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      Signal‐averaged electrocardiography: Past, present, and future

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          Abstract

          Signal‐averaged electrocardiography records delayed depolarization of myocardial areas with slow conduction that can form the substrate for monomorphic ventricular tachycardia. This technique has been examined mostly in patients with coronary artery disease, but its use has been declined over the years. However, several lines of evidence, derived from hitherto clinical data in patients with healed myocardial infarction, indicate that signal‐averaged electrocardiography remains a valuable tool in risk stratification, especially when incorporated into algorithms encompassing invasive and noninvasive indices. Such an approach can aid the more precise identification of candidates for device therapy, in the context of primary prevention of sudden cardiac death. This article reappraises the value of signal‐averaged electrocardiography as a predictor of arrhythmic outcome in patients with ischemic heart disease and discusses potential future indications.

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          Most cited references 61

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          Diagnosis of arrhythmogenic right ventricular cardiomyopathy/dysplasia: proposed modification of the task force criteria.

          In 1994, an International Task Force proposed criteria for the clinical diagnosis of arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) that facilitated recognition and interpretation of the frequently nonspecific clinical features of ARVC/D. This enabled confirmatory clinical diagnosis in index cases through exclusion of phenocopies and provided a standard on which clinical research and genetic studies could be based. Structural, histological, electrocardiographic, arrhythmic, and familial features of the disease were incorporated into the criteria, subdivided into major and minor categories according to the specificity of their association with ARVC/D. At that time, clinical experience with ARVC/D was dominated by symptomatic index cases and sudden cardiac death victims-the overt or severe end of the disease spectrum. Consequently, the 1994 criteria were highly specific but lacked sensitivity for early and familial disease. Revision of the diagnostic criteria provides guidance on the role of emerging diagnostic modalities and advances in the genetics of ARVC/D. The criteria have been modified to incorporate new knowledge and technology to improve diagnostic sensitivity, but with the important requisite of maintaining diagnostic specificity. The approach of classifying structural, histological, electrocardiographic, arrhythmic, and genetic features of the disease as major and minor criteria has been maintained. In this modification of the Task Force criteria, quantitative criteria are proposed and abnormalities are defined on the basis of comparison with normal subject data. The present modifications of the Task Force Criteria represent a working framework to improve the diagnosis and management of this condition. URL: http://www.clinicaltrials.gov. Unique identifier: NCT00024505.
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            Defibrillator Implantation in Patients with Nonischemic Systolic Heart Failure.

            Background The benefit of an implantable cardioverter-defibrillator (ICD) in patients with symptomatic systolic heart failure caused by coronary artery disease has been well documented. However, the evidence for a benefit of prophylactic ICDs in patients with systolic heart failure that is not due to coronary artery disease has been based primarily on subgroup analyses. The management of heart failure has improved since the landmark ICD trials, and many patients now receive cardiac resynchronization therapy (CRT). Methods In a randomized, controlled trial, 556 patients with symptomatic systolic heart failure (left ventricular ejection fraction, ≤35%) not caused by coronary artery disease were assigned to receive an ICD, and 560 patients were assigned to receive usual clinical care (control group). In both groups, 58% of the patients received CRT. The primary outcome of the trial was death from any cause. The secondary outcomes were sudden cardiac death and cardiovascular death. Results After a median follow-up period of 67.6 months, the primary outcome had occurred in 120 patients (21.6%) in the ICD group and in 131 patients (23.4%) in the control group (hazard ratio, 0.87; 95% confidence interval [CI], 0.68 to 1.12; P=0.28). Sudden cardiac death occurred in 24 patients (4.3%) in the ICD group and in 46 patients (8.2%) in the control group (hazard ratio, 0.50; 95% CI, 0.31 to 0.82; P=0.005). Device infection occurred in 27 patients (4.9%) in the ICD group and in 20 patients (3.6%) in the control group (P=0.29). Conclusions In this trial, prophylactic ICD implantation in patients with symptomatic systolic heart failure not caused by coronary artery disease was not associated with a significantly lower long-term rate of death from any cause than was usual clinical care. (Funded by Medtronic and others; DANISH ClinicalTrials.gov number, NCT00542945 .).
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              Prophylactic use of implanted cardiac defibrillators in patients at high risk for ventricular arrhythmias after coronary-artery bypass graft surgery. Coronary Artery Bypass Graft (CABG) Patch Trial Investigators.

               J Bigger (1997)
              Patients with coronary heart disease, left ventricular dysfunction, and abnormalities on signal-averaged electrocardiograms have an increased risk sudden death. We evaluated the effect on survival of the prophylactic implantation of cardioverter-defibrillators in such patients at the time of coronary-artery bypass surgery. Over the course of five years, 37 clinical centers screened all patients who were scheduled for elective coronary bypass surgery. Patients were eligible for the trial if they were less than 80 years old, had a left ventricular ejection fraction of less than 0.36, and had abnormalities on signal-averaged electrocardiograms. We identified 1422 eligible patients, enrolled 1055, and randomly assigned 900 to therapy with an implantable cardioverter-defibrillator (446 patients) or to the control group (454 patients). The primary end point of the study was overall mortality, and the two groups were compared in an intention-to-treat analysis. The base-line characteristics of the two groups were similar. During an average follow-up of 32+/-16 months, there were 101 deaths in the defibrillator group (71 from cardiac causes) and 95 in the control group (72 from cardiac causes). The hazard ratio for death from any cause was 1.07 (95 percent confidence interval, 0.81 to 1.42; P=0.64). There was no statistically significant interaction between defibrillator therapy and any of 10 preselected base-line covariates. We found no evidence of improved survival among patients with coronary heart disease, a depressed left ventricular ejection fraction, and an abnormal signal-averaged electrocardiogram in whom a defibrillator was implanted prophylactically at the time of elective coronary bypass surgery.
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                Author and article information

                Contributors
                kgatzoul@med.uoa.gr
                Journal
                J Arrhythm
                J Arrhythm
                10.1002/(ISSN)1883-2148
                JOA3
                Journal of Arrhythmia
                John Wiley and Sons Inc. (Hoboken )
                1880-4276
                1883-2148
                28 May 2018
                June 2018
                : 34
                : 3 ( doiID: 10.1002/joa3.2018.34.issue-3 )
                : 222-229
                Affiliations
                [ 1 ] Electrophysiology Laboratory and First University Department of Cardiology Hippokration General Hospital National and Kapodestrian University of Athens Athens Greece
                [ 2 ] Department of Cardiology Hippokration General Hospital Athens Greece
                [ 3 ] Electrophysiology Laboratory Athens Medical Center Athens Greece
                [ 4 ] Department of Cardiology University of Ioannina Ioannina Greece
                [ 5 ] Cardiovascular Research Institute Ioannina Greece
                Author notes
                [* ] Correspondence

                Konstantinos A. Gatzoulis, Hippokration General Hospital, Athens, Greece.

                Email: kgatzoul@ 123456med.uoa.gr

                Article
                JOA312062
                10.1002/joa3.12062
                6010001
                © 2018 The Authors. Journal of Arrhythmia published by John Wiley & Sons Australia, Ltd on behalf of the Japanese Heart Rhythm Society.

                This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc-nd/4.0/ License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.

                Page count
                Figures: 6, Tables: 0, Pages: 8, Words: 5739
                Product
                Categories
                Review Article
                Review Article
                Custom metadata
                2.0
                joa312062
                June 2018
                Converter:WILEY_ML3GV2_TO_NLMPMC version:version=5.4.1.1 mode:remove_FC converted:20.06.2018

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