bluuebunny/crossref_metadata_2025 huggingface dataset:
P256 COMORBIDITY ROLE IN THE REOCCURRENCE OF HEART FAILURE EXACERBATION ON A POPULATION OF PATIENTS WHO HAVE A DEDICATED FOLLOW UP
Authors: De Masi De Luca G , Longo S , Barba F , Marzo S , Mauro R , Accogli M
Published: May 2022

Background

With this work we drew attention on the importance of a proper FUP dedicated to patients affected by heart failure (HF), while also underlining the importance of proper and efficient management of comorbidities.

Material and Methods

164 patients were put into the FUP program for HF at Cardiology Department in “Card. G.Panico Hospital” in Tricase (Lecce, IT) and with the same organization at “Cardiomed Centre” in Maglie (Lecce, IT) 61% of the patients had just been hospitalized, 24% came from a generic clinic, 15% from the ER. 59% presented a systolic HF, diastolic genesis for the other patients left. The average age was 69±21 year old. During the evaluation of admission to the FUP program, the patients were divided into patients at high, medium and low risk, based on their clinical situation regarding the risk of events. Each risk category had its own different FUP iter, which was both clinical and telemedical, commited to the clinical nurse. During the periodic call, the nurse set, where necessary, a stability judgment after confronting FUP parameters, and showed the report, or better to say, the alerts, to the medical staff who had the role of re–evaluating the patient in order to put in place proper therapeutic measures.

Results

In a 12 month FUP period of time 78 alerts have been highlighted. In 64% of the cases it was about weight gaining; in 54% an increase in Borg scale index; in 37% it was due to a reduced Spo2 during exercise; In the following clinical evaluations, in 91% of the cases correctional therapeutic measures have been put into place, consisting of: – diuretic therapy readjustment for os (31 cases); – start of transitory period diuretic therapy for ev (19 cases); – hospitalization (3 cases); – comorbidities correction (59 cases). This last parameter got most attention: in 23 cases it was highlighted a reduction of a % of transferrin saturation by less than 10%, then adjusted (target according to guidelines: >20%); in 17 cases we noticed a clinical situation of bronchial inflammation; in 19 patients showed a worsening in kidney function index.

Conclusion

Our experience in the clinic dedicated to heart failure suggests how fundamental attention to comorbidity is, especially where instability can be considered a predicting alert of re–exacerbation of HF.
P271 DOES SENILITY AFFECT THE MANIFESTATION AND MANAGEMENT OF PULMONARY EMBOLISM? EXPERIENCE OF AN ED
Authors: Savioli G , Lapia F , Fumoso F , Brattoli M , Mugellini A , Martignoni A , Ceresa I , Muzzi A , Novelli V , Preda L , Lava M , Maggioni P , Manzoni F , Bressan M
Published: May 2022

Premises

Acute pulmonary embolism is a pathology characterized by high mortality. The elderly population is destined to increase, becoming, according to some authors, 30% of the population in the developed countries.

Purpose of the Study

see if and how, in the real life of an Emergency Department, age can affect the manifestation (more severe or milder forms of pulmonary embolism; typical symptoms and atypical symptoms), patient management and adherence to guidelines. We considered subjects over 75 years of age to be elderly, as per the latest indications of the guidelines.

Methods

Single–center retrospective observational study on all patients who entered our ED, where they received a diagnosis of acute PE. Enrollment began in 2016 and ended in 2019. We collected data from medical history, physical examination, laboratory tests, imaging; we calculated the characteristic scores from the diagostic / therapeutic algorithm, both for the risk of PE (Wells, Geneva and YEARS), and for the presentation of the risk of mortality at 30 days (sPESI). We analyzed the hospitalization rate, in–hospital mortality rate, the hospitalization rate in resuscitation and the length of hospitalization. We then analyzed adherence to the guidelines valid in the period under study.

Results

We enrolled 487 patients, with equal gender distribution (F = 52%). 247 were older than 75 (50.7%). Age has a positive correlation with the presence of massive pulmonary embolism, in a statistically significant way (p < 0.05), and with the presence of organ damage, touching on statistical significance (p = 0.05). On the other hand there is no statistically significant difference in the prevalence of typical or atypical symptoms in the two groups. The vital parameters were instead comparable in the two groups with no statistically significant difference (p > 0.05). Long–term outcomes such as mortality, need for hospitalization, ICU stay and length of stay in hospital are also comparable results without statistically significant difference (p > 0.05). Adherence to international guidelines is also comparable between the two groups (p > 0.05).

Conclusions

The study suggests that age correlates with more severe forms of pulmonary embolism but does not affect either patient management or short–term outcomes.
P275 HOLDING AREA IN EMERGENCY DEPARTMENT : A STRATEGY TO IMPROVE ADHERENCE TO INTERNATIONAL GUIDELINES IN CASES OF PULMONARY EMBOLISM IN ELDERLY
Authors: Savioli G , Ceresa I , Mugellini A , Martignoni A , Fumoso F , Lapia F , Brattoli M , Maggioni P , Preda L , Lava M , Muzzi A , Novelli V , Manzoni F , Bressan M
Published: May 2022

Premises

Pulmonary embolism is a disease still characterized by high mortality. Despite a great development of the guidelines it is not clear what adherence to them is in real life, especially in the emergency room.

Purpose of the Study

See if and how, in the real life of an Emergency Department, adherence to the Guidelines varies according to the area to which the patient is addressed.

