Importance of monitoring zones in the detection of arrhythmias in patients with implantable cardioverter-defibrillators under remote monitoring | Revista Portuguesa de Cardiologia (English edition)

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Almeida, António Almeida, Teresa Melo, Lurdes Guerra, Luís Lopes, Patrícia Ribeiro, Marta Duarte, Alexandra Mota, Ricardo Fontes-Carvalho" "autores" => array:9 [ 0 => array:2 [ "nombre" => "Ana G." 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An ICD is able to terminate potentially life-threatening ventricular arrhythmias, preventing syncope, hypotension and, most importantly, sudden cardiac death. Device algorithms and thresholds for detection and therapies are programmed according to age, indication and the underlying cardiac disease.<a class="elsevierStyleCrossRef" href="#bib0130">2</a>For lower heart rates, monitoring zones (MZ), in which the device does not deliver therapy but monitors the heart rhythm, are commonly used in clinical practice. MZ provide passive features that do not interfere with the functioning of active treatment zones. MZ can also classify events as supraventricular or ventricular arrhythmias.<a class="elsevierStyleCrossRef" href="#bib0135">3</a> However, it is not known for certain whether the programming of an MZ affects arrhythmia detection by the ICD or the clinical management of these patients.The aim of the present study is to assess the benefit in clinical practice of MZ for treatment in a population of patients with ICDs or cardiac resynchronization therapy-defibrillator (CRT-D) devices for primary prevention.MethodsThis was a retrospective analysis of patients implanted with an ICD or CRT-D for primary prevention at a tertiary center between 2006 and 2015. Devices were implanted according to international guidelines.<a class="elsevierStyleCrossRef" href="#bib0140">4</a> Patients with indication for implantation for secondary prevention were excluded.All patients with a programmed MZ were considered for the study. This zone was programmed according to heart rate (140-170 bpm) and persistence (number of consecutive cycles >50). Therapy zones were programmed for 170-200 bpm for 30 out of 40 cycles (ATP attempts or shock), and >200 bpm for 12 out of 18 cycles (ATP during charge or shock).The MZ criteria were changed according to the arrhythmia data obtained via the device during follow-up. ATP-based therapy was activated only in patients presenting with slow VT (below the cut-off of 170 bpm).All enrolled patients received a remote monitoring (RM) system. The RM equipment was provided at the first outpatient visit after ICD or CRT-D implantation and reports were reviewed by trained staff under the supervision of a senior electrophysiologist.Initially a retrospective analysis was performed of MZ reports through the RM system and recorded arrhythmias were assessed in detail. In patients with single-chamber devices, atrial fibrillation (AF) detection was based on heart rate combined with absence of stability criteria, according to cycle length irregularity during the arrhythmia. Sinus tachycardia, supraventricular tachycardia and non-sustained ventricular tachycardia (NSVT) were differentiated by the onset criteria and using comparison with native QRS complex morphology and cycle length. In patients with arrhythmic events documented in the MZ, the decision of the physician at the outpatient clinic visit regarding the treatment approach was analyzed by reviewing patient files. A second analysis of MZ reports through RM systems was then performed to determine the impact of changes in medication or invasive strategy on the recurrence of arrhythmic events. For all patients, data were collected regarding arrhythmic events, device programming and appropriate and inappropriate therapies via ICD or CRT-D.Statistical analysisThe statistical analysis was performed using IBM SPSS Statistics, version 19 (IBM SPSS, Chicago, IL). Continuous variables were expressed as mean ± standard deviation and categorical variables were expressed as percentage. Study groups were compared using the Student's t test or the Wilcoxon-Mann-Whitney test for continuous variables, and Pearson's chi-square or Fisher's exact test for categorical measures, as appropriate. A p-value <0.05 was considered statistically significant.ResultsDuring the study period, 898 patients underwent ICD and CRT-D implantation, of whom 221 received the device for primary prevention with facilities for RM. The baseline characteristics of the study population are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. Of the overall population, 77% were men, mean age was 64±12 years, and mean left ventricular ejection fraction was 30±12%. Dilated and ischemic cardiomyopathy were the most common underlying conditions, followed by hypertrophic cardiomyopathy, primary electrical cardiac disease and congenital heart disease.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Mean follow-up after implantation was 63±35 months, during which MZ data were collected. One hundred and seventy-four events were documented in the MZ in 139 patients (62.9% of the overall population) (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>). Supraventricular arrhythmias accounted for almost half of all findings (49.4%), with a similar incidence of supraventricular tachycardia and AF/atrial flutter. In 29 patients (20.9%), AF and other supraventricular arrhythmias were diagnosed based on electrograms from single-chamber ICDs. NSVT occurred in 74 patients (42.5% of all events) in the MZ. Only five events were due to noise. Regarding ICD therapy delivery, of the 137 patients who presented arrhythmic events in the MZ (excluding two patients with noise detection only), 22 (16.1%) received appropriate shocks and/or ATP, while in the other 84 patients without events in the MZ, 15.5% received appropriate ICD therapies (p=0.908) (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>). In patients with NSVT in the MZ the frequency of appropriate ICD therapy was not significantly different from the others, with 15 patients (20.5%) receiving device therapy.<elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia>In accordance with the MZ findings, physicians decided to change outpatient medication in 58 patients (41.7% of all patients in whom arrhythmic events were reported in the MZ), due to supraventricular arrhythmia in 24 cases and to ventricular tachycardia in 34. In the presence of NSVT in the MZ, the initiation or titration of antiarrhythmic drugs (mainly beta-blockers and amiodarone) was based on the presence of symptoms and/or NSVT length and burden. Among these 58 subjects, six started beta-blockers, 11 started amiodarone, and eight (13.8%) started chronic oral anticoagulation. The previously prescribed antiarrhythmic drug dosage was titrated in 44 patients. Beta-blocker dosage was increased in 41 patients and amiodarone/sotalol dosage was increased in three cases. In addition to optimization of medical treatment, two patients underwent ablation of supraventricular arrhythmias detected in the MZ (atrial flutter and atrioventricular nodal reentrant tachycardia) and three underwent atrioventricular junction ablation due to AF with rapid ventricular response (and low percentage of biventricular pacing). Furthermore, internal cardioversion via the ICD was performed in one patient with persistent AF (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>). Since there was uncertainty whether the AF burden justified oral anticoagulation, the initiation of this medication was based on the physician's decision. However, in view of the high risk in this population, patients presenting AF episodes lasting >5 min were prescribed anticoagulation therapy.<elsevierMultimedia ident="fig0015"></elsevierMultimedia>After optimization of medical therapy, 37 patients (63.8%) did not have recurrence of arrhythmic events in the MZ, 70.8% in the supraventricular arrhythmia subgroup and 55.6% in the ventricular tachycardia subgroup. In those with recurrence, 16 individuals presented NSVT episodes, five showed supraventricular tachycardia and two had paroxysmal AF. In three cases there was more than one type of arrhythmia. Despite changes in medication, 15 patients (25.9%) had recurrence of the same arrhythmia.Among the 65 patients with NSVT, in whom antiarrhythmic medication was increased, during a follow-up of 10.0±7.5 months no appropriate therapies were delivered by the device, and more than half (55.6%) did not present recurrence of documented arrhythmias in the MZ. In the overall population, arrhythmic events in the MZ were detected in 62.9%, which led to treatment changes in 27.1%, with a consequent 17% decrease in the arrhythmic events detected in the MZ. There were no clinical or technical complications reported in relation to the activation of MZ.DiscussionProgramming an MZ for primary prevention in ICD patients leads to the detection of symptomatic or asymptomatic arrhythmias, indicating that it may be a useful tool in the optimization of medical and interventional treatment in this population.The benefits of RM in preventing hospital admission for heart failure or cardiovascular death are well documented.