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There is an increasing proportion of the general population surviving to old age with significant chronic disease, multi-morbidity, and disability. The prevalence of pre-frail state and frailty syndrome increases exponentially with advancing age and is associated with greater morbidity, disability, hospitalization, institutionalization, mortality, and health care resource use. Frailty represents a global problem, making early identification, evaluation, and treatment to prevent the cascade of events leading from functional decline to disability and death, one of the challenges of geriatric and general medicine. Cardiac arrhythmias are common in advancing age, chronic illness, and frailty and include a broad spectrum of rhythm and conduction abnormalities. However, no systematic studies or recommendations on the management of arrhythmias are available specifically for the elderly and frail population, and the uptake of many effective antiarrhythmic therapies in these patients remains the slowest. This European Heart Rhythm Association (EHRA) consensus document focuses on the biology of frailty, common comorbidities, and methods of assessing frailty, in respect to a specific issue of arrhythmias and conduction disease, provide evidence base advice on the management of arrhythmias in patients with frailty syndrome, and identifies knowledge gaps and directions for future research.

Cardiac resynchronization therapy-defibrillator (CRT-D) and/or cardiac resynchronization therapy-pacemaker (CRT-P) play an important role in improving cardiac synchronization and reducing the risk of ventricular fibrillation arrest (VFA) in patients with severe left ventricular systolic dysfunction (LVSD). Patients with LVSD may notice worsening symptoms when CRT-D or CRT-P is in dyssynchrony. We present a case of 59-year-old patient who presented with worsening shortness of breath (SOB) and progressive exertional dyspnea for the past few weeks accompanied by pink, frothy sputum, occasional urinary incontinence and urge. He was known to have severe LVSD with an ejection fraction of 10% and had CRT-D in situ. Clinical examination revealed bilateral crepitation and normal heart sounds. A chest radiograph showed pulmonary oedema. An electrocardiogram (ECG) showed atrial fibrillation (AF)/flutter with wide QRS complexes. The patient was treated for acute pulmonary oedema and had CRT-D reprogrammed to achieve biventricular synchrony. He was treated with intravenous furosemide and alternate day metolazone initially. He showed significant subjective and objective improvement and was planned for outpatient synchronized intra-device cardioversion. This case is important because patients with severe LVSD with malfunctioning cardiac resynchronization therapy can result in worsening heart failure (HF) leading to higher morbidity and mortality.

Cardiac resynchronization therapy with or without a defibrillator (CRT(D)) and implantable cardioverter defibrillator (ICD) may reduce the risk of arrhythmia or heart failure-specific mortality and improves the prognosis of patients with chronic kidney disease (CKD) or dialysis. The aim of this study was to perform a meta-analysis investigating the relationship between CRT(D)/ICD and renal insufficiency. Cochrane Library, Web of Science, Embase, and Pubmed were systematically searched from inception to 29 October 2019. We included studies that report all-cause mortality of patients with renal insufficiency who received CRT(D)/ICD therapy. Twenty-six studies (n = 119,263) were included, exploring the relationship between CRT(D)/ICD and renal insufficiency from two aspects: (1) Compared with ICD-only, CRT(D) was associated with lower risk of all-cause mortality in CKD patients (odds ratios (OR) = 0.67; 95% confidence interval (CI), 0.60 to 0.75). For non-primary prevention (secondary prevention or both), the analysis revealed a lower risk of all-cause mortality in the ICD group than in the no-ICD group (OR = 0.47; 95% CI, 0.40 to 0.55). (2) CKD increased all-cause mortality in comparison with control group (OR = 2.12; 95% CI, 1.85 to 2.44), and so did dialysis (OR = 2.53; 95% CI, 2.34 to 2.73). Furthermore, compared with CKD3 (eGFR: 30-59 ml/min/1.73 m2 ), CKD4/5 (eGFR <30 ml/min/1.73 m2 ) was observed to have a significantly higher risk of all-cause mortality (OR = 2.70; 95% CI, 1.93 to 3.80). This review shows a clear association between CRT(D)/ICD and renal insufficiency in the aspect of all-cause mortality, and may provide a reference for the clinical application of CRT(D)/ICD.

BACKGROUND: Inappropriate ICD therapy is associated with adverse outcome. Previous studies indicated that patients with a cardiac resynchronization therapy-defibrillator (CRT-D) might have a lower risk for inappropriate device activations than patients with a single (VVI) or dual chamber (DDD) ICD.
METHODS: All ICD recipients from a university cardiac center between 2000 - 2015 were included in this analysis. Outcome parameters were incidence of appropriate and inappropriate therapy and overall mortality.
RESULTS: A total of 1471 patients were analyzed: 629 (43%) patients with a VVI-ICD, 486 (33%) patients with a DDD-ICD and 356 (24%) with a CRT-D device. During an average follow-up of 4.1 ± 3.6 years, CRT-D patients had the lowest risk to receive at least one inappropriate shock therapy (p < 0.001). Rates of appropriate (RR (Rate Ratio) = 0.45, p = 0.019) and inappropriate shock therapy (RR = 0.38, p = 0.021) were significantly lower in CRT-D patients compared to VVI-patients. CRT-D recipients had a lower rate of appropriate shock therapy (RR = 0.323, p = 0.043) compared to DDD patients, but not of inappropriate shock therapy (p = 0.371). Kaplan Meier Analysis did not reveal a significant difference in overall survival (p = 0.396). However, after adjustment for relevant confounding factors, VVI-patients had a higher risk for overall-death (HR = 1.28, p = 0.030).
CONCLUSIONS: CRT-D recipients have a significantly lower rate of appropriate shock therapy and a lower rate of inappropriate shock therapy. More frequent inappropriate therapies in VVI-ICD recipients may account for their higher overall mortality.

