Cardiac diseases with risk of severe ventricular arrhythmias; risk stratification and impact of exercise

Mitral annulus disjunction is a gap between the mitral ring and the ventricular myocardium and is associated with mitral valve prolapse. Previous life-threatening arrhythmias were prevalent (12%) in the study population of 116 patients with mitral annulus disjunction. Markers of severe ventricular arrhythmias were lower age, subtle left ventricular dysfunction, papillary muscle fibrosis and absence of concomitant mitral valve prolapse. Mitral annulus disjunction should be considered in the clinical evaluation of patients with malignant cardiac arrhythmias. The hereditary cardiac diseases arrhythmogenic cardiomyopathy and hypertrophic cardiomyopathy are frequent causes of sudden death in the young. High intensity exercise was a strong marker of life-threatening arrhythmias and worse cardiac function in arrhythmogenic cardiomyopathy. Contrarily, in hypertrophic cardiomyopathy, increased exercise was neither associated with ventricular arrhythmias nor increased myocardial hypertrophy and correlated to better diastolic left ventricular function. The results support exercise restriction in arrhythmogenic cardiomyopathy and encourage exercise execution in hypertrophic cardiomyopathy

The Danish tax on saturated fat - demand effects for meat and dairy products

Denmark introduced a tax on saturated fat in food products with effect from October 2011. This paper makes an effect assessment of this tax for some product categories affected by the new tax: meats and dairy products. This assessment is done by conducting an econometric analysis on monthly food retail sales data from a major retail chain in Denmark (Coop Danmark), spanning the period from January 2010 until October 2012.The econometric analysis suggests that the introduction of the tax on saturated fat led to a decrease in the intake of saturated fat from cream products, but not from minced beef

Regional Socioeconomic Impacts of Livestock Regulation - an Integrated Modelling Approach

This paper addresses the combination of environmental regulation and rural development using an integrated economic modelling approach. Specifically, the regional impacts of regulating livestock density at the farm level are analysed in a projected 2010 setting. This scenario is motivated by a concern for nitrogen loads on ground and surface water. The applied model framework includes a macroeconomic CGE-model, an econometric agricultural sector model and a local economic model, and consistent links have been established between these models. The analyses show that the largest relative economic impacts occur in the western parts of Denmark. This occurs in the agricultural sector, because the highest livestock densities are found in the western regions, but also at the general economic level, because agriculture is relatively important for the regional economy in these regions. However, the maximum absolute economic impact on the regional economies in terms of regional GDP is only around one per cent in the most affected region

Harmful effects of exercise intensity and exercise duration in patients with arrhythmogenic cardiomyopathy

Objectives The goal of this study was to explore the association between exercise duration versus exercise intensity and adverse outcome in patients with arrhythmogenic cardiomyopathy (AC). Background Vigorous exercise aggravates and accelerates AC, but there are no data assessing the harmful effects of exercise intensity and duration in these patients. Methods Exercise habits at time of diagnosis were recorded by standardized interviews in consecutive AC patients. Exercise >6 metabolic equivalents was defined as high intensity, and exercise duration was categorized as long if above median. Life-threatening ventricular arrhythmia (VA) was defined as aborted cardiac arrest, documented sustained ventricular tachycardia, ventricular fibrillation, or appropriate implantable cardioverter-defibrillator therapy. Results We included 173 AC patients (53% probands; 44% female; 41 ± 16 years of age). Median weekly exercise duration was 2.5 h (interquartile range: 2.0 to 5.5 h), and 91 patients (52%) reported high-intensity exercise. VA had occurred in 83 patients (48%) and was more prevalent in patients with high-intensity exercise than low-intensity exercise (74% vs. 20%, p < 0.001), and more prevalent in long-duration than short-duration exercise (65% vs. 31%, p < 0.001). High-intensity exercise was a strong and independent marker of VA, even when adjusted for the interaction with long-duration exercise (odds ratio: 3.8; 95% confidence interval: 1.3 to 11.0, p < 0.001), whereas long-duration exercise was not. Conclusions High-intensity exercise was a strong and independent marker of life-threatening VA in AC patients, independent of exercise duration. AC patients could be advised to restrict their exercise intensity

Regional Socioeconomic Impacts of Livestock Regulation - an Integrated Modelling Approach