<a class="elsevierStyleCrossRefs" href="#bib0145">5–7</a> However, its usefulness in optimization of antiarrhythmic treatment has not been so extensively studied. As highlighted in the present study, RM enables early detection of new-onset or paroxysmal arrhythmias in the MZ and hence early therapeutic intervention.In our sample, arrhythmic events were documented in the MZ in 62.9% of patients. These findings had a significant impact on clinical practice, since in half of the patients outpatient medication was changed and/or ablation was performed. This optimization in patient management resulted in a considerable reduction in arrhythmic events reported in the MZ.As previously reported, patients with cardiac devices presented a high incidence of atrial arrhythmias, even in the absence of symptoms.<a class="elsevierStyleCrossRef" href="#bib0160">8</a> Around 50% of ICD carriers can be expected to experience AF during the lifetime of the device.<a class="elsevierStyleCrossRef" href="#bib0165">9</a> In our population, new-onset paroxysmal AF/atrial flutter was found in a significant proportion of patients (20%), leading to the initiation of oral anticoagulation. This incidence is similar to data reported by Ricci et al., who found an AF incidence of 26% in pacemaker/ICD patients.<a class="elsevierStyleCrossRef" href="#bib0170">10</a> Since AF, even if paroxysmal or asymptomatic, is associated with a five-fold increase in the risk of ischemic stroke,<a class="elsevierStyleCrossRef" href="#bib0175">11</a> recognition of these episodes and initiation of anticoagulation may provide protection against thromboembolic events such as stroke. Programming an MZ provides valuable information on AF occurrence, AF burden and consequent stroke risk. These continuous monitoring data (particularly when combined with RM systems) can be of considerable value, since many AF episodes with clinically significant duration are asymptomatic.<a class="elsevierStyleCrossRef" href="#bib0180">12</a> Improvements in use of and adherence to oral anticoagulation based on continuous ICD monitoring have recently been demonstrated.<a class="elsevierStyleCrossRef" href="#bib0185">13</a>The impact of appropriate shocks on quality of life and morbidity in ICD patients remains a concern,<a class="elsevierStyleCrossRefs" href="#bib0190">14–16</a> and reducing the rate of shock therapies is a real challenge for the ICD outpatient clinic. Initiation or titration of antiarrhythmic drugs in patients with NSVT documented in the MZ has the potential to reduce the rate of shocks and ATP delivered to patients. In fact, in our population, among patients with NSVT whose antiarrhythmic medication was optimized no shocks or ATP were delivered via the device, and 55.6% of these patients did not present recurrence of documented arrhythmias in the MZ. Since NSVT is associated with an increased risk of death in both ischemic<a class="elsevierStyleCrossRef" href="#bib0200">16</a> and non-ischemic cardiomyopathy,<a class="elsevierStyleCrossRefs" href="#bib0205">17–19</a> its detection and consequent therapeutic optimization can potentially reduce ICD therapies in these patients.It is also important to emphasize that in our study, regardless of the type of arrhythmia recorded, analysis of the MZ had the potential to change physicians’ decisions in 27.1% of cases, with an impact on arrhythmia recurrence.There have been concerns that MZ can be associated with increased risk of inappropriate device therapy,<a class="elsevierStyleCrossRefs" href="#bib0220">20,21</a> however in our study only two patients (0.9%) received inappropriate therapies due to AF with rapid ventricular response. This incidence is much lower than that described in the Detect Supraventricular Tachycardia Study, in which the rate of inappropriate detection of supraventricular tachycardias was 31%,<a class="elsevierStyleCrossRef" href="#bib0230">22</a> or in a study by van Rees et al. of a prospective registry, with 13% of inappropriate shocks.<a class="elsevierStyleCrossRef" href="#bib0235">23</a> High-rate cut-off programming for detection and therapy in primary prevention has been shown to decrease this rate substantially to 6.6%.<a class="elsevierStyleCrossRef" href="#bib0240">24</a>The present study showed that continuous rhythm monitoring by the cardiac device unmasks arrhythmias in asymptomatic and symptomatic patients, with an impact on clinical management, leading to a significant decrease in arrhythmic events detected in the MZ.Study limitationsThis is an observational long-term retrospective study with the inherent limitations, including the absence of a control group. The relatively small sample size results from the single-center nature of the study. However, our results reflect a real-life long-term clinical practice experience based on an RM program.ConclusionDetection of spontaneous ventricular and supraventricular arrhythmias are common findings in a population with implantable cardiac devices for primary prevention with a programmed MZ. The MZ appears to be of value in the diagnosis of arrhythmias, and may be a useful tool in clinical practice. In our study, the treatment approach was changed in about half of the patients based on MZ reports. It is also important to emphasize that anticoagulation was started in patients with previously unknown paroxysmal AF, providing an important measure in stroke prevention.Conflicts of interestThe authors have no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1269859" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1175321" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1269858" "titulo" => "Resumo" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introdução" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusão" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1175322" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Statistical analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0020" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0030" "titulo" => "Study limitations" ] 9 => array:2 [ "identificador" => "sec0035" "titulo" => "Conclusion" ] 10 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-09-05" "fechaAceptado" => "2018-05-13" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1175321" "palabras" => array:5 [ 0 => "Implantable cardioverter-defibrillator" 1 => "Monitoring zone" 2 => "Supraventricular arrhythmias" 3 => "Ventricular arrhythmias" 4 => "Clinical practice" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec1175322" "palabras" => array:5 [ 0 => "Cardioversor desfibrilhador implantável" 1 => "Zona de monitorização" 2 => "Arritmias supraventriculares" 3 => "Arritmias ventriculares" 4 => "Prática clínica" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "IntroductionImplantable cardioverter-defibrillator (ICD) monitoring zones (MZ) provide passive features that do not interfere with the functioning of active treatment zones. However, it is not known for certain whether programming an MZ affects arrhythmia detection by the ICD. The aim of the present study is to assess the clinical relevance of MZ in a population of patients with ICDs. MethodsIn this retrospective analysis of patients with ICDs, with or without cardiac resynchronization therapy, for primary prevention under remote monitoring, the MZ was analyzed and recorded arrhythmias were assessed in detail. ResultsA total of 221 patients were studied (77% men; age 64±12 years). Mean ejection fraction was 30±12%. The mean follow-up was 63±35 months. One hundred and seventy-four MZ events were documented in 139 patients (62.9%): 74 of non-sustained ventricular tachycardia (NSVT), 42 of supraventricular tachycardia, 44 of atrial fibrillation/atrial flutter, and five cases of noise. Among the 137 patients who presented with arrhythmias in the MZ (excluding two cases with noise detection only), 22 (16.1%) received appropriate shocks and/or antitachycardia pacing (ATP), while of the other 84 patients, 15.5% received appropriate ICD treatment (p=NS). In patients who presented with NSVT in the MZ, 15 (20.5%) received appropriate shocks and/or ATP. In accordance with the MZ findings, physicians decided to change outpatient medication in 41.7% of all patients in whom arrhythmic events were reported. ConclusionVentricular and supraventricular arrhythmias are common findings in the MZ of ICD patients. Programming an MZ is valuable in the diagnosis of arrhythmias and may be a useful tool in clinical practice." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "pt" => array:3 [ "titulo" => "Resumo" "resumen" => "IntroduçãoA zona de monitorização (ZM) de cardioversor desfibrilhador implantável (CDI) permite uma funcionalidade passiva que não interfere com o funcionamento das zonas de tratamento ativo. Contudo, não é perfeitamente conhecido se a programação de ZM afeta a deteção de arritmias pelo CDI. O objetivo do presente estudo é avaliar a relevância clínica de ZM numa população submetida a implantação de CDI. MétodosAnálise retrospetiva de doentes submetidos a implantação de CDI, com ou sem terapia de ressincronização cardíaca, em prevenção primária, sob monitorização remota. ZM foi analisada e as arritmias documentadas avaliadas em detalhe. ResultadosForam estudados 221 doentes (77% homens; 64±12 anos). Fração de ejeção média foi 30±12%. O período de seguimento médio foi 63±35 meses. Foram documentados 174 eventos na ZM, em 139 doentes (62.9%): taquicardia ventricular não sustentada (TVNS) – 74, taquicardia supraventricular – 42, fibrilhação/flutter auricular – 44, ruído – 5. Dos 137 doentes que apresentaram arritmia na ZM (excluindo dois casos de deteção de ruído), 22 (16,1%) receberam choques apropriados ou pacing antitaquicardia (PAT), enquanto que dos restantes 84 doentes, 15,5% receberam terapias apropriadas do CDI (p=NS). Dos doentes que apresentaram TVNS na ZM, 15 (20,5%) receberam choques apropriados e/ou pacing anti-taquicardia (PAT). De acordo com os achados em ZM, o médico decidiu alterar a terapia oral de ambulatório em 41,7% de todos os doentes com eventos arrítmicos reportados. ConclusãoArritmas ventriculares e supraventriculares são achados comuns na ZM de CDI. A programação de ZM é importante no diagnóstico de arritmias e poderá ser um elemento útil na prática clínica." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introdução" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusão" ] ] ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 803 "Ancho" => 2500 "Tamanyo" => 86472 ] ] "descripcion" => array:1 [ "en" => "Arrhythmic events documented in the monitoring zone during follow-up." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1015 "Ancho" => 2091 "Tamanyo" => 60768 ] ] "descripcion" => array:1 [ "en" => "Comparison of appropriate device therapies between patients with and without arrhythmic events detected in the monitoring zone." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 957 "Ancho" => 1574 "Tamanyo" => 70914 ] ] "descripcion" => array:1 [ "en" => "Influence of monitoring zone reports on the treatment approach." ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "CHD: congenital heart disease; CRT-D: cardiac resynchronization therapy-defibrillator; DCM: dilated cardiomyopathy; HCM: hypertrophic cardiomyopathy; ICD: implantable cardioverter-defibrillator; ICM: ischemic cardiomyopathy; LVEF: left ventricular ejection fraction; MZ: monitoring zone; VHD: valvular heart disease." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Overall population (n=221) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Events in MZ (n=139) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">No events in MZ (n=82) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age, years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">64±12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">64.7±12.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">63.0±15.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.364 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Male, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">170 (76.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">103 (74.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">67 (81.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.120 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LVEF, % \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30±12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27.6±11.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">33.5±12.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.002 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Etiology, n (%)</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">DCM \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">95 (43.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">75 (54.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20 (24.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.007 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ICM \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">94 (42.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">50 (36.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">44 (53.6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.027 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">HCM \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 (6.8%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 (5.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 (9.8%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.237 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Primary electrical cardiac disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 (5.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (2.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 (9.8%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.077 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CHD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (1.8%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (2.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (1.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.300 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">VHD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (0.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (0.6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (1.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.000 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Device, n (%)</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ICD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">138 (62.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">73 (52.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">65 (79.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Single-chamber \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">124 (89.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">65 (47.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">59 (42.8%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dual-chamber \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 (10.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 (5.8%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (4.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CRT-D \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">83 (37.6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">66 (47.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17 (20.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Device programming, n (%)</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MZ 140 bpm/VT 170 bpm/VF 210 bpm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">171 (77.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">94 (67.6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">77 (93.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MZ 140 bpm/VT 170 bpm/VF 214 bpm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">50 (22.6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">45 (32.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 (6.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2172285.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Baseline characteristics of the study population." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:24 [ 0 => array:3 [ "identificador" => "bib0125" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "2015 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: the Task Force for the Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death of the European Society of Cardiology (ESC). 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Original Article

