During the 40th Heart Rhythm Scientific Session to be held in San Francisco, USA, between May 8 and 11, a Joint Session will be held between HRS and LAHRS: the S-JS13. LAHRS / HRS Joint Session: Catheter Ablation of Atrial Fibrillation: Is the Epicardium the Key to Improve the Results? Soon we will expand on date, time and room.
A clinical update article published in the JAMA on March 19 addressed the issue of the evaluation of heart rhythm abnormalities using portable devices *
Dr. James E. Ip, author of the note, points out that while portable devices for use by patients are potentially useful for detecting arrhythmias, physicians must understand the limitations of these devices and be prepared to analyze the data. which will be corroborated with the respective clinic of the patients.
In the article, reference is made to the KardiaTM by AliveCor®, which is an application for smartphone and smartwatch and the Apple Watch Series 4, which is a wristwatch, both capable of recording ECG tracings for 30 consecutive seconds.
Portable devices initially used accelerometers to stimulate physical activity and assess cardiac activity during sleep, but recently incorporated heart rate sensors to allow them to adapt to specific physical fitness programs and also to assess resting heart rate (as an indicator of fitness physical).
Most devices estimate heart rate using photoplethysmographic (PPG) sensors that detect changes in tissue blood volume (caused by peripheral pulses) and perform measurements using dedicated photodetectors and light-emitting diodes.
Accurate measurements depend on adequate blood flow and contact with the skin, and can be modified by patient or device movements, environmental conditions and ectopic beats.
Although most of these devices can show heart rate in real time, retrospective analysis of heart rate trends may be limited and depend on each of them and the respective application used.
Recently, Apple Watch incorporated an irregular rhythm notification function that detects irregularity based on resting PPG and can notify the user of the possible occurrence of atrial fibrillation (AF).
In addition, this device can provide notifications of tachycardia (the default is> 120 / min, but it is adjustable) and bradycardia (the default is <40 / min which is also adjustable) for 10 minutes of inactivity. Therefore, said alert parameters may not detect transient arrhythmias or induced by exercise.
Due to the limited specificity of PPG-based sensors, abnormal findings need confirmation with direct measurement of the conventional electrocardiogram (ECG).
For example, as noted, the Kardia Mobile device and the Apple Watch Series 4 can record, store and transfer single-channel ECG rhythms of 30 seconds.
Although these patient-activated intermittent ambulatory ECG monitors may be convenient to use compared to traditional ambulatory ECG monitors (eg, wired adhesive electrodes or patch-based Holter monitors, event monitors, mobile cardiac by telemetry), no they record continuously and are prone to inaccuracy due to electrical and sound interferences, movement artifacts and inadequate skin contact. A heart rate out of range (<50 or => 100 / min) also does not allow automated interpretation.
Detection and evaluation of FA
Although PPG-based sensors can detect irregularities, they may not distinguish between AF and atrial / ventricular premature beats or variable AV conduction (ie, second-degree AVB).
Apple emphasizes that “the irregular rhythm notification function is not constantly looking for the FA and should not be trusted as a continuous monitor.” Therefore, it is not intended to replace traditional methods of FA detection, but patients may receive a “talk to their doctor” message.
If an FA alert is detected, confirmation with direct ECG measurement is essential. During the concurrent use of Apple Watch and an outpatient ECG patch, 57 participants in the Apple Heart Study received an FA notification.
However, only 45 of them (79%) showed AF concordant with that recorded with the ECG patch and 11 (19%) showed “Other clinically relevant arrhythmias” (no further details were reported).
Inappropriate detections of AF may have been caused by ectopic rhythms (ie, atrial or ventricular premature beats) or variable AV conduction (ie, second-degree atrioventricular block type I or atrial flutter with variable block).
The extrasystoles, which are common, may not be clinically relevant unless they cause significant symptoms or ventricular dysfunction.
Variable AV block may also not be clinically relevant unless it causes symptoms of the resulting bradycardia.
Therefore, if other non-FA arrhythmias are detected with the ECG test, the physician should ask about symptoms related to frequent extrasystole (ie, palpitations, intolerance to exertion) or atrioventricular block (ie, presyncope, syncope) and perform a thorough examination. If there are no symptoms present, no further evaluation is necessary, but if there are symptoms such as palpitations, intolerance to exertion, presyncope or syncope, follow-up tests would be appropriate with ambulatory ECG monitoring.
If AF is confirmed with ambulatory ECG monitoring, the physician should consider the patient’s risk factors for thromboembolism (CHADS-VASc score [congestive heart failure, hypertension, age, diabetes, stroke, vascular disease]) and the risks individualized about the effects of prophylactic anticoagulation.