This paper addresses the combination of environmental regulation and rural development using an integrated economic modelling approach. Specifically, the regional impacts of regulating livestock density at the farm level are analysed in a projected 2010 setting. This scenario is motivated by a concern for nitrogen loads on ground and surface water. The applied model framework includes a macroeconomic CGE-model, an econometric agricultural sector model and a local economic model, and consistent links have been established between these models. The analyses show that the largest relative economic impacts occur in the western parts of Denmark. This occurs in the agricultural sector, because the highest livestock densities are found in the western regions, but also at the general economic level, because agriculture is relatively important for the regional economy in these regions. However, the maximum absolute economic impact on the regional economies in terms of regional GDP is only around one per cent in the most affected region.economic models, livestock density regulation, regional impacts, Livestock Production/Industries,

Cardiac phenotypes and markers of adverse outcome in elite athletes with ventricular arrhythmias

Objectives This study describes the cardiac phenotypes and markers of adverse outcome in athletes with ventricular arrhythmias with no other discernable etiology than high exercise doses. Background Little is known about phenotypes and risk markers of life-threatening arrhythmic events in athletes with ventricular arrhythmia. Methods We compared high-performance athletes who have ventricular arrhythmia with healthy controls using clinical data and cardiac imaging. None of the patients had family history of arrhythmogenic cardiomyopathy or any other discernable etiology of ventricular arrhythmia. Right (RV) and left ventricular (LV) function was assessed by echocardiographic longitudinal strain (right ventricular free wall strain longitudinal [RVFWSL] and left ventricular global longitudinal strain [LVGLS]). Mechanical dispersion was defined as the standard deviation of time to peak strain in 16 LV segments. RV ejection fraction and presence of late gadolinium enhancement was assessed by cardiac magnetic resonance. Results We included 43 athletes (45 ± 14 years of age, 16% female) with ventricular arrhythmias and 30 healthy athletes (41 ± 9 years of age, 7% female). Athletes with ventricular arrhythmias had worse RV function than healthy athletes by echocardiography (RVFWSL: −22.9 ± 4.8% vs. −26.6 ± 3.3%; p < 0.001) and by cardiac magnetic resonance (RV ejection fraction 48 ± 7% vs. 52 ± 6%; p = 0.04), and had more late gadolinium enhancement (24% vs. 3%; p = 0.03). Life-threatening arrhythmic events (aborted cardiac arrest, sustained ventricular tachycardia, or appropriate implantable cardioverter-defibrillator therapy) had occurred in 23 (53%) athletes with ventricular arrhythmias. These had impaired LV function compared to those with less severe ventricular arrhythmias (LVGLS: -17.1 ± 3.0% vs. -18.8 ± 2.0%; p = 0.04). LV mechanical dispersion was an independent marker of life-threatening events (adjusted odds ratio: 2.2 [1.1 to 4.8] by 10 ms increments; p = 0.03). Conclusions Athletes with ventricular arrhythmias had impaired RV function and more myocardial fibrosis compared to healthy athletes. Athletes with life-threatening arrhythmic events had additional LV contraction abnormalities. These phenotypes mimic arrhythmogenic cardiomyopathy and may potentially be induced by high doses of exercise in susceptible individuals

Life-threatening arrhythmic presentation in patients with arrhythmogenic cardiomyopathy before and after entering the genomic era; a two-decade experience from a large volume center

Background: Arrhythmogenic cardiomyopathy (AC) is an inheritable progressive heart disease with high risk of life-threatening ventricular arrhythmia (VA). We aimed to explore the prevalence of VA as presenting event in patients with AC over two decades, symptoms preceding VA and compare the clinical presentations and rate of AC-diagnosis over time. Methods: We included consecutive AC-patients from our tertiary referral center. We recorded clinical history, VA (aborted cardiac arrest, sustained ventricular tachycardia or appropriate implantable cardioverter-defibrillator therapy), cardiac symptoms preceding VA in AC, and compared the history of patients diagnosed before and after implementation of genetic testing. Results: We included 179 consecutive AC-patients and mutation-positive family members (95 [53%] probands, 84 [45%] female, 49 ± 17 years), 33 (18%) diagnosed before and 146 (82%) after genetic testing became available. VA led to the AC-diagnosis in 46 (26%), and was less prevalent after implementation of genetic testing (17[52%] vs. 29[20%], p < 0.001), also when adjusted for proband status (Adjusted OR 2.7, 95% CI 1.1–6.7, p = 0.03). Yearly rate of AC-diagnosis increased after implementation of genetic testing in probands (2.7 ± 1.3 vs. 6.8 ± 4.3, p = 0.01) and family members (0.7 ± 1.1 vs. 7.7 ± 5.9, p = 0.002). Most patients with VA (92%) reported cardiac symptoms prior to event, and exercise-induced syncope was the strongest marker of subsequent VA (Adjusted OR 5.3, 95% CI 1.7–16.4, p = 0.004). Conclusion: VA led to AC-diagnosis in 46% of probands and was preceded by cardiac symptoms in the majority of cases. Yearly rate of AC-diagnoses increased after the implementation of genetic testing and life-threatening presentation of AC-disease seemed to decrease