Methods

Monocentric retrospective observational study, on a group of geriatric patients (<75 y) that include all the people accessed to our ED, where they received acute PE dignosis. Enrolment started on 2016 and finished on 2019. We collected data from medical history, physical examination, lab tests, imaging; we calculated characteristic scores from the diagostic/therapeutic algorhitm, both regarding PE risk (Wells, Geneva and Years), and the 30–day mortality risk presentazione (sPESI). We then analized guidelines adherence in three decision–making turning–points: 1 Correct applicarion of decisional scores examined, which classify the patient in low, intermediate or high risk of PE, calculated with Wells and simplified Geneva score; 2 Correct therapy administration since the ED as suggested by the guidelines; 3 The eventual observation in the medium–intensity care area with close monitoring for the subpopulation of patients with finding of right ventricular dilation or myocardial enzymes impairement (considered at high risk of short–term shock and mortality).

Results

we enrolled 249 patients, with a mean age of 83 years and female prevalence (F = 62%). Of these, 69% were referred by Triage to medium–high intensity of care, the remaining 31% was directed to low intensity of care. 42.5% of the total patients were referred to OBI. The two areas of intensity of care showed similar adherence to guidelines (approximately 50%) without there being a statistically significant difference between the two areas (p > 0.05) Adherence to guidelines was higher in the holding area – OBI (75 %) compared to that of those managed in theaters (50%) in a statistically significant way (p < 0.001).

Conclusions

The study suggests that holding areas located in Emergency Departments can considerably increase adherence to international guidelines.
P329 SEVERE ISOLATED MITRAL STENOSIS: ARE WE FACING DIFFERENT PHENOTYPES?
Authors: Vriz O , Eltayeb A , Anwar K , Alenazy A , Galzerano D , Mohammed A
Published: May 2022

Introduction

The aim of the study was the evaluate the different characteristics between high gradients (HG) and low gradient (LG) mitral stenosis (MS) and, within the LG group those with high (LG–HF) or low flow (LG–LF). Moreover, we wanted to evaluated if there was any difference in overall complications and atrial fibrillation (AFib) incidence.

Methods

A total of 147 patients with isolated severe MS were retrospectively enrolled from the institutional echo database. Echocardiograms were read off line and clinical information were obtained from patients` records. Patients were divided into a group with HG (31 patients, mean MS gradient > 10 mmHg) and LG (116 patients, mean MS gradient ≤ 10 mmHg). The group of LG was then divided in low flow (Stroke volume index (SVi) ≤ 35 ml/m2, LF–LG: 68 patients) and in high flow (SVi > 35 ml/m2, HF–LG: 48 patients).

Results

The HG group was younger, although the difference did not reach statistical significance, higher percent of males (45% M vs 22% F, p = 0.02), higher heart rate (HR), left atrial volume, higher tricuspid regurgitation velocity and derived pulmonary artery systolic pressure (PASP), right ventricular fractional area changes (RV FAC) but similar RV longitudinal contraction. Moreover, the HG group had more severe MS calculated according to PHT. The group of LG was divided according to SVi: LF–LG compare to HG–MS had higher percent of females (45% F vs 13% M, p < 0.001), similar AFib (43% vs 32%, p=ns) and pre surgical complications (19% vs 16%, p=ns). LF–LG group had smaller LA volumes (LAV systole: 117±51 51 ml vs 148.6±38 ml, p < 0.0001), lower LV–S` (5.3±1.4 vs 6±1.6 cm/s, p = 0.004), lower tricuspid velocity regurgitation (TVR 2.47±0.5 vs 3.24±0.7 m/s, p < 0.0001), higher TAPSE/PASP (0.64±0.3 vs 0.45±0.29, p < 0.001), lower RV S` (9.79±2.01m/s vs 11.25±3.1 m/s, p = 0.01), higher RVFAC (38.5±9.6% vs 30.9±9.2%, p = 0.0005). The group of LG–LF had also less severe MS (1.3±0.6 cm2 vs 1.15±0.3 cm2, p < 0.01). The 3 groups of MS were similar in terms of cardiovascular risk factors.

Conclusion

Patients with HG MS were those with worst left ventricular involvement, higher PASP and lower RV function. However LF–LG MS were older and more females were included and even though they had smaller LA, lower values of PASP they had significantly higher percent of Afib and similar pre surgical complications. It could be speculated that LF–LG severe MS patients could be a different fenotype of the disease.
P333 INFECTIVE ENDOCARDITIS ON TRICUSPID VALVE CAUSED BY S. AUREUS METHICILLIN RESPONSIVE: RESOLUTION AND RECURRENCE OF DISEASE
Authors: Gizzi G , D‘Agostino S , Parato V
Published: May 2022

Introduction

Tricuspid valve endocarditis accounts for 5–10% of endocarditis cases and is more frequent in intravenous drug abusers. Recurrence of endocarditis occurs not infrequently in patients treated with conservative therapy.

Clinical Case

In June 2021, a 32–year–old man with a history of intravenous drug abuse came to our observation. He had been presenting for about a week high fever with shaking shivering resistant to antipyretic and antibiotic therapy and laboratory tests with neutrophilic leukocytosis with increase in CRP and procalcitonin. Trans–thoracic echocardiogram was performed and it showed mild tricuspid regurgitation with the presence of filamentous mobile isoechoic formations adhering to the valve leaflets compatible with endocarditic vegetations. A trans–esophageal echocardiogram was performed that confirmed the transthoracic finding of endocarditis on the tricuspid valve with evidence of 11 mm mobile oval vegetation adhering to the posterior flap; blood cultures were positive for methicillin susceptible S. Aureus and antibiotic therapy with oxacillin was administered as a continuous infusion for 6 weeks. The cardiac surgery center was consulted and the surgeons did not indicate any intervention because of the normofunction of the tricuspid valve and the absence of embolic phenomena on total body CT. Subsequent laboratory tests showed negative inflammation indices and negative surveillance blood cultures. Control ETE was planned with the confirmation of complete resolution of endocardial lesions. In September the patient affered the emergency room for an accidental fall from a work vehicle: transthoracic and trans–esophageal echocardiograms were repeated for the concomitant finding of hyperpyrexia and cough with an increase in CRP and procalcitonin. They showed the presence of new larger endocarditic lesions on tricuspid valve with moderate regurgitation. Blood cultures were negative. Antibiotic therapy with oxacillin was reintroduced and the patient was transferred to the infectious disease clinic in prevision of cardiac surgery.
P343 VALIDATION OF ESC 2014 GUIDELINES PROTOCOL FOR CORONARY ARTERY DISEASE DETECTION IN PATIENTS CANDIDATES TO LIVER TRANSPLANTATION
Authors: Mircoli L , Carugo S
Published: May 2022