Additional evaluation includes evaluation of any structural heart disease (echocardiography) and consideration of the optimal frequency or rhythm control strategy, which depends on the patient’s symptoms and comorbidities.
Detection and evaluation of tachycardia
The detection of sinus tachycardia with the development of activity is expected, although a sudden acceleration of resting heart rate suggests a non-physiological tachycardia such as AF or a paroxysmal supraventricular tachycardia. Resting tachycardia may be due to anxiety, dehydration, or other underlying conditions (eg, anemia, pregnancy, infection, hyperthyroidism)
Although PPG-based sensors are reasonably accurate during regular rhythms, performance decreases during AF due to beat-to-beat pulse variations. Among patients with tachycardia during AF, only 15% of the readings of the Fitbit device and 60% of the Apple Watch readings were within a precision range of 10 beats.
If an inappropriate tachycardia is detected and it is not due to an artifact, the ECG recordings during the tachycardia and at the beginning are fundamental to determine its mechanism and guide its later handling.
In general, if the episodes are sporadic, the patient may need ambulatory monitoring with ECG. Once paroxysmal tachycardia is confirmed, an invasive electrophysiology can accurately determine the mechanism of the tachycardia and provide definitive therapy.
Detection and evaluation of bradycardia
Inadequate bradycardia can be observed with a heart rate that is very slow at rest (<40 beats / min) or that does not accelerate properly with exercise (chronotropic incompetence).
False detections of bradycardia can occur from a frequent ectopia (ventricular bigeminy). True bradycardia may be due to primary electrical disorders, such as sinus node dysfunction or atrioventricular block, or secondary to a vagal hypertonia (chronic at rest or transient during sleep apnea).
Chronotropic incompetence would not trigger a bradycardia alert when the patient is at rest, but could be triggered by a slow heart rate response during activity. Bradycardia of sinus node dysfunction or atrioventricular block is diagnosed by an ECG test.
If bradycardia is detected, the doctor should ask the patient about any correlative symptoms (ie, syncope or presyncope) because symptomatic bradycardia may justify pacemaker implantation. Pacemakers that have characteristics of frequency adaptation can improve the symptoms of chronotropic incompetence.
However, it is important to rule out the secondary causes of bradycardia, such as hypothyroidism, medications and sleep apnea, especially if bradycardia occurs only during rest.
As conclusions the author states that as they increase the use of portable devices and direct medical devices for use by the patient and the potential anomalies detected by them are brought to the attention of physicians, it is essential to carry out an adequate evaluation and perform confirmatory tests of ECG.
Understanding the possible triggers of patient notifications and concerns, as well as a careful evaluation of symptoms, are important for diagnosing arrhythmias and treating inappropriate alarms. The future development and incorporation of this technology with the practice of medicine will continue to evolve.
* Ip JE. Evaluation of Cardiac Rhythm Abnormalities From Wearable Devices. JAMA 2019 Mar 19; 321 (11): 1098-1099. doi: 10.1001 / jama.2019.1681.
On November 29th and 30th, the first official conference of our society –LAHRS 2018- was held in Cartagena, Colombia. More than 300 specialists from all Latin America attended the conference, and it was considered a success in all possible ways.
The scientific program approached and discussed topical issues about syncope, sudden cardiac death, atrial fibrillation ablation, ventricular tachycardia, prevention of thromboembolism, resynchronization therapy, and electrode extraction, among others.
There were joint sessions with sister supranational societies from Europe (EHRA), Asia/Oceania (APHRS), and the United States (HRS), ending the year’s schedule agreed with them, besides having the presence of official delegates from all those institutions. The joint activity with the Pacing and Electrophysiology Section of the Sociedad Española de Cardiología was outstanding, as well as the meeting with the first authorities of the Pediatric and Congenital Electrophysiology Society (PACES).
There was also time for social activities, in an informal and relaxed environment, between attendees and guests. This is quite significant, as it helps to disseminate Latin American electrophysiology to the rest of the world.
The regular annual assembly was held, in which there were decisions made on all the topics included in the agenda.
Everything went according to plan, with sensible expectations for our first event, and with a lot of room to grow and improve. LAHRS is a consolidated hallmark that rightly makes all Latin Americans proud. We hope that the enthusiasm we feel as we returned, keeps spreading.
Thursday, November 29, 2018, Hall Bolívar 2, Hilton Hotel, Cartagena, Colombia.
First call at 13 hours: no statutory quorum.
Second call at 13:30 hours; the session starts with 46 attendees. The outgoing President, Dr. Roberto Keegan reads the agenda, already reported in the announcement.
