Response to “Atrioventricular Conduction Abnormalities Amid Armed Conflict: Beyond the Electrophysiological Perspective”

We want to thank Dr Song and Dr Li for their thoughtful comments on our article, “The Prevalence and Predictors of Atrioventricular Blocks in Syrian Patients Reporting to the Emergency Department During the Ongoing Conflict: A Cross-Sectional Study” [1]. We are grateful for their recognition of the challenges of conducting cardiovascular research under conflict conditions, and we welcome the opportunity to address the important issues they have raised. First, regarding the limitations of the cross-sectional design, we agree that causal inference cannot be firmly established. Our primary aim was to provide initial data from a conflict-affected population where none previously existed. We fully concur that prospective longitudinal studies are necessary to delineate whether the atrioventricular conduction abnormalities observed represent transient stress-related changes or underlying degenerative disease. Unfortunately, conducting follow-up in this setting remains logistically difficult due to population displacement and resource constraints in the midst of a decade-long conflict. The difficulties of the Syrian healthcare system arealso presented in our previous work on communicable diseases in the country [2, 3]. Second, regarding selection bias, this is an inherent limitation in emergency department-based studies, particularly in conflict zones. As acknowledged in our paper, the prevalence reported should not be interpreted as representative of the entire community, since asymptomatic or less severe conduction abnormalities are unlikely to present to an emergency department. Nonetheless, our findings highlight the significant burden of clinically apparent AV block in those accessing acute care, which has direct implications for emergency physicians and cardiologists working in similar contexts. Third, the correspondents rightly highlight the role of potential confounding factors such as medication interruption, electrolyte imbalance, infection, and dehydration. In our study, only a subset of patients had routine electrolyte data available, which we reported in the manuscript. We did not systematically collect information on drug adherence or infectious status, which is a limitation. These variables may transiently influence conduction and merit inclusion in future prospective studies. Kindly note that there is no stable primary care in Syria, nor are there reliable sources to access drug records other than the patient′s history. This was not reliably documented in all the notes; therefore, we acknowledge this as a limitation. Fourth, regarding diagnostic criteria, AV block was defined based on a standard 12-lead ECG reviewed independently by two cardiologists. Continuous monitoring was not feasible in our emergency department setting due to limited telemetry resources. Kindly note that there is no telemetry or prolonged ECG monitoring in the whole city of Latakia during the time that the data was collected. We recognise that this approach may under-recognise transient or paroxysmal conduction disturbances, and we agree that ambulatory or continuous monitoring would enhance detection accuracy in future studies. Finally, we acknowledge the insightful comment on the potential link between psychological stress and AV conduction abnormalities. Although we did not collect objective stress markers, the hypothesis is indeed biologically plausible and consistent with prior research in extreme environments. Incorporating validated stress assessments and neurohormonal markers, as suggested, will be an important direction for future collaborative studies. In conclusion, we appreciate the constructive feedback, which complements our findings and underscores the need for further longitudinal, multicenter, and mechanistic research. We hope our work stimulates continued dialogue and investigation into the cardiovascular consequences of conflict-related adversity. The authors declare no conflicts of interest.