Introduction

Orthotopic liver transplantation (OLT) is the only effective treatment in patients with end–stage liver disease. Coronary artery disease (CAD) is associated with increased peri–operative OLT mortality. Thus, identification of CAD is crucial in pre–OLT evaluation. There is not a specific pre–OLT accepted diagnostic algorithm for CAD detection. 2014 ESC guidelines for non–cardiac surgery management consider OLT as a high–risk abdominal surgery and only patients with CAD history, suspected symptoms and low exercise capacity are invited to undergo to specific functional exams such as stress–echo.

Purpose of the present study was to compare the ESC protocol with our cardiologic pre–OLT protocol, in which tests of ischemia and coronary CT are largely administered on based on presence of risk factors. Methods. From 2014 to 2021 all OLT candidates have been evaluated by visit, electrocardiography, rest and, when possible, stress echocardiography. In subject aged > 50 years with diabetes and/or two or more of the following risk factors: smoking, CAD family history, peripheral vascular disease, CT was performed. CGF was scheduled when CAD history and typical symptoms of angina. We theoretically re–analyse our database in order to consider the potential destiny of each patient in case of application of ECS 2014 protocol. We were able to calculate the differences in the number of potentially loss CAD diagnosis. Results. 367 patients (58.2%, age 57±5.7 years, males 74%) underwent OLT. Stress Echo was performed in 239 (65.1%) and positivity was found in 24 pz (6,5%). Coronary CT was performed in 95 (25,8%). CGF was performed in 75 patients (20.1%), 38 (9,2%) directly for known CAD and/or symptoms. Critical coronary lesions were found in 12 patients (3,2 %): 7 revascularized by PTCA, 1 by CABG and 4 medically managed, 25 patients had non critical lesions (7.8%), 31 patients (9.6%) referred to CGF were subsequently removed by transplant list, whereas OLT was successfully performed in PTCA patients (n = 8). During follow–up (35±20 months) 28 patients died (14.2%), 5 with symptoms of congestive heart failure, but no ischemic events were observed.

Conclusions

CAD detectionis remains a clinical challenge in candidates to OLT. The large number of normal stress echoes and normal CGF, even in presence of cardiovascular risk factors, demonstrates that CAD prevalence in ESLD is no higher than in general population, but a gold method to detect CAD is still unclear.
P356 PREVALENCE AND PROGNOSTIC IMPACT OF LIPID GOAL ATTAINMENT AND PATIENT ADHERENCE TO LOWERING LIPID TREATMENT: DATA FROM COMMUNITY ITALIAN SETTING
Authors: Di Lenarda A , Garavaglia A , Poli S , Peruzzi E , Scagnetto A , Cappelletto C , Barbati G
Published: May 2022

Aims

The aim of the study was to provide real–world data on low–density lipoprotein cholesterol (LDL–C) goal achievement at the time of current 2019 ESC/EAS Guidelines, treatment patterns and patient adherence to lowering lipid treatment (LLT).

Methods and Results

This community–based study identified patients with at least one LDL–C measurement and cardiological evaluation from 01–Jan–2016 to 31–Dec–2018. Patients risk stratification and LDL–C target achievement were assessed according to 2019 EAS/ESC guidelines. To identify the proportion of patients at LDL–C target, only patients with an available LDL–C evaluation after 1 year from baseline were considered (7317 patients, 51% of initial cohort 14317 pts). Of those, 492 pts (7%) presented LDL–C at target. Among them, 187 were at very high risk (4% of very high risk subgroup) and 47 at high risk (3% of high risk subgroup). Statin intolerance was reported in 7,5% of patients (1073 out of 14317). The adherence evaluation was performed in patients having 1–year of follow–up and at least one statin purchase. It was estimated through the Proportion of Days Covered (PDC), defining as adherent patients with a PDC value ≥ 75%. 8332 (58% of initial cohort 14317 pts) met the selection criteria for PDC calculation. Of those, 3346 (40%) patients resulted as adherent (46% and 22% in very high e high CV risk categories). In a multivariable Cox regression model, adjusted for age, sex, risk factors and comorbidities, patients adherence emerged as a protective factor (HR 0.62; 95% CI 0.43–0.89; p = 0,010).

Conclusion

In a real–world setting, the achievement of LDL–C target and patient adherence was suboptimal across different CV risk categories. In a full adjusted survival model, patient adherence was independently associated with a prognosis improvement.
P373 INCIDENCE OF EMBOLIC EVENTS IN PATIENTS WITH HYPERTROPHIC CARDIOMYOPATHY AND ATRIAL ARRYTHMIAS
Authors: Buongiorno A , Aranzulla T , Mabritto B , Luceri S , Albani S , Tommasello A , Bongioanni S , Campagnuolo S , De Rosa C , Musumeci G
Published: May 2022

Background

Atrial arrythmias (AA) are well–known major complications in HCM patients. Nevertheless, there are only a few studies investigating clinical features of HCM patients with AA who experienced embolic events (EVs).