- Statement of accounts
The outgoing treasurer, Dr. Alejandro Cuesta, presents a report on the institutional situation: Achievement of legal status, record of by-laws, founding members, opening of bank accounts, and agreement with credit cards to collect the membership fees.
It is reported that the Society still has no headquarters of its own, and that it operates by an agreement with the Sociedad Uruguaya de Cardiología. It is reported that there is still no hired staff and that all work is done by the payment of independent professional fees or for free.
An institutional Web page has been created, posted in three languages (Spanish, Portuguese and English) and a weekly report letter is sent by e-mail to all members.
The financial report is presented. To this date, there is a positive balance of 43,635 US dollars.
From the financial point of view, there is a debt of 40,527 US dollars with EHRA for their participation in two documents, for which there is planned funding that has not realized yet. There is also a debt of 11,920 US dollars not yet due and with no funding for it.
Questions are asked, and satisfaction is expressed because of the historical level of organization achieved.
The following is approved:
- Approval of temporary regulations
The regulations on elections and conferences, already presented on the Web site, are submitted for the consideration of the attendees, and no objections or modifications are proposed.
The following is decided: To approve both regulations permanently.
- Appointment of Honorary Members
It is reported that the outgoing Executive Committee proposed the appointment of all the previous Presidents of SOLAECE as Honorary Members, as well as colleagues from other countries that have made very significant contributions for LAHRS to become a reality. There are no objections or modifications proposed. The proposal is approved.
Andrea Natale, Angelo Auricchio, Antonio Curnis, Bryan cannon, Carlos Morillo, Gabriel Varnagy, Diego Vanegas, Douglas Packer, George Van Hare, Gerhard Hindricks, Guilherme Fenelon, Hugh Calkins, John Camm, Jonathan Kalman, Jose Luis Merino, Josep Brugada, Lluis Mont, Luis Aguinaga, Luis Molina, Oscar Oseroff, Raul Weiss, Sami Viskin, Silas Galvao y Thomas Deering.
Daniel Barnaghi by Gabriel Varnagy and Thomas Deering by Deering.
- Annual membership fee
The outgoing President reports that the payment system of the fee by online credit card is already operational, but payment increases slowly.
It is proposed to keep the yearly fee in 100 US dollars for the next term. There are no objections, and there are no modifications proposed. It is approved.
- Future conferences
- LAHRS 2019
There was a proposal to conduct LAHRS 2019 in Buenos Aires, jointly with the Congreso Argentino de Arritmias and with the support of local societies.
The outgoing President reports the existence of a signed agreement between the World Society of Arrhythmias (WSA) and the Sociedad Argentina de Electrofisiología Cardíaca (SADEC) to make a joint conference. In the conversations held with their authorities, LAHRS offered a participation that does not satisfy the Executive Committee in terms of form and finances.
Alternatives are discussed and different opinions are proposed, with the presence and participation in the room of Dr. Oscar Oseroff, that is also a representative of WSA and Dr. Rodolfo Sansalone, who is also the current President of SADEC.
The following is decided:
- To hand over to the Executive Committee the necessary measures to make possible the performance of a joint conference in year 2019 in Buenos Aires, taking into account the level of representation and influence of LAHRS in Latin America.
- To request from the WSA and SADEC a proposal contemplating our previous goals.
- LAHRS 2020
The performance of said event is proposed, this time to be held in Mexico. There is a chance to advance it to 2019 if the previous agreement is not achieved.
It is decided to approve it.
- Dr. Fernando Vidal from the Dominican Republic makes a formal presentation offering the city of Punta Cana in his country to hold LAHRS 2021.
It is decided to approve the candidacy of the city.
- Brazil is proposed as next host country, and the choice of city is being defined internally in said country.
If the steps taken to hold LAHRS 2019 in Buenos Aires fail, the order of host cities will be maintained, advancing them one year.
- Election of the Official LAHRS Journal
Proposals have been received from the prestigious journals: PACE, HICE and JCE to conduct agreements by which they would be the official scientific journal of LAHRS.
The outgoing Secretary, Dr. Marcio Figueiredo shows a presentation with a comparative study of the three proposals.
Opinions are exchanged.
It is decided to entrust the incoming Executive Committee with deciding between the proposals presented.