Importance of monitoring zones in the detection of arrhythmias in patients with implantable cardioverter-defibrillators under remote monitoring

Importância da zona de monitorização na deteção de arritmias em portadores de cardioversor desfibrilhador implantável em programa de monitorização remota

Sílvia Aguiar Rosa

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silviaguiarosa@gmail.com

Corresponding author.

, Pedro Silva Cunha, Ana Lousinha, Bruno Valente, Ana Sofia Delgado, Ricardo Pimenta, Manuel Brás, Madalena Coutinho Cruz, Guilherme Portugal, André Viveiros Monteiro, Mário Oliveira, Rui Cruz Ferreira

Cardiology Department, Santa Marta Hospital, Lisbon, Portugal

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        "autoresLista" => "S&#237;lvia Aguiar Rosa, Pedro Silva Cunha, Ana Lousinha, Bruno Valente, Ana Sofia Delgado, Ricardo Pimenta, Manuel Br&#225;s, Madalena Coutinho Cruz, Guilherme Portugal, Andr&#233; Viveiros Monteiro, M&#225;rio Oliveira, Rui Cruz Ferreira"
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            "entidad" => "Cardiology Department&#44; Santa Marta Hospital&#44; Lisbon&#44; Portugal"
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        "titulo" => "Import&#226;ncia da zona de monitoriza&#231;&#227;o na dete&#231;&#227;o de arritmias em portadores de cardioversor desfibrilhador implant&#225;vel em programa de monitoriza&#231;&#227;o remota"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Comparison of appropriate device therapies between patients with and without arrhythmic events detected in the monitoring zone&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Implantable cardioverter-defibrillators &#40;ICDs&#41; are the treatment of choice for primary prevention against sudden cardiac death&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">1</span></a> Arrhythmia therapy is delivered in the form of antitachycardia pacing &#40;ATP&#41; or shock&#46; An ICD is able to terminate potentially life-threatening ventricular arrhythmias&#44; preventing syncope&#44; hypotension and&#44; most importantly&#44; sudden cardiac death&#46; Device algorithms and thresholds for detection and therapies are programmed according to age&#44; indication and the underlying cardiac disease&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">For lower heart rates&#44; monitoring zones &#40;MZ&#41;&#44; in which the device does not deliver therapy but monitors the heart rhythm&#44; are commonly used in clinical practice&#46; MZ provide passive features that do not interfere with the functioning of active treatment zones&#46; MZ can also classify events as supraventricular or ventricular arrhythmias&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">3</span></a> However&#44; it is not known for certain whether the programming of an MZ affects arrhythmia detection by the ICD or the clinical management of these patients&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The aim of the present study is to assess the benefit in clinical practice of MZ for treatment in a population of patients with ICDs or cardiac resynchronization therapy-defibrillator &#40;CRT-D&#41; devices for primary prevention&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">This was a retrospective analysis of patients implanted with an ICD or CRT-D for primary prevention at a tertiary center between 2006 and 2015&#46; Devices were implanted according to international guidelines&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">4</span></a> Patients with indication for implantation for secondary prevention were excluded&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">All patients with a programmed MZ were considered for the study&#46; This zone was programmed according to heart rate &#40;140-170 bpm&#41; and persistence &#40;number of consecutive cycles &#62;50&#41;&#46; Therapy zones were programmed for 170-200 bpm for 30 out of 40 cycles &#40;ATP attempts or shock&#41;&#44; and &#62;200 bpm for 12 out of 18 cycles &#40;ATP during charge or shock&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The MZ criteria were changed according to the arrhythmia data obtained via the device during follow-up&#46; ATP-based therapy was activated only in patients presenting with slow VT &#40;below the cut-off of 170 bpm&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">All enrolled patients received a remote monitoring &#40;RM&#41; system&#46; The RM equipment was provided at the first outpatient visit after ICD or CRT-D implantation and reports were reviewed by trained staff under the supervision of a senior electrophysiologist&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Initially a retrospective analysis was performed of MZ reports through the RM system and recorded arrhythmias were assessed in detail&#46; In patients with single-chamber devices&#44; atrial fibrillation &#40;AF&#41; detection was based on heart rate combined with absence of stability criteria&#44; according to cycle length irregularity during the arrhythmia&#46; Sinus tachycardia&#44; supraventricular tachycardia and non-sustained ventricular tachycardia &#40;NSVT&#41; were differentiated by the onset criteria and using comparison with native QRS complex morphology and cycle length&#46; In patients with arrhythmic events documented in the MZ&#44; the decision of the physician at the outpatient clinic visit regarding the treatment approach was analyzed by reviewing patient files&#46; A second analysis of MZ reports through RM systems was then performed to determine the impact of changes in medication or invasive strategy on the recurrence of arrhythmic events&#46; For all patients&#44; data were collected regarding arrhythmic events&#44; device programming and appropriate and inappropriate therapies via ICD or CRT-D&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Statistical analysis</span><p id="par0045" class="elsevierStylePara elsevierViewall">The statistical analysis was performed using IBM SPSS Statistics&#44; version 19 &#40;IBM SPSS&#44; Chicago&#44; IL&#41;&#46; Continuous variables were expressed as mean &#177; standard deviation and categorical variables were expressed as percentage&#46; Study groups were compared using the Student&#39;s t test or the Wilcoxon-Mann-Whitney test for continuous variables&#44; and Pearson&#39;s chi-square or Fisher&#39;s exact test for categorical