Methods

We retrospectively collected clinical data from patients with HCM and atrial fibrillation or flutter followed at our Cardiology Department. The aim of this study was to assess the occurrence of EVs during long–term follow up.

Results

Among 702 HCM patients, 126 had AA: 79% AF (56% paroxysmal, 23% chronic), 6% AFL, 15 % both AF and AFL. Among those, 21 (16.7%) patients experienced at least one ischemic episode since HCM diagnosis and overall 29 ischemic events occurred (17 strokes, 11 TIAs, 1 lower limb embolism). 5 ischemic events occurred in 3 patients for whom no certain correlation with AA could be detected as the events occurred before the AA–diagnosis was performed. Therefore, they were excluded from the analysis. In the remaining 18 patients, age at first embolic event was 72 ± 5 years old. The mean CHA2DS2VASc score was 1.82 ± 1.16. We registered 24 EVs (15 strokes, 8 TIAs, 1 lower limb embolism) at a follow–up of 6.8 ± 5 years: in 5 (all >70 years old) the diagnosis of AA was done at the moment of the first EV, in 13 the embolism occurred at a mean time of 6.3 ± 4.5 years after the diagnosis of AA. Among the patients with previously diagnosed AA, in 8 the embolism happened despite proper anticoagulation (2 NOACs, 6 VKA), 2 were not in therapeutic range, 1 had temporary NOAC withdrawal for surgery and 2 started anticoagulation only after the embolic event occurred. 5 out of 18 patients (28%) had permanent neurological impairment and 1 patient died of stroke. The independent predictors of the first embolic event in patients with a previous diagnosis of AA were female sex (p = 0.017) and inappropriate anticoagulation (p = 0.002). CHA2DS2VASc score (1.85 ± 1.19 in EVs vs 1.81 ± 1.16 in no EVs) was not a predictor of embolism (p = 0.167).

Conclusions

In our cohort of HCM patients with AA, embolic events are frequent regardless of CHA2DS2VASc score. Therefore, anticoagulation should be started immediately after the first arrhythmic episode as recommended by most recent guidelines.
P388 CORONARY PLAQUE CHARACTERISTICS ASSOCIATED WITH MAJOR ADVERSE CARDIOVASCULAR EVENTS AMONG ATHEROSCLEROTIC PATIENTS AND LESIONS: A SYSTEMATIC REVIEW AND META–ANALYSIS
Authors: Gallone G , Bellettini M , Gatti M , Bruno F , Scudeler L , Cusenza V , Lanfranchi A , Angelini A , De Filippo O , Iannaccone M , Prati F , Porto I , Pontone G , Depaoli A , Usmiani T , D‘ascenzo F , De Ferrari G , Forni J
Published: May 2022

Background

The clinical value of coronary plaque characteristics (CPCs) to inform intensified medical therapy or revascularization of non–flow–limiting lesion remains uncertain. We performed a systematic review and meta–analysis to study the prognostic impact of CPCs comprehensively assessed with invasive and non–invasive imaging technologies on patient–level and lesion–level major cardiovascular adverse events (MACE).

Methods

We systematically reviewed MEDLINE, EMBASE, and the Cochrane database for studies evaluating the association of CPC with patient–level and lesion–level (MACE). CPCs included high plaque burden, low minimal lumen area, thin cap fibroatheroma, high lipid core burden index, low attenuation plaque, spotty calcification, napkin ring sign or positive remodelling.

Results

Thirty studies (21 retrospective, 9 prospective) with 30.369 patients were included. CPCs were evaluated by invasive intravascular techniques in 9 studies (optical coherence tomography=4, intravascular ultrasound imaging=3, near–infrared spectroscopy intravascular ultrasound imaging=2) and by coronary computed tomography angiography (CCTA) in 21 studies. CPCs were significantly predictive of patient–level and lesion–level MACE, also when only adjusted data where considered. For each CPC, the odds appeared higher for lesion–level (HR range 3.2–16.8) as compared to patient–level MACE (HR range 1.8–4.1). Accuracy was modest to moderate for most CPCs at the patient–level (AUC for MACE ranging between 0.53 and 0.84) and moderate to good for most CPCs at the lesion–level (AUC for MACE ranging between 0.71 and 0.83). Plaques with more than one CPC had the highest accuracy for lesion–level MACE (AUC 0.87, 95%CI 0.84–0.90). CPC pooled sensitivities for lesion–level MACE ranged between 40% and 63% and specificities between 73% and 98%. As the pooled prevalence of CPCs among plaques was low (3% to 28%), the estimated positive predictive values for lesion–level MACE were modest (range 33% to 45%).

Conclusion

CCTA and intravascular imaging characterization of CPCs provides independent prognostic value among atherosclerotic patients and lesions. However, the modest sensitivity and positive predictive value observed across all CPCs seem to suggest modest clinical value, especially to predict lesion–level events (PROSPERO identifier: CRD42021251810).
The PONTE (

P

DTA FOR INTEGRATED F

O

LLOW-UP TERRITORY HOSPITAL OF THE PATIE

N

T WITH CARDIAC HEAR

T

FAILUR

E

) (BRIDGE) Heart Failure project: increased adherence to guideline-recommended therapies through web-based shared clinical database
Authors: De Gennaro Luisa , Iacoviello Massimo , Donadeo Vittorio , Ruggiero Massimo , Brunetti Natale Daniele , Caldarola Pasquale
Published: May 2022