- Change of Authorities
Elections are held in time and manner, according to the by-laws and the transitory regulations, and the result of the elections is presented to the Assembly. There are no objections, it is approved, and the new Authorities of LAHRS for the 2019-2020 term are proclaimed.
|President||Luis Carlos Sáenz||Colombia|
|First Board Member||José Moltedo||Argentina|
|Second Board Member||Heliodoro Rodríguez||Venezuela|
|Vice President||Márcio Figueiredo||Brazil|
|Deputy Secretary||Néstor López Cabanillas||Argentina|
|Deputy Treasurer||Sebastián Massaferro||Uruguay|
|Third Board Member||Armando Alfaro||Costa Rica|
|Fourth Board Member||Ricardo Alkmin||Brazil|
The elected President, Dr. Luis Carlos Sáenz speaks, expresses his gratefulness, summarizes his aims for the next term, and the assembly ends.
Dr. Roberto Keegan
Dr. Marcio Figueiredo
Elected Vice President
Dr. Luis Carlos Sáenz
Dr. Alejandro Cuesta
Outgoing and elected Treasurer
We would like to express our most sincere gratefulness for the support received during these 2 years of management leading SOLAECE/LAHRS. Particularly, from the more than 360 members of our society from 19 countries (Argentina, Bolivia, Brazil, Chile, Colombia, Costa Rica, Cuba, Ecuador, El Salvador, Spain, Honduras, Mexico, Nicaragua, Paraguay, Peru, Dominican Republic, Uruguay, USA and Venezuela) and living in 24 countries (Saudi Arabia, Argentina, Bolivia, Brazil, Canada, Chile, Colombia, Costa Rica, Cuba, Ecuador, El Salvador, Spain, Guyana, Holland, Honduras, Israel, Mexico, Nicaragua, Paraguay, Peru, Dominican Republic, Uruguay, USA and Venezuela) currently constituting the society.
There were many goals proposed, very ambitious too, and the road has been difficult. The need to establish a modern society, with institutional strength and that would be a deserving follower of our dear SOLAECE, required a great deal of work to achieve our first significant aim: our legal identity as LAHRS. It was established on May 20th, 2017 in the city of Montevideo, Uruguay, with new by-laws and regulations that provided the necessary framework for a proper institutional operation. Another example of this has been our first elections, which ended legitimizing the new authorities for the 2019-2020 term.
Also, we set out to expand our educational activity. We worked very hard on the development of programs that may benefit our Latin American community of electrophysiologists, particularly the young ones and those who are still training. We could continue with the LAHRS and Memorial Health System scholarship programs, that enabled the participation of young colleagues from Argentina, Brazil and Mexico over these 2 years. Also, we started the LAHRS & McGill EP Fellowship program, by which two young Latin Americans in training (from Uruguay and Ecuador) were selected to participate in this 2-year training program in a Canadian center of international standing.
In the scientific and academic field, we continued with the agreements of participation with our sister international societies (APHRS, EHRA and HRS). Since year 2014, SOLAECE/LAHRS has participated in 32 joint documents (14 published between 2017 and 2018), with a total of 93 outstanding participations by members of our society, representing 13 countries (Brazil, Argentina, Colombia, Mexico, Uruguay, Venezuela, Chile, Peru, Costa Rica, Paraguay, Dominican Republic, Cuba and Canada).
Finally, we could realize our first Conference – LAHRS 2018 (Cartagena, Colombia). This originated an eagerly awaited schedule of international conferences on arrhythmias, agreed with APHRS, EHRA and HRS, so that each will have a major academic-scientific event, distributed throughout the year.
Support from national societies is and will continue to be fundamental to consolidate LAHRS; societies such as SOBRAC (Brazil), SADEC (Argentina), SOMEEC (Mexico) and the Colegio Colombiano de Electrofisiología (Colombia) and all committees and/or chapters of cardiac electrophysiology of national societies of cardiology. We would like to grow to be a large Latin American tree, and these are our roots.
Our process coincided with the change of rules for scientific societies to relate to the industry, the historical and essential support to conduct medical updating events. Maybe, this was the most significant challenge we faced. Scientific meetings from all over the world, with a long and prestigious history, suffered the impact by this new scenario, particularly the number of attendees. But LAHRS was capable of generating the transparent mechanisms to continue taking advantage of the continuing predisposition by the industry to provide support. We could accomplish a conference in a short time, with more than 300 registrations, and we became the referential organization in the continent in regard to this matter.
Finally, we would like to highlight that the support of all the exemplary colleagues that preceded us has been essential to advance with this process. With this spirit that they transmitted to us, we will continue working and supporting those that will come after us, with the conviction that LAHRS will be very beneficial for the quality of care of all the population of our Latin America.
On behalf of the 2017-2018 Executive Committee, we say goodbye to all members, and seize this opportunity to wish you a Merry Christmas and a Happy New Year.
President of LAHRS 2017-2018
Secretary of LAHRS 2017-2018
Treasurer of LAHRS 2017-2018