measures&#44; as appropriate&#46; A p-value &#60;0&#46;05 was considered statistically significant&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0050" class="elsevierStylePara elsevierViewall">During the study period&#44; 898 patients underwent ICD and CRT-D implantation&#44; of whom 221 received the device for primary prevention with facilities for RM&#46; The baseline characteristics of the study population are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; Of the overall population&#44; 77&#37; were men&#44; mean age was 64&#177;12 years&#44; and mean left ventricular ejection fraction was 30&#177;12&#37;&#46; Dilated and ischemic cardiomyopathy were the most common underlying conditions&#44; followed by hypertrophic cardiomyopathy&#44; primary electrical cardiac disease and congenital heart disease&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Mean follow-up after implantation was 63&#177;35 months&#44; during which MZ data were collected&#46; One hundred and seventy-four events were documented in the MZ in 139 patients &#40;62&#46;9&#37; of the overall population&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; Supraventricular arrhythmias accounted for almost half of all findings &#40;49&#46;4&#37;&#41;&#44; with a similar incidence of supraventricular tachycardia and AF&#47;atrial flutter&#46; In 29 patients &#40;20&#46;9&#37;&#41;&#44; AF and other supraventricular arrhythmias were diagnosed based on electrograms from single-chamber ICDs&#46; NSVT occurred in 74 patients &#40;42&#46;5&#37; of all events&#41; in the MZ&#46; Only five events were due to noise&#46; Regarding ICD therapy delivery&#44; of the 137 patients who presented arrhythmic events in the MZ &#40;excluding two patients with noise detection only&#41;&#44; 22 &#40;16&#46;1&#37;&#41; received appropriate shocks and&#47;or ATP&#44; while in the other 84 patients without events in the MZ&#44; 15&#46;5&#37; received appropriate ICD therapies &#40;p&#61;0&#46;908&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46; In patients with NSVT in the MZ the frequency of appropriate ICD therapy was not significantly different from the others&#44; with 15 patients &#40;20&#46;5&#37;&#41; receiving device therapy&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">In accordance with the MZ findings&#44; physicians decided to change outpatient medication in 58 patients &#40;41&#46;7&#37; of all patients in whom arrhythmic events were reported in the MZ&#41;&#44; due to supraventricular arrhythmia in 24 cases and to ventricular tachycardia in 34&#46; In the presence of NSVT in the MZ&#44; the initiation or titration of antiarrhythmic drugs &#40;mainly beta-blockers and amiodarone&#41; was based on the presence of symptoms and&#47;or NSVT length and burden&#46; Among these 58 subjects&#44; six started beta-blockers&#44; 11 started amiodarone&#44; and eight &#40;13&#46;8&#37;&#41; started chronic oral anticoagulation&#46; The previously prescribed antiarrhythmic drug dosage was titrated in 44 patients&#46; Beta-blocker dosage was increased in 41 patients and amiodarone&#47;sotalol dosage was increased in three cases&#46; In addition to optimization of medical treatment&#44; two patients underwent ablation of supraventricular arrhythmias detected in the MZ &#40;atrial flutter and atrioventricular nodal reentrant tachycardia&#41; and three underwent atrioventricular junction ablation due to AF with rapid ventricular response &#40;and low percentage of biventricular pacing&#41;&#46; Furthermore&#44; internal cardioversion via the ICD was performed in one patient with persistent AF &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41;&#46; Since there was uncertainty whether the AF burden justified oral anticoagulation&#44; the initiation of this medication was based on the physician&#39;s decision&#46; However&#44; in view of the high risk in this population&#44; patients presenting AF episodes lasting &#62;5 min were prescribed anticoagulation therapy&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">After optimization of medical therapy&#44; 37 patients &#40;63&#46;8&#37;&#41; did not have recurrence of arrhythmic events in the MZ&#44; 70&#46;8&#37; in the supraventricular arrhythmia subgroup and 55&#46;6&#37; in the ventricular tachycardia subgroup&#46; In those with recurrence&#44; 16 individuals presented NSVT episodes&#44; five showed supraventricular tachycardia and two had paroxysmal AF&#46; In three cases there was more than one type of arrhythmia&#46; Despite changes in medication&#44; 15 patients &#40;25&#46;9&#37;&#41; had recurrence of the same arrhythmia&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Among the 65 patients with NSVT&#44; in whom antiarrhythmic medication was increased&#44; during a follow-up of 10&#46;0&#177;7&#46;5 months no appropriate therapies were delivered by the device&#44; and more than half &#40;55&#46;6&#37;&#41; did not present recurrence of documented arrhythmias in the MZ&#46; In the overall population&#44; arrhythmic events in the MZ were detected in 62&#46;9&#37;&#44; which led to treatment changes in 27&#46;1&#37;&#44; with a consequent 17&#37; decrease in the arrhythmic events detected in the MZ&#46; There were no clinical or technical complications reported in relation to the activation of MZ&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discussion</span><p id="par0075" class="elsevierStylePara elsevierViewall">Programming an MZ for primary prevention in ICD patients leads to the detection of symptomatic or asymptomatic arrhythmias&#44; indicating that it may be a useful tool in the optimization of medical and interventional treatment in this population&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The benefits of RM in preventing hospital admission for heart failure or cardiovascular death are well documented&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">5&#8211;7</span></a> However&#44; its usefulness in optimization of antiarrhythmic treatment has not been so extensively studied&#46; As highlighted in the present study&#44; RM enables early detection of new-onset or paroxysmal arrhythmias in the MZ and hence early therapeutic intervention&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">In our sample&#44; arrhythmic events were documented in the MZ in 62&#46;9&#37; of patients&#46; These findings had a significant impact on clinical practice&#44; since