The aim of this study was to evaluate the effects on the adherence of drug prescription to the guideline recommendations of a chronic care model based on the close interaction between hospital and local healthcare district cardiologists through a shared web-based database. From 2018 to 2021, patients hospitalized for an episode of acute decompensated heart failure (HF) (de novo or worsening) in cardiology wards from the healthcare district of Bari, Italy, were enrolled. The follow-up programme was based on a first visit after discharge within 1 month; patients were therefore addressed to the local health district cardiologist outpatient clinics when not requiring further invasive investigations and haemodynamically stable and followed-up with at least one visit every 6 months. In order to share in-hospital patients’ data with outpatient clinics, at discharge, they were entered in a web-based database accessible for all cardiologists and centres participating in the Ponte Project. The group of patients affected by HF with reduced ejection fraction (HFrEF) were considered for the analyses. Drug prescription rates at 1-year follow-up were analysed as endpoint, as well as the re-admission for HF worsening. Out of 1200 HF patients enrolled in the project until December 2021, 56% were affected by HFrEF. At 1-year follow-up, 91% of patients were assuming beta-blockers, 86% mineralocorticoid receptor antagonists, 98% angiotensin-converting enzyme inhibitors/angiotensin receptor antagonists/neprilysin angiotensin receptor antagonists, and 13% ARNI. Compared to patients enrolled before 2020, ARNI prescription increased in 2021 (60% vs. 13%, respectively, P < 0.001). In 30% of patients, ARNI were prescribed before hospital discharge. Furthermore, in 10% of the population (most diabetics), sodium-glucose cotransporter 2 inhibitors were also prescribed. The implementation of the PONTE project was associated with an improved adherence to guidelines recommendations.
Genetic predisposition according to the age at the onset of atrial fibrillation
Authors: Hwang I , Hong M , Hwang T H , Yu H T , Kim T-H , Uhm J-S , Joung B , Lee M-H , Jee S H , Pak H-N
Published: May 2022

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The Ministry of Health and Welfare National Research Foundation of Korea (NRF)

Background

Although atrial fibrillation (AF) is a heritable disease, multiple comorbid factors, including aging, contribute to its development.

Purpose

We investigated the association between a weighted genetic risk score (wGRS) for AF and the age at onset.

Methods

We included 1,968 patients with AF (Yonsei AF Ablation cohort) and 5,486 controls from the Korean Genome Epidemiology Study (KoGES). After 1:1 matching, 1,416 patients and 1,416 controls were included in the analyses. The age of AF onset was determined by the first electrocardiogram (ECG) documentation.

Results

We selected nine previously reported AF-associated single-nucleotide polymorphisms (SNPs). Among nine proven AF-associated SNPs, 4 genes (PRRX1, PPFIA4, PITX2, and ZFHX3) were independently associated with the age at the onset of AF (p<0.05), but no associated genes were found in the controls. In the quartile and multivariate analyses, the lower quartile age at the onset of AF had a higher wGRS (p<0.001), and a younger age at the onset of AF was independently associated with the wGRS (β -0.29 [-0.57--0.01], p=0.045), but that association was not observed in the control cohort. Contrarily, the higher quartile of the wGRS group had a younger age of AF onset (p<0.001), and the wGRS was independently associated with the age at onset of AF (β -0.02 [-0.03--0.01], p=0.002). In the subgroup analyses, these age-wGRS associations were significant in males (p<0.001) and in those without heart failure (p<0.001) or strokes (p<0.001).

Conclusions

AF-associated genetic loci significantly contributed to the age at the onset of AF, as determined by the first ECG.
Machine-learned physiological signatures from the ECG predict sudden death in ischemic cardiomyopathy
Authors: Deb B , Selvalingam A , Alhusseini M , Rogers A , Ganesan P , Feng R , Clopton P , Ruiperez-Campillo S , Narayan S
Published: May 2022

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Institute of Health (NIH)

Background

Low left ventricular ejection fraction (LVEF) is an imperfect predictor of sudden cardiac death (SCD) in patients with ischemic cardiomyopathy. Novel features from the ECG might provide a readily available tool to better predict risk.

Purpose

We hypothesized that machine learning (ML) of the ECG can be used to predict SCD, and the ML-learned ECG features could be referenced to interpretable intracardiac signals (monophasic action potentials: MAP) to provide mechanistic insights.

Methods

We studied 5603 ECG Lead V1 beats in 41 patients (64±10 Y) with coronary disease and LVEF≤40% in steady-state pacing. Patients were randomly allocated to independent training and test cohorts in a 70:30 ratio, repeated K=10-fold. Support vector machines were trained to predict mortality at 3Y from the top 20 features derived from these beats. Patient-level predictions were made by computing an ECG score that indicates the proportion of test set beats in that patient computed by the beat-level model to predict death. Explainability analysis was performed using the arithmetic mean of MAP and ECG beats that predicted SCD versus those that predicted survival.

Results

Fig 1A. shows ECG lead V1 and MAP in a 79 Y man with LVEF 29%. Fig 1B shows the dataflow in the study. Predictive accuracies of ML models were 78 and 70% and optimal with 20 features for both ECG and MAP models respectively (Fig. 1C). Beat-level predictions in the validation (n=1678 Lead I beats) cohorts yielded c-statistics of 0.78 with the ECG (95% CI, 0.62–0.91) and 0.75 with MAPs (95% CI, 0.75-0.76) (data not shown). In multivariable patient-level models, c-statistic was 0.87 with ECGs (95% CI, 0.76-0.98) (Fig 1D) and 0.82 with MAPs. On explainability analysis, ECG beats that predicted SCD (Fig 2; red) had lower amplitude and more notched T-waves in lead V1 than beats that predicted no SCD (Fig 2; blue). MAP that predicted SCD had higher repolarization current at the same time points. Both QT duration (ECG) and action potential duration (MAP) did not differ (Fig 2).

