Endocrine disorders are associated with various tachyarrhythmias, including atrial fibrillation (AF), ventricular tachycardia (VT), ventricular fibrillation (VF), and bradyarrhythmias. Along with underlying arrhythmia substrate, electrolyte disturbances, glucose, and hormone levels, accompanying endocrine disorders contribute to development of arrhythmia. Arrhythmias may be life-threatening, facilitate cardiogenic shock development and increase mortality. The knowledge on the incidence of tachy- and bradyarrhythmias, clinical and prognostic significance as well as their management is limited; it is represented in observational studies and mostly in case reports on management of challenging cases. It should be also emphasized, that the topic is not covered in detail in current guidelines. Therefore, cardiologists and multidisciplinary teams participating in care of such patients do need the evidence-based, or in case of limited evidence expert-opinion based recommendations, how to treat arrhythmias using contemporary approaches, prevent their complications and recurrence in patients with endocrine disorders. In recognizing this close relationship between endocrine disorders and arrhythmias, the European Heart Rhythm Association (EHRA) convened a Task Force, with representation from Asia-Pacific Heart Rhythm Society (APHRS) and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLAECE), with the remit of comprehensively reviewing the available evidence and publishing a joint consensus document on endocrine disorders and cardiac arrhythmias, and providing up-to-date consensus recommendations for use in clinical practice.

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Normal function and the most common problems that occur during pacemaker operation while performing physical exercise, are discussed. Physically active individuals with an implantable cardiac device, should be evaluated during exercise, because some conflicts issues may arise that are not detectable during routine, at rest, telemetry.

A dual-chamber pacemaker was implanted in a hypertensive 69 years old male with symptomatic sinus bradycardia. He had a normal ejection fraction and mild concentric left ventricle hypertrophy. A 12-lead electrocardiogram (ECG) was recorded during a routine clinic visit following the implant. Multiple QRS morphologies observed in association with pacemaker stimulation (Figure 1). A major issue and question is what is the mechanism involved? Discussion of ECGThe patient's 12-lead ECG is shown with a lead II rhythm strip at the bottom of the tracing. The first beat is stimulated by the pacemaker in DDD mode with an atrial spike, resulting in a P wave, followed by a ventricular spike, and then a subsequent stimulated broad QRS complex (i.e., atrial stimulation-ventricular stimulation); the next 5 beats are stimulated in a different DDD mode known as the VAT mode, which represents atrial detection-ventricular stimulation. It should be noted that the P wave is intrinsic and is not preceded by a spike. The different QRS morphology is presumed to be a consequence of a different degree of fusion with the intrinsic ventricular rhythm, which is usually observed when the stimulation mode changes spontaneously. A premature ventricular contraction (PVC), noted in the center of Figure 1, resets the pacemaker, followed by 3 beats in DDD mode, which have the same QRS morphology of the first stimulated QRS. After the PVC, the third beat shows atrial pseudofusion, which consists of an atrial spike delivered at the same time the intrinsic P wave starts; therefore, its morphology is not changed; this beat and the following beat show fused positive QRS complexes, that suggests predominance of the intrinsic QRS complexes; subsequently VAT mode; the last beat is another PVC, with a morphology differing from the first one. Points to ponder Different QRS morphologies are frequently observed during normal pacemaker function (1).  The most common mechanism of different QRS morphologies during a paced rhythm is a different degree of fusion with the intrinsic ventricular rhythm (2,3).  This condition is usually observed when a spontaneous change occurs in the mode of stimulation or in the intrinsic rhythm of the patient.

BackgroundIdentification and early initiation of antiretroviral therapy (ART) during acute HIV infection (AHI) can preserve the immune system, reduce HIV reservoir size, and prevent transmission. We aimed to characterize patients with symptomatic AHI and their linkage/retention to care in a county clinic.MethodsRetrospective chart review of 60 patients diagnosed with AHI from 7/2012 to 4/2017 at two county hospitals emergency departments in Houston, TX. We compared the interval between diagnosis and initiation of ART before and after implementation of an AHI protocol in 11/2014 comprised of trained service linkage workers and use of the fourth-generation Ag/Ab combination assay as newly recommended by the CDC in 6/2014. AHI was defined as 1) detectable HIV RNA or reactive fourth-generation Ag/Ab combination assay with non-reactive HIV-1 antibody, 2) reactive third-generation Ab assay and negative/indeterminate Western blot (WB), or 3) positive WB that is negative for p31 band. CDC and DHHS definitions were used for linkage to and retention to care respectively.Results10 patients were diagnosed prior to AHI protocol (25-month period) and 50 after (31-month period). 92% established care with 78% retention. Median age 34 years (IQR 25–42), with 78% men, 58% Hispanic, 36% Black non-Hispanic, 50% men having sex with men. Presenting symptoms include fever 78%, chills 47%, malaise/fatigue 47%, nausea 38%, sore throat 37%, and headache 37%. Physical exam findings include rash 20%, pharyngeal edema/erythema 14%, cervical lymphadenopathy 8%, and thrush 7%. Baseline median CD4+ T cell count was 205 cells/µL (IQR 123–350), median HIV RNA 4.75 x 106 copies/mL (IQR 1.1–10.0 x 106). 56% had leukopenia, 47% thrombocytopenia, 37% syphilis, 12% aseptic meningitis and 8% K103N mutation. Median time to ART initiation decreased from 17 days (IQR 11.75–23.5) to 7 days (IQR 4.0–13.25) after protocol implementation (P = 0.011).ConclusionEmploying trained service linkage workers and the new CDC testing algorithm significantly decreased time to initiating ART, which may improve long-term outcomes in these patients. However, 14% of patients were lost to follow-up, highlighting the need for a strategy to maintain engagement of care.Disclosures All authors: No reported disclosures.