in half of the patients outpatient medication was changed and&#47;or ablation was performed&#46; This optimization in patient management resulted in a considerable reduction in arrhythmic events reported in the MZ&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">As previously reported&#44; patients with cardiac devices presented a high incidence of atrial arrhythmias&#44; even in the absence of symptoms&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">8</span></a> Around 50&#37; of ICD carriers can be expected to experience AF during the lifetime of the device&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">9</span></a> In our population&#44; new-onset paroxysmal AF&#47;atrial flutter was found in a significant proportion of patients &#40;20&#37;&#41;&#44; leading to the initiation of oral anticoagulation&#46; This incidence is similar to data reported by Ricci et al&#46;&#44; who found an AF incidence of 26&#37; in pacemaker&#47;ICD patients&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">10</span></a> Since AF&#44; even if paroxysmal or asymptomatic&#44; is associated with a five-fold increase in the risk of ischemic stroke&#44;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">11</span></a> recognition of these episodes and initiation of anticoagulation may provide protection against thromboembolic events such as stroke&#46; Programming an MZ provides valuable information on AF occurrence&#44; AF burden and consequent stroke risk&#46; These continuous monitoring data &#40;particularly when combined with RM systems&#41; can be of considerable value&#44; since many AF episodes with clinically significant duration are asymptomatic&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">12</span></a> Improvements in use of and adherence to oral anticoagulation based on continuous ICD monitoring have recently been demonstrated&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">13</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">The impact of appropriate shocks on quality of life and morbidity in ICD patients remains a concern&#44;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">14&#8211;16</span></a> and reducing the rate of shock therapies is a real challenge for the ICD outpatient clinic&#46; Initiation or titration of antiarrhythmic drugs in patients with NSVT documented in the MZ has the potential to reduce the rate of shocks and ATP delivered to patients&#46; In fact&#44; in our population&#44; among patients with NSVT whose antiarrhythmic medication was optimized no shocks or ATP were delivered via the device&#44; and 55&#46;6&#37; of these patients did not present recurrence of documented arrhythmias in the MZ&#46; Since NSVT is associated with an increased risk of death in both ischemic<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">16</span></a> and non-ischemic cardiomyopathy&#44;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">17&#8211;19</span></a> its detection and consequent therapeutic optimization can potentially reduce ICD therapies in these patients&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">It is also important to emphasize that in our study&#44; regardless of the type of arrhythmia recorded&#44; analysis of the MZ had the potential to change physicians&#8217; decisions in 27&#46;1&#37; of cases&#44; with an impact on arrhythmia recurrence&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">There have been concerns that MZ can be associated with increased risk of inappropriate device therapy&#44;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">20&#44;21</span></a> however in our study only two patients &#40;0&#46;9&#37;&#41; received inappropriate therapies due to AF with rapid ventricular response&#46; This incidence is much lower than that described in the Detect Supraventricular Tachycardia Study&#44; in which the rate of inappropriate detection of supraventricular tachycardias was 31&#37;&#44;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">22</span></a> or in a study by van Rees et al&#46; of a prospective registry&#44; with 13&#37; of inappropriate shocks&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">23</span></a> High-rate cut-off programming for detection and therapy in primary prevention has been shown to decrease this rate substantially to 6&#46;6&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">24</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">The present study showed that continuous rhythm monitoring by the cardiac device unmasks arrhythmias in asymptomatic and symptomatic patients&#44; with an impact on clinical management&#44; leading to a significant decrease in arrhythmic events detected in the MZ&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Study limitations</span><p id="par0115" class="elsevierStylePara elsevierViewall">This is an observational long-term retrospective study with the inherent limitations&#44; including the absence of a control group&#46; The relatively small sample size results from the single-center nature of the study&#46; However&#44; our results reflect a real-life long-term clinical practice experience based on an RM program&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusion</span><p id="par0120" class="elsevierStylePara elsevierViewall">Detection of spontaneous ventricular and supraventricular arrhythmias are common findings in a population with implantable cardiac devices for primary prevention with a programmed MZ&#46; The MZ appears to be of value in the diagnosis of arrhythmias&#44; and may be a useful tool in clinical practice&#46; In our study&#44; the treatment approach was changed in about half of the patients based on MZ reports&#46; It is also important to emphasize that anticoagulation was started in patients with previously unknown paroxysmal AF&#44; providing an important measure in stroke prevention&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflicts of interest</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Implantable cardioverter-defibrillator &#40;ICD&#41; monitoring zones &#40;MZ&#41; provide passive features that do not interfere with the functioning of active treatment zones&#46; However&#44; it is not known for certain whether programming an MZ affects arrhythmia detection by the ICD&#46; The aim of the present study is to assess the clinical relevance of MZ in a population of patients with