Conclusions

Machine learning of the ECG reveals novel predictors of SCD risk in patients with ischemic cardiomyopathy analogous to those identified in intracardiac signals. This approach can be used as a point-of-care ECG risk tool to improve risk stratification and allocation for ICD therapy beyond LVEF alone and may shed insights into the pathophysiology of ventricular arrhythmias.
Assessment of activation duration across the right ventricular outflow tract in patients with premature ventricular contractions using noninvasive electrocardiographic mapping: a validation study
Authors: Parreira A , Carmo P , Marinheiro R , Mesquita D , Marques L , Mancelos S , Ferreira A , Goncalves A , Nunes S , Chmelevsky M , Ferreira J , Coelho R , Goncalves P , Marques H , Adragao P
Published: May 2022

Funding Acknowledgements

Type of funding sources: Private hospital(s). Main funding source(s): Learning Health

Introduction

Previous studies have reported that wavefront propagation speed across the right ventricular outflow tract (RVOT) can distinguish premature ventricular contractions (PVCs) with a RVOT origin from PVCs with a left ventricular outflow tract (LVOT) origin.

Aim

Validate the non-invasive electrocardiographic mapping (ECGI) for assessment of RVOT activation duration (AD) during PVCs and assess its value as a predictor of the origin of the PVCs.

Methods

We studied 18 consecutive patients, 8 males, median age 55 (35-63) years that underwent ablation of frequent (> 10.000 per 24 h) idiopathic PVCs with inferior axis, that had and an ECGI performed before ablation and the RVOT mapped in PVC. The ECGI was performed with the Amycard system, and invasive mapping was performed with the Carto or Ensite system. Isochronal activation maps of the RVOT in PVC were obtained with the activation direction method (ADM) of the ECGI, and with the Carto and Ensite systems. Total RVOT AD was measured as the time interval between the earliest and the latest activated region. Agreement between the two methods was performed using a Bland-Altman plot and linear regression . The cutoff value of AD to predict PVC origin was calculated with ROC curve.

Results

PVCs originated from the RVOT in 11 (61%) patients. The median (Q1-Q3) RVOT AD measured with ECGI was 54 (39-68) ms and with invasive map 57 (36-70) ms. The agreement between both methods was good with an R2 of 0.747, p<0.0001. Figure displays the Bland-Altman plot (panel A), the linear regression plot (panel B). and two examples of the ECGI isochronal map (panel C). The AD was significantly higher in PVCs from the RVOT vs LVOT, both with ECGI and Carto, respectively 62 (58-73) vs 37 (33-40) ms, p<0.0001 and 68 (60-75) vs 34 (30-40) ms, p<0.0001. The cutoff value of 43 ms for AD measured with ECGI, predicted the origin of the PVCs with a sensitivity and specificity of 100%.

Conclusions

We found good agreement between ECGI and Carto. The AD obtained with ECGI was accurate to predict the origin of the PVCs.
PR and QRS intervals in basal electrocardiogram as a useful tool in screening family members for diagnosis of Brugada Syndrome
Authors: Devesa Neto V , Santos JM , Pereira JG , Ferreira Santos L
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Introduction

Diagnosis of Brugada Syndrome (BrS) requires documentation of a spontaneous or pharmacologically induced type 1 Brugada pattern. In individuals with normal basal electrocardiography, screening methods could be challenging. The aim of the study was to detect if other parameters in basal ECG could be a tool to predict the diagnosis of BrS in family members.

Methods

Prospective analysis of 78 patients with family history of BrS and referenced for screening. Basal electrocardiogram was performed in all patients. Patients with spontaneous type 1 Brugada pattern in basal ECG were initially excluded. Definitive diagnosis required a presence of a type 1 ECG pattern or conversion of a type 2 to type 1 following provocative test. The Mann-Whitney U test was used for median comparison between groups as univariate analysis. Analysis of the receiver operating characteristic (ROC) curves were performed to evaluate the predictive values of ECG parameters.

Results

6% (n=5) had spontaneous type 1 Brugada syndrome. 53% were male (n=41); mean age of 28,9±15,3 years. 31% (n=24) had confirmative diagnosis of BrS. 27% (n=21) were carriers of SCN5A mutation. Mean duration of intervals on basal ECG were: RR 871,2±156,0ms; PR 159,3±34,1ms; QRS 91,4±13,4ms; QTc 404,2±32,0. Syncope occurred in 5% of patients (n=5), 94% were asymptomatic.

By univariate analysis the distribution of PR and QRS intervals was significantly different. Wider PR interval was found in patients with BrS (p<0,01) with a median of 200ms (variance of 1269) versus healthy individuals (median of 150ms and variance of 601). Wider QRS intervals were also found in BrS patients compared with healthy individuals (p<0,01) (100ms (288) versus 80ms (204)). The cut-off point, with the most sensitivity (S) and specificity (E) obtained using the Youden index (YI) for PR interval was 170ms (YI 0,5389; Sensitivity (S)≈65% and Specificity(E)≈89%) and for QRS interval was 97ms (YI 0,5148; Sensitivity (S)≈70% and Specificity(E)≈82%).

Conclusion

Higher PR and QRS intervals were associated with BrS diagnosis comparing to healthy family members which may pose a cost-effective screening tool. More studies are needed to validate this hypothesis.
Incidental arrhythmias during atrial fibrillation screening in a hospital-based patient population
Authors: Goulouti E , Lam A , Nozica N , Elchinova E , Spirito A , Servatius H , Noti F , Seiler J , Baldinger S , Haeberlin A , Babken A , Franzeck F , Tanner H , Reichlin T , Roten L
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Introduction

Screening for atrial fibrillation may reveal other, incidental arrhythmias of relevance. We sought to describe such incidental arrhythmias in the prospective STARFIB cohort study, which screened for silent atrial fibrillation in hospitalized patients aged 65-84 years.