BACKGROUND: Systemic sclerosis is a rare connective tissue disease characterized by localized or diffuse skin thickening and fibrosis, which usually accumulates in various organs throughout the body. Tachyarrhythmia is a common clinical manifestation of cardiovascular damage in systemic sclerosis patients. However, few studies have reported the use of catheter ablation and an implantable cardioverter defibrillator in patients with systemic sclerosis complicated by ventricular tachycardia.
METHODS: A 39-year woman with an 11-year history of systemic sclerosis was referred to our hospital due to three syncopal episodes in the past 6 mo. The results of an electrocardiogram and a transthoracic echocardiogram revealed ventricular tachycardia and left ventricular systolic and ventricular septum segmental motion abnormalities, respectively. The results of an electrocardiogram showed a sinus rhythm with complete blockage of the left bundle branch. In light of the progressive nature of systemic sclerosis, the presence of a left bundle branch block, and the decreased ejection fraction, a cardiac resynchronization therapy-defibrillator was implanted. The patient\'s clinical conditions improved, and at the 3-mo follow-up, the patient was free of ventricular tachycardia and all cardiac symptoms.
CONCLUSIONS: We report the first case of systemic sclerosis complicated by ventricular tachycardia that was successfully treated with a cardiac resynchronization therapy-defibrillator.

UNASSIGNED: Patients have increasing comorbidities and competing causes of death with advancing age, raising questions about the effectiveness of the implantable cardioverter defibrillators (ICD) in older age. We therefore investigated the effect of patients\' age at initial device implantation on all-cause mortality and on the risk of ICD shocks in single-chamber (V-ICD), dual-chamber (D-ICD), and cardiac resynchronization therapy defibrillator (CRT-D) recipients.
UNASSIGNED: We reviewed de-identified records of 67 128 ICD recipients enrolled in the Boston Scientific ALTITUDE database of remote monitored patients [V-ICD (n = 11 422), D-ICD (n = 23 974), and CRT-D (n = 31 732)]. Over a mean follow-up of 2.3 ± 1.4 years, patients in all ICD groups had increased all-cause mortality but decreased risk of defibrillator shocks and/or anti-tachycardia pacing per 10 year increase in age. Compared with the youngest age group (<50 years), patients in the oldest age group (≥80 years) had a 6.8-fold, 5.9-fold, and 3.4-fold increase in all-cause mortality (P < 0.001 for all comparisons) and a 31, 45, and 53% decrease in the risk of ICD shock (P ≤ 0.002 for all comparisons) for the V-ICD, D-ICD, and CRT-D groups, respectively.
UNASSIGNED: Older recipients of standard and CRT defibrillators have higher mortality but fewer ICD shocks and/or therapies compared with younger patients. These data highly suggest less benefit of ICD therapy with increasing age, presumably because of competing risks of non-arrhythmic mortality. The role of defibrillator therapy in older patients may need to be evaluated with randomized controlled trials.

OBJECTIVE: To compare outcome between patients with and without super-response to cardiac resynchronization therapy-defibrillator (CRT-D).
RESULTS: In this cohort study, 167 consecutive CRT-D candidates were included. Super-response to CRT-D was defined clinically [improvement of ≥1 New York Heart Association (NYHA) class or ≥50 m in six-minute walk distance (6MWD)] and echocardiographically [increase of left ventricular ejection fraction (LVEF) ≥1 category (LVEF <30 to 30-40 % or 30-40 to 41-51 %) or reduction of left ventricular end-diastolic diameter (LVEDD) ≥10 mm]. Clinical outcome (death, cardiac transplantation and appropriate shock therapy) was compared between super-responders (n = 32) and non-super-responders (n = 135). During follow-up (616 patient-years; median 3.3 years), all-cause mortality was significantly lower in super-responders compared to non-super-responders (log rank p < 0.05). At least one appropriate shock was noted in 22 % of super-responders and 39 % of non-super-responders (p = 0.069). Time to appropriate shock therapy was significantly longer in super-responders (log rank p < 0.05). Event-free survival from death or cardiac transplantation was comparable between the two groups.
CONCLUSIONS: Super-response to CRT-D is associated with improved survival and lower risk of appropriate shock therapy compared to non-super-responders. Further information about the mechanisms of super-response and its long-term consequences are needed to foresee favorable outcome after implantation of CRT-D.

BACKGROUND: J wave is known to be associated with increased risk of life-threatening ventricular arrhythmias in both structural and nonstructural heart disease. A documented history of ventricular tachycardia (VT) is also a known predictor for future arrhythmic events. The purpose of this study is to investigate prognostic factors in ventricular tachyarrhythmias in patients with an implanted defibrillator.
METHODS: Intracardiac electrograms were thoroughly analyzed in patients with either an implanted implantable cardioverter-defibrillator or with cardiac resynchronization therapy with a defibrillator. The relation between the clinical characteristics and the device interventions for ventricular tachyarrhythmias was evaluated retrospectively with multivariate Cox proportional hazards models.
RESULTS: This study enrolled a total of 160 patients who were followed for a mean period of 44 ± 28 months. Of these patients, 31 (19%) showed J wave and 77 (48%) showed documented VT before the device implantation. Multivariate Cox proportional hazards models revealed that the presence of J wave and the documented history of VT before the device implantation were independently associated with device intervention in patients with device implantation even after the adjustment of confounding factors (hazard ratio [HR], 2.90; 95% confidence interval [CI], 1.56-5.24; p=0.001 and HR, 4.34; 95% CI, 2.43-8.05; p<0.0001, respectively).
CONCLUSIONS: The presence of J wave and the documented history of VT prior to device implantation served as independent predictors of future device intervention for ventricular tachyarrhythmias.

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