ICDs&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">In this retrospective analysis of patients with ICDs&#44; with or without cardiac resynchronization therapy&#44; for primary prevention under remote monitoring&#44; the MZ was analyzed and recorded arrhythmias were assessed in detail&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A total of 221 patients were studied &#40;77&#37; men&#59; age 64&#177;12 years&#41;&#46; Mean ejection fraction was 30&#177;12&#37;&#46; The mean follow-up was 63&#177;35 months&#46; One hundred and seventy-four MZ events were documented in 139 patients &#40;62&#46;9&#37;&#41;&#58; 74 of non-sustained ventricular tachycardia &#40;NSVT&#41;&#44; 42 of supraventricular tachycardia&#44; 44 of atrial fibrillation&#47;atrial flutter&#44; and five cases of noise&#46; Among the 137 patients who presented with arrhythmias in the MZ &#40;excluding two cases with noise detection only&#41;&#44; 22 &#40;16&#46;1&#37;&#41; received appropriate shocks and&#47;or antitachycardia pacing &#40;ATP&#41;&#44; while of the other 84 patients&#44; 15&#46;5&#37; received appropriate ICD treatment &#40;p&#61;NS&#41;&#46; In patients who presented with NSVT in the MZ&#44; 15 &#40;20&#46;5&#37;&#41; received appropriate shocks and&#47;or ATP&#46; In accordance with the MZ findings&#44; physicians decided to change outpatient medication in 41&#46;7&#37; of all patients in whom arrhythmic events were reported&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Ventricular and supraventricular arrhythmias are common findings in the MZ of ICD patients&#46; Programming an MZ is valuable in the diagnosis of arrhythmias and may be a useful tool in clinical practice&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introdu&#231;&#227;o</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A zona de monitoriza&#231;&#227;o &#40;ZM&#41; de cardioversor desfibrilhador implant&#225;vel &#40;CDI&#41; permite uma funcionalidade passiva que n&#227;o interfere com o funcionamento das zonas de tratamento ativo&#46; Contudo&#44; n&#227;o &#233; perfeitamente conhecido se a programa&#231;&#227;o de ZM afeta a dete&#231;&#227;o de arritmias pelo CDI&#46; O objetivo do presente estudo &#233; avaliar a relev&#226;ncia cl&#237;nica de ZM numa popula&#231;&#227;o submetida a implanta&#231;&#227;o de CDI&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">An&#225;lise retrospetiva de doentes submetidos a implanta&#231;&#227;o de CDI&#44; com ou sem terapia de ressincroniza&#231;&#227;o card&#237;aca&#44; em preven&#231;&#227;o prim&#225;ria&#44; sob monitoriza&#231;&#227;o remota&#46; ZM foi analisada e as arritmias documentadas avaliadas em detalhe&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Foram estudados 221 doentes &#40;77&#37; homens&#59; 64&#177;12 anos&#41;&#46; Fra&#231;&#227;o de eje&#231;&#227;o m&#233;dia foi 30&#177;12&#37;&#46; O per&#237;odo de seguimento m&#233;dio foi 63&#177;35 meses&#46; Foram documentados 174 eventos na ZM&#44; em 139 doentes &#40;62&#46;9&#37;&#41;&#58; taquicardia ventricular n&#227;o sustentada &#40;TVNS&#41; &#8211; 74&#44; taquicardia supraventricular &#8211; 42&#44; fibrilha&#231;&#227;o&#47;flutter auricular &#8211; 44&#44; ru&#237;do &#8211; 5&#46; Dos 137 doentes que apresentaram arritmia na ZM &#40;excluindo dois casos de dete&#231;&#227;o de ru&#237;do&#41;&#44; 22 &#40;16&#44;1&#37;&#41; receberam choques apropriados ou <span class="elsevierStyleItalic">pacing</span> antitaquicardia &#40;PAT&#41;&#44; enquanto que dos restantes 84 doentes&#44; 15&#44;5&#37; receberam terapias apropriadas do CDI &#40;p&#61;NS&#41;&#46; Dos doentes que apresentaram TVNS na ZM&#44; 15 &#40;20&#44;5&#37;&#41; receberam choques apropriados e&#47;ou <span class="elsevierStyleItalic">pacing</span> anti-taquicardia &#40;PAT&#41;&#46; De acordo com os achados em ZM&#44; o m&#233;dico decidiu alterar a terapia oral de ambulat&#243;rio em 41&#44;7&#37; de todos os doentes com eventos arr&#237;tmicos reportados&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#227;o</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Arritmas ventriculares e supraventriculares s&#227;o achados comuns na ZM de CDI&#46; A programa&#231;&#227;o de ZM &#233; importante no diagn&#243;stico de arritmias e poder&#225; ser um elemento &#250;til na pr&#225;tica cl&#237;nica&#46;</p></span>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Overall population &#40;n&#61;221&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">Age&#44; years</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">Male&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">170 &#40;76&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">103 &#40;74&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">67 &#40;81&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">LVEF&#44; &#37;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">30&#177;12&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">27&#46;6&#177;11&#46;0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">33&#46;5&#177;12&#46;0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;002&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " colspan="5" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">DCM</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">95 &#40;43&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">75 &#40;54&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">20 &#40;24&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;007&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">ICM</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">94 &#40;42&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">50 &#40;36&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">44 &#40;53&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;027&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">HCM</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">15 &#40;6&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7 &#40;5&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">8 &#40;9&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;237&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Primary electrical cardiac disease</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3 &#40;2&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3 &#40;2&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204919300078?idApp=UINPBA00004E"
]