Method

Patients included in the STARFIB cohort study had up to three 7-day Holter ECGs, performed in two-month intervals. We analysed all the 7-day Holter ECGs of study participants for the presence of one of the following incidental arrhythmias: 1) sick-sinus-syndrome (SSS), defined as sinus arrest of ≥3 seconds duration; 2) second or higher degree atrioventricular block (AVB); 3) sustained atrial tachycardia of ≥30 seconds duration (AT); and 4) sustained ventricular tachycardia of ≥30 seconds duration (VT).

Results

A total of 2’077 Holter ECGs were performed in 794 patients (mean age 74.7 years; 49% females), resulting in a mean cumulative duration of an analyzable ECG signal of 414±136 hours per patient. We found incidental arrhythmias in 94 patients (11.8%). Among these were SSS in 14 patients (1.8%), AVB in 41 (5.2%), AT in 41 (5.2%), and VT in two (0.3%). The median pause duration in SSS was 4 seconds and SSS resulted in pacemaker implantation in one patient with a pause of 9 seconds duration. The most severe type of AVB found per patient was second degree AVB type Wenkebach in 23 patients (2.9%), second degree AVB type Mobitz or 2:1 AV conduction in 10 patients (1.3%) and complete AVB in 8 (1%; maximum pause 18 seconds). AVB led to pacemaker implantation in 9 patients (1.1%). The median duration and heart rate of AT was 2.2 minutes and 144 bpm, respectively. Initiation of betablocker therapy was recommended in 3 patients (0.4%) due to symptomatic AT. The duration and heart rate of VT was 3 minutes at 216 bpm in one patient and 38 seconds at 150 bpm in another. The former patient with VT experienced syncope and an ICD was implanted, whereas in the latter the betablocker dose was increased. One patient died from a non-cardiac cause during a Holter ECG, which showed progressive bradycardia and finally asystole.

Conclusion

Incidental arrhythmias were frequently discovered during screening for atrial fibrillation and resulted in device therapy in 1.4% of our cohort patients.
Prediction of ablation success in atrial fibrillation patients based on electrocardiographic imaging
Authors: Molero R , Climent AM , Guillem MS
Published: May 2022

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Instituto de Salud Carlos III, and Ministerio de Ciencia, Innovación y Universidades (supported by FEDER Fondo Europeo de Desarrollo Regional PI17/01106), Agencia Estatal de Investigación (RYC2018-024346B-750 and PID2020-119364RB-100), Generalitat Valenciana Grants (ACIF/2020/265) and EIT Health (Activity code 19600), EIT Health is supported by EIT, a body of the European Union).

Introduction

Success rates of pulmonary vein isolation (PVI) are still suboptimal for termination of Atrial Fibrillation (AF). Electrocardiographic imaging (ECGI) could be used to determine the state of the atrial substrate non-invasively.

Objective

Improve the current stratification protocol for AF patients candidates to PVI using ECGI metrics prior to the referral to an ablation procedure.

Methods

ECGI from 35 AF patients (22 male, 10 paroxysmal, 63.3 ± 9.5 years) were recorded prior to PVI plus rotor ablation. Patients were latter classified based on their 6 months follow-up (23 sinus rhythm vs. 12 arrhythmia recurrence). ECGI dominant frequencies (DF) and rotor metrics were calculated in each patient, together with their temporal variability. Multivariate logistic regression was computed on the metrics, their variability and AF type to study the prediction power on ablation outcome.

Results

Dominant frequency metrics present higher values in patients with arrhythmia recurrence after the ablation. Rotor metrics showed higher variability in patients with bad PVI outcome (Table 1). ECGI metrics alone allow better outcome prediction (Fig. 1) than standard AF classification (AUC = 0.85 vs. 0.65). ECGI metrics combined with the type of AF increased outcome prediction, AUC = 0.88.

Conclusion

Patients with poor ablation outcome presented higher DFs and reentrant activity variability than patients with good PVI outcome. ECGI derived metrics in combination with AF classification increase PVI follow-up prediction compared to traditional patient stratification showing potential to be an alternative to the standard of care.
Low coronary flow reserve in patients with long-standing persistent atrial fibrillation is associated with worse clinical outcomes
Authors: Daniels F , Elvan A , Beemsterboer ITA , Mouden M
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background / Introduction

Atrial fibrillation (AF) is associated with an increased risk of myocardial infarction, stroke and all-cause mortality. Myocardial perfusion imaging (MPI) is well-established for the diagnosis of coronary artery disease (CAD) and risk-stratification in sinus rhythm (SR) patients.

Purpose

The aim of this study was to determine the prognostic impact of AF and coronary flow reserve (CFR) in patients undergoing positron emission tomography (PET) MPI.

Methods

680 patients without a known history of CAD were included. 226 paroxysmal AF (PAF) and 114 long-standing persistent AF (LSPAF) patients were identified from a prospective PET MPI registry in the Isala Hospital and propensity matched in a 1:1 ratio to SR patients. The main indications for PET MPI were chest pain and dyspnea. Follow-up was obtained for the occurrence of major adverse cardiac and cerebrovascular events (MACCE, composite of myocardial infarction (MI), stroke/transient ischemic attack (TIA) or all-cause death).

