidaan ehdottaa merkittäviä käytännön sovelluksia. Ympäristön stressiin liittyvän LQTS -oireisuusriskin määrittäminen ja mahdollisesti muuntaminen yleistettävän riskiluokituksen muotoon olisi syytä olla tulevaisuuden tutkimuksen tavoitteena. Käynnissä on parhaillaan laboratorio- ja pitkittäisseurantatutkimus, joissa LQTS:n kausaalisia ympäristön stressiin liittyviä yhteyksiä voidaan selvittää. Luokittelemalla ihmisiä stressiperäisesti korkeaan rytmihäiriöriskiryhmään voitaisiin mahdollisesti pelastaa ihmishenkiä suuntaamalla esimerkiksi stressinvähennysinterventioita kyseisille potilaille. Lisäksi Suomessa LQTS:n tutkimukselle on hyvät mahdollisuudet: LQTS on Suomessa yleisempi kuin muualla maailmassa. Suomessa ylläpidetään rekisteriä kaikista diagnosoiduista LQTS -mutaationkantajista