Article information

ISSN: 21742049
Original language: English

DOI:10.1016/j.repce.2018.05.013

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Year/Month	Html	Pdf	Total

2024 October	37	26	63
2024 September	36	29	65
2024 August	38	25	63
2024 July	54	36	90
2024 June	24	14	38
2024 May	30	24	54
2024 April	26	21	47
2024 March	30	21	51
2024 February	24	21	45
2024 January	25	28	53
2023 December	35	27	62
2023 November	56	37	93
2023 October	21	14	35
2023 September	25	23	48
2023 August	22	19	41
2023 July	27	13	40
2023 June	31	15	46
2023 May	41	32	73
2023 April	27	9	36
2023 March	49	23	72
2023 February	31	21	52
2023 January	16	15	31
2022 December	58	28	86
2022 November	42	33	75
2022 October	48	29	77
2022 September	29	30	59
2022 August	17	22	39
2022 July	27	35	62
2022 June	24	24	48
2022 May	22	29	51
2022 April	26	28	54
2022 March	25	49	74
2022 February	24	41	65
2022 January	30	27	57
2021 December	24	34	58
2021 November	34	42	76
2021 October	34	43	77
2021 September	20	22	42
2021 August	33	33	66
2021 July	19	16	35
2021 June	22	17	39
2021 May	33	36	69
2021 April	82	42	124
2021 March	21	24	45
2021 February	29	19	48
2021 January	21	16	37
2020 December	24	13	37
2020 November	22	14	36
2020 October	18	9	27
2020 September	19	16	35
2020 August	9	7	16
2020 July	17	14	31
2020 June	12	20	32
2020 May	11	8	19
2020 April	19	9	28
2020 March	15	9	24
2020 February	24	12	36
2020 January	18	9	27
2019 December	16	7	23
2019 November	10	6	16
2019 October	17	4	21
2019 September	14	5	19
2019 August	17	5	22
2019 July	19	7	26
2019 June	30	24	54
2019 May	20	22	42
2019 April	21	21	42
2019 March	24	30	54
2019 February	2	2	4

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