Results

Compared with patients with PAF, patients with LSPAF were older (p=0.011) and more frequently male (p=0.031), with no significant differences in medical history. There were no significant differences between SR and AF in the occurrence of MACCE during a mean follow-up of 36 months. However, the incidence of downstream coronary angiography (p<0.001) and MACCE (p=0.028) was higher in patients with LSPAF compared to those with PAF and SR. A low CFR (defined as CFR below the median of 2.4) in patients with LSPAF showed significantly more MACCE compared with SR and PAF (p<0.001). Moreover, LSPAF was an independent predictor of MACCE (odds ratio 1.667, 95% confidence interval 1.028±2.705).

Conclusion

Low CFR in patients with LSPAF is associated with a higher incidence of MI, stroke/TIA and death compared with low and normal coronary flow parameters in patients with SR and PAF.
Nurse-led compared to physician-led implant of cardiac monitors
Authors: Steinhauer B , Spicher J , Aerschmann S , Ambord N , Bartkowiak J , Servatius H , Noti F , Seiler J , Baldinger S , Haeberlin A , Madaffari A , Tanner H , Reichlin T , Roten L , Duetschler S
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

Implantation of an implantable cardiac monitor (ICM) is a simple and straightforward procedure. However, with a growing demand for such implants, workload significantly increases. In January 2020, we established a completely nurse-led ICM implantation service (N-IMPLANT) with a standard operating procedure.

Purpose

The present study aimed to analyze the safety, efficacy, and patient satisfaction of N-IMPLANT compared to implantation of ICMs by a physician (P-IMPLANT).

Method

Consenting patients implanted with an ICM were included in a prospective registry, which collects patient characteristics, procedural and remote monitoring data. All patients were followed-up by phone interview four weeks after ICM implantation and a standardized questionnaire was completed.

Results

Of 321 patients implanted with an ICM (median age 67 years; 33% women), 189 (59%) were N-IMPLANT. Significantly more N-IMPLANT were performed in the outpatient clinic compared to P-IMPLANT (94% vs. 10%; p<0.001). For wound closure, N-IMPLANT used wound glue in 65 (34%) and a single subcutaneous stitch in 124 patients (66%). Two N-IMPLANT patients experienced vaso-vagal reaction during implantation, whereas no adverse events occurred during P-IMPLANT (p=0.51). Two-hundred and fifty-two patients (79%) completed the questionnaire. We found no difference between N-IMPLANT and P-IMPLANT regarding pain after implant, analgesic use, wound closure after 2 weeks and presence and size of patient reported hematoma (see Table). Duration of pain was longer after P-IMPLANT. All N-IMPLANT patients indicated to be satisfied with the implant procedure. Three patients were dissatisfied with P-IMPLANT for the following reasons: ongoing pain at implant site; discomfort at implant site; and too numerous people present during the implant procedure. In three N-IMPLANT (2%) the ICM was explanted prematurely. The reasons for explantation were infection (with reimplantation of another ICM), discomfort at implant site and attempt to avoid interferences during magnetic resonance tomography in one patient each. One P-IMPLANT (1%) was explanted prematurely because of ICM malfunction.

Conclusion

Nurse-led implantation of cardiac monitors is effective without compromising patient safety and has excellent patient satisfaction. N-IMPLANT is a suitable model to reduce the workload of physicians.
Unipolar voltage mapping in right ventricular cardiomyopathy: pitfalls, solutions and advantages
Authors: Hoogendoorn J , Venlet J , De Riva Silva M , Wijnmaalen AP , Piers SRD , Zeppenfeld K
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Endocardial unipolar and bipolar voltage mapping (UVM/BVM) of the right ventricle (RV) are used for transmural substrate delineation. Epicardial BVM is considered less accurate due to the impact of fat thickness (FT). Data on epicardial UVM are sparse. Far-field electrograms and electrogram changes due to injury current may influence automatically generated UVM, which rely on the largest peak-to-peak amplitude within the window-of-interest (WOI).

Purpose

To assess the influence of manually corrected WOI and the potential role of epicardial UVM in RV cardiomyopathies.

Methods

Consecutive patients who underwent endo-epicardial RV mapping with computed-tomography (CT) integration were included. Mapping points were superimposed on short-axis CT-slices and correlated with local FT. All points were manually re-analyzed and the WOI was adjusted to correct for false high UV. Per point-pair endo-epicardial BV and UV were correlated for different FT categories.

Results

A total of 4225 point-pairs of 33 patients were analyzed. In 71% of endocardial points and 65% of epicardial points the window-of-interest needed to be adjusted, due to inclusion of far-field electrograms, injury current components or RV-pacing artifacts (Figure 1). The median absolute difference between epi- and endocardial UV was -0.21mV (IQR:-1.05-0.36) for FT<1mm, compared to -0.60mV (IQR:-2.00-0.30) for FT≥2.8mm. This difference was larger for BV, with a median of -0.36mV (IQR:-2.03-0.23) and -1.29mV (IQR:-3.36-0.05), respectively (p-value epi-endo difference UV vs. BV in all fat categories: <0.001). The Pearson correlation between corrected endo-epicardial BV and UV was lower for point-pairs with greater FT; however, this correlation was stronger and less influenced by fat for UV (coefficient for UV 0.696 for FT<1mm and 0.544 for FT≥2.8mm; for BV 0.437 and 0.155, respectively; Figure 2). In a subanalysis of point-pairs with distance<5mm and FT<1mm, the Pearson coefficient was 0.789 for UV and 0.525 for BV.

Conclusions

At the majority of mapping sites the window-of-interest needs to be manually adjusted for correct unipolar voltage mapping. Unadjusted UVM underestimates low UV regions. UV seems to be less influenced by epicardial fat and endo-epicardial wavefront, suggesting a promising role for UVM in epicardial substrate delineation.