Prediction of Life-Threatening Ventricular Arrhythmia in Patients With Arrhythmogenic Cardiomyopathy: A Primary Prevention Cohort Study

Objectives: This study aimed to identify clinical, electrocardiographic (ECG) and cardiac imaging predictors of first-time life-threatening ventricular arrhythmia in patients with arrhythmogenic cardiomyopathy (AC). Background: The role of clinical, electrocardiographic, and cardiac imaging parameters in risk stratification of patients without ventricular arrhythmia is unclear. Methods: We followed consecutive AC probands and mutation-positive family members with no documented ventricular arrhythmia from time of diagnosis to first event. We assessed clinical, electrocardiographic, and cardiac imaging parameters according to Task Force Criteria of 2010 in addition to left ventricular (LV) and strain parameters. High-intensity exercise was defined as >6 metabolic equivalents. Results: We included 117 patients (29% probands, 50% female, age 40 ± 17 years). During 4.2 (interquartile range [IQR]: 2.4 to 7.4) years of follow-up, 18 (15%) patients experienced life-threatening ventricular arrhythmias. The 1-, 2-, and 5-year incidence was 6%, 9%, and 22%, respectively. History of high-intensity exercise, T-wave inversions ≥V3, and greater LV mechanical dispersion were the strongest risk markers (adjusted hazard ratio [HR]: 4.7 [95% confidence interval (CI): 1.2 to 17.5]; p = 0.02, 4.7 [95% CI: 1.6 to 13.9]; p = 0.005), and 1.4 [95% CI: 1.2 to 1.6] by 10-ms increments; p < 0.001, respectively). Median arrhythmia-free survival in patients with all risk factors was 1.2 (95% CI: 0.4 to 1.9) years, compared with an estimated 12.0 (95% CI: 11.5 to 12.5) years in patients without any risk factors. Conclusions: History of high-intensity exercise, electrocardiographic T-wave inversions ≥V3, and greater LV mechanical dispersion were strong predictors of life-threatening ventricular arrhythmia. Patients without any of these risk factors had minimal risk, whereas ≥2 risk factors increased the risk dramatically. This may help to make decisions on primary preventive implantable cardioverter defibrillator (ICD) therapy

Exercise is Associated With Impaired Left Ventricular Systolic Function in Patients With Lamin A/C Genotype

Background Lamin A/C cardiomyopathy is a malignant and highly penetrant inheritable cardiomyopathy. Competitive sports have been associated with adverse events in these patients, but data on recreational exercise are lacking. We aimed to explore associations between exercise exposure and disease severity in patients with lamin A/C genotype. Methods and Results Lamin A/C genotype positive patients answered a questionnaire on exercise habits from age 7 years until genetic diagnosis. We recorded exercise hours >3 metabolic equivalents and calculated cumulative lifetime exercise. Patients were grouped in active or sedate based on lifetime exercise hours above or below median. We performed echocardiography, 12‐lead ECG, Holter monitoring, and biomarkers including NT‐proBNP (N‐terminal pro‐B‐type natriuretic peptide). We defined left ventricular ejection fraction <45% as a clinically significant impairment of left ventricular function. We included 69 patients (age 42±14 years, 41% probands, 46% women) with median lifetime exercise 4160 (interquartile range 1041–6924) hours. Active patients were more frequently probands (53% versus 29%, P=0.04), had lower left ventricular ejection fraction (43±13% versus 51±11%, P=0.006), and higher NT‐proBNP (78 [interquartile range 32–219] pmol/L versus 30 [interquartile range 13–64] pmol/L, P=0.03) compared with sedate, while age did not differ (45±13 years versus 40±16 years, P=0.16). The decrease in left ventricular ejection fraction per tertile increment in lifetime exercise was 4% (95% CI −7% to −0.4%, P=0.03), adjusted for age and sex and accounting for dependence within families. Left ventricular ejection fraction <45% was observed at a younger age in active patients (log rank P=0.007). Conclusions Active lamin A/C patients had worse systolic function compared with sedate which occurred at younger age. Our findings may improve exercise recommendations in patients with lamin A/C